The experience of initiating injection drug use and its social context: a qualitative systematic review and thematic synthesis

The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States

BACKGROUND

Co-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality.

METHOD

We recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant.

RESULTS

A clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand.

CONCLUSION

Transformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs' market dominance at this location and possible interventions.

Gender, sexual orientation identity, and initiation of amphetamine injecting among people who inject drugs: Examination of an expanding drug era in Montreal, Canada, 2011-19

BACKGROUND

Amphetamine injection is expanding in North America and has been associated with male homosexuality among people who inject drugs (PWID). Applying subcultural evolution theory, we examined overall and gender-stratified trends in amphetamine injection and assessed sexual orientation as a gender-specific predictor of initiation among PWID in Montreal, Canada.

METHODS

Data were from HEPCO, an open prospective cohort of PWID. Gender and sexual orientation were self-identified at enrolment. Interviewer-administered questionnaires at three-monthly (HCV RNA-negative participants) or yearly (RNA-positive) intervals captured past three-month amphetamine injection and covariates. Annual prevalence and linear trends in amphetamine injection were estimated using GEE. Incidence was computed among naïve individuals and hazard ratios for initiation estimated using gender-stratified, time-varying Cox regression models.

RESULTS

803 participants contributed 8096 observations between March 2011 and December 2019. Annual prevalence of amphetamine injecting increased from 3.25% [95%CI: 2.06-4.43%] to 12.7% [9.50-16.0] (trend p<0.001). Bivariate Cox regression models suggested similar and divergent predictors of initiation by gender. Incidence was 3.27 per 100 person-years [95%CI: 2.51-4.18] among heterosexual men, 7.18 [3.50-13.2] among gay/bisexual men, 1.93 [0.78-4.02] among heterosexual women and 5.30 [1.69-12.8] among gay/bisexual women. Among men, gay/bisexual identity doubled risk of initiation after adjusting for age, ethnicity, calendar year (aHR 2.16 [1.07-4.36]) and additional covariates (2.56 [1.24-5.30]). Among women, evidence for an association with gay/bisexual identity was inconclusive (aHR 2.63 [0.62-11.2]) and sample size precluded further adjustment CONCLUSIONS: Prevalence of amphetamine injection among PWID increased four-fold from 2011 to 2019, with elevated risk of initiation in gay and bisexual men.

Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis

BACKGROUND AND AIMS

Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections.

METHODS

We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes.

RESULTS

We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission).

CONCLUSIONS

Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.

Latent polydrug use patterns and the provision of injection initiation assistance among people who inject drugs in three North American settings

INTRODUCTION

We sought to identify latent profiles of polysubstance use patterns among people who inject drugs in three distinct North American settings, and then determine whether profile membership was associated with providing injection initiation assistance to injection-naïve persons.

METHODS

Cross-sectional data from three linked cohorts in Vancouver, Canada; Tijuana, Mexico; and San Diego, USA were used to conduct separate latent profile analyses based on recent (i.e., past 6 months) injection and non-injection drug use frequency. We then assessed the association between polysubstance use patterns and recent injection initiation assistance provision using logistic regression analyses.

RESULTS

A 6-class model for Vancouver participants, a 4-class model for Tijuana participants and a 4-class model for San Diego participants were selected based on statistical indices of fit and interpretability. In all settings, at least one profile included high-frequency polysubstance use of crystal methamphetamine and heroin. In Vancouver, several profiles were associated with a greater likelihood of providing recent injection initiation assistance compared to the referent profile (low-frequency use of all drugs) in unadjusted and adjusted analyses, however, the inclusion of latent profile membership in the multivariable model did not significantly improve model fit.

DISCUSSION AND CONCLUSIONS

We identified commonalities and differences in polysubstance use patterns among people who inject drugs in three settings disproportionately impacted by injection drug use. Our results also suggest that other factors may be of greater priority when tailoring interventions to reduce the incidence of injection initiation. These findings can aid in efforts to identify and support specific higher-risk subpopulations of people who inject drugs.

Role of social context in addiction etiology and recovery

While social context has long been considered central to substance use disorder prevention and treatment and many drug-taking events occur in social settings, experimental research on social context has historically been limited. Recent years have seen an emergence of concerted preclinical and human laboratory research documenting the direct impact of social context on substance use, delineating behavioral and neurobiological mechanisms underlying social influence's role. We review this emerging preclinical and human laboratory literature from a theoretical lens that considers distinct stages of the addiction process including drug initiation/acquisition, escalation, and recovery. A key conclusion of existing research is that the impact of the social environment is critically moderated by the drug-taking behavior and drug use history of a social peer. Specifically, while drug-free social contexts can reduce the likelihood of drug use initiation and act as a competitive non-drug alternative preventing escalation, drug-using peers can equally facilitate initiation and escalation through peer modeling as a contingent reward of use. Likewise, social context may facilitate recovery or serve as a barrier that increases the chances of a return to regular use. We conclude by discussing evidence-based treatments and recovery support services that explicitly target social mechanisms or that have identified social context as a mechanism of change within treatment. Ultimately, new areas for research including the expansion of drug classes studied and novel human laboratory designs are needed to further translate emerging findings into clinical practice.

First-line opioid agonist treatment as prevention against assisting others in initiating injection drug use: A longitudinal cohort study of people who inject drugs in Vancouver, Canada

Background

Among people who inject drugs, frequent injecting and experiencing withdrawal are associated with facilitating others' first injections. As these factors may reflect an underlying substance use disorder, we investigated whether first-line oral opioid agonist treatment (OAT; methadone or buprenorphine/naloxone) reduces the likelihood that people who inject drugs help others initiate injecting.

