The urban built environment and overdose mortality in New York City neighborhoods

Radical hospitality: Innovative programming to build community and meet the needs of people who use drugs at a government-sanctioned overdose prevention site in San Francisco, California

BACKGROUND

The Tenderloin Center (TLC), a multi-service center where people could receive or be connected to basic needs, behavioral health care, housing, and medical services, was open in San Francisco for 46 weeks in 2022. Within a week of operation, services expanded to include an overdose prevention site (OPS), also known as safe consumption site. OPSs have operated internationally for over three decades, but government-sanctioned OPSs have only recently been implemented in the United States. We used ethnographic methods to understand the ways in which a sanctioned OPS, situated in a multi-service center, impacts the lives of people who use drugs (PWUD).

METHODS

We conducted participant observation and in-depth interviews June-December 2022. Extensive field notes and 39 in-depth interviews with 24 TLC guests and 15 TLC staff were analyzed using an inductive analysis approach. Interviewees were asked detailed questions about their experiences using and working at the TLC.

RESULTS

TLC guests and staff described an atmosphere where radical hospitality-welcoming guests with extraordinary warmth, generosity, and unconditional acceptance-was central to the culture. We found that the co-location of an OPS within a multi-service agency (1) allowed for the culture of radical hospitality to flourish, (2) yielded a convenient one-stop shop model, (3) created a space for community building, and (4) offered safety and respite to guests.

CONCLUSIONS

The co-location of an OPS within a multi-service drop-in center is an important example of how such an organization can build positive sociality among PWUD while protecting autonomy and reducing overdose mortality. Overdose response and reversal is an act of relational accountability in which friends, peers, and even strangers intervene to protect and revive one another. This powerful intervention was operationalized as an anti-oppressive, horizontal activity through radical hospitality with a built environment that allowed PWUD to be both social and safe.

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

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

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

BACKGROUND

Recent studies underscore the significance of adopting a syndemics approach to study opioid misuse, overdose, hepatitis C (HCV) and HIV infections, within the broader context of social and environmental contexts in already marginalized communities. Social interactions and spatial contexts are crucial structural factors that remain relatively underexplored. This study examines the intersections of social interactions and spatial contexts around injection drug use. More specifically, we investigate the experiences of different residential groups among young (aged 18-30) people who inject drugs (PWID) regarding their social interactions, travel behaviors, and locations connected to their risk behaviors. By doing so, we aim to achieve a more comprehensive understanding of the multidimensional risk environment, thereby facilitating the development of informed policies.

METHODS

We collected and examined data regarding young PWID's egocentric injection network and geographic activity spaces (i.e., where they reside, inject drugs, purchase drugs, and meet sex partners). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multidimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

RESULTS

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residential group on the West side of Chicago in Illinois where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages. Significant differences were observed in social network structures and travel behaviors: suburban participants had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections, while the urban group had the shortest travel distance for all types of risk activities.

CONCLUSION

Distinct residential groups exhibit varying patterns of network interaction, travel behaviors, and geographical contexts related to their risk behaviors. Nonetheless, these groups share common concentrated risk activity spaces in a large outdoor urban drug market area, underscoring the significance of accounting for risk spaces and social networks in addressing syndemics within PWID populations.

Creation and Validation of a New Socio-built Environment Index Measure of Opioid Overdose Risk for Use in Both Non-urban and Urban Settings

A great deal of literature has examined features of the physical built environment as predictors of opioid overdose and other substance use-related outcomes. Other literature suggests that social characteristics of settings are important predictors of substance use outcomes. However, there is a dearth of literature simultaneously measuring both physical and social characteristics of settings in an effort to better predict opioid overdose. There is also a dearth of literature examining built environment as a predictor of overdose in non-urban settings. The present study presents a novel socio-built environment index measure of opioid overdose risk comprised of indicators measuring both social and physical characteristics of settings - and developed for use in both urban and non-urban settings - and assesses its validity among 565 urban, suburban, and rural New Jersey municipalities. We found that this novel measure had good convergent validity, based on significant positive associations with a social vulnerability index and crime rates, and significant negative associations with a municipal revitalization index and high school graduation rates. The index measure had good discriminant validity, based on lack of association with three different racial isolation indices. Finally, our index measure had good health outcome-based criterion validity, based on significant positive associations with recent overdose mortality. There were no major differences between rural, suburban, and urban municipalities in validity analysis findings. This promising new socio-built environment risk index measure could improve ability to target and allocate resources to settings with the greatest risk, in order to improve their impact on overdose outcomes.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Geo-spatial risk factor analysis for drug overdose death in South Florida from 2014 to 2019, and the independent contribution of social determinants of health

PURPOSE

The physical environment and social determinants of health have been shown to influence health behaviors including drug use and fatal drug overdose. The current research examines the effects of the built environment, social determinants of health measures and aggregated risk from the built environment at neighborhood-level on drug overdose death locations in Miami-Dade County, Florida.

METHODS

Risk Terrain Modeling (RTM) was used to assess the place features risk factors that significantly increase the risk of drug overdose death spatially in Miami-Dade County ZIP Code Tabulation Areas, Florida from 2014 to 2019. An aggregated neighborhood risk of fatal drug overdose measure was developed by averaging the risk per grid cell from the RTM within census block groups each year. Six logistic and zero-inflated regression models were built to examine the effects of three indices of incident-specific social determinants of health (IS-SDH) measures and aggregated risk measures separately, and simultaneously on drug overdose death locations each year.

RESULTS

Seven place features including parks, bus stops, restaurants and grocery stores were significantly related to the occurrence of fatal drug overdoses. When examined separately, one or more indices of the IS-SDH were significant covariates of drug overdose locations in some years. When examined simultaneously, the three indices of the IS-SDH and aggregated risk of fatal drug overdose measure could be all significant in certain years.

CONCLUSIONS

The patterns of high-risk areas and place features identified from the RTM related to drug overdose deaths may be used to inform the placement of treatment and prevention resources. A multi-factor approach that combines an aggregated neighborhood risk measure reflecting the risk from the built environment and the incident-specific social determinants of health measures can be used to identify the drug overdose death locations in certain years.

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

Background

It is estimated that there are 1.5% US adult population who inject drugs in 2018, with young adults aged 18-39 showing the highest prevalence. PWID are at a high risk of many blood-borne infections. Recent studies have highlight the importance of employing the syndemic approach to study opioid misuse, overdose, HCV and HIV, along with the social and environmental contexts where these interrelated epidemics occur in already marginalized communities. Social interactions and spatial contexts are important structural factors that are understudied.

Methods

Egocentric injection network and geographic activity spaces for young (aged 18-30) PWID and their injection, sexual, and social support network members (i.e., where reside, inject drugs, purchase drugs, and meet sex partners) were examined using baseline data from an ongoing longitudinal study (n=258). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multi-dimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

Results

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residence group on the West side of Chicago where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages (e.g., higher poverty rate, p <0.001). Significant ( p <0.01 for all) differences were observed in social network structures: suburban had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections.

Conclusion

We identified concentrated risk activity spaces among PWID from urban, suburban, and transient groups in a large outdoor urban drug market area, which highlights the need for considering the role of risk spaces and social networks in addressing the syndemics in PWID populations.

