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Swartz JA, Zhao P, Jacobucci R, Watson DP, Mackesy-Amiti ME, Franceschini D, Jimenez AD. Associations among drug acquisition and use behaviors, psychosocial attributes, and opioid-involved overdoses. BMC Public Health 2024; 24:1692. [PMID: 38918744 PMCID: PMC11197316 DOI: 10.1186/s12889-024-19217-y] [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: 01/04/2024] [Accepted: 06/20/2024] [Indexed: 06/27/2024] Open
Abstract
AIMS This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses. DESIGN We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. SETTING AND PARTICIPANTS We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe services program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). MEASUREMENTS Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any. FINDINGS The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (β = .234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (β = .683, p < .001) and drug use (β = .567, p = .001). Drug use behaviors (β = .287, p = .04) but not drug acquisition (β = .105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors. CONCLUSIONS Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. Further research is needed to replicate these findings with populations at high-risk of an opioid-related overdose to assess generalizability and refine the metrics used to assess psychosocial characteristics.
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Affiliation(s)
- James A Swartz
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St. MC (309), Chicago, IL, 60612, United States.
| | - Peipei Zhao
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St. MC (309), Chicago, IL, 60612, United States
| | - Ross Jacobucci
- University of Notre Dame, 390 N. Corbett Family Hall, South Bend, IN, 46556, United States
| | - Dennis P Watson
- Lighthouse Institute, Chestnut Health Systems, 221 W Walton St, Chicago, IL, 60610, United States
| | - Mary Ellen Mackesy-Amiti
- Community Outreach Intervention Projects, School of Public Health, University of Illinois Chicago, 1603 W. Taylor St, Chicago, IL, 60612, United States
| | - Dana Franceschini
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St. MC (309), Chicago, IL, 60612, United States
| | - A David Jimenez
- Community Outreach Intervention Projects, School of Public Health, University of Illinois Chicago, 1603 W. Taylor St, Chicago, IL, 60612, United States
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2
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M FM, Doug LM, Peter F, Vivian F G, Wiley J, P Todd K, William M, Mai P, David S, Tom S, Ryan W, William Z, M YA, Lf CH. Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites. Drug Alcohol Depend 2024; 258:111261. [PMID: 38581919 DOI: 10.1016/j.drugalcdep.2024.111261] [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: 09/21/2023] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD. METHODS This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework. RESULTS The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]). CONCLUSION As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.
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Affiliation(s)
- Fadanelli Monica M
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA.
| | | | - Friedmann Peter
- UMass Chan Medical School - Baystate, 3601 Main Street, Springfield, MA 01199, USA
| | - Go Vivian F
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Jenkins Wiley
- SIU School of Medicine, 801 N Rutledge St., Springfield, IL 62702, USA
| | - Korthuis P Todd
- Oregon Health & Science University, School of Medicine, 3266 SW Research Dr, Portland, OR 97239, USA
| | - Miller William
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Pho Mai
- The University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Seal David
- Tulane School of Public Health & Tropical Medicine, 1440 Canal St, New Orleans, LA 70112, USA
| | - Stopka Tom
- Tufts University School of Medicine, Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Westergaard Ryan
- University of Wisconsin, School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705-2281, USA
| | - Zule William
- Research Triangle Park, 3040 East Cornwallis Road, P.O. Box 12194, NC 27709-2194, USA
| | - Young April M
- University of Kentucky, College of Public Health, 111 Washington Ave., Lexington, KY 40536, USA
| | - Cooper Hannah Lf
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA
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Darke S, Duflou J, Peacock A, Farrell M, Lappin J. A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times. Addiction 2024; 119:559-569. [PMID: 37921084 DOI: 10.1111/add.16377] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND AIMS Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation. DESIGN Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System. SETTING This study was conducted Australia-wide. CASES There were 610 cases of fatal heroin-related drug toxicity. MEASUREMENTS Information was collected on characteristics, manner of death, toxicology and autopsy results. FINDINGS The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood. CONCLUSIONS The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Julia Lappin
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- School of Psychiatry, University of New South Wales, Sydney, Australia
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Swartz JA, Zhao P, Jacobucci R, Watson D, Mackesy-Amiti ME, Franceschini D, Jimenez AD. Associations among Drug Acquisition and Use Behaviors, Psychosocial Attributes, and Opioid-Involved Overdoses: A SEM Analysis. RESEARCH SQUARE 2024:rs.3.rs-3834948. [PMID: 38260334 PMCID: PMC10802739 DOI: 10.21203/rs.3.rs-3834948/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Aims This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses. Methods We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe service program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any. Results The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (β=.234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (β=.683, p < .001) and drug use (β=.567, p = .001). Drug use behaviors (β=.287, p = .04) but not drug acquisition (β=.105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors. Conclusions Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. To increase effectiveness, prevention efforts might address the interacting overdose risks that span multiple functional domains.