Methods

We used questionnaire data from semi-annual visits between December 2014-May 2018 on 334 people who inject drugs with frequent non-medical opioid use in Vancouver, Canada. We estimated the effect of current first-line OAT on subsequent injection initiation assistance provision (i.e., helped someone initiate injecting in the following six months) using inverse-probability-weighted estimation of repeated measures marginal structural models to reduce confounding and informative censoring by time-fixed and time-varying covariates.

Results

By follow-up visit, 54-64% of participants reported current first-line OAT whereas 3.4-6.9% provided subsequent injection initiation assistance. Per the primary weighted estimate (n = 1114 person-visits), participants currently on first-line OAT (versus no OAT) were 50% less likely, on average, to subsequently help someone initiate injecting (relative risk [RR]=0.50, 95% CI=0.23-1.11). First-line OAT was associated with reduced risk of subsequent injection initiation assistance provision in participants who, at baseline, injected opioids less than daily (RR=0.15, 95% CI=0.05-0.44) but not in those who injected opioids daily (RR=0.86, 95% CI=0.35-2.11).

Conclusions

First-line OAT seemingly reduces the short-term likelihood that people who inject drugs facilitate first injections. However, the extent of this potential effect remains uncertain due to imprecise estimation and observed heterogeneity by baseline opioid injecting frequency.

A Scoping Review of Risk and Protective Factors for Negative Cannabis Use Consequences

Objective

Numerous reviews have examined risk and protective factors for alcohol-related negative consequences, but no equivalent review of risk and protective factors exists for cannabis-related negative consequences (CRNCs)-a gap filled by the present study. This scoping review examined survey-based research of risk and protective factors for CRNCs such as neglecting responsibilities, blacking out, or needing more cannabis.

Methods

Three databases (PubMed, PsycINFO, and Google Scholar) were searched for peer-reviewed manuscripts published between January 1, 1990, and December 31, 2021. A qualitative synthesis was performed using the matrix method and the results were organized using the socioecological model as a framework.

Results

Eighty-three studies were included in the review. There was considerable variation in measures and operationalizations of CRNCs across studies. Risk factors were identified in the intrapersonal (depression, social anxiety, PTSD, impulsivity, sensation seeking, motives, expectancies), interpersonal/community (trauma, victimization, family and peer substance use, social norms), and social/policy (education, employment, community attachment, legalization, availability of substances) domains of influence. Protective behavioral strategies were a robust protective factor for CRNCs. Males consistently reported more CRNCs than females, but there were no differences observed across race.

Conclusions

Future research should identify person- and product-specific patterns of CRNCs to refine theoretical models of cannabis misuse and addiction. Public health interventions to reduce the risk of negative consequences from cannabis should consider utilizing multilevel interventions to attenuate the cumulative risk from a combination of psychological, contextual, and social influences.

Behavioural Risk for HIV, Hepatitis B, and Hepatitis C Infections among a Population of Drug Users and Injectors across Four Regions in Ghana

Background

Blood borne infections such as HIV, Hepatitis B (HBV), and Hepatitis C (HCV) are of great importance to governments and their implementing partners, especially among people who use drugs (PWUD) and people who inject drugs (PWID). Prevalence and determinants of HIV, HBV, and HCV among PWUD and PWID in Ghana are not well established, the significance of this study.

Method

This assessment was a cross-sectional study implemented via the respondent driven sampling approach. A team of community advisory boards that comprised former users, current users, and civil society organizations were constituted to help in the implementation of the study. The study was conducted in four regions in Ghana. The assessment was based on a representation of populations of PWID and PWUD from the four regions. Efforts were made by the team to ensure adequate representation of women where feasible. A quantitative questionnaire was developed and used to obtain information on the respondents' sociodemographics, sexual behavior, substance use, and biological characteristics. The prevalence of HIV, HBV, and HCV among PWID and PWUD was determined using blood samples. First response and oral quick test for confirmation of HIV positivity were carried out, while SD bioline was used to test for the presence of HBV and HBC. Data were analyzed using the Bayesian generalized linear model via the binomial family of distributions under the logit link function with weak Cauchy and Normal distribution as prior.

Results

A total of 323 PWUD and PWID participants were interviewed across four regions of Ghana. The overall median age of the respondents was 36 (28, 43) years. The prevalence of HIV, HBV, and HCV infection in the study was 2.5%, 4.6%, and 5.9%, respectively. The prevalence of HIV, HBV, and HCV among drug users was 2.5% (95% CI: 0.7%–4.2%), 4.1% (95% CI: 1.8%–6.2%), and 6.7% (95% CI: 3.9%–9.4%), respectively. Most drug injectors and users started using and injecting drugs at ages less than 20 years and between 20 and 29 years, respectively. Drug users who identified themselves as part of the general population were 66% less likely to be tested HIV positive (POR = 0.34, CrI: 0.12–0.81) compared to sex workers. Part time employment respondents had fivefold odds (POR = 5.50, CrI: 1.20–16.16) of being HBV positive as against full-time employment.

Conclusion

Most of the injectors and users started drugs at an early age. Drug users and injectors are at higher risk of these infections because of associated risky sexual behaviors and risky injection practices. Harm reduction programs to help addicts who are willing to quit the practice are recommended.

What Prevention and Treatment of Substance Dependence Can Tell Us About Addressing Violent Extremism

In this article, the authors examine similarities between violent extremism and substance dependence. They review evidence from psychology, neuroscience, sociology, and public health that suggests that there are similarities in violent extremism and substance dependence in terms of the underlying neural pathways, social and psychological causes, behavioral patterns, and opportunities for prevention and intervention.

