Public injection settings in Vancouver: Physical environment, social context and risk

"The machine doesn't judge": Counternarratives on surveillance among people accessing a safer opioid supply via biometric machines

People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs.

Addressing overdose risks and fatalities in public bathrooms: insights from the development of a Safer Bathroom Toolkit in British Columbia, Canada

SETTING

In British Columbia (BC), over 11,000 people have died of an overdose since 2016. Recently, an all-party standing committee on health tabled a report identifying several gaps in BC's overdose response. Chief among these is the inequitable distribution of supervised consumption and overdose prevention services across BC and barriers to accessing services that are currently available. In this context, public bathrooms continue to act as consumption spaces and contribute to overdose-related risks and fatalities.

INTERVENTION

The Safer Bathroom project sought to address long-standing policy and practice gaps by developing a toolkit to improve bathroom overdose prevention and response. Activities included a literature review and cross-sectoral, province-wide consultation (Fall 2021), the creation and launch of the Safer Bathroom Toolkit (Fall 2022), and knowledge transfer activities (ongoing).

OUTCOMES

The toolkit meets four objectives. First, it provides a bathroom safety checklist that helps identify and, most importantly, mitigate safety risks. Second, it offers organizational guidance on developing a bathroom safety policy and procedure. Third, it includes practical resources such as staff training material and signs that communicate bathroom safety messages in a non-stigmatizing manner. Finally, it identifies bathroom architecture and design features that can increase or decrease overdose-related risks.

IMPLICATIONS

The Safer Bathroom Toolkit is a highly comprehensive resource developed in response to the overdose crisis. However, significant reporting, research, policy, and practice gaps remain. This paper concludes with an overview of recommendations for advancing overdose prevention and response efforts within and beyond the bathroom context.

Socioeconomic marginalization and risk of overdose in a community-recruited cohort of people who use drugs: A longitudinal analysis

BACKGROUND

Poverty and socioeconomic disadvantage are important contributors to drug-related harm, but their precise role in overdose risk remains poorly understood. We sought to examine linkages between socioeconomic marginalization and non-fatal overdose risk in a community deeply affected by the ongoing drug poisoning crisis.

METHODS

This observational study used data derived from two community-recruited prospective cohorts of people who use drugs (PWUD) in Vancouver, British Columbia, Canada. Generalized linear mixed-effects models were used to assess longitudinal associations between multiple dimensions of socioeconomic disadvantage and self-reported non-fatal overdose.

RESULTS

Between 2014 and 2020, 1,493 participants (38.2% women; 59.6% white; 35.7% Indigenous) provided 9,968 interviews. Non-fatal overdose was reported by 32.5% of participants over the study period. In multivariable analyses, non-fatal overdose was independently associated with incarceration (adjusted odds ratios [AOR]: 1.42, 95% confidence interval [CI]: 1.08-1.88, p=0.012), homelessness (AOR: 1.57, 95%CI: 1.27-1.93, p<0.001), increased monthly income (AOR: 1.01, 95%CI: 1.00-1.01, p=0.029), and lower material security (AOR: 0.76, 95%CI: 0.67-0.88, p<0.001). We also observed differing strengths of association between illegal income generation and overdose in men (AOR: 1.84, 95%CI: 1.46-2.32, p<0.001) compared to women (AOR: 1.37, 95%CI: 1.06-1.78, p=0.016).

CONCLUSION

Non-fatal overdose was positively associated with incarceration, homelessness, higher monthly income, material insecurity, and engagement illegal income generating activities, underscoring the importance of addressing the socioeconomic production of overdose risk. These initiatives may include supportive housing interventions, alternative economic supports, and broader drug policy reform.

A Novel Index Measure of Housing-related Risk as a Predictor of Overdose among Young People Who Inject Drugs and Injection Networks

Background

For people who inject drugs (PWID), housing instability due to decreasing housing affordability and other factors (e.g., loss of housing due to severed relational ties, evictions due to drug use) results in added pressure on an already vulnerable population. Research has shown that housing instability is associated with overdose risk among PWID. However, the construct of housing instability has often been operationalized as a single dimension (e.g., housing type, homelessness, transience). We propose a multi-dimensional measure of housing instability risk and examine its association with drug overdose to promote a more holistic examination of housing status as a predictor of overdose.

Methods

The baseline data from a network-based, longitudinal study of young PWID and their networks living in metropolitan Chicago, Illinois was analyzed to examine the relationship between a housing instability risk index-consisting of five dichotomous variables assessing housing instability-and lifetime overdose count using negative binomial regression.

Results

We found a significant positive association between the housing instability risk score and lifetime overdose count after adjusting for 12 variables.

Conclusions

Our results support the practical utility of a multi-dimensional measure of housing instability risk in predicting overdose and highlight the importance of taking a holistic approach to addressing housing instability when designing interventions.

Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis

PURPOSE

This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs.

METHODS

We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach.

RESULTS

The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1).

CONCLUSION

SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.

The Importance of Perceived Safety, Stigma and Pleasure for Solitary Injecting

Many people who inject drugs (PWID) inject when they are alone which increases the risk for drug-related mortality, and the majority of overdose-related deaths occur among solitary users in residential environments. Drawing on qualitative data from interviews with 80 PWID in Norway, this study explores the complex practices of solitary injecting. The analysis illustrates that the risk environments in which they participated involved high levels of distress, fear and stigma that made them prefer solitary injecting. This involved a perceived notion of safety from an unpredictable social environment. Stigma was described as causing additional harms and they therefore wanted to hide their drug-using practices. Finally, injecting drug use involved contextual pleasures that were maximised by injecting alone. The study illustrates how the risk environment the PWID inhabited caused additional harms, by which solitary injections was rationalized, despite its increased mortality risks. Future harm-reduction initiatives should reflect this important aspect.

Sex Work Venue Disorder and HIV/STI Risk Among Female Sex Workers in Two México-US Border Cities: A Latent Class Analysis

Research increasingly recognizes the importance of social and built environments in shaping health, including risks for and outcomes related to HIV and sexually transmitted infections (STI), but research on sex work venues is limited. We use latent class analysis to identify patterns of sex work venue characteristics and factors associated with class membership in two México-US border cities. Among 603 female sex workers (FSW), three classes of sex work venues were identified: low, medium, and high disorder venues, characterized by level of violence, policing and drug activity. In multivariable analysis, risk exposures and outcomes varied by class, suggesting the need for place-based interventions that are tailored to specific venue profiles and that promote FSW health and safety in the workplace.

