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Lim J, Panagiotoglou D. The effect of Montreal's supervised consumption sites on injection-related infections among people who inject drugs: An interrupted time series. PLoS One 2024; 19:e0308482. [PMID: 39190638 PMCID: PMC11349102 DOI: 10.1371/journal.pone.0308482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/23/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Between June and November 2017, four supervised consumption sites (SCS) began operating in Montreal, Quebec. Earlier studies on SCS focused on examining their effects on blood-borne viral infections and overdose mortality. Our objective was to examine the effect of Montreal's SCS on the incidence, health service use and outcomes of injection-related infections (IRI) in people who inject drugs. METHODS We used Quebec's provincial administrative health data to identify people who inject drugs in Montreal and calculated the incidence of IRI in this population between December 2014 and December 2019. We conducted a retrospective, population-based interrupted time series to estimate the effect of Montreal's four SCS on the monthly incidence rates of IRI-related hospitalizations, emergency department (ED) visits, physician visits, and mortality. We also examined the effects of SCS on average length of IRI-related hospitalizations and incidence of hospitalizations involving surgery. RESULTS The average age of Montreal's people who inject drugs was 41.84 years, and 66.41% were male. After the implementation of SCS, there was a positive level change in the incidence of hospitalizations (0.97; 95% confidence interval [CI]: 0.26, 1.68) for IRI. There was also a significant post-intervention decline in hospitalization trends (-0.05; 95% CI: -0.08, -0.02), with modest trend changes in ED visits (-0.02; 95% CI: -0.05, 0.02). However, post-intervention changes in level (0.72; 95% CI: -3.85, 5.29) and trend (0.06; 95% CI: -0.23, 0.34) for physician visits remained limited. SCS had no effect on the average length of hospitalizations, but there was a decreasing post-intervention trend in hospitalizations involving surgery (-0.03; 95% CI: -0.06, 0.00). CONCLUSION Following the opening of the SCS, there was a moderate decline in the rate of hospitalizations to treat IRI, but the impact of the sites on the rate of physician visits remained limited. These findings suggest that SCS may mitigate the incidence of more serious and complicated IRI over time.
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Calderón-Villarreal A, Abramovitz D, Avelar Portillo LJ, Goldenberg S, Flanigan S, Quintana PJE, Harvey-Vera A, Vera CF, Rangel G, Strathdee SA, Kayser GL. Water, sanitation and hygiene insecurity predict abscess incidence among people who inject drugs in a binational US-Mexico metropolitan area: A longitudinal cohort study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 129:104485. [PMID: 38901113 DOI: 10.1016/j.drugpo.2024.104485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 06/01/2024] [Accepted: 06/03/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION People who inject drugs (PWID) are at high risk of developing injection-related infections, including abscesses. Access to water, sanitation, and hygiene (WASH) are key human rights and services; yet these services have been underexplored as predictors of abscesses among PWID. METHODS Longitudinal analysis was employed among a cohort of PWID to determine if WASH insecurity (lack of access) was associated with abscess incidence in the Tijuana, Mexico and San Diego, United States metropolitan area during 24-months of follow-up survey data from 2020 to 2023. We calculated abscess prevalence at baseline and tracked the incidence of new abscesses among individuals without an abscess during the previous visit. Time dependent Cox regression modeling was employed with variance clustered by participant to characterize the relationship between WASH insecurity and abscess incidence. RESULTS At baseline, hand hygiene insecurity, bathing insecurity in the previous six months and open defecation in the last week, were reported by 60 %, 54 % and 38 % of participants, respectively; 21 % reported an abscess in the last six months. The incidence of abscesses was 24.4 (95 %CI: 21.1-27.6) per 100 person-years. After adjusting for covariates, the hazard of developing an abscess remained significantly elevated among individuals using non-improved (with risk of contamination) water sources (e.g., surface water) for preparing drugs (adjusted HR [adjHR]: 1.49 [95 %CI: 1.01-2.21], experiencing bathing insecurity (adjHR: 1.59 [95 %CI: 1.12-2.24]) and open defecation (adjHR: 1.65 [95 %CI: 1.16-2.35]). CONCLUSIONS PWID in the Tijuana-San Diego metropolitan area reported facing high rates of insecurity accessing WASH services. Abscess incidence was higher (four to nine times) than observed rate among PWID cohorts in other settings. Access to continuously available toilet facilities, bathing infrastructure, and safe water sources for preparing drugs for injection could prevent abscesses among PWID. Accessible WASH infrastructure should be ensured among PWID communities and promoted as a key component of harm reduction infrastructure.
