Barriers to Healthcare for People Who Inject Drugs: A Survey at a Syringe Exchange Program

Examining the association between psychological resilience and chronic versus discrete stressors among individuals who use opioids in Baltimore, Maryland

INTRODUCTION

Psychological resilience has emerged as a key construct of interest in the study of substance use. However, very few studies have examined resilience among individuals who are actively using drugs. Furthermore, many studies of psychological resilience have focused on individual-level factors. This study addresses the call for a more 'ecological' approach to the study of resilience by exploring how socio-structural vulnerabilities may shape individuals' assessment of their own ability to cope.

METHODS

The Peer Harm Reduction of Maryland Outreach Tiered Evaluation study conducted a cross-sectional survey of people who used opioids in Baltimore, Maryland, USA (n = 565). Resilience was measured using the 10-item Connor-Davidson Resilience Scale. We used linear regression to examine the association between resilience and stressors commonly encountered by individuals who use drugs, including both chronic, enduring stressors (e.g., homelessness, food insecurity) and discrete, event-based stressors (e.g., overdose, arrest).

RESULTS

We observed a negative relationship between self-reported resilience and chronic stressors. Specifically, individuals who reported experiencing three (β = -4.08; p = 0.002) or four (β = -4.67; p = 0.008) types of chronic stress had significantly lower resilience scores. Additionally, we found that an unmet need for mental health treatment was associated with reduced resilience (β = -1.74; p = 0.040) and greater educational attainment was associated with increased resilience (β = 2.13; p = 0.005).

DISCUSSION AND CONCLUSIONS

Overlapping experiences of socio-structural vulnerability, as well as access to mental health care, may influence how individuals who use drugs evaluate their own resilience. Interventions that seek to promote the resilience of this population should focus on addressing structural drivers of marginalisation and barriers to mental health treatment.

"I Was Treated Differently": Reproductive Health Care Experiences Among Women With Recent Experiences of Incarceration, Homelessness, And/Or Substance Use in a Medically Underserved Area in the Southwestern US

Background: Women with upstream social determinants of health, particularly those with recent experiences of incarceration, homelessness, and/or substance use, encounter a series of barriers in accessing health care services and consequently face poor sexual and reproductive health outcomes. Driven by a community concern for increasing rates of syphilis and congenital syphilis among women who are structurally disadvantaged, this study focuses on their experiences with reproductive healthcare access across healthcare settings.Research Design and Study Sample: This community-based pláticas (conversational) research project gathered 12 in-depth interviews and testimonios (testimonies) with women who reported a criminalized upstream barrier (incarceration, homelessness, and/or substance use) in a small city in the southwestern U.S. - most of whom identified as Latina/Hispanic.Analysis and Results: Using a grounded analysis and drawing upon Chicana feminist methodologies, this study identifies four major themes: (1) homelessness and economic vulnerabilities, (2) incarceration and health care, (3) drug use, provider stigma, and motherhood, and (4) desired changes to the healthcare experience.Conclusion: Results highlight the need for economic and transportation supports, community-based preventive services as alternatives to incarcerated healthcare, along with more compassionate and structurally competent provider-patient dialogue.

Factors associated with experiencing stigma, discrimination, and negative health care treatment among people who inject drugs

INTRODUCTION

Stigma has negative consequences for the health of people who inject drugs and people living with hepatitis C virus (HCV). This study evaluated factors associated with stigma related to injecting drug use (IDU) or HCV and those associated with being treated negatively by health workers.

METHODS

ETHOS Engage is an observational cohort study of people who inject drugs attending drug treatment clinics and needle and syringe programs in Australia. Participants completed a questionnaire including IDU- and HCV-related stigma, and negative treatment by health workers. Logistic regression was used to identify factors associated with experiencing stigma and negative treatment in a cross-sectional sample.

RESULTS

Of 1,211 participants, 31% were women, 64% had injected drugs in the previous month, and 65% had been diagnosed with HCV. IDU-related stigma was reported by 57% of participants and was associated with being a woman, higher than Year 10 education, homelessness, opioid agonist treatment, recent injecting, overdose history, hospitalisation for drug use, and unknown HCV status. HCV-related stigma was reported by 34% of participants diagnosed with HCV and was associated with being a woman, homelessness, receptive needle/syringe sharing, arrest for drug use/possession, and recent HCV testing. Negative treatment from health workers was reported by 45% of participants and was associated with being a woman, receptive needle/syringe sharing, hospitalisation for drug use, and arrest for drug use/possession.

DISCUSSION AND CONCLUSIONS

Results highlight important intersections and disparities in stigmatising experiences among people who inject drugs. Considering these intersections can assist health services provide more inclusive care.

Barriers to and facilitators of screening for cervical and breast cancer: Experiences of non-adherent women with current or previous drug use

Objective

Women with current or previous drug use (WCPDU) have an increased risk of poor cervical and breast cancer outcomes, and low participation in screening for these cancer forms. The aim of this study was to assess self-reported barriers to and facilitators of cervical and breast cancer screening, among WCPDU.

Methods

A survey based on results from a previous qualitative study about WCPDUs experiences of cancer screening was distributed to WCPDU at six opioid agonist treatment (OAT) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. Data on barriers to and facilitators of cancer screening reported by 222 non-adherent WCPDU was analyzed by descriptive statistics. The barriers were structured according to an established model of healthcare access.