Lessons Learned from a Citywide Abandoned Housing Experiment

Problem research strategy and findings

The negative impact of vacant and abandoned housing in city neighborhoods is extreme, affecting health and quality of life, promoting violence, and leading to further abandonment. One approach to addressing abandoned housing is to intervene with low-cost interventions that provide a visual sense of ownership. We tested whether a low-cost remediation of abandoned and vacant houses or a trash cleanup intervention would make a noticeable difference in the levels of nearby disrepair, disorder, and public safety. The abandoned housing remediation and trash cleanup interventions were a test of compliance with municipal ordinances. We used an experimental design to test the causal effects of the ordinances, and because the scale of abandonment was too large to provide treatment to all abandoned houses in the city. We used systematic social observation methods to rate changes in disrepair, disorder, and litter at housing sites and on the city blocks they were located, and police reported data on gun violence and illegal substance uses. Our experimental design allowed us to see if observed disrepair, disorder, and public safety improved after working windows and doors were installed on abandoned houses compared with a trash cleanup around properties or a no-intervention control condition. Our results showed significant changes in observed disrepair, disorder, and gun violence and illustrate the benefits of experimental evaluations of place-based changes to the built environment.

Takeaway for practice

Improving compliance with ordinances to remediate abandoned housing can make a noticeable difference in disrepair in neighborhoods and contribute improved public safety. We illustrate how planners can use field experiments in partnership with city agencies, nonprofit community groups, and local universities to discover novel approaches to advance place-based changes to the built environment that can help economically disadvantaged communities abate problems of physical disorder.

Effect of Abandoned Housing Interventions on Gun Violence, Perceptions of Safety, and Substance Use in Black Neighborhoods: A Citywide Cluster Randomized Trial

Importance

Structural racism has resulted in long-standing disinvestment and dilapidated environmental conditions in Black neighborhoods. Abandoned houses signal neglect and foster stress and fear for residents, weakening social ties and potentially contributing to poor health and safety.

Objective

To determine whether abandoned house remediation reduces gun violence and substance-related outcomes and increases perceptions of safety and use of outdoor space.

Design, Setting, and Participants

This cluster randomized trial was conducted from January 2017 to August 2020, with interventions occurring between August 2018 and March 2019. The study included abandoned houses across Philadelphia, Pennsylvania, and surveys completed by participants living nearby preintervention and postintervention. Data analysis was performed from March 2021 to September 2022.

Interventions

The study consisted of 3 arms: (1) full remediation (installing working windows and doors, cleaning trash, weeding); (2) trash cleanup and weeding only; and (3) a no-intervention control.

Main Outcomes and Measures

Difference-in-differences mixed-effects regression models were used to estimate the effect of the interventions on multiple primary outcomes: gun violence (weapons violations, gun assaults, and shootings), illegal substance trafficking and use, public drunkenness, and perceptions of safety and time outside for nearby residents.

Results

A master list of 3265 abandoned houses was randomly sorted. From the top of this randomly sorted list, a total of 63 clusters containing 258 abandoned houses were formed and then randomly allocated to 3 study arms. Of the 301 participants interviewed during the preintervention period, 172 (57.1%) were interviewed during the postintervention period and were included in this analysis; participants were predominantly Black, and most were employed. Study neighborhoods were predominantly Black with high percentages of low-income households. Gun violence outcomes increased in all study arms, but increased the least in the full remediation arm. The full housing remediation arm, compared with the control condition, showed reduced weapons violations by -8.43% (95% CI, -14.68% to -1.19%), reduced gun assaults by -13.12% (95% CI, -21.32% to -3.01%), and reduced shootings by a nonsignificant -6.96% (95% CI, -15.32% to 3.03%). The trash cleanup arm was not associated with a significant differential change in any gun violence outcome. Instances of illegal substance trafficking and use and public drunkenness outcomes were not significantly affected by the housing remediation or trash cleanup treatment. Perceptions of neighborhood safety and time spent outside were unaffected by the intervention. The study arms did differ in a baseline characteristic and some preintervention trends, which raises questions regarding other potential nonmeasured differences between study arms that could have influenced estimates. No evidence of displacement of gun violence outcomes was found.

Conclusions and Relevance

In this cluster randomized controlled trial among low-income, predominantly Black neighborhoods, inexpensive, straightforward abandoned housing remediation was directly linked to significant relative reductions in weapons violations and gun assaults, and suggestive reductions in shootings.

Trial Registration

isrctn.org Identifier: ISRCTN14973997.

Drug overdoses, geographic trajectories, and the influence of built environment and neighborhood characteristics

Much research has analyzed the spatial patterns of drug overdose events and identified features of the environment associated with heightened overdose levels. Generally absent from the literature are studies that analyze how unique trajectories of overdoses vary over time. We address this gap in the literature through an analysis of drug overdoses occurring in Passaic County, New Jersey from 2015 through 2019. A group-based trajectory analysis classifies block groups according to their overdose trends. A mixed-effects panel negative binomial regression model then examines the built environment and neighborhood characteristics associated with overall overdose levels. Results indicate that Passaic County block groups can be classified across three groups based upon their overdose levels over the study period: low and stable, low with moderate increase, and elevated and increasing. While the largest effects were observed for concentrated disadvantage in the regression analysis, most variables positively associated with overdose levels were built environment measures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

City streetscapes and neighborhood characteristics of fatal opioid overdoses among people experiencing homelessness who use drugs in New York City, 2017-2019

BACKGROUND

While housing is a critical social determinant of nonprescription opioid overdose, little is known about how place impacts fatal overdose for people experiencing homelessness (PEH) who use drugs beyond the public versus private domains. This study investigated patterns of neighborhood environment features at locations of fatal overdoses among PEH.

METHODS

We remotely visited locations of opioid-involved fatal overdoses provided by the New York City Office of the Chief Medical Examiner, 2017-2019 (n=3276), with Google Street View and used systematic social observation to assess characteristics of the street block related to drug exposures. We cross-referenced home address with city shelters and supportive housing to identify PEH (n=503). We used the differences of K functions from the spatial point patterns and kernel ratio function maps to identify geographic clusters. We then used logistic regression to identify significant individual-, block-, and neighborhood-level covariates (neighborhood deprivation, segregation, population density).

RESULTS

Over half (55.9%, n=281) of fatal overdoses among PEH occurred in supportive housing or shelters, and 15.5% (n=78) occurred in public spaces (e.g., parks). Spatial analyses identified areas of significant concentrated fatal overdoses among PEH in Manhattan, the South Bronx, and Brooklyn. We identified several significant indicators of physical and social order and disorder associated with increased odds of experiencing homelessness at time of fatal overdose, including construction/renovation, graffiti, traffic calming features, and loitering.

CONCLUSION

Harm reduction services should be co-located in facilities that serve PEH and targeted to street blocks with indicators of physical and social disorder. While supportive housing is a crucial step in preventing fatal opioid overdoses among PEH, identifying neighborhoods for intervention services delivery and harm reduction outreach for PEH is necessary.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Conceptualizing the Socio-Built Environment: An Expanded Theoretical Framework to Promote a Better Understanding of Risk for Nonmedical Opioid Overdose Outcomes in Urban and Non-Urban Settings

Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs.

Impact of a publicly funded pharmacy-dispensed naloxone program on fatal opioid overdose rates: A population-based study

BACKGROUND

Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths.

METHODS

We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units.

RESULTS

In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates.

CONCLUSION

The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.

