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Eger WH, Abramovitz D, Bazzi AR, Bórquez A, Vera CF, Harvey-Vera A, Friedman JR, Strathdee SA. Changes in injecting versus smoking heroin, fentanyl, and methamphetamine among people who inject drugs in San Diego, California, 2020-2023. Drug Alcohol Depend 2024; 259:111318. [PMID: 38692135 DOI: 10.1016/j.drugalcdep.2024.111318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/27/2024] [Accepted: 04/16/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Amidst an increasingly toxic drug supply in North America, people who inject drugs may be transitioning to smoking them. We aimed to assess changes in injecting and smoking opioids and methamphetamine among a cohort of people who inject drugs from San Diego, California. METHODS Over five six-month periods spanning October 2020-April 2023, we assessed prevalence of injecting and smoking opioids or methamphetamine and whether participants used these drugs more frequently by smoking than injecting. Multivariable Poisson regression via generalized estimating equations was used to examine time trends. RESULTS Of 362 participants, median age was 40 years; a minority were female (29%), Hispanic/Latinx/Mexican (45%), and housed (33%). Among this cohort, of whom 100% injected (and 84% injected and smoked) in period one (October 2020-April 2021), by period five (November 2022-April 2023), 34% only smoked, 59% injected and smoked, and 7% only injected. By period five, the adjusted relative risk (aRR) of injecting opioids was 0.41 (95% Confidence Interval [CI]: 0.33, 0.51) and the aRR for injecting methamphetamine was 0.50 (95% CI: 0.39, 0.63) compared to period one. Risks for smoking fentanyl rose significantly during period three (aRR=1.44, 95% CI: 1.06, 1.94), four (aRR=1.65, 95% CI: 1.24, 2.20) and five (aRR=1.90, 95% CI: 1.43, 2.53) compared to period one. Risks for smoking heroin and methamphetamine more frequently than injecting these drugs increased across all periods. CONCLUSIONS Opioid and methamphetamine injection declined precipitously, with notable increases in smoking these drugs. Research is needed to understand the health consequences of these trends.
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Affiliation(s)
- William H Eger
- School of Social Work, San Diego State University, San Diego, CA, USA; School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Daniela Abramovitz
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA; Boston University School of Public Health, Boston, MA, USA
| | - Annick Bórquez
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Carlos F Vera
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Alicia Harvey-Vera
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Joseph R Friedman
- Center for Social Medicine and Humanities, University of California, Los Angeles, Los Angeles, USA
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Eger WH, Abramovitz D, Bazzi AR, Bórquez A, Vera CF, Harvey-Vera A, Friedman JR, Strathdee SA. Changes in injecting versus smoking heroin, fentanyl, and methamphetamine among people who inject drugs in San Diego, California, 2020 to 2023. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.23.24303293. [PMID: 38464097 PMCID: PMC10925373 DOI: 10.1101/2024.02.23.24303293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Amidst a rapidly evolving drug supply in North America, people who inject drugs may be transitioning to smoking them. We aimed to assess changes in injecting and smoking heroin, fentanyl and methamphetamine among a cohort of people who injected drugs at baseline from San Diego, California. Methods Over five six-month periods spanning October 2020-April 2023, we assessed prevalence of injecting and smoking opioids or methamphetamine and whether participants used these drugs more frequently by smoking than injecting. Multivariable Poisson regression via Generalized Estimating Equations was used to examine time trends. Results Of 362 participants, median age was 40 years; most were male (72%), non-Hispanic (55%), and unhoused (67%). Among this cohort, of whom 100% injected (or injected and smoked) at baseline, by period five (two years later), 34% reported only smoking, while 59% injected and smoked, and 7% only injected. By period five, the adjusted relative risk (aRR) of injecting opioids was 0.41 (95% Confidence Interval [CI]: 0.33, 0.51) compared to period one, and the aRR for injecting methamphetamine was 0.50 (95% CI: 0.39, 0.63). Compared to period one, risks for smoking fentanyl rose significantly during period three (aRR=1.44, 95% CI: 1.06, 1.94), four (aRR=1.65, 95% CI: 1.24, 2.20) and five (aRR=1.90, 95% CI: 1.43, 2.53). Risks for smoking heroin and methamphetamine more frequently than injecting these drugs increased across all periods. Conclusions Opioid and methamphetamine injection declined precipitously, with notable increases in smoking these drugs. Research is urgently needed to understand the health consequences of these trends.
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Affiliation(s)
- William H. Eger
- School of Social Work, San Diego State University, San Diego, California, USA
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Daniela Abramovitz
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Angela R. Bazzi
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Annick Bórquez
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Carlos F. Vera
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alicia Harvey-Vera
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Joseph R. Friedman
- Center for Social Medicine and Humanities, University of California, Los Angeles, Los Angeles
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Megerian CE, Bair L, Smith J, Browne EN, Wenger LD, Guzman L, Kral AH, Lambdin BH. Health risks associated with smoking versus injecting fentanyl among people who use drugs in California. Drug Alcohol Depend 2024; 255:111053. [PMID: 38128362 DOI: 10.1016/j.drugalcdep.2023.111053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/02/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Given the attention, funding, and services that seek to reduce overdose mortality from fentanyl, it is important to understand whether a potential solution is for more people to switch from injecting to smoking fentanyl. As such, we set out to conduct a study to compare health and healthcare utilization outcomes associated with different modes of illicit fentanyl administration. METHODS From January to February 2023, we recruited people who use drugs from 34 syringe services programs across California, USA (N=999) and surveyed their substance use, health outcomes, and healthcare utilization. We compared health risks among people who injected fentanyl (78% of whom also smoked) to people who solely smoked fentanyl (n=563). RESULTS Of the 563 participants, forty-one percent injected fentanyl and 59% only smoked fentanyl. People who injected fentanyl were 40% more likely to have experienced a non-fatal overdose in the past 3 months (27% vs. 19%; aRR=1.40; 95% CI=1.03, 1.93) and 253% more likely to have had a skin and soft tissue infection in the past 3 months (39% vs. 15%; aRR=2.53; 95% CI=1.74, 3.67), compared to people who only smoked fentanyl. The average number of nights spent in the hospital was higher among people who injected fentanyl (average 1.2 nights vs. 0.7 nights; aIRR=1.78; 95% CI=1.02, 3.09; p=0.04).There were non-significant associations between mode of fentanyl administration and number of emergency department visits and probability of hospitalization. CONCLUSIONS Findings suggested that people who injected fentanyl were at higher risk for overdose and skin and soft tissue infections than people who only smoked fentanyl. Distribution of safe smoking supplies may facilitate transitions from injecting to smoking fentanyl, thereby reducing health risks associated with fentanyl use.