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Affiliation(s)
- Alhelí Calderón-Villarreal
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego (UCSD), San Diego, CA, USA; School of Public Health, San Diego State University (SDSU), San Diego, CA, USA.
| | - Daniela Abramovitz
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA
| | - Lourdes Johanna Avelar Portillo
- Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, CA, USA
| | - Shira Goldenberg
- School of Public Health, San Diego State University (SDSU), San Diego, CA, USA
| | | | | | - Alicia Harvey-Vera
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA; Universidad Xochicalco, Tijuana, Baja California, Mexico
| | - Carlos F Vera
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA
| | - Gudelia Rangel
- El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico; Border Health Commission, Tijuana, Baja California, Mexico
| | - Steffanie A Strathdee
- Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, CA, USA
| | - Georgia L Kayser
- Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, CA, USA
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Lim J, Russell WA, El-Sheikh M, Buckeridge DL, Panagiotoglou D. Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach. Harm Reduct J 2024; 21:126. [PMID: 38943164 PMCID: PMC11212409 DOI: 10.1186/s12954-024-01037-3] [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: 03/12/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID. METHODS We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks. RESULTS The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI. CONCLUSIONS Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - W Alton Russell
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Mariam El-Sheikh
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada.
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Jörgensen J, Dahlman D, Alanko Blomé M, Janson H, Riesbeck K, Nilsson AC. Staphylococcus aureus carriage and prevalence of skin and soft tissue infections among people who inject drugs: a longitudinal study. Sci Rep 2024; 14:12919. [PMID: 38839902 PMCID: PMC11153592 DOI: 10.1038/s41598-024-63574-y] [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: 01/19/2024] [Accepted: 05/30/2024] [Indexed: 06/07/2024] Open
Abstract
People who inject drugs are frequently colonized with Staphylococcus aureus and have an increased risk for skin and soft tissue infections. This longitudinal study aims to describe S. aureus carriage in this group and the risk for infections during a 1-year follow-up. We included 61 participants from the Malmö Needle Exchange Program. Mapping of S. aureus carriage was conducted by screening cultures every third month and S. aureus growth was semi-quantified. Data regarding infections and living conditions were collected from structured interviews. Statistics included univariate analysis with the Fischer's exact test, univariate logistic regression and multivariate logistic regression. S. aureus carriage was detected in 46-63% of participants, and 75% reported one or more infections during the study period. Self-reported infections were associated with carriage in perineum (OR 5.08 [95% CI 1.45-17.73]), in skin lesions (OR 1.48 [95% CI 1.21-1.81]), and unstable housing situation (OR 12.83 [95% CI 1.56-105.81]). Thus, people who inject drugs are frequent carriers of S. aureus and report a surprisingly high prevalence of skin and soft tissue infections. Homeless people and those with skin carriage seem to be at highest risk. Effective clinical interventions are needed, aiming at preventing infections in this vulnerable group.
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Affiliation(s)
- Jimmy Jörgensen
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden.
| | - Disa Dahlman
- Department of Clinical Sciences Center for Primary Health Care Research, Malmö, Faculty of Medicine, Lund University, Malmö, Sweden
- Division of Psychiatry, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Marianne Alanko Blomé
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Håkan Janson
- Clinical Microbiology, Central Hospital, Växjö, Sweden
| | - Kristian Riesbeck
- Clinical Microbiology, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Anna C Nilsson
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden
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Young AM, Havens JR, Cooper HLF, Fallin-Bennett A, Fanucchi L, Freeman PR, Knudsen H, Livingston MD, McCollister KE, Stone J, Vickerman P, Freeman E, Jahangir T, Larimore E, White CR, Cheatom C, Community Staff K, Design Team K. Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia. BMJ Open 2024; 14:e083983. [PMID: 38431295 PMCID: PMC10910671 DOI: 10.1136/bmjopen-2024-083983] [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: 01/04/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia. METHODS AND ANALYSIS KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness. ETHICS AND DISSEMINATION The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings. TRIAL REGISTRATION NUMBER NCT05657106.
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Affiliation(s)
- April M Young
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah L F Cooper
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Laura Fanucchi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia R Freeman
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah Knudsen
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Melvin D Livingston
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kathryn E McCollister
- Division of Health Services Research and Policy, University of Miami, Coral Gables, Florida, USA
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Edward Freeman
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | - Tasfia Jahangir
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Elizabeth Larimore
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Carol R White
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | | | - KyOSK Community Staff
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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Attwood LO, O'Keefe D, Higgs P, Vujovic O, Doyle JS, Stewardson AJ. Epidemiology of acute infections in people who inject drugs in Australia. Drug Alcohol Rev 2024; 43:304-314. [PMID: 37995135 PMCID: PMC10952783 DOI: 10.1111/dar.13772] [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: 03/05/2023] [Revised: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023]
Abstract
ISSUES People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described. APPROACH We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health. KEY FINDINGS The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care. IMPLICATIONS Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health-care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors. CONCLUSION Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health-care systems. Flexible health-care models, such as low-threshold wound clinics, would help directly target, and address early interventions, for these infections.