The "goldfish bowl": a qualitative study of the effects of heightened surveillance on people who use drugs in a rural and coastal Canadian setting

BACKGROUND

A growing body of research has focused on contextual factors that shape health and well-being of people who use drugs (PWUD). However, most of this research focuses on large cities and less is known about the effects of social and structural contexts on drug use and associated risks in rural Canadian settings. Therefore, we undertook this study to examine rural-specific contextual factors that affect the day-to-day experiences of PWUD.

METHODS

Twenty-seven qualitative semi-structured interviews were conducted with PWUD in a rural and coastal setting in British Columbia, Canada. Participants had to be ≥ 19 years old, used illegal opioids and/or stimulants regularly, and lived in the qathet region. Interview transcripts were coded based on themes identified by the research team.

RESULTS

Participants described progressive shifts in politics and culture in the qathet region while also identifying resource scarcity, homelessness, and changes in the drug supply, where illicit drug contents have become highly toxic and unpredictable. Participants discussed the qualities of a small community where everyone knows each other and there is a lack of privacy and confidentiality around drug use, which resulted in experiences of stigma, discrimination, and surveillance. Participants also reported rural-specific policing issues and experiences of surveillance on ferries when traveling to larger cities to purchase drugs. This led to significantly higher drug prices for PWUD due to the time dedication and criminalized risks associated with drug possession and trafficking.

CONCLUSIONS

Our findings illustrate the unique experiences faced by PWUD in a rural and coastal setting. The "goldfish bowl" effect in this rural community created heightened social and structural surveillance of PWUD, which led to a variety of negative consequences. There is a clear need for interventions to address the larger contextual drivers affecting people who use drugs in rural settings, including decriminalization and peer-led anti-stigma strategies, in order to improve the lives of PWUD.

A qualitative exploration of daily path and daily routine among people in Ukraine who inject drugs to understand associated harms

Background

Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals’ movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources.

Methods

This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine.

Results

We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources.

Conclusions

Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.

Public injecting and its association with mental health and other drug-related outcomes among people who inject drugs in Iran

BACKGROUND

Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID). We examined the prevalence of public injecting and associations with non-fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.

METHODS

Using respondent-driven sampling, we recruited 2684 PWID from 11 major cities between July 2019 and March 2020. We defined public injecting as injecting primarily in public places, such as streets, parks, or abandoned buildings. Multivariable logistic regression models assessed public injecting and its associated factors, as well as the association of public injecting with certain health outcomes.

RESULTS

Of 2388 respondents, 69.6 % reported public injecting in the previous year. Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting. Compared to PWID who primarily inject in non-public places, PWID who mostly used public places had significantly greater odds of reporting non-fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.

CONCLUSION

These results suggest the potential utility of a safer injecting environment to mitigate the multiple harms associated with public injecting in Iran. Optimizing health and well-being of PWID necessitates integrating supervised injection facilities into the current harm reduction programs and services in Iran. Future studies should also consider the experiences of additional mental health harms associated with public injecting when exploring adverse health outcomes among PWID.

Acute injection-related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management

INTRODUCTION

People who inject drugs are at risk of hospitalisation with injection-related infections (IRI). We audited the clinical features, microbiology and management of IRI at a tertiary service in Melbourne to describe the burden and identify quality improvement opportunities.

METHODS

We performed retrospective review of IRI admissions from January 2017 to April 2019. We extracted admissions where ICD-10 codes or triage text suggested injecting drug use, and the diagnosis suggested IRI. We reviewed these for eligibility and extracted data using a standardised form. We performed mixed-effects logistic regression to determine predictors of unplanned discharge.

RESULTS

From 574 extracted candidate admissions, 226 were eligible, representing 178 patients. Median age was 41 years (interquartile range 36-47), 66% (117/178) male and 49% (111/226) had unstable housing. Over 50% (96/178) had a psychiatric diagnosis and 35% (62/178) were on opioid agonist therapy (OAT) on admission. Skin and soft tissue infection was the most common IRI (119/205, 58%), followed by bacteraemia (36/205, 18%) and endocarditis (26/205, 13%). Management included addictions review (143/226, 63%), blood-borne virus screening (115/226, 51%), surgery (77/226, 34%) and OAT commencement (68/226, 30%). Aggression events (54/226, 15%) and unplanned discharge (69/226, 30%) complicated some admissions. Opioid use without OAT was associated with almost 3-fold increased odds of unplanned discharge compared to no opioid use (odds ratio 2.90, 95% confidence interval 1.23, 6.85, p = 0.015).

DISCUSSION AND CONCLUSION

Comorbidities associated with IRI may be amenable to opportunistic intervention during hospitalisation. Further research is needed to develop optimal models of care for this vulnerable patient group.

Prevalence and associates of non-fatal overdose among people who inject drugs in Saveh, Iran

Background

As a public health issue, non-fatal overdose (NFOD) is highly prevalent among people who inject drugs (PWID). This can lead to an elevated risk of future overdose, causing various harms including possible death. It is essential to improve knowledge concerning this problem and its associated risk factors to inform overdose prevention and assistance programs. The primary aim of the present study was to determine the prevalence of NFOD and associated risk factors among PWID in Saveh, Iran.

Methods

In the present cross-sectional study, 272 PWID living in Saveh, Iran were interviewed face-to-face using a structured survey. Data concerning socio-demographics, substance use, risky behaviors, and services utilization data were collected. The outcome variable (i.e., NFOD) was assessed by answering “Yes” to the question: “In the past three months, have you ever overdosed (at least once) by accident?”

Results

The prevalence of NFOD among PWID in the past three months was 54%. The characteristics and behaviors that were associated with an increased risk of experiencing NFOD in the past three months were being of older age (AOR = 5.2, p < 0.05), drug use initiation under the age of 22 years (AOR = 7.8, p < 0.05), being an alcohol user (AOR = 3.0, p < 0.05), and being a simultaneous multiple drug user (AOR = 5.8, p < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing a non-fatal overdose in the past three months. Findings also indicated that those who (i) attended a needle and syringe program (AOR: 0.3, p < 0.05), (ii) were visited by a general practitioner (AOR: 0.03, p < 0.05), and (iii) received a psychosocial intervention (AOR: 0.1, p < 0.05) were 0.3, 0.03 and 0.1 times less likely to report non-fatal overdosing than other participants, respectively.