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Affiliation(s)
- Cariné E Megerian
- RTI International, 2150 Shattuck Avenue, 8th Floor, Berkeley, CA 94704, USA
| | - Luka Bair
- National Harm Reduction Coalition, 243 5th Ave #529, New York, NY 10016, USA
| | - Jessica Smith
- RTI International, 2150 Shattuck Avenue, 8th Floor, Berkeley, CA 94704, USA
| | - Erica N Browne
- RTI International, 2150 Shattuck Avenue, 8th Floor, Berkeley, CA 94704, USA
| | - Lynn D Wenger
- RTI International, 2150 Shattuck Avenue, 8th Floor, Berkeley, CA 94704, USA
| | - Laura Guzman
- National Harm Reduction Coalition, 243 5th Ave #529, New York, NY 10016, USA
| | - Alex H Kral
- RTI International, 2150 Shattuck Avenue, 8th Floor, Berkeley, CA 94704, USA
| | - Barrot H Lambdin
- RTI International, 2150 Shattuck Avenue, 8th Floor, Berkeley, CA 94704, USA.
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Perdue T, Carlson R, Daniulaityte R, Silverstein SM, Bluthenthal RN, Valdez A, Cepeda A. Characterizing prescription opioid, heroin, and fentanyl initiation trajectories: A qualitative study. Soc Sci Med 2024; 340:116441. [PMID: 38061222 DOI: 10.1016/j.socscimed.2023.116441] [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: 03/17/2023] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 01/23/2024]
Abstract
We understand the current crisis of overdose deaths to be driven by widespread opioid use, characterized by distinct 'waves' of drug use. The first wave was driven by prescription opioids, the second by heroin, and the third by illicit, non-pharmaceutical fentanyl and fentanyl analogues (henceforth, fentanyl). The purpose of this study is to describe opioid initiation within each of the three waves from the perspective of people who use illicit opioids, with a focus on emerging pathways into fentanyl use. The authors recruited sixty people reporting past-30-day illicit opioid use in Dayton, Ohio. Participants completed a brief survey and a semi-structured in-depth qualitative interview, conducted from March to November 2020 with a total of 13 in-person and 47 virtual interviews. The qualitative interviews were transcribed in their entirety and analyzed thematically using NVivo 12. We noted supply-side changes as influencing trajectories in all three waves. However, we also noted differences in the experiences of prescription opioid and heroin initiation, with these trajectories influenced by pharmacological effects, pain management, curiosity, intergenerational use, pricing, and peers. In comparison, most participants were unaware that they were initiating fentanyl, and many reported overdosing with their first use of fentanyl. We identified a trajectory into fentanyl with limited to no prior heroin use among a few participants. The increased risk of overdose with initiation into fentanyl use further emphasizes the need for an expansion of naloxone distribution and the implementation of more comprehensive measures, such as overdose prevention centers, drug testing, and a safer supply. Further research on the dynamics of the ongoing overdose death crisis in the era of fentanyl and the 4th wave of the overdose crisis is critical in developing responsive prevention and intervention strategies.
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Affiliation(s)
- Tasha Perdue
- John Glenn College of Public Affairs, The Ohio State University, Columbus, OH, United States.
| | - Robert Carlson
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, Dayton, OH, United States
| | - Raminta Daniulaityte
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Sydney M Silverstein
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, Dayton, OH, United States
| | - Ricky N Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, United States
| | - Avelardo Valdez
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Alice Cepeda
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
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5
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Kennedy MC, Dong H, Tobias S, Buxton JA, Lysyshyn M, Tupper KW, Ti L. Fentanyl Concentration in Drug Checking Samples and Risk of Overdose Death in Vancouver, Canada. Am J Prev Med 2024; 66:10-17. [PMID: 37633426 DOI: 10.1016/j.amepre.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION The proliferation of fentanyl and its analogs in illegal, unregulated drug markets remains a major driver of the overdose crisis in North America. Drug checking services have been implemented as a harm reduction strategy to address the crisis. However, little is known about their potential utility as a mechanism for monitoring population-level risk of overdose stemming from changing fentanyl concentration in unregulated drugs over time. Therefore, this study assessed the relationship between median fentanyl concentration in expected opioid drug checking samples and the death rate due to illicit drug toxicity over time in Vancouver, Canada. METHODS Monthly population-based rates of death due to illicit drug toxicity were drawn from provincial coroner records. Monthly median percent fentanyl concentration was calculated using a validated quantification model from point-of-care Fourier-transform infrared spectra among expected opioid samples that tested positive for fentanyl at community drug checking services. A time-series analysis using generalized additive modeling was conducted to examine the association between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, controlling for calendar month. Analyses were conducted in 2021-2022. RESULTS Between January 2019 and October 2020, 577 deaths due to illicit drug toxicity occurred in Vancouver, and the observed monthly rate ranged from 1.75 to 7.65 deaths per 100,000 population. A significant, positive association was observed between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, adjusting for calendar month (chi-square=52.21, p<0.001). CONCLUSIONS Findings suggest a role for point-of-care drug checking as a tool for monitoring evolving overdose risk at the population level.
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Affiliation(s)
- Mary Clare Kennedy
- School of Social Work, Faculty of Health and Social Development, The University of British Columbia - Okanagan Campus, Kelowna, British Columbia, Canada; British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.