Factors associated with smoking and transitioning to nyaope injection amongst women in the City of Tshwane Municipality: A self-report by women

Background

Substance use disorder has emerged as a key health and social challenge in South Africa (SA). It is projected that about 15% of South African youth, especially young women are prone to engage in drug use and the prospects of coming into contact with nyaope, a highly addictive drug, are higher. Nyaope is mainly smoked, but the prevalence of injecting it is increasing in most regions.

Aim

This study aimed to explore and describe the perception of women, who use nyaope, about the factors contributing to nyaope smoking and transitioning to injecting nyaope amongst women in the City of Tshwane Municipality (CoT), Gauteng.

Setting

The research was conducted within Community Oriented Substance Use Programme sites across the CoT Municipality.

Methods

Qualitative research methods were utilised to explore and describe the perceptions of the participants on factors contributing to the use of nyaope amongst women residing in the CoT. Data were collected through face-to-face interviews and thematically analysed.

Results

Intimate partner influence (IPI), peer pressure, being misled by friends, weight loss, lack of effective coping mechanisms and counteracting other drugs contributed to women smoking nyaope. Additionally, a need for an intense high, IPI, influence by the social network, curiosity and cost-effectiveness contributed to women transitioning from smoking to injecting nyaope.

Conclusion

The study has established factors contributing to smoking and transition to injecting nyaope as viewed by women residing in the CoT.

Contribution

This research affirms that women are influenced by different factors to use and transition to injecting Nyaope.

The influence of poly-drug use patterns on the association between opioid agonist treatment engagement and injecting initiation assistance

BACKGROUND

Evidence suggests people who inject drugs (PWID) prescribed opioid agonist treatment (OAT) are less likely to provide injection drug use (IDU) initiation assistance. We investigated the association between OAT engagement and providing IDU initiation assistance across poly-drug use practices in Vancouver, Canada.

METHODS

Preventing Injecting by Modifying Existing Responses (PRIMER) is a prospective study seeking to identify structural interventions that reduce IDU initiation. We employed data from linked cohorts of PWID in Vancouver and extended the findings of a latent profile analysis (LPA). Multivariable logistic regression models were performed separately for the six poly-drug use LPA classes. The outcome was recently assisting others in IDU initiation; the independent variable was recent OAT engagement.

RESULTS

Among participants (n = 1218), 85 (7.0%) reported recently providing injection initiation assistance. When adjusting for age and sex, OAT engagement among those who reported a combination of high-frequency heroin and methamphetamine IDU and low-to-moderate-frequency prescription opioid IDU and methamphetamine non-injection drug use (NIDU) was associated with lower odds of IDU initiation assistance provision (Adjusted Odds Ratio [AOR]: 0.18, 95% CI: 0.05-0.63, P = 0.008). Significant associations were not detected among other LPA classes.

CONCLUSIONS

Our findings extend evidence suggesting that OAT may provide a population-level protective effect on the incidence of IDU initiation and suggest that this effect may be specific among PWID who engage in high-frequency methamphetamine and opioid use. Future research should seek to longitudinally investigate potential causal pathways explaining the association between OAT and initiation assistance provision among PWID to develop tailored intervention efforts.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Young and invisible: a qualitative study of service engagement by people who inject drugs in India

OBJECTIVES

The HIV epidemic in India is concentrated in key populations such as people who inject drugs (PWID). New HIV infections are high among young PWID (≤30 years of age), who are hard to engage in services. We assessed perspectives of young PWID to guide development of youth-specific services.

SETTING

We conducted focus group discussions (FGDs) with PWID and staff at venues offering services to PWID in three Indian cities representing historical and emerging drug use epidemics.

PARTICIPANTS

PWID were eligible to participate if they were between 18 and 35 years, had initiated injection as adolescents or young adults and knew adolescent PWID in their networks. 43 PWID (81% male, 19% female) and 10 staff members participated in FGDs. A semistructured interview guide was used to elicit participants' narratives on injection initiation experiences, barriers to seeking harm reduction services, service delivery gaps and recommendations to promote engagement. Thematic analysis was used to develop an explanatory model for service engagement in each temporal stage across the injection continuum.

RESULTS

Injection initiation followed non-injection opioid dependence. Lack of services for non-injection opioid dependence was a key gap in the preinjection initiation phase. Lack of knowledge and reliance on informal sources for injecting equipment were key reasons for non-engagement in the peri-injection phase. Additionally, low-risk perception resulted in low motivation to seek services. Psychosocial and structural factors shaped engagement after established injection. Housing and food insecurity, and stigma disproportionately affected female PWID while lack of confidential adolescent friendly services impeded engagement by adolescent PWID.

CONCLUSIONS

Development of youth-specific services for young PWID in India will need to address unique vulnerabilities and service gaps along each stage of the injection continuum. Scaling-up of tailored services is needed for young female PWID and adolescents, including interventions that prevent injection initiation and provision of confidential harm reduction services.

Exploring multilevel determinants of co-occurring violence, HIV, mental health and substance use problems

Multiple factors contribute to co-occurring issues such as violence, HIV, and mental disorders among people who inject drugs (PWID), particularly those residing in limited resource settings. Using an ecological framework, this study explored multilevel determinants of co-occurring violence, HIV, mental health, and substance use issues among PWID. Data were collected via semi-structured in-depth interviews with 31 men and women PWID in India. Findings revealed factors at the community (e.g., stigma), interpersonal (e.g., abusive partners), and individual (e.g., financial stress) levels. Findings highlight the need for prevention and intervention programs addressing factors at multiple ecological levels to reduce comorbidity among PWID.