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Affiliation(s)
- Lucy O. Attwood
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
| | | | - Peter Higgs
- Burnet InstituteMelbourneAustralia
- Department of Public HealthLa Trobe UniversityMelbourneAustralia
| | - Olga Vujovic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
| | - Joseph S. Doyle
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
- Burnet InstituteMelbourneAustralia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
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Kesten J, Hussey D, Lord C, Roberts L, Bayliss J, Erswell H, Preston A, Telfer M, Scott J, Harris M, Mellon D, Hickman M, MacArthur G, Fisher H. Development, acceptability and feasibility of a personalised, behavioural intervention to prevent bacterial skin and soft tissue infections among people who inject drugs: a mixed-methods Person-Based Approach study. Harm Reduct J 2023; 20:114. [PMID: 37608267 PMCID: PMC10463350 DOI: 10.1186/s12954-023-00823-9] [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: 12/02/2022] [Accepted: 07/10/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Skin and soft tissue infections (SSTI) among people who inject drugs (PWID) are a public health concern. This study aimed to co-produce and assess the acceptability and feasibility of a behavioural intervention to prevent SSTI. METHODS The Person-Based Approach (PBA) was followed which involves: (i) collating and analysing evidence; (ii) developing guiding principles; (iii) a behavioural analysis; (iv) logic model development; and (v) designing and refining intervention materials. Co-production activities with target group representatives and key collaborators obtained feedback on the intervention which was used to refine its design and content. The intervention, harm reduction advice cards to support conversation between service provider and PWID and resources to support safer injecting practice, was piloted with 13 PWID by four service providers in Bristol and evaluated using a mixed-methods approach. Semi-structured interviews were conducted with 11 PWID and four service providers. Questionnaires completed by all PWID recorded demographic characteristics, SSTI, drug use and treatment history. Interviews were analysed thematically and questionnaires were analysed descriptively. RESULTS Published literature highlighted structural barriers to safer injecting practices, such as access to hygienic injecting environments and injecting practices associated with SSTI included: limited handwashing/injection-site swabbing and use of too much acidifier to dissolve drugs. Co-production activities and the literature indicated vein care and minimisation of pain as PWID priorities. The importance of service provider-client relationships and non-stigmatising delivery was highlighted through the co-production work. Providing practical resources was identified as important to address environmental constraints to safer injecting practices. Most participants receiving the intervention were White British, male, had a history of SSTI and on average were 43.6 years old and had injected for 22.7 years. The intervention was well-received by PWID and service providers. Intervention content and materials given out to support harm reduction were viewed positively. The intervention appeared to support reflections on and intentions to change injecting behaviours, though barriers to safer injecting practice remained prominent. CONCLUSIONS The PBA ensured the intervention aligned to the priorities of PWID. It was viewed as acceptable and mostly feasible to PWID and service providers and has transferability promise. Further implementation alongside broader harm reduction interventions is needed.
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Affiliation(s)
- Joanna Kesten
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK.
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
| | | | | | | | - James Bayliss
- Bristol, North Somerset, South Gloucestershire Integrated Care System, Bristol, UK
| | - Helen Erswell
- UK Health Security Agency (UKHSA), South West Region, Bristol, UK
| | | | | | - Jenny Scott
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Dominic Mellon
- UK Health Security Agency (UKHSA), South West Region, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Georgie MacArthur
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Harriet Fisher
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
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Duhart Clarke SE, Megerian CE, Suen LW, Wenger LD, Lambdin BH, Davidson PJ, Kral AH. Prevalence and factors associated with neck injection among people who inject drugs in San Francisco, California. Drug Alcohol Depend 2022; 241:109686. [PMID: 36402050 DOI: 10.1016/j.drugalcdep.2022.109686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Groin and neck injections are generally a last resort for people who inject drugs (PWID) who do not have easy access to functioning veins. These alternative injection practices can lead to an increased likelihood of adverse health outcomes. There is still much we do not know about groin and neck injections among PWID in the US, as the literature to-date comes from studies primarily focused on groin injections outside the US. We assessed prevalence, predictors, and associated behaviors of neck injection through a survey fielded in San Francisco, California, US. METHODS The sample comes from a longitudinal observational study that used targeted sampling to recruit PWID in San Francisco. The current study sample includes 239 PWID who completed their 12-month survey between June 2019 and June 2020. RESULTS About a third of the sample reported injecting in their neck in the past 30 days, with the most common reason being lack of available veins. Age, past 6-month abscess / soft tissue infection, and past 30-day use of opioids mixed with cocaine were significantly associated with past 30-day neck injection in the final multivariate model. Past 30-day neck injection was also significantly associated with being injected by another person in the past 30 days. CONCLUSIONS PWID at higher risk for vein deterioration were more likely to inject into their neck. Harm reduction strategies such as safer injection counseling, safe smoking supplies, use of "street doctors," and safe consumption sites may reduce instances of neck injection and/or associated health risks.