| | - Huiru Dong
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; Harvard Medical School, Boston, Massachusetts; Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel Tobias
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mark Lysyshyn
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Kenneth W Tupper
- School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; School of Child and Youth Care, Faculty of Human and Social Development, University of Victoria, Victoria, British Columbia, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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6
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Price O, Man N, Sutherland R, Bruno R, Dietze P, Salom C, Agramunt S, Grigg J, Degenhardt L, Peacock A. Disruption to Australian heroin, methamphetamine, cocaine and ecstasy markets with the COVID-19 pandemic and associated restrictions. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 113:103976. [PMID: 36822010 PMCID: PMC9932690 DOI: 10.1016/j.drugpo.2023.103976] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Changes to drug markets can affect drug use and related harms. We aimed to describe market trends of heroin, methamphetamine, cocaine and ecstasy in Australia following the introduction of COVID-19 pandemic-associated restrictions. METHODS Australians residing in capital cities who regularly inject drugs (n ∼= 900 each year) or regularly use ecstasy and/or other illicit stimulants (n ∼= 800 each year) participated in annual interviews 2014-2022. We used self-reported market indicators (price, availability, and purity) for heroin, crystal methamphetamine, cocaine, and ecstasy crystal to estimate generalised additive models. Observations from the 2014-2019 surveys were used to establish the pre-pandemic trend; 2020, 2021 and 2022 observations were considered immediate, short-term and longer-term changes since the introduction of pandemic restrictions. RESULTS Immediate impacts on market indicators were observed for heroin and methamphetamine in 2020 relative to the 2014-2019 trend; price per cap/point increased (β: A$9.69, 95% confidence interval [CI]: 2.25-17.1 and β: A$40.3, 95% CI: 33.1-47.5, respectively), while perceived availability (adjusted odds ratio [aOR] for 'easy'/'very easy' to obtain: 0.38, 95% CI: 0.24-0.59 and aOR: 0.08, 95% CI: 0.03-0.25, respectively) and perceived purity (aOR for 'high' purity: 0.36, 95% CI: 0.23-0.54 and aOR: 0.33, 95% CI: 0.20-0.54, respectively) decreased. There was no longer evidence for change in 2021 or 2022 relative to the 2014-2019 trend. Changes to ecstasy and cocaine markets were most evident in 2022 relative to the pre-pandemic trend: price per gram increased (β: A$92.8, 95% CI: 61.6-124 and β: A$24.3, 95% CI: 7.93-40.6, respectively) and perceived purity decreased (aOR for 'high purity': 0.18, 95% CI: 0.09-0.35 and 0.57, 95% CI: 0.36-0.90, respectively), while ecstasy was also perceived as less easy to obtain (aOR: 0.18, 95% CI: 0.09-0.35). CONCLUSION There were distinct disruptions to illicit drug markets in Australia after the COVID-19 pandemic began; the timing and magnitude varied by drug.
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Affiliation(s)
- Olivia Price
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.
| | - Nicola Man
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Rachel Sutherland
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; School of Psychological Sciences, University of Tasmania, Hobart, Australia
| | - Paul Dietze
- Behaviours and Health Risks, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne Australia; National Drug Research Institute, Curtin University, Melbourne, Australia
| | - Caroline Salom
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; Institute for Social Science Research, The University of Queensland, Brisbane, Australia
| | - Seraina Agramunt
- National Drug Research Institute, Curtin University, Perth, Australia
| | - Jodie Grigg
- National Drug Research Institute, Curtin University, Perth, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; School of Psychological Sciences, University of Tasmania, Hobart, Australia
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Karamouzian M, Buxton JA, Hategeka C, Nosova E, Hayashi K, Milloy MJ, Kerr T. Shifts in substance use patterns among a cohort of people who use opioids after delisting of OxyContin in BC, Canada: An interrupted time series study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103852. [PMID: 36122483 PMCID: PMC9885984 DOI: 10.1016/j.drugpo.2022.103852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND OxyContin was delisted from Canadian provincial drug formularies in March 2012 and replaced with a reformulated tamper-resistant form of oxycodone (i.e., OxyNeo). We assessed if delisting of OxyContin was associated with changes in the use of unregulated opioids and other substances among people who use opioids (PWUO). METHODS Data were derived from two prospective cohort studies of people who use drugs in Vancouver, BC, Canada from 2006 to 2018. PWUO who had at least one follow-up visit before and after delisting of OxyContin were included. Outcomes of interest were self-reported regular (i.e., at least weekly) use of heroin, non-prescribed prescription opioids, cannabis, methamphetamine, crack cocaine, and powder cocaine during the previous six months. Using quasi-experimental interrupted time series, we fit generalized least squares models to assess participants' immediate and long-term substance use practices after the policy change. RESULTS We analyzed data from 1014 participants who contributed to 17457 visits during the study. Following the delisting of OxyContin, heroin use increased immediately by 5.17% (95% confidence intervals [CI]: 0.68 to 9.67) and over time by 0.47% (0.35 to 0.58) per month. Non-prescribed prescription opioid use increased immediately by 1.80% (0.10 to 3.50) and over time by 0.16% (0.12 to 0.19) per month. Cannabis use increased immediately by 4.37% (0.88 to 7.87) and over time by 0.11% (0.02 to 0.19) per month. Methamphetamine use did not increase immediately but increased over time by 0.10% (0.01 to 0.18) per month. Crack cocaine use decreased immediately by 6.13% (-10.94 to -1.69) but not significantly over time. Lastly, powder cocaine use did not increase immediately or over time. CONCLUSIONS Delisting of OxyContin in BC was not associated with a reduction in unregulated opioid use among PWUO. Our findings point to a shift in substance use patterns of PWUO post-intervention and further highlight the unintended consequences of supply-reduction interventions in addressing the opioid epidemic.
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Affiliation(s)
- Mohammad Karamouzian
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3; Centre on Drug Policy Evaluation, Saint Michael...s Hospital, Toronto, ON, CANADA, M5B 1T8.
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - Celestin Hategeka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA 02115,USA; Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - Ekaterina Nosova
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9
| | - Kanna Hayashi
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9
| | - M-J Milloy
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9; Department of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6
| | - Thomas Kerr
- British Columbia Centre on Substance use, Vancouver, BC, Canada, V6Z 2A9; Department of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6
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Holland A, Stevens A, Harris M, Lewer D, Sumnall H, Stewart D, Gilvarry E, Wiseman A, Howkins J, McManus J, Shorter GW, Nicholls J, Scott J, Thomas K, Reid L, Day E, Horsley J, Measham F, Rae M, Fenton K, Hickman M. Analysis of the UK Government's 10-Year Drugs Strategy-a resource for practitioners and policymakers. J Public Health (Oxf) 2022:6779883. [PMID: 36309802 DOI: 10.1093/pubmed/fdac114] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/10/2022] [Indexed: 11/12/2022] Open
Abstract
In 2021, during a drug-related death crisis in the UK, the Government published its ten-year drugs strategy. This article, written in collaboration with the Faculty of Public Health and the Association of Directors of Public Health, assesses whether this Strategy is evidence-based and consistent with international calls to promote public health approaches to drugs, which put 'people, health and human rights at the centre'. Elements of the Strategy are welcome, including the promise of significant funding for drug treatment services, the effects of which will depend on how it is utilized by services and local commissioners and whether it is sustained. However, unevidenced and harmful measures to deter drug use by means of punishment continue to be promoted, which will have deleterious impacts on people who use drugs. An effective public health approach to drugs should tackle population-level risk factors, which may predispose to harmful patterns of drug use, including adverse childhood experiences and socioeconomic deprivation, and institute evidence-based measures to mitigate drug-related harm. This would likely be more effective, and just, than the continuation of policies rooted in enforcement. A more dramatic re-orientation of UK drug policy than that offered by the Strategy is overdue.