Results

The most frequently reported barriers to cervical as well as breast cancer screening were non-receipt of screening invitations (36 % and 25 %, respectively), trouble remembering the appointment (27 % and 30 %) and other priorities (26 % and 29 %). Common suggested facilitators for both cervical and breast cancer screening were screening access at, e.g., a NEP or OAT clinic (45 % and 40 %) and practical support to attend the screening appointment (40 % and 38 %).

Conclusions

In contrast to general population women, WCPDU report mainly practical barriers to cervical and breast cancer screening. However, NEP participants frequently reported experience of stigma and poor reception as barriers to screening. Interventions to minimize barriers to screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

The Patient Perspective of an Inpatient Addiction Medicine Unit Implemented in an Urban Northern Acute Care Hospital in Ontario, Canada

Background

An Addiction Medicine Unit (AMU) represents a promising approach to enhancing hospital care for individuals who use substances, but there is limited research to understand patients' perspectives on AMUs. Therefore, the study objectives involved exploring patients' experiences with the AMU.

Methods

Qualitative semi-structured interviews were conducted with 17 patients to gather their perspectives about the AMU. The AMU offers specialized inpatient addiction support, integrating medical and psychosocial interventions while facilitating connections to community supports to stabilize patients and manage addiction-related issues using a harm reduction philosophy.

Results

Factors identified by patients that lead to positive experiences with the AMU included: efficient access to high-quality acute medical care, specialized addiction care, and additional support for non-medical needs. Patients emphasized the benefits of having peer support workers on staff, the overall positive interactions with staff, and how different these experiences were from their hospital admissions outside of the AMU. Factors identified by patients that should be considered in an AMU included: the ease of access to substances, negative interactions with other patients, and self-stigma/internalized discrimination. Also, the patient perspective reflected varied views on harm reduction. Patients' perception of the impact of an AMU overall reflected that the AMU is an effective way to deliver comprehensive treatment, to address the needs of PWUS, both medical and substance-use-related issues. They identified that the unit's intentional harm reduction philosophy facilitated access to care and positive patient-staff interactions, emphasizing the unit's progress in reducing fear and judgment and rebuilding trust in the healthcare system.

Conclusion

The introduction of a new AMU in a Northern urban acute care hospital in Ontario has yielded positive patient experiences. The AMU model shows potential to re-establish trust between patients and providers, but ongoing efforts are needed to address underlying stigma to be more effective.

Screening for breast and cervical cancer among OST patients: a qualitative study of barriers and suggested interventions to increase participation

PURPOSE

Women with current or previous drug use are at risk of poor breast and cervical cancer outcomes. While screening is known to decrease cancer mortality, screening participation is sparsely investigated among drug dependent women. The aim of this study was to explore experiences of breast and cervical cancer screening-including barriers and suggested interventions to promote increased participation-among women in opioid substitution treatment (OST).

METHODS

Three focus group interviews were conducted at one OST clinic in Malmö, Sweden. The interviews were moderated by OST staff, assisted by a researcher. A descriptive qualitative analysis was carried out using a template analysis approach, employing a model of healthcare access to organize the description of barriers.

RESULTS

The 11 participants reported several barriers to screening access, affecting the perceived need of screening and the opportunities to seek and reach screening services. Some barriers appear to be specific to women with previous or current drug use. Suggested interventions were moral and practical support, integrated/specialized delivery of screening services, and enhanced screening invitation procedures.

CONCLUSIONS

The study findings provide insight to difficulties with screening compliance among women with current or previous drug use, and provide a knowledge base for quantitative and intervention studies.

'It's a fragile open door'-enhancing COVID-19 vaccination rates in people receiving treatment for substance use disorder

BACKGROUND

People with substance use disorder are at high risk of harms from COVID-19 infection. Vaccine hesitancy is common in this population and compounds pre-existing barriers to accessing health care. A drug and alcohol service in Sydney, Australia introduced strategies to enhance COVID-19 vaccination in people receiving opioid agonist treatment (OAT). We report vaccination outcomes and staff experiences of this.

METHODS

This mixed methods study (i) retrospectively evaluated vaccine uptake in people accessing OAT and (ii) explored perceptions of staff who delivered vaccination interventions through surveys and semi-structured interviews.

RESULTS

Of the 984 patients receiving OAT on 9 December 2021, 90.9% had received the first COVID-19 vaccination and 86.7% the second. Australia wide vaccination rates on that date were 93.1% and 88.7% for first and second doses, respectively. Staff commented that having a deep knowledge, understanding and connection with the patient group drove implementation and success of vaccination interventions. This was further supported by staff engagement with the vaccination interventions, and communication and sharing information, both between staff and with patients.

CONCLUSION

High rates of COVID-19 vaccination can be achieved in a vulnerable population. Engaged staff providing information and facilitating access to healthcare underpin this success.

