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Holeksa J. 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. Harm Reduct J 2022; 19:23. [PMID: 35246162 PMCID: PMC8894830 DOI: 10.1186/s12954-022-00602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/17/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Julie Holeksa
- Department of Social Work, Faculty of Health and Society, Malmö University, Citadellsvägen 7, 211 18, Malmö, Sweden.
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Karlsson N, Berglund T, Ekström AM, Hammarberg A, Tammi T. Could 30 years of political controversy on needle exchange programmes in Sweden contribute to scaling-up harm reduction services in the world? NORDIC STUDIES ON ALCOHOL AND DRUGS 2020; 38:66-88. [PMID: 35309093 PMCID: PMC8899060 DOI: 10.1177/1455072520965013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022] Open
Abstract
Aims: To end the hepatitis and AIDS epidemics in the world by 2030, countries are encouraged to scale-up harm reduction services and target people who inject drugs (PWID). Blood-borne viruses (BBV) among PWID spread via unsterile injection equipment sharing and to combat this, many countries have introduced needle and syringe exchange programmes (NEP), though not without controversy. Sweden’s long, complicated harm reduction policy transition has been deviant compared to the Nordic countries. After launch in 1986, no NEP were started in Sweden for 23 years, the reasons for which are analysed in this study. Methods: Policy documents, grey literature and research mainly published in 2000–2017 were collected and analysed using a hierarchical framework, to understand how continuous build-up of evidence, decisions and key events, over time influenced NEP development. Results: Sweden’s first NEP opened in a repressive-control drug policy era with a drug-free society goal. Despite high prevalence of BBV among PWID with recurring outbreaks, growing research and key-actor support including a NEP law, no NEP were launched. Political disagreements, fluctuating actor-coalitions, questioning of research, and a municipality veto against NEP, played critical roles. With an individual-centred perspective being brought into the drug policy domain, the manifestation of a dual drug and health policy track, a revised NEP law in 2017 and removal of the veto, Sweden would see fast expansion of new NEP. Conclusions: Lessons from the Swedish case could provide valuable insight for countries about to scale-up harm reduction services including how to circumvent costly time- and resource-intensive obstacles and processes involving ideological and individual moral dimensions.
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Affiliation(s)
- Niklas Karlsson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; and Department of Public Health Analysis and Development, Public Health Agency of Sweden, Solna, Sweden
| | - Torsten Berglund
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; and Department of Public Health Analysis and Development, Public Health Agency of Sweden, Solna, Sweden
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; and Department of Medicine Huddinge, Division of Infectious Diseases, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Anders Hammarberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Tuukka Tammi
- Finnish Institute for Health and Welfare, Finland
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Larney S, Leung J, Grebely J, Hickman M, Vickerman P, Peacock A, Stone J, Trickey A, Dumchev KV, Colledge S, Cunningham EB, Lynskey M, Mattick RP, Degenhardt L. Global systematic review and ecological analysis of HIV in people who inject drugs: National population sizes and factors associated with HIV prevalence. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 77:102656. [PMID: 31951926 DOI: 10.1016/j.drugpo.2019.102656] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 12/05/2019] [Accepted: 12/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND People who inject drugs (PWID) are at elevated risk of HIV infection. Data on population sizes of PWID living with HIV are needed to inform the implementation of prevention, treatment and care programs. We estimated national population sizes of people who recently (past 12 months) injected drugs living with HIV and evaluated ecological associations with HIV prevalence in PWID. METHODS We used national data on the prevalence of injecting drug use and of HIV among PWID, derived from systematic reviews, to estimate national population sizes of PWID living with HIV. Uncertainty was estimated using Monte Carlo simulation with 100,000 draws. We extracted data on sample characteristics from studies of HIV prevalence among PWID, and identified national indicators that have been observed or hypothesised to be associated with HIV prevalence in PWID. We used linear regression to evaluate associations between these variables and HIV prevalence in PWID. RESULTS Four countries comprised 55% of the estimated global population of PWID living with HIV: Russia (572,500; 95% uncertainty interval (UI) 235,500-1,036,500); Brazil (462,000; 95% UI 283,500-674,500); China (316,500; 95% UI 171,500-493,500), and the United States (195,500; 95% UI 80,000-343,000). Greater anti-HCV prevalence and national income inequality were associated with greater HIV prevalence in PWID. CONCLUSION The countries with the largest populations of PWID living with HIV will need to dramatically scale up prevention, treatment and care interventions to prevent further increases in population size. The association between anti-HCV prevalence and HIV prevalence among PWID corroborates findings that settings with increasing HCV should implement effective interventions to prevent HIV outbreaks. The association between income inequality and HIV among PWID reinforces the need to implement structural interventions alongside targeted individual-level strategies.