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van Santen DK, Lodi S, Dietze P, van den Boom W, Hayashi K, Dong H, Cui Z, Maher L, Hickman M, Boyd A, Prins M. Comprehensive needle and syringe program and opioid agonist therapy reduce HIV and hepatitis c virus acquisition among people who inject drugs in different settings: A pooled analysis of emulated trials. Addiction 2023; 118:1116-1126. [PMID: 36710474 PMCID: PMC10175130 DOI: 10.1111/add.16147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/11/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS Although the Netherlands, Canada and Australia were early adopters of harm reduction for people who inject drugs (PWID), their respective HIV and hepatitis C (HCV) epidemics differ. We measured the pooled effect of needle and syringe program (NSP) and opioid agonist therapy (OAT) participation on HIV and HCV incidence in these settings. DESIGN For each cohort, we emulated the design and statistical analysis of a target trial using observational data. SETTING AND PARTICIPANTS We included PWID at risk of HIV or HCV infection from the Amsterdam Cohort Studies (1985-2013), Vancouver Injection Drug Users Study (1997-2009) and Melbourne Injecting Drug User Cohort Study (SuperMIX) (2010-2021). MEASUREMENTS Separately for each infection and cohort (only HCV in SuperMIX), marginal structural models were used to compare the effect of comprehensive (on OAT and 100% NSP coverage or on OAT only if no recent injection drug use) versus no/partial NSP/OAT (no OAT and/or <100% NSP coverage) participation. Pooled hazard ratios (HR) and 95% CI were calculated using random-effects meta-analysis. FINDINGS We observed 94 HIV seroconversions and 81 HCV seroconversions among 2023 and 430 participants, respectively. Comprehensive NSP/OAT led to a 41% lower risk of HIV acquisition (pooled HR = 0.59, 95% CI = 0.36-0.96) and a 76% lower risk of HCV acquisition (pooled HR = 0.24, 95% CI = 0.11-0.51), compared with no/partial NSP/OAT, with little heterogeneity between studies for both infections (I2 = 0%). CONCLUSIONS In the Netherlands, Canada and Australia, comprehensive needle and syringe program and opioid agonist therapy participation appears to substantially reduce HIV and hepatitis C acquisition compared with no or partial needle and syringe program/opioid agonist therapy participation. These findings from an emulated trial design reinforce the critical role of comprehensive access to harm reduction in optimizing infection prevention for people who inject drugs.
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Affiliation(s)
- Daniela K. van Santen
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, The Netherlands
- Department of Disease Elimination, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Paul Dietze
- Department of Disease Elimination, Burnet Institute, Melbourne, Australia
| | | | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Huiru Dong
- British Columbia Centre on Substance Use, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Zishan Cui
- British Columbia Centre on Substance Use, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Lisa Maher
- The Kirby Institute for Infection and Immunity, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anders Boyd
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, The Netherlands
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
- Stichting HIV Monitoring, Amsterdam, The Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, The Netherlands
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
- Amsterdam Institute for Infection and Immunity (AII), Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute (APH), Amsterdam, The Netherlands
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6
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Darke S, Farrell M, Lappin J. Overdose and suicide are different phenomena among opioid users that require different clinical management. Aust N Z J Psychiatry 2023:48674231159298. [PMID: 36872821 DOI: 10.1177/00048674231159298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Given the high rates of mental health comorbidity among opioid users, and increasing rates of opioid prescription for chronic pain, psychiatrists and mental health clinicians are likely to treat patients who are dependent on opioids. Among such patients, many will have histories of opioid overdose or suicide attempts. It is tempting to assume that these are related behaviours and that 'accidental' overdoses are actually suicide attempts. We provide evidence here to demonstrate that while some overdoses are intentional, most are not. More than half of deaths among opioid users are due to unintentional overdose. Suicides constitute a minority: less than 10% of heroin user deaths are estimated to be due to suicide, as are 20-30% of prescribed opioid fatalities. Moreover, suicide attempts are more commonly made using means other than opioids. Overdose and suicide among opioid dependent patients are two distinct phenomena, associated with different risk factors, that need to be separately assessed and their respective risk managed.
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Affiliation(s)
- Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Julia Lappin
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
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Armoon B, Higgs P, Mohammadi R. Mental health status, health service utilization, drug use behaviors associated with non-fatal overdose among people who use illicit drugs: A meta-analysis. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.2019331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, Quebec, Canada
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Peter Higgs
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
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Grebely J, Collins AB, Artenie AA, Sutherland R, Meyer JP, Barocas JA, Falade-Nwulia O, Cepeda JA, Cunningham EB, Hajarizadeh B, Lafferty L, Lazarus JV, Bonn M, Marshall AD, Treloar C. Progress and remaining challenges to address hepatitis C, other infectious diseases, and drug-related harms to improve the health of people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103469. [PMID: 34610884 DOI: 10.1016/j.drugpo.2021.103469] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, Australia.
| | | | | | - Rachel Sutherland
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Jaimie P Meyer
- AIDS Program, Yale School of Medicine, New Haven, United States; Chronic Disease Epidemiology, Yale School of Public Health, New Haven, United States
| | - Joshua A Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado School of Medicine, Aurora, United States
| | - Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Javier A Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health,Baltimore, United States
| | | | | | - Lise Lafferty
- The Kirby Institute, UNSW Sydney, Sydney, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Matthew Bonn
- Canadian Association of People Who Use Drugs, Dartmouth, Canada
| | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
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