Hepatitis C Cascades: Data to Inform Hepatitis C Elimination in the United States

The United States has a goal to eliminate hepatitis C as a public health threat by 2030. To accomplish this goal, hepatitis C virus (HCV) care cascades (hereinafter, HCV cascades) can be used to measure progress toward HCV elimination and identify disparities in HCV testing and care. In this topical review of HCV cascades, we describe common definitions of cascade steps, review the application of HCV cascades in health care and public health settings, and discuss the strengths and limitations of data sources used. We use examples from the Massachusetts Department of Public Health as a case study to illustrate how multiple data sources can be leveraged to produce HCV cascades for public health purposes. HCV cascades in health care settings provide actionable data to improve health care quality and delivery of services in a single health system. In public health settings at jurisdictional and national levels, HCV cascades describe HCV diagnosis and treatment for populations, which can be challenging in the absence of a single data source containing complete, comprehensive, and timely data representing all steps of a cascade. Use of multiple data sources and strategies to improve interoperability of health care and public health data systems can advance the use of HCV cascades and speed progress toward HCV elimination.

Participation in screening for breast and cervical cancer among women with current or previous drug use: a survey study

BACKGROUND

Women with current or previous drug use (WCPDU) have an increased risk of poor breast and cervical cancer outcomes. Screening is known to decrease the mortality of these common cancer forms, but screening participation has been sparsely investigated among women with drug dependency. The aim of this study was to assess participation in screening for breast and cervical cancer among WCPDU.

METHODS

We recruited WCPDU to a survey study, from six opioid substitution treatment (OST) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. The survey was constructed according to results from focus group discussions about cancer screening in a sample of women in OST. Survey data were analyzed using descriptive statistics. We analyzed associations between non-compliance to screening and healthcare contact (OST, NEP or none) by logistic regression analysis; unadjusted and adjusted for age, native language, housing situation, educational attainment and main source of income.

RESULTS

A total of 298 women (median age 43 years) responded to the survey. The self-reported compliance with cancer screening recommendations was 29% for breast cancer screening and 41% for cervical cancer screening. Non-compliance with cervical cancer screening was associated with NEP participation in univariate but not multivariate analysis. We did not find an association between non-compliance with breast cancer screening and healthcare contact. Non-compliance with screening for cervical cancer was also associated with unstable housing in univariate and multivariate analyses, and inversely associated with increasing age in a univariate analysis. Non-compliance with breast cancer was associated with unstable housing in a univariate analysis, and inversely associated with not having Swedish as a native language in a multivariate analysis.

CONCLUSION

The self-reported compliance with the national cancer screening programs for breast cancer and cervical cancer of WCPDU is notably lower than in the Swedish general population. Women with unstable housing seem to be particularly vulnerable to non-compliance with cancer screening. Interventions to minimize barriers to cancer screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

Service Utilization among Persons Who Inject Drugs Attending a Syringe Exchange Program in New York State

BACKGROUND

Epidemiologic studies commonly recommend the integration of harm reduction programs with health and social services to improve the well-being of persons who inject drugs (PWIDs). This study identified service utilization clusters for PWIDs attending a syringe exchange program (SEP) in 2017 to better understand in-house service usage.

METHODS

We applied Multiple Correspondence Analysis and Hierarchical Clustering on Principal Components to classify 475 PWIDs into clusters using anonymized, SEP records data from New York. Multinomial logistic regression was used to identify sociodemographic and program engagement correlates of cluster membership.

RESULTS

Only 22% of participants utilized at least one service. We identified three clusters of service utilization defined by 1) Nonuse; 2) Support, Primary Care, & Maintenance service use; and 3) HIV/STD, Support, Primary Care, & Maintenance service use. Cluster 2 members were less likely to be living alone compared to Cluster 1 (AOR = 0.08, 95% CI: 0.04, 0.17) while Cluster 3 members were less likely to be White (AOR = 0.19, 95% CI: 0.07, 0.50) or living alone (AOR = 0.16, 95% CI: 0.06, 0.44) and more likely to be Medicaid recipients (AOR = 2.89, 95% CI: 1.01, 8.36) compared to Cluster 1. Greater than one SEP interaction, lower syringe return ratios, and being a long-term client increased the odds of service utilization.

DISCUSSION

Overall, PWID clients had a low prevalence of in-house service use particularly those who live alone. However, higher service utilization was observed among more vulnerable populations (i.e., non-White and LGBT). Future research is needed to profile services used outside of the SEP.

Accessing needle exchange services in disasters for remote areas of Aotearoa New Zealand

BACKGROUND

Needle Exchange Programme (NEP) mobile outreach services in Aotearoa New Zealand distribute injecting equipment to people who inject drugs (PWID) living in remote regions. In disasters, continued access to such services is imperative for the health and wellbeing of PWID. Disasters can compound existing inequities, particularly in regions characterised by poor or limited infrastructure, smaller populations, and challenging socioeconomic conditions. To gain insight into the barriers that prevent access to NEP harm-reduction services and understand the needs of PWID prior to and during disasters, this study foregrounds the voices of PWID based on the West Coast of the South Island, Aotearoa New Zealand.

METHODS

This qualitative study applied an interpretive phenomenological analysis approach, where 14 PWID and one key NEP staff member took part in semi-structured interviews. The interviews provided the opportunity for participants to share their experiences and perspectives about accessing sterile drug-injecting equipment during disasters, including the four-week COVID-19 Level 4 lockdown in March 2020. In total five superordinate and 14 subordinate themes were identified from the interveiws.