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Affiliation(s)
| | - Cariné E Megerian
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709, USA
| | - Leslie W Suen
- Division of General Internal Medicine, University of California San Francisco at San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA, USA
| | - Lynn D Wenger
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709, USA
| | - Barrot H Lambdin
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709, USA; Division of General Internal Medicine, University of California San Francisco at San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA, USA; University of Washington, 1400 NE Campus Parkway, Seattle, WA, USA
| | - Peter J Davidson
- University of California San Diego, 9500 Gillman Drive, La Jolla, CA, USA
| | - Alex H Kral
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709, USA
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Fitzpatrick T, McMahan VM, Frank ND, Glick SN, Violette LR, Davis S, Jama S. Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study. Harm Reduct J 2022; 19:103. [PMID: 36138407 PMCID: PMC9493152 DOI: 10.1186/s12954-022-00685-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heroin pipe distribution may encourage people who use heroin (PWUH) to transition from injecting to smoking heroin, reducing harms associated with injection drug use. A syringe services program (SSP) in Seattle, Washington, led by people who use drugs developed a heroin pipe distribution program. METHODS We conducted a pretest-posttest quasi-experimental study to evaluate the impact of heroin pipe distribution on drug consumption behaviors among PWUH between March and December 2019. SSP clients were surveyed during three weeklong timepoints before and four weeklong timepoints after heroin pipe distribution. Primary outcomes were change in proportion of SSP clients who exclusively injected heroin, exclusively smoked heroin, and both injected and smoked heroin in the past seven days comparing the pre- and post-intervention periods. RESULTS Across the seven observation timepoints, 694 unique respondents completed 957 surveys. Multiple responses from a single respondent in a given period were collapsed, resulting in 360 pre-intervention and 430 post-intervention records. Heroin use was reported in over half of pre-intervention (56%, 201/360) and post-intervention records (58%, 251/430). Compared to pre-intervention behaviors, the proportion of respondents who exclusively injected heroin was lower after the start of heroin pipe distribution (32%, 80/251 vs 43%, 86/201, p = 0.02), while the proportion of respondents who both injected and smoked heroin was higher (45%, 113/251 vs 36%, 72/201, p = 0.048). Just under half (44%, 110/251) of respondents who used heroin during the post-intervention period used a heroin pipe obtained from the SSP, of which 34% (37/110) reported heroin pipe distribution had reduced their heroin injection frequency. Self-reported hospitalization for a pulmonary cause was not associated with using a heroin pipe. CONCLUSIONS The proportion of SSP clients who exclusively injected heroin was lower after implementation of heroin pipe distribution. Randomized studies with longer follow-up are needed to investigate whether heroin pipe distribution reduces heroin injection and improves health outcomes associated with drug use. Limited intervention exposure, loss to follow-up, and pipe availability from other sources pose methodological challenges to evaluations of route transition interventions in community settings. This pilot highlights the potential for organizations led by people who use drugs to develop, implement, and evaluate novel public health programming.
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Affiliation(s)
- Thomas Fitzpatrick
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
- The People's Harm Reduction Alliance, 1959 NE Pacific St., Box 356423, Seattle, WA, 98195, USA.
| | - Vanessa M McMahan
- The People's Harm Reduction Alliance, 1959 NE Pacific St., Box 356423, Seattle, WA, 98195, USA
- Center on Substance use and Health, Department of Public Health, San Francisco, CA, USA
| | - Noah D Frank
- The People's Harm Reduction Alliance, 1959 NE Pacific St., Box 356423, Seattle, WA, 98195, USA
- Office of Infectious Disease, Washington State Department of Health, Olympia, WA, USA
| | - Sara N Glick
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lauren R Violette
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Shantel Davis
- Safer Alternatives Thru Networking and Education, Sacramento, CA, USA
| | - Shilo Jama
- Safer Alternatives Thru Networking and Education, Sacramento, CA, USA
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Harris M, Holland A, Lewer D, Brown M, Eastwood N, Sutton G, Sansom B, Cruickshank G, Bradbury M, Guest I, Scott J. Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence. BMC Med 2022; 20:151. [PMID: 35418095 PMCID: PMC9007696 DOI: 10.1186/s12916-022-02351-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/24/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England. METHODS We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research. RESULTS Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with 'drugs used in substance dependence' collectively categorised as posing low risk if delayed and moderate risk if omitted. CONCLUSIONS Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the 'low-risk' categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Adam Holland
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Dan Lewer
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Michael Brown
- Division of Infection, University College London Hospital, London, UK.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Gary Sutton
- Release, 61 Mansell Street, London, E1 8AN, UK
| | - Ben Sansom
- Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Gabby Cruickshank
- Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Molly Bradbury
- Severn Foundation School, Park House, 1200 Parkway, Bristol, BS34 8YU, UK
| | - Isabelle Guest
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, Claverton Down, Bath, BA2 7AY, UK
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11
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Factors associated with injury and blood-borne infection risk when providing assisted injection among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103297. [PMID: 34077825 PMCID: PMC9844096 DOI: 10.1016/j.drugpo.2021.103297] [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: 11/10/2020] [Revised: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Prior research has associated assisted injection with risk behaviors, but other risks such as injury, missed veins, and incidental exposures to blood-borne infections during an injection episode have not been assessed. In the following, we present the frequency of these other risks and determine factors associated with missing a vein and incidental blood exposure among people who inject drugs (PWID). METHODS We conducted a cross-sectional analysis of data from PWID who were recruited using targeted sampling in Los Angeles and San Francisco, California, during 2016 and 2017. The analytic sample consist of 336 participants who reported providing injection assistance in the last 6 months. Multivariate logistic regression models were developed for reporting the following risks: missing a vein; getting the recipient's blood on the injection provider; and getting blood on clothes or surfaces. RESULTS In the last 6 months, the most common negative consequences were getting blood on clothes or surfaces (40%), getting the recipient's blood on the injection provider (23%), and missing a vein (17%). In multivariate logistic regression analysis, missing the vein was significantly associated with higher odds of assisting a leg injection while getting the injection recipient's blood on the provider or getting blood on clothes or nearby surfaces was associated with higher odds of assisting a groin injection injecting in the groin. CONCLUSION Providing injection assistance can result in incidental blood exposures and injury, particularly when injecting in sensitive locations on the body. Harm reduction interventions to reduce risks associated with this practice are essential to improving the well-being of PWID.