Understanding the role of urban social and physical environment in opioid overdose events using found geospatial data

Opioid use disorder is a serious public health crisis in the United States. Manifestations such as opioid overdose events (OOEs) vary within and across communities and there is growing evidence that this variation is partially rooted in community-level social and economic conditions. The lack of high spatial resolution, timely data has hampered research into the associations between OOEs and social and physical environments. We explore the use of non-traditional, "found" geospatial data collected for other purposes as indicators of urban social-environmental conditions and their relationships with OOEs at the neighborhood level. We evaluate the use of Google Street View images and non-emergency "311" service requests, along with US Census data as indicators of social and physical conditions in community neighborhoods. We estimate negative binomial regression models with OOE data from first responders in Columbus, Ohio, USA between January 1, 2016, and December 31, 2017. Higher numbers of OOEs were positively associated with service request indicators of neighborhood physical and social disorder and street view imagery rated as boring or depressing based on a pre-trained random forest regression model. Perceived safety, wealth, and liveliness measures from the street view imagery were negatively associated with risk of an OOE. Age group 50-64 was positively associated with risk of an OOE but age 35-49 was negative. White population, percentage of individuals living in poverty, and percentage of vacant housing units were also found significantly positive however, median income and percentage of people with a bachelor's degree or higher were found negative. Our result shows neighborhood social and physical environment characteristics are associated with likelihood of OOEs. Our study adds to the scientific evidence that the opioid epidemic crisis is partially rooted in social inequality, distress and underinvestment. It also shows the previously underutilized data sources hold promise for providing insights into this complex problem to help inform the development of population-level interventions and harm reduction policies.

Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis

BACKGROUND

Drug overdose rates in the United States have been steadily increasing, particularly in rural areas. The COVID-19 pandemic and associated mitigation strategies may have increased overdose risk for people who use drugs by impacting social, community, and structural factors.

METHODS

The study included a quantitative survey focused on COVID-19 administered to 50 people who use drugs and semi-structured qualitative interviews with 17 people who use drugs, 12 of whom also participated in the quantitative survey. Descriptive statistics were run for the quantitative data. Qualitative coding was line-by-line then grouped thematically. Quantitative and qualitative data were integrated during analysis.

RESULTS

Findings demonstrate how COVID-19 disruptions at the structural and community level affected outcomes related to mental health and drug use at the individual level. Themes that emerged from the qualitative interviews were (1) lack of employment opportunities, (2) food and housing insecurity, (3) community stigma impacting health service use, (4) mental health strains, and (5) drug market disruptions. Structural and community changes increased anxiety, depression, and loneliness on the individual level, as well as changes in drug use patterns, all of which are likely to increase overdose risk.

CONCLUSION

The COVID-19 pandemic, and mitigation strategies aimed at curbing infection, disrupted communities and lives of people who use drugs. These disruptions altered individual drug use and mental health outcomes, which could increase risk for overdose. We recommend addressing structural and community factors, including developing multi-level interventions, to combat overdose. Trial registration Clinicaltrails.gov: NCT04427202. Registered June 11, 2020: https://clinicaltrials.gov/ct2/show/NCT04427202?term=pho+mai&draw=2&rank=3.

The leading neighborhood-level predictors of drug overdose: A mixed machine learning and spatial approach

BACKGROUND

Drug overdose is a leading cause of unintentional death in the United States and has contributed significantly to a decline in life expectancy during recent years. To combat this health issue, this study aims to identify the leading neighborhood-level predictors of drug overdose and develop a model to predict areas at the highest risk of drug overdose using geographic information systems and machine learning (ML) techniques.

METHOD

Neighborhood-level (block group) predictors were grouped into three domains: socio-demographic factors, drug use variables, and protective resources. We explored different ML algorithms, accounting for spatial dependency, to identify leading predictors in each domain. Using geographically weighted regression and the best-performing ML algorithm, we combined the output prediction of three domains to produce a final ensemble model. The model performance was validated using classification evaluation metrics, spatial cross-validation, and spatial autocorrelation testing.

RESULTS

The variables contributing most to the predictive model included the proportion of households with food stamps, households with an annual income below $35,000, opioid prescription rate, smoking accessories expenditures, and accessibility to opioid treatment programs and hospitals. Compared to the error estimated from normal cross-validation, the generalized error of the model did not increase considerably in spatial cross-validation. The ensemble model using ML outperformed the GWR method.

CONCLUSION

This study identified strong neighborhood-level predictors that place a community at risk of experiencing drug overdoses, as well as protective factors. Our findings may shed light on several specific avenues for targeted intervention in neighborhoods at risk for high drug overdose burdens.

Alcohol outlets, drug paraphernalia sales, and neighborhood drug overdose

BACKGROUND

Alcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association.

METHODS

A cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly.

RESULTS

Each additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose.

CONCLUSION

This study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.

How urban and rural built environments influence the health attitudes and behaviors of people who use drugs

Research suggests that the built environment is associated with drug use. However, there is limited scholarship focusing on specific features of the built environment that influence drug use behaviors, experiences, and patterns and how risk factors for drug use are placed in distinctive urban and rural settings. Applying Neely and Samura's conceptual theory that describes space as contested, fluid and historical, interactional and relational, and defined by inequality and difference, we assessed data from semi-structured qualitative interviews conducted between 2019 and 2020 with consumers at syringe exchange programs (SEPs) in an urban location (New York City) and a rural location (southern Illinois). We aimed to contextualize how drug use manifests in each space. In total, 65 individuals, including 59 people who use drugs (PWUD) and six professionals who worked with PWUD, were interviewed. Findings illustrate that, in both the urban and rural setting, the built environment regulates the drug use milieu by mediating social reproduction, namely the degree of agency PWUD exert to acquire and use drugs where they desire. Processes of "stigma zoning," defined as socio-spatial policing of boundaries of behavior deemed undesirable or deviant, impacted PWUD's socio-geographic mobility, social conditions, and resource access, and modulated PWUD's broader capacity and self-efficacy. Similar patterns of drug use, according to social and economic inequities chiefly related to housing instability, were further observed in both settings.

Longitudinal Study of Hurricane Preparedness Behaviors: Influence of Collective Efficacy

OBJECTIVE

Community characteristics, such as collective efficacy, a measure of community strength, can affect behavioral responses following disasters. We measured collective efficacy 1 month before multiple hurricanes in 2005, and assessed its association to preparedness 9 months following the hurricane season.

METHODS

Participants were 631 Florida Department of Health workers who responded to multiple hurricanes in 2004 and 2005. They completed questionnaires that were distributed electronically approximately 1 month before (6.2005-T1) and 9 months after (6.2006-T2) several storms over the 2005 hurricane season. Collective efficacy, preparedness behaviors, and socio-demographics were assessed at T1, and preparedness behaviors and hurricane-related characteristics (injury, community-related damage) were assessed at T2. Participant ages ranged from 21-72 (M(SD) = 48.50 (10.15)), and the majority were female (78%).

RESULTS

In linear regression models, univariate analyses indicated that being older (B = 0.01, SE = 0.003, P < 0.001), White (B = 0.22, SE = 0.08, P < 0.01), and married (B = 0.05, SE = 0.02, p < 0.001) was associated with preparedness following the 2005 hurricanes. Multivariate analyses, adjusting for socio-demographics, preparedness (T1), and hurricane-related characteristics (T2), found that higher collective efficacy (T1) was associated with preparedness after the hurricanes (B = 0.10, SE = 0.03, P < 0.01; and B = 0.47, SE = 0.04, P < 0.001 respectively).

