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Ferguson M, Choisil P, Lamb J, Burmeister C, Newman C, Lock K, Tobias S, Liu L, Buxton JA. Associations with experience of non-fatal opioid overdose in British Columbia, Canada: a repeated cross sectional survey study. Harm Reduct J 2023; 20:178. [PMID: 38093272 PMCID: PMC10717189 DOI: 10.1186/s12954-023-00912-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Lives lost in North America due to the unregulated drug poisoning emergency are preventable and those who survive an opioid overdose may suffer long-term disability. Rates of opioid overdose more than doubled following the onset of the COVID-19 pandemic in British Columbia, Canada. MATERIALS AND METHODS Our analytical sample was comprised of 1447 participants from the 2018, 2019, and 2021 Harm Reduction Client Survey who responded yes or no to having experienced an opioid overdose in the past 6 months. Participants were recruited from harm reduction sites from across British Columbia. We used logistic regression to explore associations of experiencing an opioid overdose. RESULTS Overall, 21.8% of participants reported experiencing an opioid overdose in the last six months (18.2% in 2019 and 26.6% in 2021). The following factors were positively associated with increased adjusted odds of experiencing a non-fatal opioid overdose: cis men relative to cis women (AOR 1.49, 95% CI 1.10-2.02), unstably housed compared to people with stable housing (AOR 1.87, 95% CI 1.40-2.50), and participants from 2021 compared to those from 2019 (AOR 3.06, 95% CI 1.57-5.97). The effects of both previous experience of a stimulant overdose and having witnessed an opioid overdose depended on the year of study, with both effects decreasing over subsequent years. CONCLUSIONS Overdoses have increased over time; in 2021 more than one in four participants experienced an overdose. There is an urgent need for policy and program development to meaningfully address the unregulated drug poisoning emergency through acceptable life-saving interventions and services to prevent overdoses and support overdose survivors.
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Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Paul Choisil
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jessica Lamb
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | | | - Cheri Newman
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Samuel Tobias
- British Centre on Substance Use, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Liu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
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Song M, Desai IK, Meyer A, Shah H, Saloner B, Sherman SG, Allen ST, Tomko C, Schneider KE, Krawczyk N, Whaley S, Churchill J, Harris SJ. Exploring trauma and wellbeing of people who use drugs after witnessing overdose: A qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104239. [PMID: 37890394 DOI: 10.1016/j.drugpo.2023.104239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior. METHODS We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti. RESULTS A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices. CONCLUSION Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.
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Affiliation(s)
- Minna Song
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA.
| | - Isha K Desai
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA; Department of Health Policy and Management, George Washington University, 950 New Hampshire Ave, #2, Washington, DC 20052, USA
| | - Avery Meyer
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Hridika Shah
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Sean T Allen
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Catherine Tomko
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Kristin E Schneider
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, 180 Madison Ave, New York, NY, 10065, USA
| | - Sara Whaley
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Jade Churchill
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
| | - Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD 21205, USA
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Trayner K, Yeung A, Sumnall HR, Anderson M, Glancy ME, Atkinson A, Smith M, McAuley A. National increase in the community supply of take-home naloxone associated with a mass media campaign in Scotland: a segmented time series analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104106. [PMID: 37563038 DOI: 10.1016/j.drugpo.2023.104106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Take-home naloxone (THN) programmes have been associated with reductions in opioid-related mortality. In response to high rates of drug-related deaths in Scotland, the Scottish Government commissioned the 'How to save a life' (HTSAL) mass media campaign to: (1) increase awareness of drug-related deaths and how to respond to an overdose, and (2) increase the supply of THN. The aim of this study was to assess the effect of the campaign on the supply of THN. METHODS We used an interrupted time series design to assess the effect of the HTSAL mass media campaign on the national community supply of THN. The study time period was August 2020-December 2021. We modelled two key dates: the start of the campaign (week beginning (w/b) 30th of August 2021) and after the end of the main campaign (w/b 25th of October 2021). RESULTS The total number of THN kits distributed in the community in Scotland during the study period was 27,064. The mean number of THN kits distributed per week (relative to the pre-campaign period), increased by 126% during the campaign and 57% post-campaign. In segmented regression analyses, the pre-campaign trend in the number of THN kits supplied was increasing by an average of 1% each week (RR=1.01, 95% CI 1.01 to 1.01, p<0.001). Once the campaign started, a significant change in level was observed, and the number of kits increased by 75% (RR=1.75, 95% CI 1.29 to 2.40, p<0.001). The trend during the campaign was stable (i.e. not increasing or decreasing) but a significant change in level was observed when the campaign ended, and the number of THN kits supplied decreased by 32% (RR=0.68, 95% CI 0.46 to 0.98, p = 0.042). The trend during the post-campaign period was stable. CONCLUSIONS The HTSAL campaign had a short term, but large and significant impact, on the community supply of THN in Scotland. Mass media campaigns could be combined with other interventions and strategies to maintain the increased uptake of THN outside of campaign periods.