RESULTS

This study focuses on four of the key themes that impacted accessibility to NEP services: infrastructural hazards and equipment costs; social capital and practical support from peers and key contact networks; social stigma in public locations, including NEP-based pharmacies and emergency centres; and potential solutions to NEP equipment accessibility as frequently suggested by participants.

CONCLUSIONS

Access to NEP services is essential during natural hazard and human-generated disasters, as such NEP mobile outreach services and disaster resilience efforts should focus on maintaining service continuity for PWID during adverse times. This study champions a needs-based, stigma free approach to inclusive harm-reduction and emergency management practices for groups with specific needs in a disaster context.

Awareness, perception and utilization of a mobile health clinic by people who use drugs

INTRODUCTION

People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs.

METHODS

Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory.

RESULTS

Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients.

DISCUSSION

MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.

Vaccination barriers and opportunities at syringe services programs in the United States, June-August 2021-A cross-sectional survey

BACKGROUND

Syringe services programs (SSPs) are an important venue for reaching people who inject drugs (PWID) to offer preventive services; however, not all SSPs offer vaccinations. We aimed to describe barriers and opportunities for SSPs to offer vaccinations.

METHODS

During June-August 2021, we conducted a descriptive, cross-sectional survey of SSP providers in the United States. SSPs were recruited from national listservs using purposive sampling to ensure geographic diversity. The survey included questions about SSP characteristics, client demographics, existing vaccination resources, resource needs, and staff perspectives on client vaccination barriers. Statistical comparisons were made using Pearson's chi-square test.

RESULTS

In total, 105 SSPs from 34 states responded to the survey; 46 SSPs (43.8%) offered on-site vaccinations. SSPs without on-site vaccinations were more likely operated by community-based organizations (81.4% vs 30.4%, p < 0.001) in urban areas (71.4% vs 40.0%, p = 0.002) than SSPs offering on-site vaccinations. The most common staffing need was for personnel licensed to administer vaccines (74/98, 75.5%). Over half of SSPs reported vaccine supply, administration supplies, storage equipment, and systems to follow-up clients for multidose series as important resource needs. The most common resource need was for reminder/recall systems for vaccines with multidose series (75/92, 81.5%). Vaccine safety concerns (92/95, 96.8%) and competing priorities (92/96, 95.8%) were the most common staff-reported client barriers to vaccinations.

CONCLUSIONS

Addressing missed opportunities for offering vaccinations to PWID who use SSPs will require increased numbers of on-site personnel licensed to administer vaccines and additional training, vaccination supplies, and storage and handling equipment.

Healthcare utilization for somatic conditions among Swedish patients in opioid substitution treatment, with and without on-site primary healthcare

Background

Opioid substitution treatment (OST) populations are aging and have increased mortality and somatic morbidity compared to general populations internationally. While OST patients have poor self-rated physical health and unmet healthcare needs, documented healthcare utilization has been sparsely investigated. The aim of this study was to assess registered healthcare utilization for somatic conditions in a sample of Swedish OST patients, and compare healthcare utilization among OST patients with and without use of on-site primary healthcare (PHC).

Methods

Patients in OST in Malmö, Sweden, were recruited for a survey study conducted in 2017–2018. Survey data were compared with comprehensive patient records from specialized and primary care during one year prior to study inclusion (total n = 190). All patient records were examined for healthcare utilization, source of healthcare (PHC, emergency care and secondary care), and documented diagnoses and symptoms. Factors associated with healthcare utilization were analyzed by using logistic regression analysis. Patients with and without on-site PHC were compared by using descriptive statistics and Chi-2 test.

Results

A total of 88% of the sample had been in direct or indirect contact with somatic healthcare during one year (PHC 66%; emergency care 28%; secondary care 67%). The most prevalent somatic diagnoses were infectious diseases (39%) and symptom diagnoses (37%). Respiratory, dermatological and musculoskeletal diagnoses, and trauma/intoxication were documented in 21–26% of the sample, respectively. PHC utilization was associated with older age and being born in Sweden. Among patients with on-site PHC (n = 25), the number utilizing secondary care was 84%, and certain diagnostic codes were more frequent in this group.

Conclusion

OST patients are seemingly underserved as regards their physical health. Since increased OST access decreases opioid overdose fatalities, the life expectancy among OST patients is likely to increase and thereby also increases the risk of age-related conditions. Thus, easily accessible physical healthcare is of great importance in this group. On-site PHC might be a way to establish healthcare contact with OST patients, especially for non-acute conditions, although further research is needed.

The Community-Based Medication-First program for opioid use disorder: a hybrid implementation study protocol of a rapid access to buprenorphine program in Washington State

BACKGROUND

Opioid use disorder (OUD) is a serious health condition that is effectively treated with buprenorphine. However, only a minority of people with OUD are able to access buprenorphine. Many access points for buprenorphine have high barriers for initiation and retention. Health care and drug treatment systems have not been able to provide services to all-let alone the majority-who need it, and many with OUD report extreme challenges starting and staying on buprenorphine in those care settings. We describe the design and protocol for a study of a rapid access buprenorphine program model in six Washington State communities at existing sites serving people who are unhoused and/or using syringe services programs. This study aimed to test the effectiveness of a Community-Based Medication-First Program model.