Conclusions

The results indicate that intervention and prevention initiatives seeking to reduce NFOD among PWID should not only be focused on the primary drug used but also the use of alcohol and polysubstance use. Specific and tailored psychological interventions combined with pharmacotherapy may be highly beneficial for PWID who experience more severe types of substance use, including alcohol use disorders and/or polysubstance abuse.

Changes in the development of opioid tolerance on re-exposure among people who use heroin: A qualitative study

BACKGROUND AND AIMS

This qualitative study aimed to explore how the development of tolerance to both the psychoactive and respiratory depressant effects of heroin on re-exposure are experienced by people who use heroin.

METHODS

Semi-structured one-to-one interviews were conducted with 20 adults who currently or previously used heroin (for at least 6 months), with any type of administration (injected, smoked) and experience of abstinence (at least 2 weeks) and relapse. Topic guides explored the participants understanding of tolerance, their experience of developing tolerance to heroin and of tolerance following relapse. Interviews were audio-recorded and transcribed. Thematic analysis was used to generate salient themes.

RESULTS

The analysis produced three broad themes: lay understanding of tolerance; tolerating tolerance; and rapid tolerance development following relapse. Tolerance was defined as the body adapting to regular drug use, so that the drug no longer produced the same level of effect. Tolerance was experienced as interacting and co-developing with physical dependence and the symptoms of withdrawal. Indeed, several participants did not differentiate between tolerance and dependence. Most participants did not notice tolerance to respiratory depression. Tolerance levels fluctuated-increasing over periods of regular use and reducing when abstinent. Using more drug was the most common response to increasing tolerance to the desired effects. On re-use following abstinence, tolerance was experienced as developing more quickly in the most recent relapse compared to the first. Tolerance was also perceived to return more quickly with each abstinence-relapse cycle.

CONCLUSIONS

Qualitative accounts of tolerance report that tolerance returns more quickly with each relapse episode. By elucidating the mechanism(s) involved and potentially discovering how they could be switched on prior to relapse occurring we might be able to develop a beneficial harm reduction treatment for people in abstinence that would protect against overdose occurring on subsequent relapse.

Impact of drug consumption rooms on non-fatal overdoses, abscesses and emergency department visits in people who inject drugs in France: results from the COSINUS cohort

BACKGROUND

The effectiveness of drug consumption rooms (DCRs) for people who inject drugs (PWID) has been demonstrated for HIV and hepatitis C virus risk practices, and access to care for substance use disorders. However, data on other health-related complications are scarce. Using data from the French COSINUS cohort, we investigated the impact of DCR exposure on non-fatal overdoses, abscesses and emergency department (ED) visits, all in the previous 6 months.

METHODS

COSINUS is a 12-month prospective cohort study of 665 PWID in France studying DCR effectiveness on health. We collected data from face-to-face interviews at enrolment, and at 6 and 12 months of follow-up. After adjusting for other correlates (P-value < 0.05), the impact of DCR exposure on each outcome was assessed using a two-step Heckman mixed-effects probit model, allowing us to adjust for potential non-randomization bias due to differences between DCR-exposed and DCR-unexposed participants, while taking into account the correlation between repeated measures.

RESULTS

At enrolment, 21%, 6% and 38% of the 665 participants reported overdoses, abscesses and ED visits, respectively. Multivariable models found that DCR-exposed participants were less likely to report overdoses [adjusted coefficient (95% CI): -0.47 (-0.88; -0.07), P = 0.023], abscesses [-0.74 (-1.11; -0.37), P < 0.001] and ED visits [-0.74 (-1.27; -0.20), P = 0.007].

CONCLUSION

This is the first study to show the positive impact of DCR exposure on abscesses and ED visits, and confirms DCR effectiveness in reducing overdoses, when adjusting for potential non-randomization bias. Our findings strengthen the argument to expand DCR implementation to improve PWID injection environment and health.

Health impacts of a scale-up of supervised injection services in a Canadian setting: an interrupted time series analysis

BACKGROUND AND AIMS

In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed 'overdose prevention sites' (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID).

DESIGN

Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends.

SETTING

Vancouver, Canada.

PARTICIPANTS

Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline.

MEASUREMENTS

Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment.

FINDINGS

Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation.

CONCLUSIONS

Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.

Drug Consumption Rooms: Welfare State and Diversity in Social Acceptance in Denmark and in France

Drug consumption rooms (DCRs) have the potential to have a positive impact on the opioid overdose crisis. DCRs could also potentially change the political environment for public health because they can affect the distribution of responsibility for harm reduction between the individual and society by collectivizing responsibility for harm reduction through welfare regimes. The methodology is based on 2 case studies-1 in Copenhagen, Denmark, and 1 in Paris, France-about residents, people who inject drugs (PWID), and politicians' experiences of DCRs involving semidirective interviews. Denmark has a long history of harm-reduction policy, and the implementation of DCRs in Copenhagen has happened through close collaboration between local authorities and the local community. France is far more centralized and paternalistic in terms of the distribution of authority and decision-making in welfare and drug policy. Difficulties in cohabitation between local residents and PWID happened in both countries and can sometimes make public authorities hesitate to implement DCRs because of the NIMBY ("not in my backyard") phenomenon. However, the Danish and French case studies show that DCRs have the potential to become an instrument for civic cohabitation as well as to contribute to the destigmatization and health of PWID. (Am J Public Health. 2022;112(S2):S159-S165. https://doi.org/10.2105/AJPH.2022.306808).

Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city

BACKGROUND

The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access.

METHODS

Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy.

RESULTS

Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission.

CONCLUSION

Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.

Effect of an Unsanctioned Safe Consumption Site in the United States on Syringe Sharing, Rushed Injections, and Isolated Injection Drug Use: A Longitudinal Cohort Analysis

BACKGROUND

HIV and other medical complications of drug use, including overdose, are rising among people who inject drugs in the United States (US). Risk of complications and mortality increase with injection behaviors such as syringe sharing, rushing injections, and injecting in isolated places. Studies suggest safe consumption sites (SCS) reduce high-risk injection behaviors by offering sterile syringes and a safe, supervised space to consume drugs, although this has yet to be evaluated in the US.

SETTING

An unsanctioned SCS in an undisclosed US location.

METHODS

From 2018 to 2019, we recruited people who inject drugs using targeted sampling methods (N = 494) and conducted interviews at baseline, 6-, and 12-months. We sought to determine associations of past-month SCS use with past-month receptive syringe sharing, rushed injections, and injections in isolated places. We analyzed data using inverse probability of treatment weighted Poisson regression models. Generalized estimating equations accounted for repeated measures.