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Affiliation(s)
- Adam Holland
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - Alex Stevens
- School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, CT2 7NZ
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Dan Lewer
- Public Health Specialty Registrar, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Harry Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, L3 5UX, UK
| | - Daniel Stewart
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - Eilish Gilvarry
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, NE1 7RU, UK
| | - Alice Wiseman
- Association of Directors of Public Health, London, EC4Y 0HA, UK
| | - Joshua Howkins
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - Jim McManus
- Association of Directors of Public Health, London, EC4Y 0HA, UK
| | | | - James Nicholls
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA, UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, Bath, BA2 7AY
| | - Kyla Thomas
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | | | - Edward Day
- Institute of Mental Health, University of Birmingham, Birmingham, B15 2TT
| | - Jason Horsley
- National Institute for Health Research Evaluation Trials and Studies Coordinating Centre, University of Southampton, Southampton, SO17 1BJ, UK
| | - Fiona Measham
- Department of Sociology, Social Policy and Criminology, University of Liverpool, Liverpool, L69 3BX
| | - Maggie Rae
- Epidemiological and Public Health Section, Royal Society of Medicine, London, W1G 0AE, UK
| | | | - Matthew Hickman
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
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9
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Bacon M, Spicer J. 'Breaking supply chains'. A commentary on the new UK Drug Strategy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 109:103843. [PMID: 36041960 DOI: 10.1016/j.drugpo.2022.103843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/22/2022] [Accepted: 08/21/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Matthew Bacon
- Centre for Criminological Research, University of Sheffield, United Kingdom
| | - Jack Spicer
- Department of Social and Policy Sciences, University of Bath, United Kingdom.
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10
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May T, Dawes J, Fancourt D, Burton A. A qualitative study exploring the impact of the COVID-19 pandemic on People Who Inject Drugs (PWID) and drug service provision in the UK: PWID and service provider perspectives. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103752. [PMID: 35653821 PMCID: PMC9135844 DOI: 10.1016/j.drugpo.2022.103752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND People Who Inject Drugs (PWID) are subject to distinct socio-structural inequalities that can expose them to high risks of COVID-19 transmission and related health and social complications. In response to COVID-19 mitigation strategies, these vulnerabilities are being experienced in the context of adapted drug treatment service provision, including reduced in-person support and increased regulatory flexibility in opioid substitution therapy (OST) guidelines. This study aimed to explore the longer-term impact of the pandemic on the health and wellbeing of PWID in the UK, including provider and client experiences of treatment changes. METHODS Interviews were conducted with 19 PWID and 17 drug treatment providers between May and September 2021, recruited from drug and homelessness charities providing treatment services and healthcare in the UK. Data were analysed using reflexive thematic analysis. RESULTS Most participants expressed ongoing fears of COVID-19 transmission, although socio-structural inequalities limited the contexts in which physical distancing could be practised. In addition, virus mitigation strategies altered the risk environment for PWID, resulting in ongoing physical (e.g. changing drug use patterns, including transitions to crack cocaine, benzodiazepine and pregabalin use) and socio-economic harms (e.g. limited opportunities for sex work engagement and income generation). Finally, whilst clients reported some favourable experiences from service adaptations prompted by COVID-19, including increased regulatory flexibility in OST guidelines, there was continued scepticism and caution among providers toward sustaining any treatment changes beyond the pandemic period. CONCLUSIONS Whilst our findings emphasize the importance of accessible harm reduction measures attending to changing indices of drug-related harm during this period, there is a need for additional structural supports to ensure pre-existing disparities and harms impacting PWID are not exacerbated further by the conditions of the pandemic. In addition, any sustained policy and service delivery adaptations prompted by COVID-19 will require further attention if they are to be acceptable to both service users and providers.
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Affiliation(s)
- Tom May
- Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, United Kingdom
| | - Jo Dawes
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, United Kingdom
| | - Daisy Fancourt
- Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, United Kingdom
| | - Alexandra Burton
- Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, United Kingdom.
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Kral AH, Lambdin BH, Browne EN, Wenger LD, Bluthenthal RN, Zibbell JE, Davidson PJ. Transition from injecting opioids to smoking fentanyl in San Francisco, California. Drug Alcohol Depend 2021; 227:109003. [PMID: 34482046 PMCID: PMC10790652 DOI: 10.1016/j.drugalcdep.2021.109003] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/19/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco. METHODS We used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018-2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids. RESULTS The median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID's motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma. CONCLUSION Between 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.
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Affiliation(s)
- Alex H Kral
- RTI International, Berkeley, CA, United States.
| | - Barrot H Lambdin
- RTI International, Berkeley, CA, United States; University of California, San Francisco, CA, United States; University of Washington, Seattle, WA, United States
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12
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Wallace B, MacKinnon K, Strosher H, Macevicius C, Gordon C, Raworth R, Mesley L, Shahram S, Marcellus L, Urbanoski K, Pauly B. Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review. JBI Evid Synth 2021; 19:1760-1843. [PMID: 34137739 DOI: 10.11124/jbies-20-00304] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids. INCLUSION CRITERIA To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts. METHODS An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives. RESULTS A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed. CONCLUSIONS We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.