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Doran J, Hope V, Wright T, Scott J, Ciccarone D, Harris M. Prevalence and factors associated with chronic venous insufficiency, leg ulceration and deep-vein thrombosis among people who inject drugs in London, UK. Drug Alcohol Rev 2021; 41:677-685. [PMID: 34605086 DOI: 10.1111/dar.13389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/16/2021] [Accepted: 09/04/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION People who inject drugs (PWID) are vulnerable to a range of harms, including vascular conditions such as chronic venous insufficiency (CVI), leg ulcers and deep vein thrombosis (DVT). The extent of vascular conditions has rarely been studied, despite contributing to considerable illness and disability among PWID. We assess the prevalence and associations of vascular conditions in PWID in London, UK. METHODS Survey data from the community-recruited Care and Prevent Study of PWID in London were analysed. Participants were asked about CVI and leg ulcers using pictorial questions, and if they had ever been diagnosed with DVT. Associations between vascular conditions and demographic/drug-use information were explored using univariate and multivariable logistic regression. RESULTS Among participants (n = 455), the prevalence of CVI, leg ulcers and DVT was 13% (n = 57), 10% (n = 46) and 23% (n = 105), respectively. CVI and DVT were positively associated with injecting into the groin, while injecting into the leg was positively associated with leg ulcers and DVT. CVI was also associated with not cleaning injection sites and diagnosed hepatitis C virus, and DVT with hepatitis C virus. DISCUSSION AND CONCLUSION The prevalence of vascular problems among PWID in London is very high in comparison to the general population. These conditions are primarily associated with injection into the femoral vein. Use of these injection sites indicates peripheral venous access problems. There is a need to reinvigorate safe injection information provision in harm reduction services, with attention to reducing risk practices associated with venous damage and transitions to femoral injection.
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Affiliation(s)
- Jason Doran
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,National Infection Service, Public Health England, London, UK
| | - Vivian Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Talen Wright
- Division of Psychiatry, University College London, London, UK
| | - Jenny Scott
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, USA
| | - Magdalena Harris
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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13
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In/dignity. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 98:103365. [PMID: 34404580 DOI: 10.1016/j.drugpo.2021.103365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 11/22/2022]
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Association of skin infections with sharing of injection drug preparation equipment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103198. [PMID: 33744668 PMCID: PMC8373634 DOI: 10.1016/j.drugpo.2021.103198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sharing needles and injection drug preparation equipment (IDPE) among people who inject drugs (PWID) are well-established risk factors for viral transmission. Shared needles and IDPE may serve as bacterial niduses for skin and soft tissue infections (SSTI). Given the rising rates of SSTI in PWID, we investigated the association of needle and IDPE sharing on incidence of SSTI in a cohort of PWID. METHODS Inpatient PWID (N = 252) were recruited to a randomized controlled trial of an intervention aimed at reducing infections. The primary outcome was self-reported incidence of SSTI one-year post-hospitalization. In this secondary analysis, we assessed two variables: 1) sharing of IDPE alone, 2) sharing needles with or without IDPE, and compared these groups separately to persons who reported no sharing of needles or IDPE via a mixed-effects negative binomial regression model to estimate the effect of baseline sharing behavior on SSTI during follow-up via incidence rate ratios (IRR). RESULTS Participant characteristics: 38 years [mean], 58% male, 60% White, 90% primarily injected opioids, 1.58 (± 2.35) mean SSTI in the year prior to baseline. In terms of sharing behavior, 29% didn't share needles or IDPE, 13% shared IDPE only, and 58% shared needles with or without IDPE three months prior to baseline. After adjusting for co-variables, PWID who shared IDPE alone had a 2.2 fold higher IRR of SSTI (95%CI 1.27; 3.85, p = 0.005) and PWID who shared needles with or without IDPE had a 3.31 fold higher IRR of SSTI (95%CI 2.04; 5.37, p < 0.001), compared to those who did not share any equipment. The number of SSTI at baseline was associated with an IRR of 1.20 of SSTI during follow-up (95%CI 1.09; 1.32, p < 0.001). CONCLUSIONS In this cohort of hospitalized PWID, we found a significant association between baseline sharing of IDPE alone and of sharing of needles with or without IDPE with one-year incidence of SSTI.