RESULTS

Fifty-two (11%) participants had past-month SCS use. Participants with past-month SCS use had decreased rates of receptive syringe sharing (Incident rate ratio [IRR] 0.17, 95% CI: 0.03 to 1.02) and injecting in an isolated location (IRR 0.77, 95% CI: 0.54 to 1.27) compared with those without past-month SCS use, although results were not statistically conclusive. Rate of rushed injections was only slightly lower (IRR 0.94, 95% CI: 0.70 to 1.30).

CONCLUSION

SCS may show benefit in reducing high-risk injection practices, and legal sanctioning of an SCS may offer further advantages. SCS implementation should be considered to help reduce the spread of HIV, overdose mortality, and prevent other medical complications of injection drug use.

Safety and danger: Perceptions of the implementation of harm reduction programs in two communities in Nova Scotia, Canada

People who use substances (PWUS), and specifically individuals who use injection drugs and/or smoke crack cocaine, experience risks which harm reduction programmes can help reduce. Prior to implementing harm reduction programmes, however, it is critical to understand how programme users and others in the community perceive the programmes as their perceptions may influence implementation. A mixed-methods study asked PWUS and key informants about their perceptions of implementing five harm reduction programmes in their communities, including perceptions of the advantages of the programmes, where best to locate them, and community support. Questionnaires were administered to 160 PWUS, and qualitative interviews were conducted with 11 purposefully sampled key informants. Data were collected in one medium-size and one small-size community/municipality in Nova Scotia, Canada, during 2017-2018. SPSS was used to generate descriptive statistics and means from the quantitative data, and the qualitative data were analysed for key themes using thematic analysis. Both PWUS and key informants perceived numerous advantages of the harm reduction programmes, but some key informants suggested that there might be potential opposition to the implementation of additional needle distribution and disposal programmes in some locations and potential opposition to safer consumption sites. Further research is needed to understand why these programmes were viewed as potentially generating opposition, but findings suggest that a key factor is the association of the programmes with 'danger' because the programmes are directly linked with criminalized drug use. In contrast, the three other programmes are linked to 'safety' because naloxone saves lives, peer navigation programmes support access to existing programmes and detoxification programmes are associated with safety through the reduction/elimination of drug use. Legalization/decriminalization of drugs might help to change the association of some programmes with 'danger' and therefore help support the implementation of harm reduction programmes that appear to be perceived by some as linked to danger.

Rationalities of Space and Drug-Related Harms: Accounts of People Who Inject Drugs in Nigeria

BACKGROUND

Studies have examined how people who inject drugs (PWID) navigate public spaces for drug consumption, but little is known about consumption of drugs in private apartments. This study explores social, structural and physical environment factors influencing injecting practices and the rationalities shaping how PWID make decisions about where to consume drugs.

METHODS

The study is based on qualitative data from 41 in-depth interviews conducted with both homeless and housed PWID recruited through snowball sampling in Uyo, Nigeria. Thematic analysis, framed by the theoretical constructs of structural and everyday violence, and situated rationality theories, was undertaken on transcripts.

RESULTS

Analysis revealed different socio-spatial rationalities underlying decisions about where to use drugs: avoidance of police arrest, convenience and relaxation, avoidance of drug sharing, avoidance of drug-scene violence, and stigma and shame. These factors show the impacts of social, structural and physical environment factors on the lived experiences of PWID. Injecting in private apartments potentially offset the risk of stigma, police arrest and violence linked to public injecting, but increase the risk of overdose and sharing of drugs and needle-syringes based on social relations of trust.

CONCLUSIONS

Findings show that PWID chose between competing risks when deciding on where to inject drugs. Interventions should consider the situated contexts of risk, and adapt harm reduction measures to the risk profile of different populations of PWID.

Indicators of Drug-Related Community Impacts of Open Drug Scenes: A Scoping Review

INTRODUCTION

Places where people deal and/or use drugs publicly are known as open drug scenes (ODSs). Drug-related community impacts (DRCIs) refer to drug-related issues that negatively influence public and individual health, communities, businesses, and recreational and public space enjoyment. There are no well-established criteria for identification of DRCIs. We therefore performed a scoping review of literature to determine DRCIs indicators associated with ODSs.

METHODS

The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScP). We searched English articles in PubMed, Scopus, Web of Science, and EMBASE databases from 1990 to 2021. The keywords were drug-related crime, drug-related offense, misconduct, social marginalization, homeless drug users, open drug scene, drug-related street disorder, public nuisance, and community impact.

RESULTS

Sixty-four studies were identified. Twenty-five studies were included. Two studies (8%) were about drug-related public nuisance, 1 (4%) considered drug-related social problems, 2 (8%) focused on drug-related social disorder, and 18 studies (72%) discussed indicators of community impacts such as crime, drug-related litter, safety, noise, and drug use in public. Two studies (8%) included the frequency of drug use in ODSs.

DISCUSSION

DRCI indicators are heterogenic, and various factors affect the indicators. The factors include social mores, political discourse, and historical approaches to dealing with and using drugs. Some societies do not tolerate the existence of ODSs. In contrast, many countries have adopted harm reduction programs to manage DRCIs. Identified DRCI indicators were drug using and dealing in public, drug-related litter, crime, drug-related loitering, street-based income generation activities, noise, and unsafety feelings in inhabitants. To solve the problems associated with DRCIs and to make a major change in ODSs, it is necessary to pay attention to the improvement of the economic conditions (e.g., employment opportunities), amendment (e.g., determine the limits of criminalization in drug use), and adoption of social policies (e.g., providing low-threshold and supportive services for homeless drug users).

Injection and Sexual Behavior Profiles among People Who Inject Drugs in Miami, Florida

BACKGROUND

The dynamics of injection drug use and higher-risk sexual practices compound the risk of HIV and HCV acquisition. Published literature on people who inject drugs (PWID) has examined risk of infection assuming homogeneity of cohort behavior. Categorizing subgroups by injection and sexual risk can inform a more equitable approach to how syringe services programs (SSPs) adapt harm reduction resources and implementation of evidence-based interventions. We explored injection and sexual risk profiles among PWID to determine significant predictors of class membership.