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Affiliation(s)
- Kma Trayner
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK.
| | - A Yeung
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - H R Sumnall
- Liverpool John Moores University, Liverpool, UK
| | | | - M E Glancy
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - A Atkinson
- Liverpool John Moores University, Liverpool, UK
| | - M Smith
- Public Health Scotland, Glasgow, UK
| | - A McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
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Nolte K, Romo E, Stopka TJ, Drew A, Dowd P, Del Toro-Mejias L, Bianchet E, Friedmann PD. "I've been to more of my friends' funerals than I've been to my friends' weddings": Witnessing and responding to overdose in rural Northern New England. J Rural Health 2023; 39:197-211. [PMID: 35301749 PMCID: PMC9481744 DOI: 10.1111/jrh.12660] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. METHODS We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed-methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in-depth interviews (n = 22). FINDINGS Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. CONCLUSIONS PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality.
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Affiliation(s)
- Kerry Nolte
- Department of Nursing, College of Health and Human Services, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH, 03824, USA
| | - Eric Romo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Public Health, 136 Harrison Ave., Boston, MA
| | - Aurora Drew
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Patrick Dowd
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
| | - Lizbeth Del Toro-Mejias
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
| | - Elyse Bianchet
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
| | - Peter D. Friedmann
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
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King L, Hayashi K, Genberg B, Choi J, DeBeck K, Kirk G, Mehta SH, Kipke M, Moore RD, Baum MK, Shoptaw S, Gorbach PM, Mustanski B, Javanbakht M, Siminski S, Milloy MJ. Prevalence and correlates of stocking up on drugs during the COVID-19 pandemic: Data from the C3PNO Consortium. Drug Alcohol Depend 2022; 241:109654. [PMID: 36266158 PMCID: PMC9535877 DOI: 10.1016/j.drugalcdep.2022.109654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 10/03/2022] [Accepted: 10/03/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data from the COVID-19 pandemic describes increases in drug use and related harms, especially fatal overdose. However, evidence is needed to better understand the pathways from pandemic-related factors to substance use behaviours. Thus, we investigated stockpiling drugs among people who use drugs (PWUD) in five cities in the United States and Canada. METHODS We used data from two waves of interviews among participants in nine prospective cohorts to estimate the prevalence and correlates of stockpiling drugs in the previous month. Longitudinal correlates were identified using bivariate and multivariate generalized linear mixed-effects modeling analyses. RESULTS From May 2020 to February 2021, we recruited 1873 individuals who completed 2242 interviews, of whom 217 (11.6%) reported stockpiling drugs in the last month at baseline. In the multivariate model, stockpiling drugs was significantly and positively associated with reporting being greatly impacted by COVID-19 (Adjusted Odds Ratio [AOR]= 1.21, 95% CI: 1.09-1.45), and at least daily use of methamphetamine (AOR = 4.67, 95% CI: 2.75-7.94) in the past month. CONCLUSIONS We observed that approximately one-in-ten participants reported stocking up on drugs during the COVID-19 pandemic. This behaviour was associated with important drug-related risk factors including high-intensity methamphetamine use. While these correlations need further inquiry, it is possible that addressing the impact of COVID-19 on vulnerable PWUD could help limit drug stockpiling, which may lower rates of high-intensity stimulant use.