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Valencia J, Troya J, Lazarus JV, Cuevas G, Alvaro-Meca A, Torres J, Gardeta C, Lozano D, Moreno S, Ryan P. Recurring Severe Injection-Related Infections in People Who Inject Drugs and the Need for Safe Injection Sites in Madrid, Spain. Open Forum Infect Dis 2021; 8:ofab251. [PMID: 34250189 PMCID: PMC8266667 DOI: 10.1093/ofid/ofab251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/12/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An estimated 58 749 people with opioid use disorder engaged in opioid agonist therapy (OAT) in 1132 centers in Spain during 2017. We aimed to calculate the incidence of severe injection-related infections in people who inject drugs (PWID) engaged in OAT in harm reduction settings without a safe consumption space. METHODS A retrospective cohort study was performed in PWID engaged in OAT and in a mobile harm reduction unit to quantify admissions to a referral hospital for any severe injection-related infections between 1 January 2016 and 31 December 2019. A Cox proportional hazard regression analysis was used to assess factors associated with any severe injection-related infection. RESULTS Two hundred thirty-seven PWID who engaged in OAT were included in the study. After a median follow-up of 5.5 months (interquartile range [IQR], 1.3-22.7 months), a total of 104 episodes of severe injection-related infections occurred among 56 individuals, and admission due to a second event occurred in 35.7% of this same group. The incidence density of any type of severe injection-related infection was 26.8 (95% confidence interval [CI], 20.2-34.8) episodes per 100 person-years, and the incidence density of complicated skin and soft tissue infections that required hospital admission was 20.4 (95% CI, 15.0-27.3) episodes per 100 person-years. Fifty-six (53.8%) of all the episodes were patient-directed discharge (PDD), and people who had 2 or more hospital admissions had a higher PDD frequency. CONCLUSIONS Severe injection-related infections remain highly prevalent among PWID cared for in a harm reduction setting without a safe consumption space. PDD was more frequent among higher-risk individuals who presented 2 or more hospital readmissions.
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Affiliation(s)
- Jorge Valencia
- Harm Reduction Unit “SMASD,” Addictions and Mental Health Department, Madrid, Spain
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
| | - Jesús Troya
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health, Hospital Clínic, University of Barcelona, Barcelona,Spain
| | - Guillermo Cuevas
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
| | - Alejandro Alvaro-Meca
- Unit of Preventive Medicine and Public Health, Rey Juan Carlos University, Madrid, Spain
| | - Juan Torres
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
| | - Carlos Gardeta
- Harm Reduction Unit “SMASD,” Addictions and Mental Health Department, Madrid, Spain
| | - David Lozano
- Harm Reduction Unit “SMASD,” Addictions and Mental Health Department, Madrid, Spain
| | - Santiago Moreno
- Department of Infectious Diseases, Ramon y Cajal Hospital, IRYCIS, University of Alcalá de Henares, Madrid, Spain
| | - Pablo Ryan
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid,Spain
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16
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Khan SI, Irfan SD, Khan MNM, Shafiq TKI. The wound that closes doors: Lived experiences and complexities of injection-related injuries and infections among people who inject drugs through an ethnographic lens. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103276. [PMID: 34001413 DOI: 10.1016/j.drugpo.2021.103276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Besides HIV, people who inject drugs (PWID) experience other biomedical adversities, including injection-related injuries and infections. Yet, they are often inadequately addressed due to the prioritisation of HIV-related issues. This article explored the risk environment and socio-structural adversities of PWID living with injection-related injuries and infections, as well as existing management and treatment challenges of these conditions in harm reduction interventions. METHODS We undertook an ethnographic study from April 2018 to December 2019 in selected areas of Dhaka, Bangladesh. This component of the study involved 2500 hours of observations and informal conversations, 35 in-depth interviews and five focus group discussions with PWID experiencing injection-related injuries and infections. We also performed seven key-informant interviews with service providers and clinical experts. We applied thematic analysis and used various theoretical social scientific conceptualisations to analyse the relationship between the biomedical realities and socio-structural vulnerabilities of PWID. RESULTS Our findings indicated that PWID's physical, legal and socio-economic environments predisposed PWID to risky practices which ultimately precipitated injection-related injuries and infections. These injection-related injuries and infections consequently displaced them in spheres of social exclusion, stigmatisation, physical pain and disability and, hence, fueled their feelings of distress and despondence. Our findings also presented limitations in the management strategy of these injection-related injuries and infections. Specifically, service providers misconstrued all these complexities as "abscesses", thus applying a simplistic "one-size-fits-all" approach without accounting for the diversity of these complexities. This led to a paucity of tailored care and management approaches which could precipitate unfavourable treatment outcomes, such as chronic and complicated cases with antibiotic resistance. CONCLUSION Injection-related injuries and infections nestled PWID within various prongs of biomedical and socio-structural adversity, without viable and targeted treatment modalities. Thus, it is integral to nurture a multifaceted harm reduction intervention tailored to their biomedical and socio-structural needs.