METHODS

Data were collected from 1,272 participants at an SSP in Miami-Dade County. Latent Class Analysis (LCA) examined how 10 injection/sexual behavior indicators cluster together to create profiles. Model fit statistics and multivariable multinomial latent class regression identified the optimal class structure and significant predictors of class membership. We assessed SSP visits, naloxone access, HIV/HCV testing and prevalence, and incidence of self-reported wounds.

RESULTS

Three distinct profiles of injection/sexual risk were determined: Low Injection/High Sexual (LIHS) (9.4%); High Injection/Moderate Sexual (HIMS) (18.9%); and Low Injection/Low Sexual (LILS) (71.7%). Participants reporting gay/bisexual orientation and methamphetamine injection more likely belonged to the LIHS class. LIHS class members had higher prevalence of HIV, while those of HIMS reported increased hepatitis C prevalence. Compared to members of LILS, those of HIMS more likely experienced unstable housing, gay/bisexual orientation, heroin or speedball injection, and identifying as women. HIMS cohort members had more SSP visits, naloxone accessed, and higher wound incidence than those of LILS.

CONCLUSIONS

Understanding PWID subgroups amplifies the importance of implementing evidencebased interventions such as PrEP for those engaging in highest risk behavior, with focused interventions of antiretroviral management and access to condoms for members of the LIHS class and HCV screening with wound care for those belonging to HIMS.

A Thematic Synthesis of the Roles of Nurses at Safer Consumption Sites

ABSTRACT

Opioid use, particularly via injection, is associated with an increased risk of infection, injury, and death. Safer consumption sites (SCSs), where people may consume previously obtained drugs under observation, have been shown to reduce these risks among people who use drugs. Most SCSs employ nurses, but there is limited research into their roles. The objective of this article is to describe and synthesize the roles of nurses at SCSs to better understand their importance in a rapidly proliferating public health intervention. We extracted data from 48 qualitative, quantitative, peer-reviewed, and gray literature, as well as primary source narrative articles on SCSs, whether they were explicitly about nursing or not. We coded each mention of nurses or nursing in each article and identified 11 descriptive themes or roles that SCS nurses carry out. From these, we identified the following three analytical themes or hypotheses about the character of these roles: (a) The primary aim of SCS nursing care is to reduce morbidity and mortality; (b) SCS nurses create a therapeutic community; and (c) SCS nurses engage in research, professional activities, and activism to better understand and promote SCSs. More research into the roles of SCS nurses is needed to better serve a vulnerable population.

Factors associated with injury and blood-borne infection risk when providing assisted injection among people who inject drugs

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.

Income generation and the patterning of substance use: A gender-based analysis

BACKGROUND

Previous research has demonstrated how income-generating activities among marginalized people who use drugs (PWUD)-including employment, income assistance, street-based activities, sex work, and illegal activities-can provide both benefit (e.g., additional income) and harm (e.g., violence, criminalization). However, little is known about gender differences in factors such as drug use patterns that are associated with income-generating activities among PWUD.

METHODS

Using data from prospective cohorts of HIV-positive and HIV-negative PWUD in Vancouver, Canada, we conducted exploratory gender-stratified analyses of associations between substance use patterns and income-generating activities, using generalized linear mixed-models.

RESULTS

Participants reported income sources as employment (23.4 %), income assistance (88.1 %), street-based activities (24.9 %), sex work (15.2 %), drug dealing (31.5 %), or other illegal activities (13.9 %). GLMM results showed gendered patterns of engagement in specific income-generating activities and some diverging patterns of substance use. For instance, men receiving income assistance were less likely to use opioids (Adjusted odds ratio(AOR) = 0.64; 95 % confidence interval(CI) = 0.50-0.82) and women engaged in sex work were more likely to use crack-cocaine (AOR = 2.74, 95 % CI = 2.22-3.37). However, results reflected primarily converging patterns of substance use between women and men across income-generating activities, particularly for drug dealing and other illegal activities.

CONCLUSIONS

Our results suggest that substance use patterns may be more closely associated with income generation context than gender. Given potential harms associated with some income generation activities, results highlight the need for further investigation of the social and structural context of income generation, its intersections with gender and substance use, and the expansion of low-threshold work opportunities.

Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida

INTRODUCTION

Syringe services programs (SSPs) are evidence-based HIV prevention programs for people who inject drugs. However, not all SSPs operate evidence-based syringe distribution models, such as needs-based distribution. This study aims to provide preliminary evidence from the IDEA SSP on changes in injection risk behaviors over time, and to examine factors, including syringe coverage, associated with injection risk behavior trajectories over time under a one-for-one syringe distribution model.

METHODS

We used a prospective observational study design to generate a cohort of SSP clients who completed three behavioral assessments at SSP service visits between December 2016 and January 2020 (N = 115). The study used generalized estimating equations (GEE) to examine the relationship between covariate measures and the primary outcomes. The primary outcomes were 1) sharing of any injection equipment (e.g. syringes, needles, cookers, cottons) in the previous 30 days (yes/no) and 2) reusing of needles/syringes in the previous 30 days (yes/no).

RESULTS

Men were more likely to report reusing syringes (aRR = 1.15, 95% CI: 1.01-1.37) and those who reported injecting in public were less likely to report reusing syringes (aRR = 0.90, 95% CI: 0.82-0.99). HCV-positive clients had a 62% reduction in sharing injection equipment and those who reported public injection had a 62% increase in sharing injection equipment over time. Most importantly, increasing syringe coverage was associated with a decrease in both sharing injection equipment (aRR = 0.42, 95% CI: 0.25-0.72) and reusing syringes (aRR = 0.79, 95% CI: 0.66-0.95).

CONCLUSION

This study provides preliminary evidence of reductions in injection-related risk behaviors from the IDEA SSP and highlights potential high priority groups, such as people experiencing homelessness, that may need additional intervention. In addition, improving syringe coverage among SSP clients may be an important factor in reducing behaviors that place individuals at risk for contracting HIV and HCV.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs

BACKGROUND

People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored.

METHODS

We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%.

RESULTS

In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point.

CONCLUSION

Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis

The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.

Policing pain: A qualitative study of non-criminal justice approaches to managing opioid overdose during the COVID-19 pandemic

Opioid related drug overdose deaths are a leading cause of death and injury in the United States. While research demonstrates that where people live has a major impact on drug use and abuse, most work looks at social dynamics at the county level or under the rubric of the urban/rural divide. Only recently, scholarship has become attuned to the post-industrialized areas located on the fringes of urban cores. Data presented in here are from field research conducted in McKeesport, Pennsylvania, a small river town located east of Pittsburgh. Once a thriving industrial city, it is now deteriorated and has documented high levels of overdose experience. Preliminary results suggest that McKeesport residents, even before the emergence of SARS-CoV-2 (COVID-19), practice social and physical distancing as a way of life; data indicate how the pandemic potentially exacerbates the risk of accidental opioid overdose among a population defined by both geographic and social isolation.