CONCLUSION

Programs enhancing collective efficacy may be a significant part of prevention practices and promote preparedness efforts before disasters.

"It's Helped Me a Lot, Just Like to Stay Alive": a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada

North America is experiencing an overdose crisis driven by fentanyl, related analogues, and fentanyl-adulterated drugs. In response, there have been increased calls for "safe supply" interventions based on the premise that providing a safer alternative (i.e., pharmaceutical drugs of known quality/quantity, non-adulterated, with user agency in consumption methods) to the street drug supply will limit people's use of fentanyl-adulterated drugs and reduce overdose events. This study examined outcomes of a hydromorphone tablet distribution program intended to prevent overdose events among people who use drugs (PWUD) at high risk of fatal overdose. Semi-structured qualitative interviews were conducted with 42 people enrolled in the hydromorphone distribution program. Additionally, over 100 h of ethnographic observation were undertaken in and around the study site. Transcripts were coded using NVivo and based on categories extracted from the interview guides and those identified during initial interviews and ethnographic fieldwork. Analysis focused on narratives around experiences with the program, focusing on program-related outcomes. Our analysis identified the following positive outcomes of being enrolled in the hydromorphone tablet distribution program: (1) reduced street drug use and overdose risk, (2) improvements to health and well-being, (3) improvements in co-management of pain, and (4) economic improvements. Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people's use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality. Safe supply programs should be further implemented and evaluated in both urban and rural setting across North America as a strategy to reduce exposure to the toxic drug supply and fatal overdose.

Examining the neighborhood-level socioeconomic characteristics associated with fatal overdose by type of drug involved and overdose setting

BACKGROUND

Fatal drug overdose in the United States is a public health crisis fueled by increased opioid and polysubstance use. Few studies have compared the neighborhood-level socioeconomic characteristics associated with overdoses of various substance classes and, to our knowledge, no investigation has yet assessed these factors in relation to polysubstance overdoses. Further, no study has determined whether socioeconomic conditions predict other contextually relevant aspects of overdoses such as whether they occur at-home or out-of-home.

METHODS

Overdose data (2015-2018) were obtained from the Coroner/Medical Examiner's Office of Jefferson County, Alabama. The toxicology results of decedents with a known overdose locations (N = 768) were assessed for the presence of synthetic opioids, natural and semi-synthetic opioids, heroin, stimulants, benzodiazepines, and alcohol. Socioeconomic characteristics were obtained from the Unites States Census Bureau at the census tract level.

RESULTS

Stimulant overdoses occurred in neighborhoods with the highest rates of disadvantage relative to other substance and polysubstance overdose types. The majority of included overdoses occurred at-home (63.7%) and an index of socioeconomic disadvantage predicted overdose rates for both at-home and out-of-home overdoses. Heroin overdose deaths were more likely to occur at-home while polysubstance stimulant-heroin overdoses were more common out-of-home.

CONCLUSIONS

An index of socioeconomic disadvantage was generally predictive of overdose, regardless of the setting in which the overdose occurred (in-home vs. out-of-home). The associations between neighborhood-level socioeconomic characteristics and fatal overdose can be tailored by substance type to create targeted interventions. Overdose setting may be an important consideration for future policy efforts, as overdoses were nearly twice as likely to occur at-home.

Exploring the Influence of Drug Trafficking Gangs on Overdose Deaths in the Largest Narcotics Market in the Eastern United States

Research has found that drug markets tend to cluster in space, potentially because of the profit that can be made when customers are drawn to areas with multiple suppliers. But few studies have examined how these clusters of drug markets—which have been termed “agglomeration economies”—may be related to accidental overdose deaths, and in particular, the spatial distribution of mortality from overdose. Focusing on a large neighborhood in Philadelphia, Pennsylvania, known for its open-air drug markets, this study examines whether deaths from accidental drug overdose are clustered around street corners controlled by drug trafficking gangs. This study incorporates theoretically-informed social and physical environmental characteristics of street corner units into the models predicting overdose deaths. Given a number of environmental changes relevant to drug use locations was taking place in the focal neighborhood during the analysis period, the authors first employ a novel concentration metric—the Rare Event Concentration Coefficient—to assess clustering of overdose deaths annually between 2015 and 2019. The results of these models reveal that overdose deaths became less clustered over time and that the density was considerably lower after 2017. Hence, the predictive models in this study are focused on the two-year period between 2018 and 2019. Results from spatial econometric regression models find strong support for the association between corner drug markets and accidental overdose deaths. In addition, a number of sociostructural factors, such as concentrated disadvantage, and physical environmental factors, particularly blighted housing, are associated with a higher rate of overdose deaths. Implications from this study highlight the need for efforts that strategically coordinate law enforcement, social service provision and reductions in housing blight targeted to particular geographies.

Geographic variation in the provision of naloxone by pharmacies in Ontario, Canada: A population-based small area variation analysis

BACKGROUND

Regional variation in pharmacy-dispensed naloxone rates could create access disparities that undermine the effectiveness of this approach. We explored individual and public health unit (PHU)-level determinants of regional variation in naloxone distribution through the Ontario Naloxone Program for Pharmacies.

METHODS

We conducted a population-based study between April 1, 2017 and March 31, 2018. We calculated age- and sex-standardized pharmacy-dispensed naloxone rates for the 35 Ontario PHUs, and identified determinants of these rates using generalized estimating equations negative binomial regression.

RESULTS

The age- and sex-standardized pharmacy-dispensed naloxone rate in Ontario was 5.5 (range 1.8-11.6) kits per 1000 population. Variables associated with higher naloxone dispensing rates included opioid use disorder history [rate ratio (RR) 2.27; 95% confidence interval (CI) 1.75-2.96], opioid agonist therapy (RR 11.17; 95% CI 7.15-17.44), and PHU opioid overdose rate (RR 1.09 per 10 deaths; 95% CI 1.06-1.13). Pharmacy-dispensed naloxone rates were lower in rural areas (RR 0.83; 95% CI 0.73-0.94) and among individuals dispensed one (RR 0.72; 95% CI 0.65-0.79), two to five (RR 0.67; 95% CI 0.54-0.84) or 6-10 (RR 0.92; 95% CI 0.74-1.14) opioids in the prior year relative to those receiving no opioids.

CONCLUSION

Pharmacy-dispensed naloxone programs are important components of a public health response to the opioid overdose crisis. We found considerable variation in pharmacy-dispensed naloxone rates that could limit program effectiveness, particularly in rural settings with limited access to health and harm reduction services..

COVID-19 and overdose prevention: Challenges and opportunities for clinical practice in housing settings

The global coronavirus disease 2019 (COVID-19) will exacerbate the negative health outcomes associated with the concurrent opioid overdose crisis in North America. COVID-19 brings unique challenges for practitioners who provide opioid use disorder (OUD) care. The majority of overdose deaths in the Canadian province of British Columbia occur in housing environments. Some supportive housing environments in Vancouver, British Columbia, have on-site primary care and substance use disorder treatment clinics. Some of these housing environments also include supervised consumption services. These housing environments needed to make adjustments to their care to adhere to COVID-19 physical distancing measures. Such adjustments included a pandemic withdrawal management program to provide patients with a pharmaceutical grade alternative to the toxic illicit drug supply, which allow patients to avoid the heightened overdose risk while using illicit drugs alone or potentially exposing themselves to COVID-19 while using drugs in a group setting. Other modifications to the OUD care continuum included modified supervised injection spaces to adhere to physical distancing, the use of personal protective equipment for overdose response, virtual platforms for clinical encounters, writing longer prescriptions, and providing take-home doses to promote opioid agonist treatment retention. These strategies aim to mitigate indoor overdose risk while also addressing COVID-19 risks.