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Affiliation(s)
- L. King
- British Columbia Centre for Substance Use, 400–1045 Howe Street, Vancouver, BC V6Z2A9, Canada,University of British Columbia, Faculty of Medicine, 317 - 2194 Health Sciences Mall, Vancouver V6T 1Z3, BC, Canada
| | - K. Hayashi
- British Columbia Centre for Substance Use, 400–1045 Howe Street, Vancouver, BC V6Z2A9, Canada
| | - B. Genberg
- The John Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD, United States
| | - J. Choi
- British Columbia Centre for Substance Use, 400–1045 Howe Street, Vancouver, BC V6Z2A9, Canada
| | - K. DeBeck
- British Columbia Centre for Substance Use, 400–1045 Howe Street, Vancouver, BC V6Z2A9, Canada,Simon Fraser University School of Public Policy, 8888 University Dr, Burnaby, BC, Canada, V5A 1S6
| | - G. Kirk
- The John Hopkins Bloomberg School of Public Health, 615N Wolfe St, Baltimore, MD, United States
| | - SH Mehta
- The John Hopkins University, Department of Epidemiology, 615N Wolfe Dr, Baltimore, MD, United States
| | - M. Kipke
- University of Southern California Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA, United States
| | - RD Moore
- The John Hopkins University School of Medicine, 733N Broadway, Baltimore, MD, United States
| | - MK Baum
- Florida International University, Department of Dietetics and Nutrition, 1250 SW 108th Ave, Miami, FL, United States
| | - S. Shoptaw
- University of California Los Angeles, Department of Family Medicine, 100 Medical Plaza Driveway, Los Angeles, CA, United States
| | - PM Gorbach
- University of California Los Angeles, Department of Epidemiology, 10833 Le Conte Ave, Los Angeles, CA, United States
| | - B. Mustanski
- Northwestern University, Department of Medical Social Sciences, 625N Michigan Ave, Chicago, IL, United States
| | - M. Javanbakht
- University of California Los Angeles, Department of Epidemiology, 10833 Le Conte Ave, Los Angeles, CA, United States
| | - S. Siminski
- Frontier Science Foundation, 4033 Maple Road, Amherst, NY, United States
| | - M-J Milloy
- British Columbia Centre for Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z2A9, Canada; University of British Columbia, Department of Medicine, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9.
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Schneider KE, Allen ST, Winiker AK, White RH, O’Rourke A, Sherman SG, Grieb SM. Overdose Experiences among People Who Inject Drugs in West Virginia: Personal Loss, Psychological Distress, Naloxone, and Fentanyl. Subst Use Misuse 2022; 58:22-26. [PMID: 36371695 PMCID: PMC10124002 DOI: 10.1080/10826084.2022.2136489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results: Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions: Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.
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Affiliation(s)
- Kristin E. Schneider
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Sean T. Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Abigail K. Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Allison O’Rourke
- DC Center for AIDS Research, Department of Psychological and Brain Sciences, George Washington University, 2125 G St. NW, Washington, DC 20052, USA
| | - Susan G. Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Suzanne M. Grieb
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA
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Armoon B, Higgs P, Mohammadi R. Mental health status, health service utilization, drug use behaviors associated with non-fatal overdose among people who use illicit drugs: A meta-analysis. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.2019331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, Quebec, Canada
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Peter Higgs
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
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Armoon B, Bayani A, Griffiths MD, Bayat AH, Mohammadi R, Fattah Moghaddam L, Ahounbar E. Prevalence and high-risk behaviors associated with non-fatal overdose among people who use illicit opioids: A systematic review and meta-analysis. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.1978112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Bahram Armoon
- Research Center, Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | - Azadeh Bayani
- Student Research Committee, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mark D. Griffiths
- International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, UK
| | - Amir-Hossein Bayat
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Elahe Ahounbar
- Substance Abuse and Dependence Research Center, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Past 12-month nonfatal overdose among people who inject drugs in Ukraine: City-level estimates and risk factors from a cross-sectional study. Drug Alcohol Depend 2021; 220:108513. [PMID: 33556695 DOI: 10.1016/j.drugalcdep.2021.108513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Nonfatal overdose contributes to high morbidity and is among the strongest proxies for the occurrence of overdose fatality - the leading cause of death among those who use opioids. In Ukraine, a majority of people who inject drugs (PWID) use opioids, but little is known about the relationship between drug market characteristics, nonfatal overdose (NFOD) prevalence, and risk factors for NFOD. METHODS We used cross-sectional respondent-driven sampling (RDS) data to explore the variability of recent (past 12 months) NFOD among PWID across Ukrainian cities and associations with individual factors. The population-averaged -cross-sectional associations were estimated and compared using generalized linear models for the binary outcome (NFOD vs. not) with robust variance estimates. RESULTS Recent self-reported NFOD varied between 1% and 14 % across Ukrainian cities. In adjusted analyses, overdose was associated with fewer years of injecting drugs; a higher number of types of drugs used in the past 12 months; using desomorphine, methadone, tramadol, heroin, amphetamine-type drugs or cocaine within past 12 months; using alcohol daily or weekly; recent drug treatment; and history of incarceration. Buying drugs or their ingredients through "stashes" (i.e., drugs secretly hidden in various places) and the perception of drug price increase were associated with higher odds of reporting NFOD. CONCLUSION The identified risk factors underscore the importance of evidence-based prevention efforts, such as scaling-up opioid agonist therapy, providing naloxone in the community and upon prison release, targeting those most likely to witness overdose and sharing overdose prevention strategies with them, and continuous monitoring of trends and contributing factors.