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Affiliation(s)
- Bruce Wallace
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
| | - Karen MacKinnon
- School of Nursing, University of Victoria, Victoria, BC, Canada
- Centre for Evidence-Informed Nursing and Healthcare (CEiNHC): A JBI Affiliated Group, University of Victoria, Victoria, BC, Canada
| | - Heather Strosher
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
| | - Celeste Macevicius
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
| | - Carol Gordon
- Centre for Evidence-Informed Nursing and Healthcare (CEiNHC): A JBI Affiliated Group, University of Victoria, Victoria, BC, Canada
- Library Service, University of Victoria, Victoria, BC, Canada
| | - Rebecca Raworth
- Library Service, University of Victoria, Victoria, BC, Canada
| | - Lacey Mesley
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
| | - Sana Shahram
- School of Nursing, University of British Columbia: Okanagan campus, Kelowna, BC, Canada
| | - Lenora Marcellus
- School of Nursing, University of Victoria, Victoria, BC, Canada
- Centre for Evidence-Informed Nursing and Healthcare (CEiNHC): A JBI Affiliated Group, University of Victoria, Victoria, BC, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
| | - Bernadette Pauly
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
- School of Nursing, University of Victoria, Victoria, BC, Canada
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13
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Dunleavy K, Hutchinson SJ, Palmateer N, Goldberg D, Taylor A, Munro A, Shepherd SJ, Gunson RN, Given S, Campbell J, McAuley A. The uptake of foil from needle and syringe provision services and its role in smoking or snorting heroin among people who inject drugs in Scotland. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 98:103369. [PMID: 34340168 DOI: 10.1016/j.drugpo.2021.103369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 06/01/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the UK, legislation was implemented in 2014 allowing needle and syringe provision (NSP) services to offer foil to people who inject drugs (PWID) to encourage smoking rather than injecting. This paper aims to examine the association between foil uptake and smoking or snorting heroin among PWID. This is the first large scale national study to examine foil uptake and smoking or snorting heroin among PWID post legislative change. METHOD Data from 1453 PWID interviewed via Scotland's Needle Exchange Surveillance Initiative in 2017-2018 were analysed using multivariate logistic regression. RESULTS Overall, 36% of PWID had obtained foil from NSP services in the past six months. The odds of smoking or snorting heroin were higher among those who had obtained foil (Adjusted Odds Ratio (AOR) 3.79 (95% CI 2.98-4.82) p<0.001) compared to those who had not. Smoking or snorting heroin was associated with lower odds of injecting four or more times daily (AOR 0.60 (95% CI 0.40-0.90) p = 0.012) and injecting into the groin or neck (AOR 0.57 (95% CI 0.46-0.71) p<0.001) but increased odds of having had a skin and soft tissue infection (SSTI) (AOR 1.49 (95% CI 1.17-1.89) p = 0.001) and having experienced an overdose (AOR 1.58 (95% CI 1.18-2.10) p = 0.002) both in the past year. CONCLUSION The promotion of smoking drugs via foil provision from NSP services may contribute to the package of harm reduction measures for PWID alongside the provision of injecting equipment. We found that those in receipt of foil were more likely to smoke or snort heroin, and that smoking or snorting heroin was associated with a lower likelihood of some risky injecting behaviours, namely frequent injecting and injecting into the groin or neck. But it remains uncertain if the provision of foil can lead to a reduction in health harms, such as SSTI and overdose. Future research is needed to understand PWID motivations for smoking drugs, obtaining foil from NSP services, and its uses particularly among polydrug users.
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Affiliation(s)
- Karen Dunleavy
- School of Education and Social Sciences, University of the West of Scotland, Paisley, PA1 2BE, Scotland.
| | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland; Public Health Scotland, NHS National Services Scotland, Glasgow, Scotland
| | - Norah Palmateer
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland; Public Health Scotland, NHS National Services Scotland, Glasgow, Scotland
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland; Public Health Scotland, NHS National Services Scotland, Glasgow, Scotland
| | - Avril Taylor
- School of Education and Social Sciences, University of the West of Scotland, Paisley, PA1 2BE, Scotland
| | - Alison Munro
- School of Health Sciences, University of Dundee, Dundee, Scotland
| | | | - Rory N Gunson
- West of Scotland Specialist Virology Centre, Glasgow, Scotland
| | - Sophie Given
- Scottish Drugs Forum, 139 Morrison Street, Edinburgh, Scotland
| | | | - Andrew McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland; Public Health Scotland, NHS National Services Scotland, Glasgow, Scotland
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14
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Abstract
PURPOSE OF REVIEW To assess the current state of the opioid overdose crisis along three major axes: drug markets and patterns of use, the effectiveness of systems of care, and international developments. RECENT FINDINGS Overdose is a major contributor to mortality and disability among people who use drugs. The increasing number of opioid overdoses in North America especially is an indication of changing drug markets and failing regional systems of care. Globally, we see three clusters of overdose prevalence: (1) a group of countries led by the United States with historically high rates of opioid overdose, (2) a group of countries with increasing rates within a concerning range, (3) a group with very low rates. The contamination of street drugs, the quality and accessibility of treatment, and the overall system of care all contribute to the prevalence of overdose. SUMMARY Drug markets and pattern of consumption in parts of the world are shifting towards contamination and opioids like fentanyl as the drug of choice, which dismantles insufficient and largely ineffective systems of care. Furthermore, outside of North America, more countries like Estonia, Lithuania, Sweden, Finland, and Norway show very concerning numbers. Without a consistent system response, effects will be devastating.
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Affiliation(s)
- R Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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15
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May T, Buhociu M, Holloway K. Addressing fentanyl-related harms: maximizing the efficiency of innovative interventions. Addiction 2021; 116:1313-1314. [PMID: 33263198 DOI: 10.1111/add.15323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Tom May
- Research Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Marian Buhociu
- Substance Use Research Group (SURG), Centre for Criminology, University of South Wales, Pontypridd, UK
| | - Katy Holloway
- Substance Use Research Group (SURG), Centre for Criminology, University of South Wales, Pontypridd, UK
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16
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A rapid review of the impacts of "Big Events " on risks, harms, and service delivery among people who use drugs: Implications for responding to COVID-19. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 92:103127. [PMID: 33549464 PMCID: PMC7816610 DOI: 10.1016/j.drugpo.2021.103127] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/28/2020] [Accepted: 01/07/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND "Big Events" are major disruptions to physical, political, and economic environments that can influence vulnerability to drug-related harms. We reviewed the impacts of Big Events with relevance to the COVID-19 pandemic on drug-related risk and harms and access to drug treatment and harm reduction services. METHODS We conducted a rapid review of quantitative, qualitative, and mixed methods literature relating to the following Big Events: respiratory infection pandemics, natural disasters, financial crises, and heroin shortages. Included studies reported data on changes to risks, harms, and/or service provisioning for people who use illicit drugs (other than cannabis) in the context of these Big Events. Searches were conducted in PubMed in May 2020, and two reviewers screened studies for inclusion. Peer-reviewed studies published in English or French were included. We used a narrative synthesis approach and mapped risk pathways identified in the literature. RESULTS No studies reporting on respiratory infection pandemics were identified. Twelve studies reporting on natural disaster outcomes noted marked disruption to drug markets, increased violence and risk of drug-related harm, and significant barriers to service provision caused by infrastructure damage. Five studies of the 2008 global financial crisis indicated increases in the frequency of drug use and associated harms as incomes and service funding declined. Finally, 17 studies of heroin shortages noted increases in heroin price and adulteration, potentiating drug substitutions and risk behaviors, as well as growing demand for drug treatment. CONCLUSION Current evidence reveals numerous risk pathways and service impacts emanating from Big Events. Risk pathway maps derived from this literature provide groundwork for future research and policy analyses, including in the context of the COVID-19 pandemic. In light of the findings, we recommend responding to the pandemic with legislative and financial support for the flexible delivery of harm reduction services, opioid agonist treatment, and mental health care.