•

Individuals with opioid use disorder who use illicit opioids indoors are at highest risk of overdose morbidity and mortality

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Dual epidemics of COVID-19 and opioid overdose may render individuals at higher risk of COVID-19 complications and overdose

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Novel strategies must be prioritized to keep individuals safe from infection and to address overdose risks in indoor settings

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Novel treatments to mitigate indoor overdose risks such as pandemic withdrawal management are highlighted

Associations between neighborhood-level factors and opioid-related mortality: A multi-level analysis using death certificate data

AIM

To identify associations between opioid-related mortality and neighborhood-level risk factors.

DESIGN

Cross-sectional study.

SETTING

Massachusetts, USA.

PARTICIPANTS

Using 2011-14 Massachusetts death certificate data, we identified opioid-related (n = 3089) and non-opioid-related premature deaths (n = 8729).

MEASUREMENTS

The independent variables consisted of four sets of neighborhood-level factors: (1) psychosocial, (2) economic, (3) built environment and (4) health-related. At the individual level we included the following compositional factors: age at death, sex, race/ethnicity, marital status, education, veteran status and nativity. The primary outcome of interest was opioid-related mortality.

FINDINGS

Multi-level models identified number of social associations per 10 000 [odds ratio (OR) = 0.84, P = 0.002, 95% confidence interval (CI) = 0.75-0.94] and number of hospital beds per 10 000 (OR = 0.78, P < 0.001, 95% CI = 0.68-0.88) to be inversely associated with opioid-related mortality, whereas the percentage living in poverty (OR = 1.01, P = 0.008, 95% CI = 1.00-1.01), food insecurity rate (OR = 1.21, P = 0.002, 95% CI = 1.07-1.37), number of federally qualified health centers (OR = 1.02, P = 0.028, 95% CI = 1.02-1.08) and per-capita morphine milligram equivalents of hydromorphone (OR = 1.05, P = 0.003, 95% CI = 1.01-1.08) were positively associated with opioid-related mortality.

CONCLUSIONS

Opioid-related deaths between 2011 and 2014 in the state of Massachusetts appear to be positively associated with the percentage living in poverty, food insecurity rate, number of federally qualified health centers and per-capita morphine milligram equivalents of hydromorphone, but inversely associated with number of social associations per 10 000 and number of hospital beds per 10 000.

The ecology of overdose mortality in Philadelphia

Fatal drug overdose represents a significant public health threat in Philadelphia, but substantial variation exists across its communities. This study uses negative binomial longitudinal regression to model ZIP code overdose fatalities over a seven-year period. Model covariates indicate that structural inequality, police arrest activity, and features of the built environment are associated with increased mortality across ZIP codes. Additionally, fatalities are spatially concentrated in select geographies of the city. These findings emphasize the pertinence of community ecological features in the production of stratified within-city health outcomes, and inform the geographic distribution of harm reduction interventions.

Home and health among people living with HIV who use drugs: A qualitative study

INTRODUCTION

Housing is a critical determinant of HIV-related outcomes among people living with HIV (PLHIV) who use drugs, including on HIV treatment adherence. Research shows that sense of home may have important implications for mitigating harms associated with low-income housing environments among PLHIV who use drugs, but how this shapes treatment is poorly understood.

METHODS

Semi-structured interviews were conducted with 31 PLHIV who use drugs recruited from an ongoing prospective cohort in Vancouver, Canada. Recruitment was targeted towards individuals living in single room occupancy housing who had previously reported low treatment adherence. Interviews were co-led with a peer research assistant, and focused on housing conditions, drug use patterns, and HIV management. Interviews were transcribed, analyzed thematically, and interpreted by drawing on concepts of home and place-making.

RESULTS

The ability to exert control over housing environments contributed to participants' perceptions of home by fostering feelings of safety and allowing for creation of personalized space. Participants readily identified the importance of housing stability and quality in maintaining health (e.g. food storage, pest-free), including HIV care. However, informed by social-structural mechanisms that undermined agency, negative experiences of home adversely impacted treatment adherence.

CONCLUSIONS

Findings indicate that sense of home may enable ability to manage HIV care, and is promoted through feelings of security within, and control over, housing environments. Supports in navigating competitive housing markets are needed to address the role that home plays in HIV treatment adherence.

Pharmacies and features of the built environment associated with opioid overdose: A geospatial comparison of rural and urban regions in Alabama, USA

BACKGROUND

Elements of the physical environment have been shown to influence health behaviors including drug use and overdose mortality. Throughout the opioid epidemic in the United States, rural regions have been disproportionately affected by opioid overdose. Although the relationship between the urban built environment and opioid overdose has been established, little is known as to how trends may differ in rural areas.

METHODS

Risk terrain modeling was used as a spatial analytical approach to assess environmental features that significantly increase the risk of opioid overdose in Jefferson County, Alabama. Spatial risk assessments were conducted for urban and rural regions as well as for the county as a whole. Criminogenic, opioid-related, and community variables were included and compared across spatial risk models.

RESULTS

The geographic context, rural or urban, influenced the relationship between environmental features and opioid overdose. In rural areas, community features such as bus stops and public schools were related to the occurrence of opioid overdose. In urban areas, inpatient treatment centers, transitional living facilities, express loan establishments, and liquor vendors were significantly related to the locations of opioid overdose.

CONCLUSION

Risk terrain modeling can be used to locate high-risk areas for opioid overdose while identifying factors that are contributing to the risk of events occurring in communities. The patterns of overdose risk differ in rural and urban contexts and may be used to inform the placement of treatment and prevention resources.

Urban gentrification and declining access to HIV/STI, sexual health, and outreach services amongst women sex workers between 2010-2014: Results of a community-based longitudinal cohort

Despite increasing gentrification across North American cities, little is known about impacts on work and living environments and health access for marginalized women. Drawing upon prospective cohort and external spatial data, we examined changes in land use and sex workers' work/living environments in relation to gentrification exposure in Metro Vancouver (2010-2014), and modeled independent effects of gentrification exposure on reduced utilization of HIV/STI testing, sexual health, and sex worker support services. These decreases occurred despite efforts to scale-up HIV services for marginalized populations. Planning of healthcare, housing, and other support services should be responsive to shifting urban landscapes for marginalized women.

Multivariate spatiotemporal modeling of drug- and alcohol-poisoning deaths in New York City, 2009-2014

Drug- and alcohol-poisoning deaths remain current public health problems. Studies to date have typically focused on individual-level predictors of drug overdose deaths, and there remains a limited understanding of the spatiotemporal patterns and predictors of the joint outcomes. We use a hierarchical Bayesian spatiotemporal multivariate Poisson regression model on data from (N = 167) ZIP-codes between 2009 and 2014 in New York City to examine the spatiotemporal patterns of the joint occurrence of drug (opioids) and alcohol-poisoning deaths, and the covariates associated with each outcome. Results indicate that rates of both outcomes were highly positively correlated across ZIP-codes (cross-correlation: 0.57, 95% credible interval (CrI): 0.29, 0.77). ZIP-codes with a higher prevalence of heavy drinking had higher alcohol-poisoning deaths (relative risk (RR):1.63, 95% CrI: 1.26, 2.05) and drug-poisoning deaths (RR: 1.29, 95% CrI: 1.03, 1.59). These spatial patterns may guide public health planners to target specific areas to address these co-occurring epidemics.