Involvement of people who inject drugs in injection initiation events: a cross-sectional analysis identifying similarities and differences across three North American settings

OBJECTIVES

People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk.

DESIGN

We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis.

SETTING

Tijuana, Mexico; San Diego, USA; Vancouver, Canada.

PARTICIPANTS

A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825).

MEASUREMENTS

The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models.

RESULTS

Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I²: 52%), recent housing insecurity (I²: 39%) and recent non-injection heroin use (I²: 78%).

CONCLUSION

We identified common and site-specific factors related to PWID's risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.

Investigating a bidirectional relationship between overdose and provision of injection initiation assistance among persons who inject drugs in Vancouver, Canada and Tijuana, Mexico

BACKGROUND

Individuals who initiate injection drug use often receive assistance from an injection-knowledgeable peer. Persons who assist peers in injection initiation events often inject frequently, which heightens overdose risk. As such, overdose and injection initiation events may be correlated. To explore a potential relationship, we assessed temporal associations between experiencing a non-fatal overdose and assisting others in initiating injection drug use among persons who inject drugs in two North American cities - Vancouver, Canada and Tijuana, Mexico.

METHODS

From 2014 to 2018, this retrospective cohort study included people who inject drugs from Vancouver (n=1332) and Tijuana (n=666) who completed a baseline and six-month follow-up interview. Within each site, we assessed bidirectional temporal associations using two separate multivariable logistic regression models: for model 1, recent provision of injection initiation assistance (at six months) was the outcome and recent overdose (at baseline) was the exposure; for model 2, recent overdose (at six months) was the outcome and recent provision of injection initiation assistance (at baseline) was the exposure. Both models adjusted for potential confounders.

RESULTS

Vancouver-based participants reporting overdose at baseline had 163% greater odds of reporting provision of injection initiation assistance at follow-up (adjusted Odds Ratio [aOR] 2.63; 95% Confidence Interval [CI] 1.41-4.90); while participants reporting provision of injection initiation assistance at baseline had 89% greater odds of reporting a non-fatal overdose at follow-up (aOR 1.89; 95% CI 1.00-3.57). Among Tijuana-based participants, we did not observe a statistically significant association in either direction.

CONCLUSION

Findings in Vancouver suggest that injection initiation assistance and overdose are bidirectionally-associated phenomena. The present findings highlight the need for interventions that ensure that persons who provide injection initiation assistance are given overdose prevention support, both for themselves and for those they assist to initiate injection drug use. While our Tijuana-based results did not suggest a bidirectional relationship, preventative approaches should nonetheless be undertaken.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone

BACKGROUND

Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees.

METHODS

Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used.

RESULTS

We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings.

CONCLUSION

Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

The impact of recent homelessness on the provision of injection drug use initiation assistance among persons who inject drugs in Tijuana, Mexico and Vancouver, Canada

OBJECTIVE

To assess the relationship between experiencing homelessness and assisting injection drug use (IDU) initiation among people who inject drugs (PWID) in Tijuana, Mexico and Vancouver, Canada.

METHODS

We used self-reported questionnaire data collected semi-annually on PWID from Tijuana (n = 703) and Vancouver (n = 1551) between 2014 and 2017. Within each setting, the effect of recent (i.e., past six months) homelessness on recent provision of injection initiation assistance (i.e., helping anybody inject for the first time in the past six months) was estimated using inverse-probability-of-treatment (IPT)-weighted estimation of a marginal structural model.

RESULTS

Across follow-up, the prevalence of recent homelessness at a given visit ranged from 11.6%-16.5% among Tijuana-based participants and 9.4%-18.9% among Vancouver-based participants; the prevalence of recent provision of injection initiation at a given follow-up visit was lower, ranging from 3.3%-5.4% in Tijuana and 2.5%-4.1% in Vancouver. Based on the IPT-weighted estimates, recent homelessness was associated with 66% greater odds among Tijuana-based PWID (Adjusted Odds Ratio [AOR] = 1.66; 95% CI: 1.01-2.73) and 47% greater odds among Vancouver-based PWID (AOR = 1.47, 95% CI: 1.02-2.13) of providing injection initiation assistance over the same six-month period.

CONCLUSION

We found that recently experiencing homelessness was associated with an increased likelihood of PWID reporting IDU initiation assistance over time in both Tijuana and Vancouver. Addressing homelessness may decrease the initiation of IDU via multiple pathways.

The intersection of gender and drug use-related stigma: A mixed methods systematic review and synthesis of the literature

BACKGROUND

Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma?

METHODS

Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma.

RESULTS

Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma.

CONCLUSION

The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.

The role of social capital in facilitating hepatitis C treatment scale-up within a treatment-as-prevention trial in the male prison setting

BACKGROUND AND AIMS

Hepatitis C (HCV) is a global public health concern, particularly in the prison setting where prevalence is substantially higher than in the general population. Direct-acting antivirals have changed the treatment landscape, allowing for treatment scale-up efforts potentially sufficient to achieve prevention of onward transmission (treatment-as-prevention). The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study was the first trial to examine the efficacy of HCV treatment-as-prevention in the prison setting. Social capital is a social resource which has been found to influence health outcomes. This qualitative study sought to understand the role of social capital within an HCV treatment-as-prevention trial in the prison setting.

DESIGN

Semi-structured in-depth interviews were undertaken with participants recruited from the SToP-C study following HCV treatment completion (with cure).

SETTING

Three male correctional centres in New South Wales, Australia (including two maximum-security and one minimum-security).

PARTICIPANTS

Twenty-three men in prison participated in semi-structured interviews.