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Affiliation(s)
- Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia.
| | - Janni Leung
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia
| | | | - Matthew Hickman
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Peter Vickerman
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia
| | - Jack Stone
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adam Trickey
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Samantha Colledge
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia
| | | | - Michael Lynskey
- National Addiction Centre, King's College London, London, United Kingdom
| | - Richard P Mattick
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia
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Beletsky L. 21 st Century Cures for the Opioid Crisis: Promise, Impact, and Missed Opportunities. AMERICAN JOURNAL OF LAW & MEDICINE 2018; 44:359-385. [PMID: 30106650 DOI: 10.1177/0098858818789417] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Signed into law in 2016, the landmark 21stCentury Cures Act is as complex as it is divisive. For some stakeholders, including patient groups and representatives of regulated industries, the Act represented a major leap forward in pharmaceutical innovation, human subjects protections, and numerous other provisions. For other observers, this legislation was characterized as a major rollback in important regulations, which would leave patients worse off and the payers holding the bag. The one element of the Act that was relatively uncontroversial covered a number of provisions related to addressing the opioid crisis.This was by design. Provisions related to this issue were not part of the original legislation and were added to win over additional members of Congress who needed to be brought along to support the legislation. Many of the statute's provisions were intertwined with the Comprehensive Addiction Recovery Act (“CARA”) passed previously, but that legislation was stripped of much of its funding for opioid crisis response.
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Affiliation(s)
- Leo Beletsky
- Associate Professor of Law and Health Sciences, Northeastern University; Adjunct Professor, UCSD School of Medicine; J.D., Temple University Beasley School of Law, 2008; M.P.H., Brown University, 2004; A.B., Vassar College, 2000. The author thanks the participants of the American Journal of Law & Medicine's 2018 Symposium and participants of the Second Annual Regional Health Law Works-in-Progress Retreat at Seton Hall Law School for their feedback. Sarah Seymour and Zachary Siegel provided valuable research assistance
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Marotta PL, McCullagh CA. A cross-national analysis of the association between years of implementation of opioid substitution treatments and drug-related deaths in Europe from 1995 to 2013. Eur J Epidemiol 2017; 33:679-688. [PMID: 29234968 DOI: 10.1007/s10654-017-0342-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 12/06/2017] [Indexed: 12/23/2022]
Abstract
Data at the individual-level provide evidence that opioid substitution treatment (OST) programs protect against mortality for opioid dependent populations. Prior research has not examined the merits of national implementation of opioid substitution programs for reducing mortality at the country-level. This study elucidates longitudinal associations between country-level implementation of opioid substitution treatment programs on mortality rates of drug related deaths (DRD) from 1995 to 2013 in 30 European nations. Cases of DRD were measured using National Definitions for each country from official sources of data. Preliminary analysis of dispersion of cases of DRD using means and variances justified use of the negative binomial regression model with a population offset. Year and country-level fixed effects negative binomial regression models investigated the association between years of implementation of methadone maintenance therapy (MMT), OST in prison, and high dose buprenorphine treatment (HDBT) implementation and mortality rates from drug related deaths after adjusting for unemployment rates, heroin seizures and per capita expenditures on health. Beta coefficients were converted to Incidence Rate Ratios (IRR) and standard errors bootstrapped using non-parametric methods to adjust for bias (SDbs). The mean mortality rate of DRD was 1.81 from 1995 to 2013. In adjusted models, each additional year of MMT (IRR = .61, SD = .04, p < .001; SDbs = .08, p < .001), prison OST (IRR = .90, SD = .01, p < .001; SDbs = .02, p < .001), and HDBT (IRR = .09, SD = .02, p < .001; SDbs = .02, p < .01) was significantly associated with lower rates of DRDs after adjusting for country and year fixed effects. Implementation of OST programs in the general population and in prison settings may have protected against mortality from drug use at the country-level in Europe from 1995 to 2013.