Association of the Robert Wood Johnson Foundations' Social Determinants of Health and Medicare Ocular Hospitalizations: A Cross Sectional Data Analysis

INTRODUCTION

Social determinants of health (SDH) may influence inpatient utilization rates and outcomes but have yet to be associated with ocular diagnoses. The purpose of this paper was to determine whether the SDH are associated with ocular hospitalizations.

METHODS

Patients from the national Medicare 100% Inpatient Limited Dataset were examined and linked to SDH measures from the Robert Wood Johnson Foundation (RWJF) County Health Rankings. Patients were included in the study group with either an admitting or primary diagnosis of an ophthalmic condition. All other hospitalized Medicare patients served in the comparison group. Nested logistic regression of these Medicare patients was conducted in their respective communities at the county level. SDH measures were benchmarked above or below the national median.

RESULTS

Positively associated SDH factors included communities with air pollution exceeding 11.62 micro grams per cubic meter (OR 1.05; 95% CI 1.01-1.08), communities where severe housing problems exceeding 14.38% (OR 1.13; 95% CI 1.09-1.18), children in single parent households exceeding 32.13% (OR 1.06; 95% CI 1.02-1.11), violent crime rate exceeding 250.54 per 100,000 (OR 1.07; 95% CI 1.03-1.12), diabetes exceeding 10.95% (OR 1.09: 95% CI 1.04-1.14), and drug poisoning deaths including opioids exceeding 14.17 per 100,000 (OR 1.04; 95% CI 1.01-1.08).

CONCLUSION

When compared to an all-condition, hospitalized population, ocular hospitalizations tended to have small, yet statistically significant associations with health behaviors, socioeconomic, and physical environment factors. Further research will be needed on how the physical environment, social, and community variables affect ocular health relative to all-cause hospitalizations.

Military veterans' overdose risk behavior: Demographic and biopsychosocial influences

BACKGROUND

U.S. military veterans face many biopsychosocial (BPS) challenges post-service that may elevate risk for opioid-related overdose including physical pain, mental health concerns and social stressors. Some veterans use opioids to manage pain and cope with social readjustment. This study assessed associations between BPS factors and recent engagement in overdose risk behavior in a community sample of post-9/11 veterans who used opioids in New York City.

METHODS

Participants (n = 218) were recruited through convenience sampling and completed a baseline assessment including a validated Opioid Risk Behavior Scale (ORBS) that measured past-30-day engagement in 22 opioid-related overdose risk behaviors. Analyses examined associations between ORBS scores and hypothesized demographic, biological/physical, psychological and social predictors. Incident rate ratios estimated the expected relative difference in ORBS score associated with each predictor.

RESULTS

Participants reported an average of 4.72 overdose risk behaviors in the past 30 days. Significant independent predictors of higher ORBS score, after adjustment for demographics and current prescription medications, were past-30-day: depression symptoms; unsheltered or living in a homeless shelter (vs. private housing); history of mental health treatment; experiencing stressful life events; average pain severity; and pain interference.

CONCLUSION

Veterans face myriad BPS challenges and, while drug-related overdose risks are well understood, findings suggest that other factors-including mental health, pain and stressful life events-may also be associated with overdose risk among opioid-using veterans. The larger challenges veterans face should be considered in the context of BPS forms of pain management when tailoring and delivering overdose prevention interventions.

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

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

The epidemiology of opioid overdose in Flint and Genesee County, Michigan: Implications for public health practice and intervention

As the opioid epidemic continues to worsen throughout the United States, researchers and practitioners require additional tools to help in efforts to address use and prevent overdose. Although opioids are increasingly of concern to all racial and socioeconomic groups, specific geographic regions and sub-populations remain more burdened by overdoses than others. The example of Flint, Michigan, is used to contextualize the landscape of opioid overdose death and understand geographic and demographic variation in risk. Kernel density analysis and spatial joins in ArcGIS were used to map opioid overdose death clusters, treatment availability, and neighborhood-level conditions to uncover factors related to overdose death. Spatial analysis revealed three geographic clusters in opioid overdose death in Flint. These neighborhoods tended to be somewhat poorer but also significantly Whiter than the average Flint neighborhood. Alternatively, opioid overdose death clusters did not occur in predominately African-American neighborhoods. As well, treatment sites were not coincident with the location of overdose death clusters, suggesting a potential need for geographically-targeted interventions. Of the 47 treatment sites, only 29 offered medication-assisted treatment, and expansion of these programs may therefore be warranted. This work is of great importance to ongoing prevention and treatment efforts in Flint, but also to other communities with a need for better tools to monitor and intervene in the opioid epidemic.

Expanding Tools for Investigating Neighborhood Indicators of Drug Use and Violence: Validation of the NIfETy for Virtual Street Observation

A growing body of evidence suggests that characteristics of the neighborhood environment in urban areas significantly impact risk for drug use behavior and exposure to violent crime. Identifying areas of community need, prioritizing planning projects, and developing strategies for community improvement require inexpensive, easy to use, evidence-based tools to assess neighborhood disorder that can be used for a variety of research, urban planning, and community needs with an environmental justice frame. This study describes validation of the Neighborhood Inventory for Environmental Typology (NIfETy), a neighborhood environmental observational assessment tool designed to assess characteristics of the neighborhood environment related to violence, alcohol, and other drugs, for use with Google Street View (GSV). GSV data collection took place on a random sample of 350 blocks located throughout Baltimore City, Maryland, which had previously been assessed through in-person data collection. Inter-rater reliability metrics were strong for the majority of items (ICC ≥ 0.7), and items were highly correlated with in-person observations (r ≥ 0.6). Exploratory factor analysis and constrained factor analysis resulted in one, 14-item disorder scale with high internal consistency (alpha = 0.825) and acceptable fit indices (CFI = 0.982; RMSEA = 0.051). We further validated this disorder scale against locations of violent crimes, and we found that disorder score was significantly and positively associated with neighborhood crime (IRR = 1.221, 95% CI = (1.157, 1.288), p < 0.001). The NIfETy provides a valid, economical, and efficient tool for assessing modifiable neighborhood risk factors for drug use and violence prevention that can be employed for a variety of research, urban planning, and community needs.

Using Web-Based Pin-Drop Maps to Capture Activity Spaces Among Young Adults Who Use Drugs in Rural Areas: Cross-Sectional Survey

Background

Epicenters of harmful drug use are expanding to US rural areas, with rural young adults bearing a disproportionate burden. A large body of work suggests that place characteristics (eg, spatial access to health services) shape vulnerability to drug-related harms among urban residents. Research on the role of place characteristics in shaping these harms among rural residents is nascent, as are methods of gathering place-based data.

Objective

We (1) analyzed whether young rural adults who used drugs answered self-administered Web-based mapping items about locations where they engaged in risk behaviors and (2) determined the precision of mapped locations.