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Mazhnaya A, Kiriazova T, Chernova O, Tobin K, Owczarzak J. ``Now it is mostly done through stashes, to do it in person one has to trust you'': Understanding the retail injection drug market in Dnipro, Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102988. [PMID: 33129134 DOI: 10.1016/j.drugpo.2020.102988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Abstract
Little research has been conducted in Ukraine since the 1990s to understand the organization of drug market and its implications for people who inject drugs (PWID). In this study, we explore how PWID perceive the retail drug market in a large Ukrainian city. Qualitative data were obtained during in-depth interviews and analyses included open coding, coding tree development and revision, axial coding, and identification of higher-level domains. Participants' narratives focused on types and forms of drugs available, perceptions about drug quality, methods of buying drugs, and the relationships that are formed and maintained by participating in the drug economy. The described technical organization of the drug market, with multiple contingent combinations of drug types, forms and means of obtaining drugs (hand-to-hand vs stash-based) resulted from diversification and digitalization of the retail injection drug market. The social organization of the drug market in the form of relationships with sellers and drug use partners represented the response to the fundamental problem of uncertainty. The lens of ``transaction cost'' helps explain strategies PWID used to manage uncertainties, including finding reliable and suitable sellers, sending money and picking up the stash under the threat of being stiffed or caught by the police, choosing the product itself, using the intermediaries to outsource risky operations and forming groups to procure and inject together. Our results indicate that the technical and social organization of drug distribution in Ukraine stimulates formation and continuation of relationships and impacts the choices of what, how, and when to inject beyond individual preferences. The policy and practice implications include the need to monitor and understand the retail drug market to develop and deliver more efficient and client-oriented services, incorporate and leverage social networks structure for information sharing and behavior change, pilot and implement drug testing services to assist with management of uncertainties.
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Affiliation(s)
- Alyona Mazhnaya
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA.
| | - Tetiana Kiriazova
- Ukrainian Institute on Public Health Policy, 5 Biloruska Street, Kyiv 04050, Ukraine
| | - Olena Chernova
- Ukrainian Institute on Public Health Policy, 5 Biloruska Street, Kyiv 04050, Ukraine
| | - Karin Tobin
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA
| | - Jill Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA
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Beaulieu T, Hayashi K, Nosova E, Milloy MJ, DeBeck K, Wood E, Kerr T, Ti L. Effect of witnessing an overdose on the use of drug checking services among people who use illicit drugs in Vancouver, Canada. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 46:506-511. [PMID: 31983241 DOI: 10.1080/00952990.2019.1708087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Since 2013, fentanyl-contaminated drugs have been driving North America's opioid-overdose epidemic. Drug checking, which enables people who use illicit drugs (PWUD) to test and receive feedback regarding the contents of their drugs, is being considered as a potential tool to address the toxic drug supply. While some PWUD witness overdoses, little is known about the impact of these experiences on subsequent risk reduction practices. OBJECTIVE The purpose of this study was to examine the effect of witnessing an overdose on drug checking service use. METHODS Data were derived from prospective cohorts of PWUD in Vancouver, Canada, a setting with a community-wide fentanyl overdose crisis, between June 1, 2018 and December 1, 2018. Multivariable logistic regression was used to estimate the effect of witnessing an overdose on drug checking service use. RESULTS 1,426 participants were eligible for the study, including 530 females; 767 (53.8%) participants reported witnessing an overdose and 196 (13.7%) reported using drug checking services in the last 6 months. In multivariable analyses, after adjusting for a range of confounders including the use of fentanyl, witnessing an overdose was positively associated with drug checking service use (adjusted odds ratio = 2.32; 95% confidence interval: 1.57-3.49). CONCLUSION Our findings suggest that witnessing an overdose may motivate PWUD to use drug checking services. Given that only a small proportion of PWUD in the study reported using drug checking services, our findings highlight the need to continue to scale-up a range of overdose prevention interventions.