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Affiliation(s)
- Phillip L Marotta
- School of Social Work, New York, NY, USA.
- Columbia University, New York, NY, USA.
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Ghaddar A, Nassar K, Elsoury G. Barriers to Access to Sterile Syringes as Perceived by Pharmacists and Injecting Drug Users: Implications for Harm Reduction in Lebanon. Subst Use Misuse 2017; 52:1420-1428. [PMID: 28430013 DOI: 10.1080/10826084.2017.1284235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Access to sterile syringes to injecting drug users (IDU) reduces sharing behavior and prevents the transmission of HIV. OBJECTIVES To describe the barriers to access to sterile syringes for IDUs in Lebanon from the perspectives of pharmacists and IDUs. METHODS in this qualitative study conducted in Lebanon, data were collected from 72 syringe purchase tests at pharmacies, 64 interviewees with pharmacists and 2 focus groups with injecting drug users. Two independent researchers analyzed the verbatim transcripts. RESULTS Results revealed that pharmacists often deny access to sterile syringes to IDUs who are frequently stigmatized and intimidated at pharmacies. While no large gender differences in pharmacists' attitudes and practices were observed, inequalities in syringe access were noticed with men IDUs more often denied purchase. Pharmacists had several barriers to sell syringes to IDUs including fear of disease spread, increased drug use, inappropriately discarded syringes, staff and customer safety, and business concerns. IDUs had several challenges to purchase syringes including stigmatization, intimidation, physical harassment, concern to reveal identity, fear of arrest and syringe price abuse. CONCLUSIONS Identifying the barriers to and facilitators of access to sterile syringes to IDUs is important to guide the development of efficient policies. Findings implicate the importance of empowering IDUs to purchase syringes at pharmacies through reducing the negative attitude towards IDUs and strengthening pharmacists' role in the promotion of health of IDUs. Findings also suggest that the habit of syringe sharing would decrease if the legal and cultural barriers to access are reduced.
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Affiliation(s)
- Ali Ghaddar
- a Observatory of Public Policies and Health , Beirut , Lebanon.,b Department of Biomedical Sciences , Lebanese International University , Beirut , Lebanon
| | - Karine Nassar
- c Soins Infirmiers et Developement Communitaire , Beirut , Lebanon
| | - Ghadier Elsoury
- a Observatory of Public Policies and Health , Beirut , Lebanon.,b Department of Biomedical Sciences , Lebanese International University , Beirut , Lebanon
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Roncero C, Fuster D, Palma-Álvarez RF, Rodriguez-Cintas L, Martinez-Luna N, Álvarez FJ. HIV And HCV infection among opiate-dependent patients and methadone doses: the PROTEUS study. AIDS Care 2017; 29:1551-1556. [DOI: 10.1080/09540121.2017.1313384] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Carlos Roncero
- Addiction and Dual Diagnosis Unit, Department of Psychiatry, Vall d’Hebron University Hospital- Public Health Agency, Barcelona (ASPB), CIBERSAM, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Daniel Fuster
- Department of Medicine, Universidad Autónoma de Barcelona, Internal Medicine Service, Badalona (Barcelona), Spain
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Raul Felipe Palma-Álvarez
- Addiction and Dual Diagnosis Unit, Department of Psychiatry, Vall d’Hebron University Hospital- Public Health Agency, Barcelona (ASPB), CIBERSAM, Barcelona, Spain
| | - Laia Rodriguez-Cintas
- Addiction and Dual Diagnosis Unit, Department of Psychiatry, Vall d’Hebron University Hospital- Public Health Agency, Barcelona (ASPB), CIBERSAM, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Nieves Martinez-Luna
- Addiction and Dual Diagnosis Unit, Department of Psychiatry, Vall d’Hebron University Hospital- Public Health Agency, Barcelona (ASPB), CIBERSAM, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - F. Javier Álvarez
- Departament of Pharmacology, Faculty of Medicine, University of Valladolid, Valladolid, Spain
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