MEASUREMENTS

Thematic analysis of transcripts was completed using a social capital framework, which enabled exploration of the ways in which bonding, bridging and linking social capital promoted or inhibited HCV treatment uptake within a treatment-as-prevention trial.

FINDINGS

Social capital fostered HCV treatment uptake within an HCV treatment-as-prevention trial in the prison setting. Bonding social capital encouraged treatment uptake and alleviated concerns of side effects, bridging social capital supported prison-wide treatment uptake, and linking social capital fostered trust in study personnel (including nurses and correctional officers), thereby enhancing treatment engagement.

CONCLUSIONS

Social capital, including bonding, bridging and linking, can play an important role in hepatitis C treatment-as-prevention efforts within the male prison setting.

Examining the gender composition of drug injecting initiation events: A mixed methods investigation of three North American contexts

BACKGROUND

Gender influences the health and social risks faced by individuals initiating drug injecting. Using mixed methods across three settings in North America, we investigated the gender composition of injection initiation events and the gendered risk environments in which they occurred.

METHODS

The PReventing Injecting by Modifying Existing Responses (PRIMER) study pooled data from three prospective community-recruited cohorts of people who inject drugs (PWID) in San Diego, USA, Vancouver, Canada, and Tijuana, Mexico. A qualitative subsample provided narrative data on their experiences of, and the contexts for, injection initiation events. Guided by Rhodes' risk environment framework, we examined the gender composition of initiation events stratified by city, and analyzed qualitative data using abductive thematic analyses.

RESULTS

Among 2,622 PWID (Tijuana: n = 531; San Diego: n = 352; Vancouver: n = 1,739), 112 (4.3%) reported providing initiation assistance to injection-naïve individuals in the previous six months. The proportion of gender concordant (e.g., male-male) initiation pairs varied, (χ2 = 10.32, p <0.001) with greater than expected concordance among pairs in Tijuana compared with those in Vancouver or San Diego. Sixty-one interviews provided context for the discrepancy across sites by highlighting the gendered injection initiation risk environments of prison/jail detention in Tijuana, intimate partnerships in San Diego, and overdose risk in Vancouver.

CONCLUSIONS

These results highlight how gender influences injection initiation events within spatial, social, and economic risk environments, and how this influence varies across settings. These findings can inform interventions to reduce the risk of injection initiation and related harms.

A Multistage Process Model of How a Person Who Currently Injects Drugs Comes to Assist Persons Who Do not Inject with Their First Injections

Injecting drugs for the first time almost always requires assistance from an experienced person who injects drugs (PWID). While there has been moderate amount of research on PWID who assist with first injections, most of this research has focused on identifying characteristics of PWID who assist with first injections. We do not have a formal model that describes how the minority of PWID come to assist do so, while the majority never assist. Through comparison of persons who did or did not recently assist with first injections using data from PWID in Tallinn, Estonia (N = 286) and Staten Island, New York City (N = 101), we developed a formal multi-stage model of how PWID come to assist with first injections. The model had a primary pathway 1) of engaging in "injection promoting" behaviors, 2) being asked to assist, and 3) assisting. Statistical testing using odds ratios showed participation in each stage was strongly associated with participation in the next stage (all odds ratios >3.0) and the probabilities of assisting significantly increased with participation in the successive stages. We then used the model to compare engagement in the stages pre-vs. post participation in an intervention, and to compare persons who recently assisted to persons who had assisted in the past but had not recently assisted and to persons who had never assisted. Advantages of a formal model for how current PWID come to assist with first injections include: facilitating comparisons across different PWID populations and assessing strengths and limitations of interventions to reduce assisting with first injections.

"I Know It Is Going to Ruin Their Life:" Fortune-Telling, Agency, and Harm Reduction in Narratives Concerning Injection Initiation Assistance

BACKGROUND

Considering most people who inject drugs (PWID) received help with the first injection, understanding the perspective of potential 'initiators' is a priority to inform harm reduction interventions. This paper examines how PWID narrate their experiences with injection initiation and assistance from the lens of their lived experience and perceptions of harm reduction.

METHODS

In-depth interviews were conducted with individuals who reported injection drug use and recent (past 30 days) opioid use in Baltimore (N = 19) and Anne Arundel County (N = 4), Maryland and analyzed using a narrative approach.

RESULTS

Respondents cast initiation events as meaningful transitions to a life characterized by predictable harms, including homelessness, infections, and social stigma. Respondents used examples from their personal experience to explain experiences with initiation and assistance by strategically attributing personal agency and predicting specific injection-related harms for initiates. In their narratives, respondents balanced notions of individual agency with harm reduction intentions by distinguishing between two forms of harm: perceived inevitable distal harm caused by long-term injection (e.g. socioeconomic decline) and potentially avoidable proximal harm caused by risky injection practices (e.g. overdose, HIV).

CONCLUSIONS

These findings highlight opportunities for interventions targeting injection initiation events and support the implementation of safer injection training in interventions. This identity of the 'responsible drug user' could be leveraged to support employing peers to help mitigate harm among inexperienced PWID either through peer outreach or formal venues, such as overdose prevention sites.

Drugs as Soulmates: The Construction and Validation of a 12-Item Soulmate Scale to Measure Substance Addiction and Loneliness

Substance users use substances to tackle psychological stress, frustrations, poor social support and poor-quality relationships. Such experience resembles seeking a soulmate for receiving comfort, a sense of security and satisfaction to relieve feelings of loneliness. Against this backdrop, the study aims to develop a Soulmate Scale to measure substance use and loneliness. Data were collected from 507 drug abusers between 18-71 years of age who were receiving drug addiction treatment in Hong Kong. Both exploratory factor analysis and confirmatory factor analysis were conducted. Results show a valid and reliable scale with three factors: psychological release and shelter, staunch and supportive friendship, and spiritual solace and companionship. This study offers additional support for understanding the drug-taking experience of substance users from their perspective. The Scale provides a useful tool to assess the underlying reasons for substance users to persistently take drugs and formulate corresponding intervention plans to achieve drug abstinence.