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Affiliation(s)
- Tara Beaulieu
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,Graduate Programs in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Kanna Hayashi
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University , Burnaby, BC, Canada
| | - Ekaterina Nosova
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada
| | - M-J Milloy
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Kora DeBeck
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,School of Public Policy, Simon Fraser University , Vancouver, BC, Canada
| | - Evan Wood
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Thomas Kerr
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Lianping Ti
- , British Columbia Centre on Substance Use , Vancouver, BC, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
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12
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Kahn LS, Wozniak M, Vest BM, Moore C. “Narcan encounters:” overdose and naloxone rescue experiences among people who use opioids. Subst Abus 2020; 43:113-126. [DOI: 10.1080/08897077.2020.1748165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Linda S. Kahn
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, New York, USA
| | - Monika Wozniak
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, New York, USA
| | - Bonnie M. Vest
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, New York, USA
| | - Cheryll Moore
- Erie County Department of Health, University at Buffalo, Buffalo, New York, USA
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13
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Green TC, Soipe A, Baloy B, Burstein D, Xuan Z, Tapper A, Walley AY, Case P, Bratberg J, Baird J. Pharmacy on-site overdose protocols and prevention of overdose. Subst Abus 2020; 43:64-68. [PMID: 32186478 PMCID: PMC10937094 DOI: 10.1080/08897077.2020.1736236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Opioid overdose is a preventable injury leading to high morbidity and premature mortality in communities across the United States. Overdoses take place where people use drugs, including commercial and public locations like community pharmacies, and necessitate swift detection and response to avoid harm and, even more seriously, death. The presence of emergency and safety protocols improves occupational health and safety for all in the workplace. The aim of this study was to assess the prevalence of experience with on-site pharmacy overdose and to explore pharmacist and site characteristics associated with having a known protocol for responding to on-site overdose emergencies. Methods: An anonymous, online survey about naloxone provision and opioid safety was delivered by email, through professional pharmacy associations and continuing education attendance lists, to 3,100 pharmacists in Massachusetts and Rhode Island between October 2017 and January 2018. Survey items gauged socio-demographics, practice site characteristics, safer opioid dispensing and naloxone provision. Summary statistics and bivariate analyses were conducted to describe characteristics associated with items pertaining to on-site overdose policy awareness. Results: Of the 357 respondents (11.5% response rate), 154 (5.0%) answered the questions of interest: 17.5% reported having at least one suspected overdose on-site at their practice location, while 42.9% reported that they were knowledgeable about and could locate at their practice location an on-site overdose protocol detailing how to respond to an overdose. Pharmacists who were knowledgeable about protocols were also more likely to offer naloxone to patients (p = 0.02) and did not practice at a chain pharmacy (p = 0.01). Conclusions: Community pharmacies that stock and distribute naloxone are key parts of community efforts to address the opioid crisis. Pharmacies and other healthcare settings should develop and implement on-site overdose response protocols and cultivate a norm of naloxone provision to patients.