METHODS

We are conducting a hybrid effectiveness-implementation study of a rapid access buprenorphine model of care staffed by prescribers, nurse care managers, and care navigators. The Community-Based Medication-First model of care was designed as a 6-month, induction-stabilization-transition model to be delivered between 2019 and 2022. Effectiveness outcomes will be tested by comparing the intervention group with a comparison group derived from state records of people who had OUD. Construction of the comparison group will align characteristics such as geography, demographics, historical rates of arrests, OUD medication, and health care utilization, using restriction and propensity score techniques. Outcomes will include arrests, emergency and inpatient health care utilization, and mortality rates. Descriptive statistics for buprenorphine utilization patterns during the intervention period will be documented with the prescription drug monitoring program.

DISCUSSION

Results of this study will help determine the effectiveness of the intervention. Given the serious population-level and individual-level impacts of OUD, it is essential that services be readily available to all people with OUD, including those who cannot readily access care due to their circumstances, capacity, preferences, and related systems barriers.

Self and professional treatment of skin and soft tissue infections among women who inject drugs: Implications for wound care provision to prevent endocarditis

Background:

Skin and soft tissue infections (SSTI) are common among people who inject drugs and can result in severe health consequences, including infective endocarditis. Numerous barriers to accessing care often prevent people who inject drugs from seeking healthcare including past negative healthcare experiences, transportation, and shame around drug use. These barriers can lead some people who inject drugs to self-care instead of seeking formal treatment.

Methods:

We explored the prevalence of SSTIs and associated treatment behaviors among women who inject drugs and sell sex (N = 114). Women reported their drug use and SSTI histories. Those who experienced an SSTI reported if they self-treated their SSTIs and/or sought formal treatment.

Results:

Half (50.0%) experienced at least one SSTI in the past 6 months. SSTIs were more common among those who injected painkillers (24.6% vs 8.8%, p = 0.02) and who had ever been treated for endocarditis (28.1% vs 10.5%, p = 0.02). SSTIs were less common among those who injected multiple times per day (17.9% vs 38.6%, p = 0.01) and always injected with a sterile syringe (19.3% vs 42.1%, p = 0.01). Among those who experienced an SSTI, most (85.7%) reported self-treating, and half (52.6%) sought formal care. The emergency room was the most common source of care (73.3%).

Conclusions:

When experiencing SSTIs, women often opted to self-treat rather than seek formal healthcare. A lack of formal care can lead to infections progressing to serious conditions, like endocarditis. Self-treatment with non-prescribed antibiotics may further result in antibiotic-resistant infections. Low threshold, stigma free, community-based wound care programs are warranted.

Recruitment into a Clinical Trial of People Living with Uncontrolled HIV Infection Who Inject Drugs: a Site Case Report from the CTN 67 CHOICES Study

CHOICES was an open-label, randomized, comparative effectiveness trial of office-based extended-release naltrexone versus treatment as usual in people with untreated opioid use disorder and HIV. This study explored facilitators to recruitment in Miami, a successful recruiting site in the national trial. The mixed-methods study included quantitative surveys of randomized participants, medical record abstraction, and qualitative interviews with study staff. Miami recruited 47 (40.5%) of 116 randomized participants in the six-site national trial. In-depth interviews of study staff (n = 6) revealed that Miami had a recruitment approach consisting of street level outreach and a close relationship with the local syringe services program (SSP). Partnership with a local SSP provided access to people living with HIV who inject drugs in Miami. SSPs' fundamental trust within the community of people who inject drugs can be leveraged in studies aiming to improve health outcomes in this underserved and high-priority population.

Healthcare seeking among Swedish patients in opioid substitution treatment - a mixed methods study on barriers and facilitators

BACKGROUND

Patients in opioid substitution treatment (OST) have poorer health than the general population. Thus, they do not seek somatic health care to the extent that is medically motivated. Barriers hindering patients from seeking medical help through the conventional healthcare system result in a high degree of unmet healthcare needs. Barriers to, and facilitators of, OST patients' healthcare seeking have been sparsely examined.

METHODS

Mixed methods were employed. The quantitative part consisted of a cross-sectional questionnaire covering questions on physical health, healthcare seeking, and barriers thereof, which was collected from 209 patients in OST. A sub-sample of eleven OST patients participated in semi-structured interviews, for the qualitative part of the study, covering experience of healthcare, lifestyle, and self-images, expectations, and ideals of Swedish healthcare.

RESULTS

Confirmed by qualitative data, quantitative data revealed deprioritization, fear of stigma and of being treated badly, and problems in navigation throughout the healthcare system, leading to unsuccessful establishment of contact, being most common reasons for not seeking somatic healthcare. Thus, interviewees provided a deeper knowledge of the barriers stigma, lack of means to prioritize health and difficulties navigating throughout the healthcare system, leading to resignation and deprioritization. On-site primary healthcare (PHC) seemed to contribute to increased access and utilization of healthcare.

CONCLUSION

Individual and structural barriers decreasing access to healthcare lead to increased inequalities in healthcare utilization, adding to an already deteriorating health of this ageing population. Integration of on-site primary healthcare and OST could provide acceptable and accessible healthcare.