Soft Tissue, Bone, and Joint Infections in People Who Inject Drugs

Infections are a common complication among people who inject drugs (PWID). Skin and soft tissue infections (SSTI) as well as bone and joint infections comprise a significant source of morbidity and mortality among this population. The appropriate recognition and management of these infections are critical for providers, as is familiarity with harm-reduction strategies. This review provides an overview of the presentation and management of SSTI and bone and joint infections among PWID, as well as key prevention measures that providers can take.

Factors That Affect Symptoms of Injection Site Infection among Japanese Patients Who Self-Inject Insulin for Diabetes

In Japan, skin disinfection is typically considered necessary before an insulin injection to prevent infection at the injection site. This cross-sectional study evaluated factors that influenced symptoms of injection site infection among 238 Japanese patients who self-injected insulin for diabetes between October 2015 and January 2016. A structured questionnaire was used to collect data regarding skin disinfection practices, infection symptoms at the injection site, frequency of injections, environment at the time of injection, and hygiene habits. The majority of patients (83.2%) performed skin disinfection before the self-injection. Logistic regression analysis revealed that infection at the injection site was positively associated with skin disinfection before injection, age, and performing injections outside home. It was speculated that omitting skin disinfection before administering subcutaneous insulin injection was not the factor that affected the symptoms of injection site infection. The greatest contributor to infection symptoms was injections performed outside the home. Future studies focusing on the environment, in which patients administer insulin injections, to assess its influence on symptoms of injection site infections are warranted.

Drug-related harm coinciding with income assistance payments: results from a community-based cohort of people who use drugs

BACKGROUND AND AIMS

Income assistance is critical to the health and wellbeing of socio-economically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined socio-demographic, health and drug use-related correlates of payment-coincident drug-related harm.

DESIGN

This observational study uses data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018.

SETTING

Vancouver, British Columbia, Canada.

PARTICIPANTS

A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants and 685 (42.7%) people living with HIV.

MEASUREMENTS

The primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher-frequency substance use, non-fatal overdose and service barriers or interruptions. Subanalyses disaggregated this outcome.

FINDINGS

Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation [adjusted odds ratio (aOR) = 1.48, 95% confidence interval (CI) = 1.26-1.74, P < 0.001], sex work (aOR = 1.66, 95% CI = 1.35-2.04, P < 0.001), illegal income generation (aOR = 1.57, 95% CI = 1.35-1.83 P < 0.001), homelessness (aOR = 1.34, 95% CI = 1.13-1.58, P < 0.001), exposure to violence (aOR = 1.31, 95% CI = 1.03-1.66, P = 0.032), daily crack cocaine use (aOR = 1.99, 95% CI = 1.59-2.50, P <  0.001), heavy alcohol use (aOR = 1.64, 95% CI = 1.37-1.97, P < 0.001) and injection drug use (aOR = 2.55, 95% CI = 2.01-3.23, P < 0.001). In subanalyses, specific harms were more likely among individuals reporting social, structural and health vulnerabilities.

CONCLUSIONS

In Vancouver, Canada, people who use illicit drugs who receive income assistance report high prevalence of payment-coincident drug-related harm, particularly people experiencing socioeconomic and structural marginalization or engaging in high-intensity drug use.

Prevalence and correlates of receptive syringe-sharing among people who inject drugs in rural Appalachia

BACKGROUND AND AIMS

Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia.

DESIGN

Observational, cross-sectional sample from a capture-recapture parent study.

SETTING

Cabell County, West Virginia (WV), USA, June-July 2018.

PARTICIPANTS

The sample was restricted to people who reported injecting drugs in the past 6 months (n = 420). A total of 180 participants (43%) reported recent (past 6 months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%).

MEASUREMENTS

The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS.

FINDINGS

PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) = 2.27, 95% confidence interval (CI) = 1.26-4.09], unemployment (aOR = 1.67, 95% CI = 1.03-1.72), number of drug types injected (aOR = 1.33, 95% CI = 1.15-1.53) and injection in a public location (aOR = 2.59, 95% CI = 1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR = 0.57, 95% CI = 0.35-0.92).

CONCLUSION

The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.

“…I can use any syringe I find”: contextual determinants of HIV risk in public injecting settings in Nigeria

Purpose

The purpose of this study is to explore the contextual determinants of HIV risk among people who inject drugs (PWID) in public settings in Nigeria.

Design/methodology/approach

In-depth, individual interviews were conducted with 29 street-based PWID recruited through snowball sampling in Uyo, Nigeria. Interviews were tape-recorded, transcribed, coded and analysed hematically.

Findings

Homelessness and withdrawal pains encouraged consumption of drugs in public spaces (e.g. bunks, public parks). Conversely, the benefits of participation in street drug-use scenes, including reciprocity norms that guarantee free drugs during withdrawal and protection during overdose, fostered a preference for public injecting. Although participants recognized the need to inject with sterile syringes, scarcity of syringes compelled them to improvise with old syringes or share syringes, increasing risk for HIV transmission. HIV risk was exacerbated by unlawful and discriminatory policing practices, which deterred possession of syringes and encouraged risky behaviours such as rushing injection and sharing of equipment.

Practical implications

Contextual factors are key determinants of HIV risk for street-based PWID. Implementation of needle and syringe programmes as well as reforming legal frameworks and policing practices to support harm reduction are needed responses.

Originality/value

This is one of very few qualitative studies that explore risk factors for HIV transmission among PWID in West Africa. The focus on scarcity of sterile syringes and HIV risk is unique and has important policy implications.

Incidence and treatment costs of severe bacterial infections among people who inject heroin: A cohort study in South London, England

BACKGROUND

People who inject drugs often get bacterial infections. Few longitudinal studies have reported the incidence and treatment costs of these infections.

METHODS

For a cohort of 2335 people who inject heroin entering treatment for drug dependence between 2006 and 2017 in London, England, we reported the rates of hospitalisation or death with primary causes of cutaneous abscess, cellulitis, phlebitis, septicaemia, osteomyelitis, septic arthritis, endocarditis, or necrotising fasciitis. We compared these rates to the general population. We also used NHS reference costs to calculate the cost of admissions.