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Affiliation(s)
- Traci C Green
- Department of Emergency Medicine, Injury Prevention Center, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Emergency Medicine, Injury Prevention Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ayorinde Soipe
- Department of Emergency Medicine, Injury Prevention Center, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Brianna Baloy
- Department of Emergency Medicine, Injury Prevention Center, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
| | - Dina Burstein
- Department of Emergency Medicine, Injury Prevention Center, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Abigail Tapper
- Department of Emergency Medicine, Injury Prevention Center, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Patricia Case
- Department of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Jeffrey Bratberg
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Janette Baird
- Department of Emergency Medicine, Injury Prevention Center, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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14
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Nesoff ED, Branas CC, Martins SS. The Geographic Distribution of Fentanyl-Involved Overdose Deaths in Cook County, Illinois. Am J Public Health 2020; 110:98-105. [PMID: 31725315 PMCID: PMC6893352 DOI: 10.2105/ajph.2019.305368] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2019] [Indexed: 11/04/2022]
Abstract
Objectives. To contrast the geographic distribution of fentanyl-involved and non-fentanyl-involved fatal overdoses between 2014 and 2018 in Cook County, Illinois.Methods. We conducted a spatial analysis using locations of fentanyl-involved fatal overdoses (n = 1433) compared with nonfentanyl opioid and polydrug fatal overdoses (n = 1838) collected through the Cook County Medical Examiner's Office from 2014 to 2018. We also used logistic regression to test significant individual- and neighborhood-level covariates.Results. Fentanyl overdoses geographically clustered more than nonfentanyl overdoses, and this difference was statistically significant. One area in particular showed significantly elevated risk for fentanyl overdoses (P < .05) located in 2 specific neighborhoods of Chicago. The odds of a fentanyl-involved overdose were significantly increased for men, Blacks, Latinos/as, and younger individuals. Neighborhood deprivation score was the only significant neighborhood-level predictor (odds ratio = 1.11; 95% confidence interval = 1.07, 1.17).Conclusions. Fentanyl-involved fatal overdoses follow a distinct geographic distribution associated with resource deprivation in neighborhoods where they occur. This suggests an evolving bifurcated drug market, with drug markets in resource-deprived neighborhoods disproportionately likely to include fentanyl.
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Affiliation(s)
- Elizabeth D Nesoff
- The authors are with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Charles C Branas
- The authors are with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Silvia S Martins
- The authors are with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
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15
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Dayton L, Gicquelais RE, Tobin K, Davey-Rothwell M, Falade-Nwulia O, Kong X, Fingerhood M, Jones AA, Latkin C. More than just availability: Who has access and who administers take-home naloxone in Baltimore, MD. PLoS One 2019; 14:e0224686. [PMID: 31697736 PMCID: PMC6837378 DOI: 10.1371/journal.pone.0224686] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/19/2019] [Indexed: 01/11/2023] Open
Abstract
Background Fatal opioid overdose is a pressing public health concern in the United States. Addressing barriers and augmenting facilitators to take-home naloxone (THN) access and administration could expand program reach in preventing fatal overdoses. Methods THN access (i.e., being prescribed or receiving THN) was assessed in a Baltimore, Maryland-based sample of 577 people who use opioids (PWUO) and had a history of injecting drugs. A sub-analysis examined correlates of THN administration among those with THN access and who witnessed an overdose (N = 345). Logistic generalized estimating equations with robust standard errors were used to identify facilitators and barriers to accessing and using THN. Results The majority of PWUO (66%) reported THN access. In the multivariable model, decreased THN access was associated with the fear that a person may become aggressive after being revived with THN (aOR: 0.55, 95% CI: 0.35–0.85), police threaten people at an overdose event (aOR: 0.68, 95% CI: 0.36–1.00), and insufficient overdose training (aOR: 0.43, 95% CI: 0.28–0.68). Enrollment in medication-assisted treatment, personally experiencing an overdose, and graduating from high school were associated with higher access. About half (49%) of PWUO with THN access and who had witnessed an overdose reported having administered THN. THN use was positively associated with “often” or “always” carrying THN (aOR: 3.47, 95% CI: 1.99–6.06), witnessing more overdoses (aOR:5.18, 95% CI: 2.22–12.07), experiencing recent homelessness, and injecting in the past year. THN use was reduced among participants who did not feel that they had sufficient overdose training (aOR: 0.56, 95% CI: 0.32–0.96). Conclusion THN programs must bolster confidence in administering THN and address barriers to use, such as fear of a THN recipient becoming aggressive. Normative change around carrying THN is an important component in an overdose prevention strategy.