HCV communication within ego-centric networks of men and women who inject drugs

INTRODUCTION

Leveraging interpersonal communication among social networks of people who inject drugs (PWID) may be an innovative strategy to increase awareness and access to hepatitis C (HCV) care. However, little is known about HCV communication patterns among PWID and if these patterns vary by gender.

METHODS

Egocentric network data collected at baseline from HCV-infected PWID enrolled in a randomized HCV treatment intervention trial in Baltimore, Maryland were analyzed. Logistic generalized estimating models were conducted to identify predictors of HCV communication.

RESULTS

Among 227 PWID, the mean age was 43.8 (SD=10.3), 28.2% (n = 64) were women and 71.8% (n = 163) were men. Female participants reported 516 dyadic relationships and male participants 1139 dyadic relationships. While there were significant gender differences based on socio-demographics, risk behavior and network composition, there were few differences in HCV communication patterns. Both men and women had increased odds of HCV communication with alters who are currently enrolled in drug treatment (AOR 1.7, 95% CI: 1.3-2.4), alters with whom participants share drug preparation equipment (AOR 3.0, 95% CI: 1.9-4.6), alters who are sex partners compared to kin (AOR 3.0; 95% CI: 1.9-4.9) and alters with whom respondents have increased trust (AOR 1.1; 95% CI: 1.11.2) and daily/weekly interactions (AOR 1.7; 95% CI 1.3-2.1).

CONCLUSION

PWID engaged with trusted alters about HCV disclosure and information, highlighting the important role network interventions could play in this vulnerable population.

Drug use disorder and risk of incident and fatal prostate cancer among Swedish men: a nationwide epidemiological study

Purpose

Prostate cancer is the second most common cancer in men and a leading cause of cancer mortality worldwide. Men with drug use disorders (DUD) may potentially be at high risk for prostate cancer mortality because of delayed diagnosis and/or undertreatment. In this study, we aimed to investigate prostate cancer incidence, mortality, and stage at time of diagnosis among men with DUD compared to the general male population in Sweden.

Methods

We performed a follow-up study based on Swedish national register data for the period January 1997–December 2016. The study was based on 1,361,532 men aged 50–75 years at inclusion, of whom 9,259 were registered with DUD. Cox regression analysis was used to compute adjusted hazard ratios (HRs) for incident and fatal prostate cancer, and cancer stage at time of diagnosis, associated with DUD.

Results

DUD was associated with a slightly increased risk of incident prostate cancer (HR: 1.07, 95% confidence interval [CI] 1.00–1.14, p = 0.048) and substantially higher risk of fatal prostate cancer (HR: 1.59, 95% CI 1.40–1.82, p < 0.001), adjusted for age, socioeconomic factors, and comorbidities related to tobacco smoking and alcohol use disorder. No association was found between DUD and prostate cancer stage at diagnosis.

Conclusions

Men with DUD have an increased risk of fatal prostate cancer, possibly related to undertreatment in this patient population. Our findings should raise attention among medical staff and decision-makers towards a disadvantaged group of men in need of easily accessible prostate cancer evaluation and treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-021-01513-2.

A qualitative examination of substance use service needs among people who use drugs (PWUD) with treatment and service experience in Ontario, Canada

BACKGROUND

People who use drugs (PWUD) often have complex health and social support needs related to substance use, yet face numerous barriers to service access, resulting in unmet treatment needs and a corresponding gap in treatment. While initiatives to scale up substance use services for PWUD in Canada - and Ontario - have been undertaken, these have excluded PWUD' perspectives, and their needs have largely been defined by other actors. As end-users of services, PWUD' perspectives are vital to understanding what services are required, and whether existent services are adequate, appropriate and effective. Thus, the present study aimed to elicit in-depth knowledge from PWUD with lived experience of accessing services to better understand their unmet treatment and service needs, towards closing the service and treatment gap in Ontario.

METHODS

This qualitative study included one-on-one interviews conducted with a cohort of n = 45 adult PWUD with substance use and treatment experience in Ontario, Canada. Participants were recruited from substance use services based on ConnexOntario's directory of all provincial addiction services, as well as by word-of-mouth. Questions focused on participants' experiences and perspectives on substance use services towards understanding their service needs. Data underwent an inductive thematic analysis based on key themes that emerged.

RESULTS

Participants commonly engaged in polysubstance use, and identified a number of unmet substance use service needs including complex factors within the current service system that influenced access to available programs. Specifically, participants suggested the need to address stigmatization and system fragmentation, increase service provision and capacity, and scale up specific services and related supports such as harm reduction, counseling, treatment, and housing.

CONCLUSIONS

This study identified PWUD' needs in relation to substance use service provision in Ontario, Canada, and highlighted important areas for policy change and program planning and implementation. Concrete recommendations include the development of a government-funded, low-barrier, comprehensive and integrated service delivery and referral models that include PWUD as collaborators and program facilitators to ensure that services are as accessible, effective, and cohesive as possible. Results from this study can be used to enhance provincial substance use treatment and service provision.