RESULTS

During a median of 8.0 years of follow-up, 24 % of patients (570/2335) had a severe bacterial infection, most commonly presenting with cutaneous abscesses or cellulitis. Bacterial infections accounted for 13 % of all hospital admissions. The rate was 73 per 1000 person-years (95 % CI 69-77); 50 times the general population, and the rate remained high throughout follow-up. The rate of severe bacterial infections for women was 1.50 (95 % CI 1.32-1.69) times the rate for men. The mean cost per admission was £4980, and we estimate that the annual cost of hospital treatment for people who inject heroin in London is £4.5 million.

CONCLUSIONS

People who inject heroin have extreme and long-term risk of severe bacterial infections.

Anticipated use of a supervised drug consumption site among syringe services program clients in King County, Washington: Assessing the role of opioid overdose and injection behavior

BACKGROUND

US jurisdictions are considering implementing supervised drug consumption sites (SCSs) to combat the overdose epidemic. No sanctioned SCS exists in the US, but King County, Washington has proposed Community Health Engagement Locations (CHELs), which would include supervised drug consumption. We assessed characteristics of people engaged in syringe services programs (SSPs) who anticipated SCS use.

METHODS

We estimated prevalence of anticipated SCS use in a 2017 cross-sectional sample of King County SSP participants (N = 377). We used Poisson regression with robust standard errors to estimate likelihood of anticipated SCS use by overdose history (experienced, witnessed only, neither), public injection frequency (always, some/most times, never), drug use behaviors, and sociodemographic characteristics.

RESULTS

The sample was primarily male (66.8 %), white (69.5 %), and averaged 37 years old. Almost two-thirds of participants witnessed or experienced an overdose in the past year (43.2 % witnessed only; 19.6 % experienced overdose). Four in five SSP participants (83.0 %) anticipated any SCS use. Anticipated SCS use was higher among participants who experienced an overdose (risk ratio [RR] = 1.14, 95 % CI = 1.04, 1.24) than those with no overdose experience. In multivariable analyses, anticipated SCS use was higher among people reporting injecting publicly (e.g., always vs. never: aRR = 1.26, 95 % CI = 1.11, 1.43), and lower among people primarily using methamphetamine (aRR = 0.80, 95 % CI = 0.67, 0.96) compared to people primarily using opioids.

CONCLUSIONS

In King County, SCS services would be used by people at high risk of overdose, including SSP participants reporting injecting in public. SCSs could be an important step to promote health and safety across communities.

Impact of migration from an illicit drug scene on hospital outcomes among people who use illicit drugs in Vancouver, Canada

INTRODUCTION AND AIMS

People who use illicit drugs (PWUD) are vulnerable to an array of negative health outcomes, and increased hospital services utilisation. PWUD are also a transient population which poses challenges to the provision of optimal health care. The objective of this study was to identify out-migration patterns from Vancouver's Downtown Eastside (DTES), a neighbourhood where services for PWUD are concentrated, and to estimate the impact of these patterns on hospitalisation events among PWUD.

DESIGN AND METHODS

Data were collected through three prospective cohorts of PWUD in Vancouver, which were linked with health administrative data. Latent class growth analysis was used to define migration trajectory groups. Poisson regression was used to estimate the effect of migration patterns on hospitalisation events.

RESULTS

A total of 1180 participants were included in the study. Four latent classes were identified: early migration out (243, 20.6%); frequent revisit (112, 9.5%); late migration out (219, 18.6%); and consistently living in the DTES (606, 51.4%). Compared with those who consistently lived in the DTES, participants in the early migration out group had lower hospitalisation events (adjusted rate ratio = 0.65; 95% confidence interval: 0.48-0.90).

DISCUSSION AND CONCLUSION

We found that PWUD who migrated out of the DTES early had lower hospitalisation events compared to those who consistently lived in the DTES, which may be a function of lesser addiction severity among this trajectory group. These findings underscore a need to provide transitional health and social service supports for other trajectory groups in an effort to minimise hospitalisation for preventable causes.

Supervised injection facility use and exposure to violence among a cohort of people who inject drugs: A gender-based analysis

BACKGROUND

Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting.

METHODS

Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively.

RESULTS

Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46-0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57-1.66).

CONCLUSION

In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.

Examining risk behavior and syringe coverage among people who inject drugs accessing a syringe services program: A latent class analysis

INTRODUCTION

Injection drug use (IDU) remains a significant public health problem. IDU has been associated closely with the opioid crisis; driving overdose, HIV, and Hepatitis C (HCV) infection nationwide. Syringe services programs (SSPs) remain pivotal evidence-based interventions to reduce harm and engage subgroups of people who inject drugs (PWID). This study aims to provide policy considerations from the IDEA SSP, the first legal SSP in the state of Florida.

METHODS

We performed a latent class analysis on patterns of substance use among participants (N = 982) newly enrolled in a syringe services program (SSP). Associations between classes of substance use and sociodemographic variables, risky injection and sex behaviors, HIV/HCV status and syringe coverage were analyzed using the R3STEP and BCH 3-step procedures in latent class regression.

RESULTS

We found a three-class solution: Heroin-Dominant class (73.9%), Methamphetamine-Dominant class (9.5%) and Heroin/Cocaine class (16.6%). Compared to Heroin-Dominant class, the Heroin/Cocaine class were more likely to report homelessness, sharing works, unprotected sex, public injection, and to be HCV positive. Compared to both Heroin-Dominant and Heroin/Cocaine classes, the Methamphetamine-Dominant class were more likely to be male, Hispanic, gay or bisexual orientation, HIV positive, to report unprotected sex and sex with PWID. In addition, the lowest and highest syringe coverage were among those in the Heroin/Cocaine and Methamphetamine-Dominant classes, respectively.

CONCLUSION

Existing interventions among this population to mitigate infectious disease risk, such as SSPs, can be a used to engage differing PWID populations. However, multi-component, targeted preventive interventions and need-based syringe distribution policies are required to further reduce HIV and HCV risk among various PWID populations.