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17
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Abstract
Krokodil is the street name for a homemade mixture that has been used as a cheap substitute for heroin. The main active substance in krokodil is desomorphine, an opioid that is 10 times more potent than morphine. Krokodil use began in Russia and Ukraine but has spread throughout several countries in Europe and North America. Krokodil is produced from codeine tablets in a bootleg reaction performed under clandestine and unsanitary conditions. The toxicity of krokodil is characterized by devastating symptoms that start as black ulcers at the injection site and evolve to gangrene and limb amputation. The dangerous effects of krokodil are associated with its homemade nature and lack of purification prior to use. In this review, we discuss the chemical and pharmacological properties and the metabolism of desomorphine, the preparation of krokodil, and how its homemade nature contributes to its toxicity. The synthesis of krokodil produces several other morphinans in addition to desomorphine that warrant further study as possible analgesic alternatives to morphine.
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Affiliation(s)
- Emanuele Amorim Alves
- Department of Forensic Science, College of Humanities and Sciences, Virginia Commonwealth University 1015 Floyd Avenue, Richmond, Virginia 23284, United States
- Oswaldo Cruz Foundation, 21040-900 Rio de Janeiro-RJ, Brazil
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18
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May T, Holloway K, Buhociu M, Hills R. Not what the doctor ordered: Motivations for nonmedical prescription drug use among people who use illegal drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 82:102823. [PMID: 32585584 DOI: 10.1016/j.drugpo.2020.102823] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/20/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nonmedical Prescription Drug Use (NMPDU) is common among people who use illegal drugs. NMPDU is particularly problematic among this population however, as medications such as benzodiazepines and gabapentinoids can potentiate the harmful effects of opioids. Despite these harms, there is some evidence that NMPDU can have harm reducing and therapeutic potential for some people who use illegal drugs. This study provides further evidence of the harm reducing motives for NMPDU among people who use illegal drugs in community and prison settings in Wales, UK. METHODS In depth, semi-structured interviews were conducted with 60 interviewees recruited from statutory and third sector drug treatment providers operating in five towns and cities in Wales, and from two Welsh prisons. Eligibility was based primarily on whether the person was currently (or previously) a user of illegal drugs and had recent experience of NMPDU. RESULTS NMPDU was found to be largely driven by insufficient access to certain prescription medications and treatment. In this context, NMPDU played an important role in alleviating legitimate medical concerns and overcoming logistical and regulatory barriers associated with Opioid Substitution Therapy. NMPDU also had everyday practicality and mitigated many of the everyday harms experienced by people who use drugs, including opioid withdrawal and stimulant comedowns. CONCLUSION Results suggest that NMPDU has the potential to mitigate a number of legitimate medical concerns in the absence of treatment. Finding nuanced ways of responding to patient need whilst reducing the potential for NMPDU are therefore needed, and harm reduction strategies that harness the knowledge and expertise of people who use drugs should be encouraged. Additional policy measures that attend to the inequities and social-structural factors that produce and maintain the need to consume prescription medications in ways that are not intended are also required.
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Affiliation(s)
- Tom May
- Substance Use Research Group (SURG), Centre for Criminology, University of South Wales, Pontypridd, CF37 1DL, Wales.
| | - Katy Holloway
- Substance Use Research Group (SURG), Centre for Criminology, University of South Wales, Pontypridd, CF37 1DL, Wales
| | - Marian Buhociu
- Substance Use Research Group (SURG), Centre for Criminology, University of South Wales, Pontypridd, CF37 1DL, Wales
| | - Rhian Hills
- Senior Policy Manager - Substance Misuse, Welsh Government, Merthyr Tydfil, CF48 1UZ, Wales
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19
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Carlson RG, Daniulaityte R, Silverstein SM, Nahhas RW, Martins SS. Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 79:102722. [PMID: 32311513 PMCID: PMC9387534 DOI: 10.1016/j.drugpo.2020.102722] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/21/2020] [Accepted: 03/04/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Unintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period. METHODS Participants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use. RESULTS Almost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis. DISCUSSION The findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed.
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Affiliation(s)
- Robert G Carlson
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3171 Research Blvd, Suite 124, Kettering, OH 45420, USA.
| | - Raminta Daniulaityte
- College of Health Solutions, Arizona State University, 425 N 5th Avenue, Arizona Biomedical Center Room 121, Phoenix, AZ 85004
| | - Sydney M Silverstein
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3171 Research Blvd, Suite 124, Kettering, OH 45420, USA
| | - Ramzi W Nahhas
- Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3123 Research Blvd, Kettering, OH 45420, USA; Department of Psychiatry, 627 Edwin C. Moses Blvd, Dayton, OH, USA
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
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20
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McLean K, Monnat SM, Rigg K, Sterner GE, Verdery A. "You Never Know What You're Getting": Opioid Users' Perceptions of Fentanyl in Southwest Pennsylvania. Subst Use Misuse 2019; 54:955-966. [PMID: 30676198 PMCID: PMC6476660 DOI: 10.1080/10826084.2018.1552303] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Urban areas in the United States have experienced a dramatic surge in fentanyl overdose deaths since 2014, a trend affecting both larger and smaller metropolitan areas. Encompassing only 1.2 million residents, Allegheny County, Pennsylvania, nevertheless saw 412 fentanyl-involved deaths in 2016, a number surpassed only by New York City and Cook County (Chicago), Illinois. OBJECTIVES This article seeks to describe opioid users' perceptions of fentanyl in Allegheny and three adjacent counties; it further considers how the drug's emergence shapes some users' market behaviors and consumption practices. METHODS This article reports on qualitative interview data (N = 30) collected as part of a larger, multi-phase, mixed methods study (N = 125) among individuals reporting past-year prescription opioid misuse or heroin use in four southwest Pennsylvania Counties. RESULTS Most interviewees reported past-year suspected exposure to fentanyl, and many reported suffering or seeing suspected fentanyl overdoses. Where roughly one-third reported strategies for avoiding fentanyl, a small group of interviewees identified advantages to fentanyl, while still acknowledging its associated risks. Conclusions/Importance: Given users' diverse opinions around fentanyl, the distribution of fentanyl test strips may represent an effective response to the current crisis.
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Affiliation(s)
- Katherine McLean
- a Administration of Justice , Penn State Greater Allegheny , McKeesport , Pennsylvania , USA
| | - Shannon M Monnat
- b Sociology , Maxwell School of Citizenship and Public Affairs, Syracuse University , Syracuse , New York , USA
| | - Khary Rigg
- c Department of Mental Health Law and Policy, College of Behavioral and Community Sciences , University of South Florida, Tampa , Florida, USA
| | - Glenn E Sterner
- d The Justice Center for Research , The Pennsylvania State University, University Park , Pennsylvania, USA
| | - Ashton Verdery
- e Department of Sociology and Criminology , The Pennsylvania State University, University Park , Pennsylvania, USA
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21
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McGowan CR, Harris M, Platt L, Hope V, Rhodes T. Fentanyl self-testing outside supervised injection settings to prevent opioid overdose: Do we know enough to promote it? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 58:31-36. [PMID: 29758542 DOI: 10.1016/j.drugpo.2018.04.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 01/01/2023]
Abstract
Since 2013, North America has experienced a sharp increase in unintentional fatal overdoses: fentanyl, and its analogues, are believed to be primarily responsible. Currently, the most practical means for people who use drugs (PWUD) to avoid or mitigate risk of fentanyl-related overdose is to use drugs in the presence of someone who is in possession of, and experienced using, naloxone. Self-test strips which detect fentanyl, and some of its analogues, have been developed for off-label use allowing PWUD to test their drugs prior to consumption. We review the evidence on the off-label sensitivity and specificity of fentanyl test strips, and query whether the accuracy of fentanyl test strips might be mediated according to situated practices of use. We draw attention to the weak research evidence informing the use of fentanyl self-testing strips.