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Affiliation(s)
- Sharful Islam Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, Bangladesh.
| | - Samira Dishti Irfan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, Bangladesh
| | - Mohammad Niaz Morshed Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, Bangladesh
| | - Tanveer Khan Ibne Shafiq
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, Bangladesh
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A randomized controlled trial of a brief behavioral intervention to reduce skin and soft tissue infections among people who inject drugs. Drug Alcohol Depend 2021; 221:108646. [PMID: 33677353 PMCID: PMC8055301 DOI: 10.1016/j.drugalcdep.2021.108646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND People who inject drugs (PWID) are at high risk for skin and soft tissue infections (SSTIs), but few interventions have targeted their reduction. The goal of the current study was to test the effects of a brief skin and needle hygiene behavioral intervention (SKIN) in a two-group randomized controlled trial with 12-month follow-up. METHOD PWID (N = 252) were recruited from inpatient hospital units at a single urban medical center site and randomly assigned to an assessment-only (AO) condition or SKIN, which was a two-session intervention that included psychoeducation, behavioral skills demonstrations, and motivational interviewing. Mixed effects generalized linear models assessed the impact of the intervention on frequency of: 1) self-reported SSTIs, 2) uncleaned skin injections, and 3) injection. RESULTS Participants were 58.3 % male, 59.5 % White, and averaged 38 years of age. SKIN participants had 35 % fewer SSTIs compared to AO (p = .179), a difference of nearly one infection per year. The mean rate of uncleaned skin injections was about 66 % lower (IRR = 0.34, 95 % CI 0.20; 0.59, p < .001) among SKIN participants compared to AO. Almost one-third of participants reported no injection over follow-up and the mean rate of injection during follow-up was about 39 % lower (IRR = 0.61; 95 % CI 0.36; 1.02, p = .058) among persons randomized to SKIN than AO. CONCLUSIONS The SKIN intervention reduced uncleaned skin injections but did not reduce SSTIs significantly more than a control condition. Brief interventions can improve high-risk practices among PWID and lead to clinically meaningful outcomes.
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Pollini RA, Ozga JE, Blanchard D, Syvertsen JL. Consider the Source: Associations between Syringe Sources and Risky Injection Behaviors in California's Central Valley. Subst Use Misuse 2021; 56:2007-2016. [PMID: 34379030 DOI: 10.1080/10826084.2021.1963987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Sterile syringe access is critical to prevent serious viral and bacterial infections among people who inject drugs (PWID) but many areas across the United States lack sufficient access. Although California law allows nonprescription pharmacy syringe sales and syringe services programs (SSPs), access gaps remain in the largely rural Central Valley. OBJECTIVE The purpose of this study was to examine syringe access and related injection behaviors among PWID in Fresno, California. METHODS We used respondent driven sampling to recruit 494 individuals for a survey about syringe access and injection behaviors between April and September 2016. Participants were ≥18 years old and injected at least twice in the past 30 days. Descriptive statistics examined syringe access and logistic regression determined if discrete syringe source categories were significantly associated with syringe sharing and/or reuse. RESULTS A majority (67%) obtained syringes from an authorized source; SSPs were most common (59%), while few reported pharmacy purchase (14%). Unauthorized sources were even more common (79%), primarily friends (64%) or someone on the street (37%). Compared to PWID who used only authorized sources, those using only unauthorized sources had a higher odds of syringe sharing (AOR = 3.40, 95% CI: 1.66, 6.95) and syringe reuse (AOR = 6.22; 95% CI: 2.24, 17.29), as did those who reported mixed sources (AOR = 3.78; 95% CI: 1.90, 7.54 and AOR = 4.64; 95% CI: 2.08, 10.35). CONCLUSIONS Our findings demonstrate a need to expand syringe access in nonurban California to prevent the syringe sharing and reuse that contributes to serious viral and bacterial infections among PWID.