Steps toward a theory of place effects on drug use: Risk, marginality, and opportunity in small and remote California towns

The risk environment concept provides a framework for documenting ecological influences on drug use, and a platform to engage with social theory to identify mechanisms behind place-based health disparities. Health scientists conceptualize these mechanisms in terms of social determinants of health, social scientists in terms of syndemics and structural violence. I supplement these perspectives with Pierre Bourdieu's concepts of social space, practice, and habitus to offer a broader analysis of how place shapes drug-related health risks, particularly outside of the large cities where most research is conducted. This approach encompasses inequality, conflict, and social change at multiple levels of social organization, from macrodistributions of power to trajectories of individual drug use. I offer three pointers for scholarship on drug use in nonurban places, which I illustrate with findings from an ethnographic study of opioid use and opioid-related services in California. First, replace the folk notion of "rural" with geographic categories grounded in relevant social structures and institutions, such as social networks or illicit drug markets. Second, examine how variation in the structure of social and physical space affects processes of marginalization and criminalization. Third, avoid negative definitions of nonurban places, and instead explore their distinctive institutions and opportunity structures. Following this approach, I define acquainted marginality and small-town habitus to explain how dense networks and geographic isolation shape local government and survival strategies among people who use drugs. I find that in small and remote towns, personal and professional relationships overlap in ways that augment surveillance and stigma, but can also facilitate leniency and progressive policy change. I conclude by using these findings to outline a theory of place effects on drug use and addiction to encourage future research in these directions.

Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

BACKGROUND

Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).

METHODS

Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017-18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).

RESULTS

Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48-8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61-5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69-3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93-5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13-3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01-2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27-2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17-1.73, p<0.001).

CONCLUSIONS

These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.

Accessibility of Needle and Syringe Programs and Injecting and Sharing Risk Behaviors in High Hepatitis C Virus Prevalence Settings

Background: Access to healthcare services is a basic human right. Objective: The main purpose of this study is to assess the association between accessibility of needle and syringe programs (NSP) and injecting and sharing risk behaviors. Methods: A cross-sectional study employed respondent-driving sampling (RDS) to recruit a sample of 634 people who inject drugs (PWID) from three provinces, Golestan, Ardabil, and Sistan and Baluchestan, in Iran between November 2018 and February 2019. Participants completed a questionnaire based on the WHO Drug Injecting Study Phase II survey. Results: Participants reported their accessibility of NSP services as low (6%), middle (19%), and high (75%) in the past 2 months at the time of the survey. PWID who had increased access to NSP services were less likely to report utilization of used cooker (aOR = 1.40; CI 95% 0.99-1.82), cotton (aOR = 1.30; CI 95% 0.79-1.81), and water (aOR = 1.07; CI 95% 0.89-1.26), receptive needle/syringe sharing (aOR= 1.86, 95% CI 1.69-2.03), and distributive needle/syringe sharing (aOR= 1.09, 95% CI 0.81-1.37). Conclusions/Importance: There is evidence of inequality in PWID's access to health care as they relate to the prevention of HCV transmission. An understanding of both the social determinants and prevention of injecting and sharing risk behaviors seeks to connect HCV risk reduction within the context of human rights and vulnerability.

Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting

The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.

People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky

BACKGROUND

Though overdose rates have been increasing in US rural areas for two decades, little is known about the rural risk environment for overdoses. This qualitative study explored the risk environment for overdoses among young adults in Eastern Kentucky, a rural epicenter of the US opioid epidemic.

METHODS

Participants were recruited via community-based outreach. Eligibility criteria included living in one of five rural Eastern Kentucky counties; being aged 18-35; and using opioids to get high in the past 30 days. Semi-structured interviews explored the rural risk environment, and strategies to prevent overdose and dying from an overdose. Interviews were transcribed verbatim and analyzed using constructivist grounded-theory methods.

RESULTS

In this sample (N = 19), participants reported using in a range of locations, including homes and outdoor settings; concerns about community stigma and law enforcement shaped the settings where participants used opioids and the strategies they deployed in these settings to prevent an overdose, and to survive an overdose. Almost half of participants reported using opioids in a "trap house" or other dealing locations, often to evade police after buying drugs, and reported that others present pressed them to use more than usual. If an overdose occurred in this setting, however, these same people might refuse to call EMS to protect themselves from arrest. Outdoor settings presented particular vulnerabilities to overdose and dying from an overdose. Most participants reported using opioids outdoors, where they skipped overdose prevention steps to reduce their risk of arrest; they worried that no one would find them if they overdosed, and that cell phone coverage would be too weak to summon EMS.

CONCLUSION

Findings suggest that initiatives to reduce overdoses in Eastern Kentucky would be strengthened by de-escalating the War on Drugs and engaging law enforcement in initiatives to protect the health of people who use opioids.

"That's a double-edged sword": Exploring the integration of supervised consumption services within community health centres in Toronto, Canada

Supervised consumption services (SCS) have been integrated into community health centres in Toronto. We draw on qualitative interviews and ethnographic observations to examine the implementation contexts of these SCS. Participants' perspectives on the integration of SCS within CHCs were mixed. Some participants identified the benefits of integrated SCS such as convenience and access to other health and social services. However, others identified negative consequences of integration, including building design, lack of privacy and anonymity, and limited hours of operation. These perspectives highlight the ways in which contextual factors affect the experiences of clients in accessing SCS, and suggest that various factors need to be considered in order to improve service uptake.

Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review

BACKGROUND

Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement.

METHODS

We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN.

RESULTS

Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97).

CONCLUSIONS

In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.

"We don't got that kind of time, man. We're trying to get high!": Exploring potential use of drug checking technologies among structurally vulnerable people who use drugs

BACKGROUND

Novel public health interventions are being considered to address the opioid overdose epidemic, including drug checking technologies. We examined the willingness to use various drug checking technologies among structurally-vulnerable people who use drugs (PWUD).

METHODS

We conducted one-to-one qualitative semi-structured interviews with 20 PWUD in Vancouver, Canada's Downtown Eastside. Participants were purposively recruited from ongoing cohort studies of PWUD.

RESULTS

Overall willingness to use drug checking technologies was low among participants. A range of factors undermined potential use of various drug checking technologies including: having to give up a drug sample; time dedication; discrepancies regarding measurements and accuracy; recourse following positive fentanyl results; ambivalence to overdose risk; and availability and accessibility of drug checking technologies.

CONCLUSIONS

Participants discussed numerous factors that undermined potential willingness to use drug checking technologies. These factors underscore the structural vulnerabilities experienced by PWUD and how they may constrain uptake of drug checking technologies. Future drug checking programming should consider these influencing factors prior to the implementation of drug checking technologies to ensure that drug checking interventions are appropriate and meeting the needs of target populations.