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Affiliation(s)
- Catherine R McGowan
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom; Humanitarian Public Health Technical Unit, Save the Children UK, London, United Kingdom.
| | - Magdalena Harris
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vivian Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | - Tim Rhodes
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre for Social Research in Health, University of New South Wales, Australia
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Mars SG, Ondocsin J, Ciccarone D. Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore, MD. J Psychoactive Drugs 2017; 50:167-176. [PMID: 29211971 DOI: 10.1080/02791072.2017.1394508] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Since 2001, heroin-related overdose deaths in the United States have risen six-fold, a rise unaccounted for by the expanding user population. Has heroin become a more dangerous drug? Reports of fentanyl and its analogs, often concealed in or sold as heroin, have also increased sharply. This article investigates heroin injectors' perceptions and experiences of changes in the heroin supply in the East Coast city of Baltimore, Maryland, currently facing an epidemic in heroin- and fentanyl-related overdose deaths. Unusually, Baltimore's heroin market is divided between two types: "Raw," believed to be Colombian in origin and relatively pure, and the more adulterated "Scramble" (raw heroin traditionally blended with quinine and lactose). Users reported that Scramble heroin, while gaining market share, has become a highly unstable product, varying dramatically in appearance, intensity of onset, duration of action, and effect. Some considered that Scramble was no longer "heroin," but was heavily adulterated or even replaced, mentioning fentanyl, benzodiazepines, and crushed opioid pills as additives. There was intense awareness of overdose as a present danger in users' lives, which they linked to the recent adulteration of the heroin supply. Responses to this perceived adulteration varied, including information gathering, attraction, avoidance, taking precautions, and acceptance.
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Affiliation(s)
- Sarah G Mars
- a Qualitative Project Director, Heroin in Transition, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
| | - Jeff Ondocsin
- b Ethnographer, Heroin in Transition, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
| | - Daniel Ciccarone
- c Professor of Family and Community Medicine, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
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Ciccarone D. Fentanyl in the US heroin supply: A rapidly changing risk environment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:107-111. [PMID: 28735776 PMCID: PMC5742018 DOI: 10.1016/j.drugpo.2017.06.010] [Citation(s) in RCA: 286] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Daniel Ciccarone
- University of California, San Francisco, Department of Family and Community Medicine, MU-3E, Box 900, 500 Parnassus Ave., San Francisco, CA 94143, United States.
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Ciccarone D, Ondocsin J, Mars SG. Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:146-155. [PMID: 28735775 PMCID: PMC5577861 DOI: 10.1016/j.drugpo.2017.06.004] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/01/2017] [Accepted: 06/12/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use. METHODS A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin. RESULTS (1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports. CONCLUSION Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.
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Affiliation(s)
- Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Ave., MU-3E, Box 900, San Francisco, CA 94143-0900, United States.
| | - Jeff Ondocsin
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Ave., MU-3E, Box 900, San Francisco, CA 94143-0900, United States
| | - Sarah G Mars
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Ave., MU-3E, Box 900, San Francisco, CA 94143-0900, United States
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25
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Roy É, Arruda N, Leclerc P, Morissette C, Blanchette C, Blouin K, Alary M. Drug use practices among people who inject drugs in a context of drug market changes: Challenges for optimal coverage of harm reduction programs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 45:18-24. [DOI: 10.1016/j.drugpo.2017.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/31/2017] [Accepted: 05/02/2017] [Indexed: 11/28/2022]
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26
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The cutting of cocaine and heroin: A critical review. Forensic Sci Int 2016; 262:73-83. [DOI: 10.1016/j.forsciint.2016.02.033] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 02/06/2016] [Accepted: 02/18/2016] [Indexed: 11/23/2022]
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Syvertsen JL, Ohaga S, Agot K, Dimova M, Guise A, Rhodes T, Wagner KD. An ethnographic exploration of drug markets in Kisumu, Kenya. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 30:82-90. [PMID: 26838470 DOI: 10.1016/j.drugpo.2016.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 12/15/2015] [Accepted: 01/03/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Illegal drug markets are shaped by multiple forces, including local actors and broader economic, political, social, and criminal justice systems that intertwine to impact health and social wellbeing. Ethnographic analyses that interrogate multiple dimensions of drug markets may offer both applied and theoretical insights into drug use, particularly in developing nations where new markets and local patterns of use traditionally have not been well understood. This paper explores the emergent drug market in Kisumu, western Kenya, where our research team recently documented evidence of injection drug use. METHODS Our exploratory study of injection drug use was conducted in Kisumu from 2013 to 2014. We draw on 151 surveys, 29 in-depth interviews, and 8 months of ethnographic fieldwork to describe the drug market from the perspective of injectors, focusing on their perceptions of the market and reports of drug use therein. RESULTS Injectors described a dynamic market in which the availability of drugs and proliferation of injection drug use have taken on growing importance in Kisumu. In addition to reports of white and brown forms of heroin and concerns about drug adulteration in the market, we unexpectedly documented widespread perceptions of cocaine availability and injection in Kisumu. Examining price data and socio-pharmacological experiences of cocaine injection left us with unconfirmed evidence of its existence, but opened further possibilities about how the chaos of new drug markets and diffusion of injection-related beliefs and practices may lend insight into the sociopolitical context of western Kenya. CONCLUSIONS We suggest a need for expanded drug surveillance, education and programming responsive to local conditions, and further ethnographic inquiry into the social meanings of emergent drug markets in Kenya and across sub-Saharan Africa.