Feasibility, acceptability, concerns, and challenges of implementing supervised injection services at a specialty HIV hospital in Toronto, Canada: perspectives of people living with HIV

BACKGROUND

Substance use significantly impacts health and healthcare of people living with HIV/AIDS (PLHIV), especially their ability to remain in hospital following admission. Supervised injection services (SIS) reduce overdoses and drug-related harms, but are not often provided within hospitals/outpatient programs. Leading us to question, what are PLHIV's perceptions of hospital-based SIS?

METHODS

This mixed-methods study explored feasibility and acceptability of implementing SIS at Casey House, a Toronto-based specialty HIV hospital, from the perspective of its in/outpatient clients. We conducted a survey, examining clients' (n = 92) demand for, and acceptability of, hospital-based SIS. Following this, we hosted two focus groups (n = 14) and one-on-one interviews (n = 8) with clients which explored benefits/drawbacks of in-hospital SIS, wherein participants experienced guided tours of a demonstration SIS space and/or presentations of evidence about impacts of SIS. Data were analysed using descriptive statistics and thematic analysis.

RESULTS

Among survey participants, 76.1% (n = 70) identified as cis-male and over half (n = 49;54.4%) had been a hospital client for 2 years or less. Nearly half (48.8%) knew about clients injecting in/near Casey House, while 23.6% witnessed it. Survey participants were more supportive of SIS for inpatients (76.1%) than for outpatients (68.5%); most (74.7%) reported SIS implementation would not impact their level of service use at Casey House, while some predicted coming more often (16.1%) and others less often (9.2%). Most focus group/interview participants, believed SIS would enhance safety by reducing health harms (e.g. overdose), increasing transparency between clients and clinicians about substance use, and helping retain clients in care. Debate arose about who (e.g., in/outpatients vs. non-clients) should have access to hospital-based SIS and how implementation may shift organizational priorities/resources away from services not specific to drug use.

CONCLUSIONS

Our data showed widespread support of, and need for, hospital-based SIS among client stakeholders; however, attempts to reduce negative impacts on non-drug using clients need to be considered in the balance of implementation plans. Given the increased risks of morbidity and mortality for PLHIV who inject drugs as well as the problems in retaining them in care in a hospital setting, SIS is a key component of improving care for this marginalized group.

Healthcare Contacts Regarding Circulatory Conditions among Swedish Patients in Opioid Substitution Treatment, with and without On-Site Primary Healthcare

Patients in Opioid Substitution Treatment (OST) have increased mortality and morbidity, with circulatory conditions suggested to be a contributing factor. Since OST patients tend to have unmet physical healthcare needs, a small-scale intervention providing on-site primary healthcare (PHC) in OST clinics was implemented in Malmö, Sweden in 2016. In this study, we assessed registered circulatory conditions and healthcare utilization in OST patients with and without use of on-site PHC. Patients from four OST clinics in Malmö, Sweden, were recruited to a survey study in 2017-2018. Medical records for the participants were retrieved for one year prior to study participation (n = 192), and examined for circulatory diagnoses, examinations and follow-ups. Patients with and without on-site PHC were compared through descriptive statistics and univariate analyses. Eighteen percent (n = 34) of the sample had 1≤ registered circulatory condition, and 6% (n = 12) attended any clinical physiology examination or follow-up, respectively. Among patients utilizing on-site PHC (n = 26), the numbers were 27% (n = 7) for circulatory diagnosis, 15% (n = 4) for examinations, and 12% (n = 3) for follow-up. OST patients seem underdiagnosed in regard to their circulatory health. On-site PHC might be a way to diagnose and treat circulatory conditions among OST patients, although further research is needed.

Predictors of enrollment in opioid agonist therapy after opioid overdose or diagnosis with opioid use disorder: A cohort study

BACKGROUND

Medicaid recipients have a high burden of opioid overdose and opioid use disorder (OUD). Opioid agonist therapies are an effective treatment for OUD, but there is a wide and persisting gap between those who are indicated and those who receive treatment. The objective of this study was to identify the predictors of enrollment in opioid agonist therapy within 6 months of an opioid overdose or OUD diagnosis in a cohort of Medicaid recipients.

METHODS

Using multiple linked, state-level databases, we conducted a retrospective cohort study of 17,449 Medicaid recipients in Rhode Island who had an opioid overdose or an OUD diagnosis between July 2013 and June 2018.

RESULTS

The majority (58 %) of Medicaid recipients did not enroll in opioid agonist therapy within 6 months. In adjusted models, having one or more prior overdose (adjusted risk ratio [ARR] = 0.33, 95 % CI: 0.28, 0.38), alcohol use disorder (ARR = 0.56, 95 % CI: 0.52, 0.60), or back problems (ARR = 0.58, 95 % CI: 0.55, 0.61) were strong predictors of non-enrollment. Conversely, emergency department (ARR = 1.31, 95 % CI: 1.28-1.34) and primary care provider (ARR = 1.03, 95 % CI: 1.01-1.34) visit frequency above the 75th percentile were associated with timely enrollment in opioid agonist therapy.

CONCLUSIONS

Our findings underscore the need to enhance pathways to treatment for OUD through varied nodes of engagement with healthcare systems. Interventions to improve screening for OUD and referrals to opioid agonist therapies should include high-impact settings, such as treatment programs for alcohol and substance use disorders, pain clinics, and outpatient behavioral care settings.