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Affiliation(s)
- Lauren Dayton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Rachel E. Gicquelais
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Karin Tobin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Melissa Davey-Rothwell
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Xiangrong Kong
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michael Fingerhood
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Abenaa A. Jones
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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16
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Rouhani S, Park JN, Morales KB, Green TC, Sherman SG. Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence. Harm Reduct J 2019; 16:39. [PMID: 31234942 PMCID: PMC6591810 DOI: 10.1186/s12954-019-0311-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/30/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Exposure to potent synthetic opioids such as illicitly manufactured fentanyl (IMF) has fueled the escalating overdose crisis in the USA, particularly in the east coast. Drug checking services, which allow people who use drugs (PWUD) to learn about the contents of their drugs, remain limited and even criminalized in many states. Further, there is a persistent belief that PWUD are not willing or able to change their behaviors despite being aware of their potential exposure to fentanyl through drug use. METHODS We conducted a multi-site cross-sectional study among PWUD to assess what behaviors, if any, were employed in the case of suspected fentanyl exposure, and the correlates of engaging in harm reduction behaviors (HRB). PWUD (N = 334) were recruited in Boston (n = 80), Providence (n = 79), and in Baltimore (n = 175). At the time of the survey, no legal drug checking services were available in these cities. RESULTS The majority of PWUD (84%) expressed concern about fentanyl. Among those who suspected fentanyl exposure prior to using their drugs (n = 196), 39% reported employing HRB including using less of the drug (12%) or abstaining altogether (10%), using more slowly (5%), and doing a tester shot (5%). In adjusted logistic regression models, the odds (aOR) of practicing HRB after suspecting fentanyl exposure were increased among PWUD who were non-White (aOR 2.1; p = 0.004) and older (aOR 1.52 per decade of age; p < 0.001). Daily injection (aOR 0.50; p < 0.001), using drugs in public (aOR 0.58; p = 0.001), using drugs alone (aOR 0.68; p < 0.001), and experiencing multiple recent overdoses (aOR 0.55; p < 0.001) were associated with decreased odds of practicing HRB. CONCLUSIONS These data illustrate that PWUD employ a number of practices to reduce overdose risk in a context of unknown drug purity and content. Results may also guide efforts to identify early adopters of drug checking services and engage them in peer-outreach to target the most socially and structurally vulnerable PWUD, who are not reporting behavior change, with harm reduction messaging.
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Affiliation(s)
- Saba Rouhani
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA.
| | - Ju Nyeong Park
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
| | - Kenneth B Morales
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
| | - Traci C Green
- Miriam Hospital and Alpert Medical School of Brown University, Providence, RI, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
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17
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Stigma and drug use settings as correlates of self-reported, non-fatal overdose among people who use drugs in Baltimore, Maryland. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 68:86-92. [PMID: 31026734 DOI: 10.1016/j.drugpo.2019.03.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/15/2019] [Accepted: 03/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fatalities from opioid overdose quadrupled during the last 15 years as illicit opioid use increased. This study assesses how stigma and drug use settings are associated with non-fatal overdose to identify targets for overdose risk reduction interventions and inform overdose education and naloxone distribution programs. METHODS We surveyed 444 people who used drugs in Baltimore, Maryland, USA, from 2009 to 2013 as part of a randomized clinical trial of a harm reduction intervention. Participants reported demographic characteristics, drug use, overdose history, use of a local syringe services program, involvement in the local drug economy, and whether they experienced discrimination from others (i.e., enacted stigma) or stigmatized themselves (i.e., internalized stigma) related to their drug use. We used multinomial logistic regression models to identify correlates of experiencing a non-fatal overdose within the past year or >1 year ago relative to participants who never experienced an overdose. RESULTS Stigma was positively associated with experiencing a non-fatal overdose in the past year (adjusted Odds Ratio [aOR]: 1.7, 95% Confidence Interval [CI]: 1.1-2.7) and >1 year ago (aOR [95% CI]: 1.5 [1.1-2.0]) after adjustment for demographic and substance use characteristics. The association of stigma with overdose was stronger for enacted versus internalized stigma. The number of public settings (shooting gallery, crack house, abandoned building, public bathroom, outside) where participants used drugs was also positively associated with experiencing an overdose. CONCLUSIONS Stigma related to drug use and using drugs in more settings may increase overdose risk. The effectiveness of overdose prevention and naloxone training may be improved by reducing discrimination against people who use drugs in community and medical settings and diversifying the settings in which overdose prevention trainings are delivered. These efforts may be enhanced by use of peer outreach approaches in which people who use drugs diffuse prevention messages through their social networks and within settings of drug consumption outside the medical setting.
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