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Affiliation(s)
- Robin A Pollini
- Pacific Institute for Research and Evaluation, Calverton, Maryland, USA.,Department of Behavioral Medicine & Psychiatry, West Virginia University, Morgantown, West Virginia, USA.,Department of Epidemiology, West Virginia University, Morgantown, West Virginia, USA
| | - Jenny E Ozga
- Department of Behavioral Medicine & Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | | | - Jennifer L Syvertsen
- Department of Anthropology, University of California, Riverside, Riverside, California, USA
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Picchio CA, Valencia J, Doran J, Swan T, Pastor M, Martró E, Colom J, Lazarus JV. The impact of the COVID-19 pandemic on harm reduction services in Spain. Harm Reduct J 2020; 17:87. [PMID: 33143699 PMCID: PMC7609370 DOI: 10.1186/s12954-020-00432-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/15/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Containment policies and other restrictions introduced by the Spanish government in response to the COVID-19 pandemic present challenges for marginalised populations, such as people who use drugs. Harm reduction centres are often linked to social services, mental health services, and infectious disease testing, in addition to tools and services that help to reduce the harms associated with injecting drugs. This study aimed to explore the impact of the pandemic on these services in four autonomous communities in Spain. METHODS This is a cross-sectional study that employed a seven-section structured survey administered electronically to 20 centres in July 2020. Data from the most heavily affected months (March-June) in 2020 were compared to data from the same period in 2019. Averages were calculated with their ranges, rates, and absolute numbers. RESULTS All 11 responding centres reported having had to adapt or modify their services during the Spanish state of alarm (14 March-21 June 2020). One centre reported complete closure for 2 months and four reported increases in their operating hours. The average number of service users across all centres decreased by 22% in comparison to the same period in the previous year and the average needle distribution decreased by 40% in comparison to 2019. Most centres reported a decrease in infectious disease testing rates (hepatitis B and C viruses, human immunodeficiency virus, and tuberculosis) for March, April, and May in 2020 compared to the previous year. Reported deaths as a result of overdose did not increase during the state of alarm, but 2/11 (18%) centres reported an increase in overdose deaths immediately after finalisation of the state of alarm. CONCLUSION Overall, Spanish harm reduction centres were able to continue operating and offering services by adjusting operating hours. The number of overall service users and needles distributed fell during the Spanish state of alarm lockdown period, suggesting that fewer clients accessed harm reduction services during this time, putting them at greater risk of reusing or sharing injecting equipment, overdosing, acquiring infectious diseases with decreased access to testing or discontinuing ongoing treatment such as methadone maintenance therapy, hepatitis C treatment, or antiretroviral therapy.
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Affiliation(s)
- Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Jason Doran
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Marta Pastor
- Comisión Ciudadana Antisida de Bizkaia, Bilbao, Spain
| | - Elisa Martró
- Microbiology Department, Laboratori Clínic Metropolitana Nord, Hospital Universitari Germans Trias I Pujol, Institut D'Investigació en Ciències de La Salut Germans Trias I Pujol (IGTP), Badalona, Spain
- Centro de Investigación Biomédica en Red en Epidemiología Y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Colom
- Programme for Substance Abuse and for Prevention, Control and Treatment of HIV, STIs and Viral Hepatitis, Agency of Public Health of Catalonia, Barcelona, Spain
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain.
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Wright T, Hope V, Ciccarone D, Lewer D, Scott J, Harris M. Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK. PLoS One 2020; 15:e0235350. [PMID: 32663203 PMCID: PMC7360031 DOI: 10.1371/journal.pone.0235350] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis. METHODS We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity. RESULTS We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all. CONCLUSIONS Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.
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Affiliation(s)
- Talen Wright
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vivian Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | - Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Dan Lewer
- Institute of Epidemiology and Healthcare, University College London, London, United Kingdom
| | - Jenny Scott
- Department of Pharmacy and Pharmacology, University of Bath, Claverton Down, Bath, United Kingdom
| | - Magdalena Harris
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Harris M. Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care. Soc Sci Med 2020; 260:113183. [PMID: 32682207 PMCID: PMC7441308 DOI: 10.1016/j.socscimed.2020.113183] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/18/2023]
Abstract
In the United Kingdom, increases in premature mortality among the intersecting populations of people made homeless and people who inject drugs map onto the implementation and solidification of fiscal austerity policies over the past decade, rather than drug market fluctuations and trends as in North America. In this context, it is crucial to explore how poverty, multi-morbidity and care delay interplay in exacerbating vulnerability to mortality among an aging population of people who use illicit drugs. The mixed methods Care & Prevent study generated survey data with 455 PWID and in-depth qualitative interviews with a subsample (n = 36). Participants were recruited though drug treatment services and homeless hostels in London from October 2017-June 2019. This paper focuses on qualitative findings, analysed thematically and contextualised in relation to the broader survey sample. Survey participants report an extensive history of rough sleeping (78%); injecting-related bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts emphasise engagement with the medical system as a 'last resort', with admission to hospital in a critical or a "near death" condition common. For many severe physical pain and debility were normalised, incorporated into the day to day. In a context of everyday violence and marginalisation, avoidance of medical care can have a protective impetus. Translation of cultural safety principles to care for people who inject drugs in hospital settings offers transformative potential to reduce serious health harms among this population.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, United Kingdom.
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