Methods

Eligible individuals had to report recently using opioids to get high; be aged between 18 and 35 years; and live in the 5-county rural Appalachian Kentucky study area. We used targeted outreach and peer-referral methods to recruit participants. The survey asked participants to drop a pin in interactive maps to mark where they completed the survey, and where they had slept most; used drugs most; and had sex most in the past 6 months. Precision was assessed by (1) determining whether mapped locations were within 100 m of a structure and (2) calculating the Euclidean distance between the pin-drop home location and the street address where participants reported sleeping most often. Measures of central tendency and dispersion were calculated for all variables; distributions of missingness for mapping items and for the Euclidean distance variable were explored across participant characteristics.

Results

Of the 151 participants, 88.7% (134/151) completed all mapping items, and ≥92.1% (>139/151) dropped a pin at each of the 4 locations queried. Missingness did not vary across most participant characteristics, except that lower percentages of full-time workers and peer-recruited participants mapped some locations. Two-thirds of the pin-drop sex and drug use locations were less than 100 m from a structure, as were 92.1% (139/151) of pin-drop home locations. The median distance between the pin-drop and street-address home locations was 2.0 miles (25th percentile=0.8 miles; 75th percentile=5.5 miles); distances were shorter for high-school graduates, staff-recruited participants, and participants reporting no technical difficulties completing the survey.

Conclusions

Missingness for mapping items was low and unlikely to introduce bias, given that it varied across few participant characteristics. Precision results were mixed. In a rural study area of 1378 square miles, most pin-drop home addresses were near a structure; it is unsurprising that fewer drug and sex locations were near structures because most participants reported engaging in these activities outside at times. The error in pin-drop home locations, however, might be too large for some purposes. We offer several recommendations to strengthen future research, including gathering metadata on the extent to which participants zoom in on each map and recruiting participants via trusted staff.

Characterizing the Rural Opioid Use Environment in Kentucky Using Google Earth: Virtual Audit

Background

The opioid epidemic has ravaged rural communities in the United States. Despite extensive literature relating the physical environment to substance use in urban areas, little is known about the role of physical environment on the opioid epidemic in rural areas.

Objective

This study aimed to examine the reliability of Google Earth to collect data on the physical environment related to substance use in rural areas.

Methods

Systematic virtual audits were performed in 5 rural Kentucky counties using Google Earth between 2017 and 2018 to capture land use, health care facilities, entertainment venues, and businesses. In-person audits were performed for a subset of the census blocks.

Results

We captured 533 features, most of which were images taken before 2015 (71.8%, 383/533). Reliability between the virtual audits and the gold standard was high for health care facilities (>83%), entertainment venues (>95%), and businesses (>61%) but was poor for land use features (>18%). Reliability between the virtual audit and in-person audit was high for health care facilities (83%) and entertainment venues (62%) but was poor for land use (0%) and businesses (12.5%).

Conclusions

Poor reliability for land use features may reflect difficulty characterizing features that require judgment or natural changes in the environment that are not reflective of the Google Earth imagery because it was captured several years before the audit was performed. Virtual Google Earth audits were an efficient way to collect rich neighborhood data that are generally not available from other sources. However, these audits should use caution when the images in the observation area are dated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using Google Street View to examine associations between built environment characteristics and U.S. health outcomes

Neighborhood attributes have been shown to influence health, but advances in neighborhood research has been constrained by the lack of neighborhood data for many geographical areas and few neighborhood studies examine features of nonmetropolitan locations. We leveraged a massive source of Google Street View (GSV) images and computer vision to automatically characterize national neighborhood built environments. Using road network data and Google Street View API, from December 15, 2017-May 14, 2018 we retrieved over 16 million GSV images of street intersections across the United States. Computer vision was applied to label each image. We implemented regression models to estimate associations between built environments and county health outcomes, controlling for county-level demographics, economics, and population density. At the county level, greater presence of highways was related to lower chronic diseases and premature mortality. Areas characterized by street view images as 'rural' (having limited infrastructure) had higher obesity, diabetes, fair/poor self-rated health, premature mortality, physical distress, physical inactivity and teen birth rates but lower rates of excessive drinking. Analyses at the census tract level for 500 cities revealed similar adverse associations as was seen at the county level for neighborhood indicators of less urban development. Possible mechanisms include the greater abundance of services and facilities found in more developed areas with roads, enabling access to places and resources for promoting health. GSV images represents an underutilized resource for building national data on neighborhoods and examining the influence of built environments on community health outcomes across the United States.

Social Networks of Substance-Using Populations: Key Issues and Promising New Approaches for HIV

PURPOSE OF REVIEW

This paper presents recent literature on substance using networks and HIV, highlighting renewed and emerging themes in the field. The goal is to draw attention to research that holds considerable promise for advancing our understanding of the role of networks in shaping behaviors, while also providing critical information for the development of interventions, programs, and policies to reduce HIV and other drug-related harms.

RECENT FINDINGS

Recent research advances our understanding of networks and HIV, including among understudied populations, and provides new insight into how risk environments shape the networks and health of substance-using populations. In particular, the integration of network approaches with molecular epidemiology, research on space and place, and intervention methods provides exciting new avenues of investigation. Continued advances in network research are critical to supporting the health and rights of substance-using populations and ensuring the development of high-impact HIV programs and policies.

Addressing Intersecting Housing and Overdose Crises in Vancouver, Canada: Opportunities and Challenges from a Tenant-Led Overdose Response Intervention in Single Room Occupancy Hotels

We examined the acceptability, feasibility, and implementation of the Tenant Overdose Response Organizers program (TORO)-a tenant-led naloxone training and distribution intervention. This pilot project was implemented in privately owned single room occupancy (SRO) hotels that were disproportionately affected by overdose in Vancouver's Downtown Eastside (DTES) neighborhood. Semi-structured qualitative interviews were conducted with 20 tenants who had participated in a TORO training session and administered naloxone to someone in their SRO hotel or had overdosed in their SRO hotel and received naloxone from another tenant. Focus groups were conducted with 15 peer workers who led the TORO program in their SRO building. Interviews and focus groups were transcribed and analyzed thematically. Ethnographic observation at SRO hotels involved in the intervention was also co-led with peer research assistants. Ten SROs were included in the study. The level of acceptability of the TORO program was high, with participants describing the urgency for an intervention amid the frequency of overdoses in their buildings. Overdose response training enhanced participants' knowledge and skills, and provided them a sense of recognition. Additionally, the TORO program was feasible in some buildings more than others. While it provided important training and engaged isolated tenants, there were structural barriers to program feasibility. The implementation of the TORO program was met with some successes in terms of its reach and community development, but participants also discussed a lack of emotional support due to overdose frequency, leading to burnout and vulnerability. Our findings suggest that the TORO program was affected by social, structural, and physical environmental constraints that impacted program feasibility and implementation. Despite these constraints, peer-led in-reach overdose response interventions are effective tools in addressing overdose risk in SROs. Future housing interventions should consider the intersecting pathways of overdose risk, including how these interventions may exacerbate other harms for people who use drugs. Further research should explore the impacts of environmental factors on overdose response interventions in other housing contexts.

Posttraumatic Stress Disorder and Mental Distress Following the 2004 and 2005 Florida Hurricanes

OBJECTIVE

Community characteristics, such as perceived collective efficacy, a measure of community strength, can affect mental health outcomes following disasters. We examined the association of perceived collective efficacy with posttraumatic stress disorder (PTSD) and frequent mental distress (14 or more mentally unhealthy days in the past month) following exposure to the 2004 and 2005 hurricane seasons.