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach

BACKGROUND

In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England.

METHODS

This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England.

RESULTS

Median age of first injection was 22 years (interquartile range 18-28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection.

CONCLUSIONS

Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.

Peer to peer communication about hepatitis C treatment amongst people who inject drugs: A longitudinal qualitative study

BACKGROUND

Little is known about how information on direct-acting antiviral treatment for hepatitis C circulates through peer networks of people who inject drugs. In this study we aimed to explore what and how treatment-related information is shared between people undergoing treatment and their peers.

METHODS

Participants were recruited from two general practice clinics and the community-based hepatitis C Treatment and Prevention Study. Semi-structured interviews were conducted with each participant (N = 20) before, during and following treatment. Interviews explored hepatitis C treatment experiences, key sources of DAA information and the impact of receiving and sharing knowledge. Inductive thematic analysis was conducted. Time sequential matrices were generated to understand thematic change over time.

RESULTS

Fifty-four interviews were conducted with 20 participants across seven field-sites in Melbourne, Australia. Key themes were: 'peers as a source treatment information', 'do it together' and 'becoming a treatment advocate'. Peers were a crucial trusted source of information. Positive treatment anecdotes were important for building confidence in and motivation to initiate treatment. Many participants adopted a 'treatment advocate' role in their close peer networks, which was described as empowering. Some participants described benefits of undertaking treatment alongside members of their close network.

CONCLUSION

Findings illustrate the importance of close peers in shaping treatment perceptions and engagement. This will be important in designing health promotion messaging and interventions to increase treatment uptake.

Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use

Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.

Self-perception of assisting with future injection drug initiation: The influence of relationships in the process of drug injecting initiation

INTRODUCTION AND AIMS

People who inject drugs (PWID) play critical roles in assisting others into injection drug use (IDU) initiation. Understanding perceptions of PWID's risk of initiating others is needed to inform interventions for prevention. The objective was to examine factors associated with self-perception of assisting with future IDU initiation events. The primary variables of interest are the relationships of PWID with the person(s) they assisted and their reasons for previously providing initiation assistance.

DESIGN AND METHODS

Data from Preventing Injecting by Modifying Existing Responses, a multi-site prospective community-recruited cohort study, were analysed. Analyses were restricted to PWID who reported ever providing IDU initiation assistance. Site-specific (Vancouver, Canada [n = 746]; San Diego, USA [n = 95] and Tijuana, Mexico [n = 92]) multivariable logistic regression analyses were performed to determine factors associated with self-perception of assisting with future IDU initiation.

RESULTS

Having provided IDU initiation assistance to a family member or intimate partner decreased the odds of self-perception of assisting with future IDU initiation in Vancouver (AOR = 0.4; 95% CI 0.2-0.8); however, previous IDU initiation assistance to an 'other' increased the odds of self-perception of assisting with future IDU in Tijuana (AOR = 12.0; 95% CI 2.1-70.3). Daily IDU (Vancouver: AOR = 3.7; 95% CI 2.1-6.4) and less than daily IDU (San Diego: AOR = 5.9; 95% CI 1.3-27.1) (Vancouver: AOR = 2.6; 95% CI 1.4-2.9) were associated with increased self-perception of assisting with future IDU compared to current non-injectors.

DISCUSSION AND CONCLUSIONS

Relationship to past initiates and IDU frequency might increase PWID's self-perception of assisting with future IDU. Interventions focused on social support and reducing IDU frequency may decrease occurrences of IDU initiation assistance.

Law and mental health: A bridge between individual neurobiology and the collective organization of behaviors

Mental disorders (MD) or mental symptoms (MS) have multifactorial causes. Today we know much more about the variables that cause individual MD\MS, but in our opinion these characterizations, although essential, are not sufficient to account for the complexity in which we live. For example, they do not explain in a coherent and empirically verifiable way how the biological individual relates to the social architecture in which he lives. This article presents a hypothesis that connects social and organizational structures to the emergence of symptoms and mental disorders in the population. It is our belief that some of these structures fundamentally impact the distribution of MD/MS in a population and the medical and psychological communities must consider this impact seriously. Laws aim at directing the behavior of groups of people, whose behavior is strictly interdependent with their neurobiology. Given the ability of laws to direct the behaviors that regulate social interactions, traumatic factors may be considered capable of linking a non-material object (e.g., a law) to a real effect (e.g., MS/MD). We discuss, as a paradigmatic example, the laws that regulate the use of psychotropic substances.

Reasons for assisting with injection initiation: Results from a large survey of people who inject drugs in Los Angeles and San Francisco, California

Injection drug initiation usually requires assistance by someone who already injects drugs. To develop interventions that prevent people from starting to inject drugs, it is imperative to understand why people who inject drugs (PWID) assist with injection initiation.

METHODS

Injection initiation history and motives for initiating others were collected from 978 PWID in Los Angeles and San Francisco, CA, from 2016-17. This article documents motivations for providing injection initiation assistance and examines demographic, economic, and health-related factors associated with these motivations using multivariable logistic regression modeling.