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Affiliation(s)
- Jennifer L Syvertsen
- Department of Anthropology, The Ohio State University, 4046 Smith Laboratory, 174 W. 18th Ave., Columbus, OH 43210-1106, USA.
| | - Spala Ohaga
- Impact Research and Development Organization, P.O. Box 9171-40141, Kisumu, Kenya
| | - Kawango Agot
- Impact Research and Development Organization, P.O. Box 9171-40141, Kisumu, Kenya
| | - Margarita Dimova
- Department of Politics and International Studies, SOAS, Thornhaugh Street, Russell Square, London, England WC1H 0XG, United Kingdom
| | - Andy Guise
- Division of Global Public Health, University of California, San Diego, Central Research Services Facility (CRSF), La Jolla, CA 92093-0507, USA; London School of Hygiene & Tropical Medicine, Keppel Street, London, England WC1E 7HT, United Kingdom
| | - Tim Rhodes
- London School of Hygiene & Tropical Medicine, Keppel Street, London, England WC1E 7HT, United Kingdom
| | - Karla D Wagner
- School of Community Health Sciences, University of Nevada, Reno, 1664 N. Virginia St. MS 0274, Reno, NV 89557, USA
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Bancroft A, Scott Reid P. Concepts of illicit drug quality among darknet market users: Purity, embodied experience, craft and chemical knowledge. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 35:42-9. [PMID: 26777135 DOI: 10.1016/j.drugpo.2015.11.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/30/2015] [Accepted: 11/20/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Users of darknet markets refer to product quality as one of the motivations for buying drugs there, and vendors present quality as a selling point. However, what users understand by quality and how they evaluate it is not clear. This article investigates how users established and compared drug quality. METHODS We used a two-stage method for investigating users' assessments. The user forum of a darknet market that we called 'Merkat' was analysed to develop emergent themes. Qualitative interviews with darknet users were conducted, then forum data was analysed again. To enhance the applicability of the findings, the forum was sampled for users who presented as dependent as well as recreational. RESULTS Quality could mean reliability, purity, potency, and predictability of effect. We focused on the different kinds of knowledge users drew on to assess quality. These were: embodied; craft; and chemical. CONCLUSION Users' evaluations of quality depended on their experience, the purpose of use, and its context. Market forums are a case of indigenous harm reduction where users share advise and experiences and can be usefully engaged with on these terms.
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Guise A, Dimova M, Ndimbii J, Clark P, Rhodes T. A qualitative analysis of transitions to heroin injection in Kenya: implications for HIV prevention and harm reduction. Harm Reduct J 2015; 12:27. [PMID: 26337729 PMCID: PMC4558953 DOI: 10.1186/s12954-015-0061-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 08/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heroin injection is emerging as a significant dimension of the HIV epidemic in Kenya. Preventing transitions to injecting drug use from less harmful forms of use, such as smoking, is a potentially important focus for HIV prevention. There is, however, little evidence to support comprehensive programming in this area, linked to a shortage of analysis of the social and structural context for transitions, particularly in low-income settings. We explore accounts of transitions from smoking to injecting in Kenya to understand the role of individual, social and structural processes. METHODS We combine data from two separate studies conducted in Kenya: an in-depth qualitative study of HIV care access for people who inject drugs (study 1) and an ethnographic study of the political economy of the heroin trade in Kenya (study 2). In-depth interviews with PWID and community observation from study 1 are triangulated with accounts from stakeholders involved in the heroin trade and documentary data from study 2. RESULTS People who inject drugs link transitions to injecting from smoking to a range of social and behavioural factors, as well as particular aspects of the local drug supply and economy. We present these results in the form of two narratives that account for factors shaping transitions. A dominant narrative of 'managing markets and maintaining a high' results from a process of trying to manage poverty and a shifting heroin supply, in the context of deepening addiction to heroin. A secondary narrative focuses on people's curiosity for the 'feeling' of injecting, and the potential pleasure from it, with less emphasis on structural circumstances. CONCLUSIONS The narratives we describe represent pathways through which structural and social factors interact with individual experiences of addiction to increase the risk of transitions to injecting. In response, HIV and harm reduction programmes need combinations of different strategies to respond to varied experiences of transitions. These strategies should include, alongside behaviour-oriented interventions, structural interventions to address economic vulnerability and the policing of the drug supply.
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Affiliation(s)
- Andy Guise
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Margarita Dimova
- School of Oriental and African Studies, Thornhaugh Street, London, WC1H 0XG, UK.
| | - James Ndimbii
- Kenyan AIDS NGOs Consortium, Jabavu Lane, P.O. Box 69866-00400, Nairobi, Kenya.
| | - Phil Clark
- School of Oriental and African Studies, Thornhaugh Street, London, WC1H 0XG, UK.
| | - Tim Rhodes
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Mital S, Miles G, McLellan-Lemal E, Muthui M, Needle R. Heroin shortage in Coastal Kenya: A rapid assessment and qualitative analysis of heroin users' experiences. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 30:91-8. [PMID: 26470646 DOI: 10.1016/j.drugpo.2015.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 08/11/2015] [Accepted: 08/13/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION While relatively rare events, abrupt disruptions in heroin availability have a significant impact on morbidity and mortality risk among those who are heroin dependent. A heroin shortage occurred in Coast Province, Kenya from December 2010 to March 2011. This qualitative analysis describes the shortage events and consequences from the perspective of heroin users, along with implications for health and other public sectors. METHODS As part of a rapid assessment, 66 key informant interviews and 15 focus groups among heroin users in Coast Province, Kenya were conducted. A qualitative thematic analysis was undertaken in Atlas.ti. to identify salient themes related to the shortage. RESULTS Overall, participant accounts were rooted in a theme of desperation and uncertainty, with emphasis on six sub-themes: (1) withdrawal and strategies for alleviating withdrawal, including use of medical intervention and other detoxification attempts; (2) challenges of dealing with unpredictable drug availability, cost, and purity; (3) changes in drug use patterns, and actions taken to procure heroin and other drugs; (4) modifications in drug user relationship dynamics and networks, including introduction of risky group-level injection practices; (5) family and community response; and (6) new challenges with the heroin market resurgence. CONCLUSIONS The heroin shortage led to a series of consequences for drug users, including increased risk of morbidity, mortality and disenfranchisement at social and structural levels. Availability of evidence-based services for drug users and emergency preparedness plans could have mitigated this impact.
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Affiliation(s)
- Sasha Mital
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-04, Atlanta, GA 30329, United States.
| | - Gillian Miles
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-04, Atlanta, GA 30329, United States
| | - Eleanor McLellan-Lemal
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-45, Atlanta, GA 30329, United States
| | - Mercy Muthui
- KEMRI Complex, Mbagathi Road off Mbagathi Way, PO Box 606-00621, Village Market, Nairobi, Kenya
| | - Richard Needle
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-04, Atlanta, GA 30329, United States; Office of the Global AIDS Coordinator, SA-29, 2nd floor, 2201 C. Street NW, Washington, DC 20522-2920, United States
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