METHODS

Participants were 1486 Florida Department of Health workers who completed anonymous questionnaires that were distributed electronically 9 months after the 2005 hurricane season. Participant ages ranged from 20 to 79 years (mean, 48; SD, 10.7), and the majority were female (79%), white (75%), and currently married (64%). Fifty percent had a BA/BS degree or higher.

RESULTS

In 2 separate logistic regression models, each adjusted for individual sociodemographics, community socioeconomic characteristics, individual injury/damage, and community storm damage, lower perceived collective efficacy was significantly associated with a greater likelihood of having PTSD (OR, 0.93; 95% CI, 0.90-0.96), and lower collective efficacy was significantly associated with frequent mental distress (OR, 0.94; 95% CI, 0.92-0.96).

CONCLUSIONS

Programs enhancing community collective efficacy may be a significant part of prevention practices and possibly lead to a reduction in the rate of PTSD and persistent distress postdisaster. (Disaster Med Public Health Preparedness. 2019;13:44-52).

Negotiating space & drug use in emergency shelters with peer witness injection programs within the context of an overdose crisis: A qualitative study

Vancouver, Canada is experiencing an overdose crisis due to the proliferation of fentanyl and related analogues and novel overdose response interventions are being implemented across multiple high overdose risk environments, including emergency shelters. We draw on ethnographic fieldwork and qualitative interviews to examine how social, structural, and physical contexts at two emergency shelters implementing a peer-based supervised injection intervention influenced injection drug use and overdose risks. Findings reveal that the implementation of this intervention reduced stigma and shame through the normalization of drug use in shelter spaces, and yet underlying social norms and material constraints led people to inject alone in non-designated injecting spaces. Whereas these spatial dynamics of injection drug use potentially increased overdose vulnerability, an emerging sense of collective responsibility in relation to the overdose crisis led to the routinization of peer witnessing practices across the shelter environment to extend the impact of the intervention.

Structural factors associated with methamphetamine smoking among female sex workers in Tijuana, Mexico

INTRODUCTION AND AIMS

Smoking methamphetamine is associated with increased risk of HIV among female sex workers (FSW). The structural context of substance use is an important shaper of individual behaviour; however, structural determinants of methamphetamine use among FSWs are largely unknown. We identified individual, structural and neighbourhood factors associated with smoking methamphetamine among FSWs in the border city of Tijuana, Baja California, Mexico.

DESIGN AND METHODS

A prospective cohort of 301 FSWs sampled from indoor and outdoor sex work venues throughout Tijuana participated in quantitative surveys on behaviours and mapping of home and work neighbourhoods across three visits. Multinomial logistic regression using generalised estimating equations identified individual, structural and neighbourhood variables associated with smoking methamphetamine.

RESULTS

Methamphetamine use, particularly smoking, was highly prevalent among FSWs. Over half (61%) of FSWs had ever used methamphetamine in their lifetime and at baseline, 38% currently smoked methamphetamine. Smoking methamphetamine daily was associated with living in the red light district [adjusted odds ratio (AOR) = 2.72, 95% confidence interval (CI) = 1.23-6.02] and with perceived homelessness, but only among women in a good financial situation (AOR = 4.08, 95% CI = 1.58-10.50). Smoking methamphetamine less than daily was associated with older age (AOR = 1.06, 95% CI = 1.02-1.10).

DISCUSSION AND CONCLUSIONS

Our findings point to the important dynamic between the residential environment and more severe methamphetamine use. FSWs may prioritise the purchase of methamphetamine over stable housing if they have the financial means. Given the high prevalence of smoking methamphetamine among FSWs in Tijuana, drug treatment options, especially for women living in the red light district, are needed.

Web-Based Survey Application to Collect Contextually Relevant Geographic Data With Exposure Times: Application Development and Feasibility Testing

Background

Although studies that characterize the risk environment by linking contextual factors with individual-level data have advanced infectious disease and substance use research, there are opportunities to refine how we define relevant neighborhood exposures; this can in turn reduce the potential for exposure misclassification. For example, for those who do not inject at home, injection risk behaviors may be more influenced by the environment where they inject than where they live. Similarly, among those who spend more time away from home, a measure that accounts for different neighborhood exposures by weighting each unique location proportional to the percentage of time spent there may be more correlated with health behaviors than one’s residential environment.

Objective

This study aimed to develop a Web-based application that interacts with Google Maps application program interfaces (APIs) to collect contextually relevant locations and the amount of time spent in each. Our analysis examined the extent of overlap across different location types and compared different approaches for classifying neighborhood exposure.

Methods

Between May 2014 and March 2017, 547 participants enrolled in a Baltimore HIV care and prevention study completed an interviewer-administered Web-based survey that collected information about where participants were recruited, worked, lived, socialized, injected drugs, and spent most of their time. For each location, participants gave an address or intersection which they confirmed using Google Map and Street views. Geographic coordinates (and hours spent in each location) were joined to neighborhood indicators by Community Statistical Area (CSA). We computed a weighted exposure based on the proportion of time spent in each unique location. We compared neighborhood exposures based on each of the different location types with one another and the weighted exposure using analysis of variance with Bonferroni corrections to account for multiple comparisons.

Results

Participants reported spending the most time at home, followed by the location where they injected drugs. Injection locations overlapped most frequently with locations where people reported socializing and living or sleeping. The least time was spent in the locations where participants reported earning money and being recruited for the study; these locations were also the least likely to overlap with other location types. We observed statistically significant differences in neighborhood exposures according to the approach used. Overall, people reported earning money in higher-income neighborhoods and being recruited for the study and injecting in neighborhoods with more violent crime, abandoned houses, and poverty.

Conclusions

This analysis revealed statistically significant differences in neighborhood exposures when defined by different locations or weighted based on exposure time. Future analyses are needed to determine which exposure measures are most strongly associated with health and risk behaviors and to explore whether associations between individual-level behaviors and neighborhood exposures are modified by exposure times.

Barrios, ghettos, and residential racial composition: Examining the racial makeup of neighborhood profiles and their relationship to self-rated health

Racial/ethnic disparities in self-rated health persist and according to the social determinants of health framework, may be partially explained by residential context. The relationship between neighborhood factors and self-rated health has been examined in isolation but a more holistic approach is needed to understand how these factors may cluster together and how these neighborhood typologies relate to health. To address this gap, we conducted a latent profile analysis using data from the Chicago Community Adult Health Study (CCAHS; N = 2969 respondents in 342 neighborhood clusters) to identify neighborhood profiles, examined differences in neighborhood characteristics among the identified typologies and tested their relationship to self-rated health. Results indicated four distinct classes of neighborhoods that vary significantly on most neighborhood-level social determinants of health and can be defined by racial/ethnic composition and class. Residents in Hispanic, majority black disadvantaged, and majority black non-poor neighborhoods all had significantly poorer self-rated health when compared to majority white neighborhoods. The difference between black non-poor and white neighborhoods in self-rated health was not significant when controlling for individual race/ethnicity. The results indicate that neighborhood factors do cluster by race and class of the neighborhood and that this clustering is related to poorer self-rated health.

Housing and overdose: an opportunity for the scale-up of overdose prevention interventions?

Background

North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings.

Overdose prevention interventions

There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also “supervised” spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated.

Conclusions

Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death.