RESULTS

Among the 405 PWID who ever facilitated injection initiation, motivations for initiating were: injury prevention (66%), skilled at injecting others (65%), to avoid being pestered (41%), in exchange for drugs/money (45%), and for food/shelter/transportation (15%). High frequency initiation (>5 lifetime injection initiations) was associated with all motivations except for being pestered. Initiation to prevent injury was associated with being female. Initiation due to pestering was associated with recycling income and sex work. Being skilled was associated with age and HIV status, while initiation for money or drugs was associated with age, race, education, social security income, and substance use treatment. Lastly, initiation for food, shelter, or transportation was associated with age, sexual orientation and education level.

CONCLUSION

Diverse factors were associated with reported motivations for assisting someone to initiate injection for the first time. Our analysis underscores the need for prevention strategies focused on improving economic and housing conditions along with implementing drug consumption rooms to disrupt the social processes of injection initiation.

Drivers of opioid use in Appalachian Pennsylvania: Cross-cutting social and community-level factors

BACKGROUND

Four Appalachian states including Pennsylvania (PA) have the highest drug overdose rates in the country, calling for better understanding of the social and economic drivers of opioid use in the region. Using key informant interviews, we explored the social and community drivers of opioid use in a non-urban Appalachian Pennsylvania community.

METHODS

In 2017, we conducted qualitative interviews with 20 key stakeholders from a case community selected using the results from quantitative spatial models of hospitalizations for opioid use disorders. In small town located 10 miles outside Pittsburgh, PA, we asked participants to share their perceptions of contextual factors that influence opioid use among residents. We then used qualitative thematic analysis to organize and generate the results.

RESULTS

Participants identified several contextual factors that influence opioid use among residents. Three cross-cutting thematic topics emerged: 1) acceptance and denial of use through familial and peer influences, community environments, and social norms; 2) impacts of economic shifts and community leadership on availability of programs and opportunities; and 3) the role of coping within economic disadvantage and social depression.

CONCLUSION

Uncovering multi-level, contextual drivers of opioid use can benefit the development of future public health interventions. These results suggest that social and community-level measures of structural deprivation, acceptance and/or denial of the opioid epidemic, community engagement and development, social support, and social depression are important for future research and programmatic efforts in the Appalachian region.

Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis

BACKGROUND AND AIMS

Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment.

DESIGN, SETTING AND PARTICIPANTS

Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD.

MEASUREMENTS

Incremental cost per quality-adjusted life-year gained in the simulated population.

FINDINGS

An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand.

CONCLUSIONS

It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.

Risk perception, changing social context, and norms prevent transition to regular injection among people who smoke heroin

BACKGROUND

There is a lack of research examining what prevents people who smoke heroin from transitioning to regular injection. This qualitative study aims to improve understanding of environmental influences preventing people who smoke heroin from transitioning to regular injection.

METHODS

In-depth, semi-structured interviews (n = 15) were conducted with people who currently smoked heroin but never injected (n = 10) and those who injected on a few occasions but did not transition to regular injection (n = 5) in Northern Ireland. Multiple recruitment strategies were utilized to generate a community-based sample. Interviews were thematically analysed.

MAIN FINDINGS

Participants identified two main, interconnected influences preventing transition to injecting heroin. Firstly, resistance towards injecting was rooted in micro level perceptions of risks primarily arising from meso level social interactions with people who inject drugs and, to a lesser extent, harm reduction agencies. Secondly, participants identified meso and macro environments defined as changing social contexts and normative beliefs surrounding the acceptability of injecting within their drug-using social networks, facilitated by expanding heron markets, negative interactions with people who inject drugs and new groups of people choosing to smoke heroin due to perceptions of injection risks.

CONCLUSIONS

Findings illuminate environmental influences surrounding and shaping drug consumption practices. Harm reduction strategies should develop and implement safer smoking rooms, community and peer interventions, and improve accessibility to opioid substitution therapy and low threshold outreach services to prevent transitioning to regular heroin injecting.

When and how do individuals transition from regular drug use to injection drug use in Uganda? Findings from a rapid assessment

Background

In Uganda, injection drug use is a growing but less studied problem. Preventing the transition to injection drug use may help prevent blood-borne viral transmission, but little is known about when and how people transition to injection drug use. A greater understanding of this transition process may aid in the country’s efforts to prevent the continued growth of injection drug use, HIV, and hepatitis C Virus (HCV) infection among people who inject drugs (PWID).

Methods

Using a rapid situation assessment framework, we conducted semi-structured interviews among 125 PWID (102 males and 23 females)—recruited through outreach and snow-ball sampling. Participants were interviewed about their experiences on when and how they transitioned into injection drug use and these issues were also discussed in 12 focus groups held with the participants.

Results

All the study participants started their drug use career with non-injecting forms including chewing, smoking, and sniffing before transitioning to injecting. Transitioning was generally described as a peer-driven and socially learnt behavior. The participants’ social networks and accessibility to injectable drugs on the market and among close friends influenced the time lag between first regular drug use and first injecting—which took an average of 4.5 years. By the age of 24, at least 81.6% (95.7% for females and 78.4% for males) had transitioned into injecting. Over 84.8% shared injecting equipment during their first injection, 47.2% started injecting because a close friend was already injecting, 26.4% desired to achieve a greater “high” (26.4%) which could reflect drug-tolerance, and 12% out of curiosity.

Conclusions

Over 81% non-injecting drug users in Kampala and Mbale districts transitioned into injecting by the age of 24; a process that reproduces a population of PWID but also puts them at increased risk of HIV and HCV infection. As Uganda makes efforts to introduce and/or strengthen harm reduction services, interventions targeting non-injecting drug users before they transition into injecting should be considered as a key component for HIV/HCV epidemic control efforts, and their evaluation considered in future researches.