Drug use disorder and risk of incident and fatal breast cancer: a nationwide epidemiological study

Purpose

Breast cancer is one of the most common cancer forms in women and it is often detected by screening. However, women with drug use disorders (DUD) are less likely to be reached by screening programs. In this study, we aimed to investigate breast cancer incidence, mortality and stage at time of diagnosis among women with DUD compared to the general female population in Sweden.

Methods

We performed a follow-up study based on Swedish national register data for the period January 1997–December 2015. The study was based on 3,838,248 women aged 15–75 years, of whom 50,858 were registered with DUD. Adjusted hazard ratios (HRs) for incident and fatal breast cancer, and cancer stage at time of diagnosis, were calculated for women with and without DUD using Cox regression analysis.

Results

DUD was associated with incident breast cancer (HR 1.08, 95% confidence interval [CI] 1.02–1.14, p = 0.0069), fatal breast cancer (HR 1.60, 95% CI 1.42–1.82, p < 0.001), and stage IV breast cancer, i.e. metastasis at diagnosis (HR 2.06, 95% CI 1.44–2.95, p < 0.001).

Conclusions

Women with DUD were identified as a risk group for incident, fatal and metastasized breast cancer, which calls for attention from clinicians and policy makers. Cancer screening attendance and other healthcare seeking barriers are likely to affect the risk increase among women who use drugs; however, more research is needed on the underlying mechanisms.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05998-4) contains supplementary material, which is available to authorized users.

Health Literacy among Swedish Patients in Opioid Substitution Treatment: A Mixed-Methods Study

BACKGROUND

Poor health and unmet healthcare needs is common among people with substance use disorder (SUD) including patients in opioid substitution treatment (OST). Low health literacy (HL) is associated with poverty, low education and physical limitations, but is unexplored in an OST context.

METHODS

Mixed-methods were used. Participants were consecutively recruited by clinic staff or researcher, from five OST clinics in Malmö, Sweden, during September - November 2019. HL level was measured through HLS-EU-Q16 (n?=?286). Self-reported socioeconomic correlates of HL were analyzed through logistic regression. Patients' experiences of HL-related problems were assessed through six focus group interviews (n?=?23) moderated by an OST employee.

RESULTS

While 46% had sufficient HL (13-16 points of maximum 16), 32% did not receive a HL score due to too many missing answers. No correlates of sufficient HL level were found. Missing HL level was associated with low educational attainment (Ajusted odds ratio [AOR] 1.94; 95% Confidence interval [CI] 1.13-3.32) and negatively associated with employment (AOR 0.28; 95% CI 0.11-0.71). Qualitative data revealed a diversity in participants' self-assessed capabilities, and problems associated with access, comprehension, trust and dependency on addiction-specific services.

CONCLUSIONS

This study highlights that HL level is low, and identifies a number of concrete problems related to HL in the studied population. The results implicate a need for tailored interventions regarding health information among OST patients.

Community Perceptions of Harm Reduction and Its Implications for Syringe Exchange Policy

In the United States, the rising prevalence of opioid addiction has led to an increase in opioid-related overdose deaths and transmission of infectious disease. This resulted in the declaration of a national public health emergency and the need for harm reduction strategies such as syringe exchange. Florida has seen increases in blood-borne diseases and fatal/nonfatal opioid overdoses, yet harm reduction policy integration has been historically limited. To inform policy change, this study explores the perspectives of community members in Manatee County, Florida, on harm reduction services. Six focus groups were conducted with findings centralized around three emergent themes related to the implementation of a syringe exchange program: (a) awareness and acceptability; (b) facilitating factors; and (c) perceived barriers. The results of this qualitative research helped to inform the successful adoption of a local syringe exchange ordinance. Recommendations for community education and engagement regarding harm reduction policy are discussed.

Factors associated with skin and soft tissue infections among people who inject drugs in the United Kingdom: A comparative examination of data from two surveys

BACKGROUND

People who inject drugs (PWID) are at high risk of injection-related skin and soft tissue infections (SSTI). If not treated promptly, these can lead to serious health complications, which are a considerable healthcare burden. Data from two community surveys, with different approaches, were used to assess SSTI prevalence and associated factors among PWID to inform intervention implementation.

METHODS

Data were analysed from two surveys, a national surveillance survey (n=2,874; 2017-18) of infections among PWID in the United Kingdom (UK) and an in-depth survey (n=455; 2018-19) of SSTI among PWID based in London, UK. Multivariable logistic regression models were constructed to ascertain the factors associated with self-reported SSTI.

RESULTS

High prevalence of SSTI were reported in both samples: 52 % of participants from the national surveillance survey reported having SSTI within the preceding 12 months and 65 % of the London sample reported a lifetime history of SSTI. The factors associated with SSTI in both surveys were similar, including older age; number of years injecting; number of attempts required to inject into the vein; injecting into the hands, feet, groin or neck and re-using or sharing needles/syringes.

CONCLUSIONS

The number of PWID reporting SSTI in the UK is concerningly high. The two surveys used different recruitment approaches but found similar associations. We provide strong evidence of a relationship between venous access difficulty and SSTI. To stem the increase of SSTI and related complications in the UK, it is crucial that interventions attend to the underlying causes of venous damage among PWID.