Opioid agonist treatment scale-up and the initiation of injection drug use: A dynamic modeling analysis

BACKGROUND

Injection drug use (IDU) is associated with multiple health harms. The vast majority of IDU initiation events (in which injection-naïve persons first adopt IDU) are assisted by a person who injects drugs (PWID), and as such, IDU could be considered as a dynamic behavioral transmission process. Data suggest that opioid agonist treatment (OAT) enrollment is associated with a reduced likelihood of assisting with IDU initiation. We assessed the association between recent OAT enrollment and assisting IDU initiation across several North American settings and used dynamic modeling to project the potential population-level impact of OAT scale-up within the PWID population on IDU initiation.

METHODS AND FINDINGS

We employed data from a prospective multicohort study of PWID in 3 settings (Vancouver, Canada [n = 1,737]; San Diego, United States [n = 346]; and Tijuana, Mexico [n = 532]) from 2014 to 2017. Site-specific modified Poisson regression models were constructed to assess the association between recent (past 6 month) OAT enrollment and history of ever having assisted an IDU initiation with recently assisting IDU initiation. Findings were then pooled using linear mixed-effects techniques. A dynamic transmission model of IDU among the general population was developed, stratified by known factors associated with assisting IDU initiation and relevant drug use behaviors. The model was parameterized to a generic North American setting (approximately 1% PWID) and used to estimate the impact of increasing OAT coverage among PWID from baseline (approximately 21%) to 40%, 50%, and 60% on annual IDU initiation incidence and corresponding PWID population size across a decade. From Vancouver, San Diego, and Tijuana, respectively, 4.5%, 5.2%, and 4.3% of participants reported recently assisting an IDU initiation, and 49.4%, 19.7%, and 2.1% reported recent enrollment in OAT. Recent OAT enrollment was significantly associated with a 45% lower likelihood of providing recent IDU initiation assistance among PWID (relative risk [RR] 0.55 [95% CI 0.36-0.84], p = 0.006) compared to those not recently on OAT. Our dynamic model predicts a baseline mean of 1,067 (2.5%-97.5% interval [95% I 490-2,082]) annual IDU initiations per 1,000,000 individuals, of which 886 (95% I 406-1,750) are assisted by PWID. Based on our observed statistical associations, our dynamic model predicts that increasing OAT coverage from approximately 21% to 40%, 50%, or 60% among PWID could reduce annual IDU initiations by 11.5% (95% I 2.4-21.7), 17.3% (95% I 5.6-29.4), and 22.8% (95% I 8.1-36.8) and reduce the PWID population size by 5.4% (95% I 0.1-12.0), 8.2% (95% I 2.2-16.9), and 10.9% (95% I 3.2-21.8) relative to baseline, respectively, in a decade. Less impact occurs when the protective effect of OAT is diminished, when a greater proportion of IDU initiations are unassisted by PWID, and when average IDU career length is longer. The study's main limitations are uncertainty in the causal pathway between OAT enrollment and assisting with IDU initiation and the use of a simplified model of IDU initiation.

CONCLUSIONS

In addition to its known benefits on preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our modeling suggests that OAT scale-up may also reduce the number of IDU initiations and PWID population size.

Identification of a Syndemic of Blood-Borne Disease Transmission and Injection Drug Use Initiation at the US-Mexico Border

BACKGROUND

Efforts to prevent injection drug use (IDU) are increasingly focused on the role that people who inject drugs (PWID) play in the assistance with injection initiation. We studied the association between recent (ie, past 6 months) injection-related HIV risk behaviors and injection initiation assistance into IDU among PWID in the US-Mexico border region.

SETTING

Preventing Injecting by Modifying Existing Responses (PRIMER) is a multicohort study assessing social and structural factors related to injection initiation assistance. This analysis included data collected since 2014 from 2 participating cohorts in San Diego and Tijuana.

METHODS

Participants were 18 years and older and reported IDU within the month before study enrollment. Logistic regression analyses were conducted to assess the association between recent injection-related HIV risk behaviors (eg, distributive/receptive syringe sharing, dividing drugs in a syringe, and paraphernalia sharing) and recent injection initiation assistance.

RESULTS

Among 892 participants, 41 (4.6%) reported recently providing injection initiation assistance. In multivariable analysis adjusting for potential confounders, reporting a higher number of injection-related risk behaviors was associated with an increased odds of recently assisting others with injection initiation (adjusted odds ratio per risk behavior: 1.3; 95% confidence interval: 1.0 to 1.6, P = 0.04).

CONCLUSIONS

PWID who recently engaged in one or more injection-related HIV risk behavior were more likely to assist others in injection initiation. These results stress the syndemic of injection initiation and risk behaviors, which indicates that prevention of injection-related HIV risk behaviors might also reduce the incidence of injection initiation.

Opioid use and misuse: health impact, prevalence, correlates and interventions

Objective: To provide a broad overview of the state of drug misuse research, particularly focusing on opioid drug use in the U.S.A. Design: An overview of published reviews of the literature. Results: Prescription opioid use has increased globally from 2008 to 2013, while use of opiates such as heroin and opium have remained stable in many countries, although, decreases have been observed in parts of Europe. Opioid misuse is highest in the United States; approximately 11.8 million Americans misused opioids in 2016. Demographic, genetic, psychosocial and structural/environmental factors all play a role in determining who will become an opioid misuser. Strategies such as increased prescribing of non-opioid derived pain relievers, expansion of medication treatment, distribution of naloxone for overdose reversal and supervised consumption sites are some of the solutions posed to reduce the spread and consequences of opioid misuse. Conclusion: Research focused on understanding of opioid neurobiology, as well as empirically based, effective alternatives to pain management and implementation studies on combined prevention and treatment approaches are needed. It will take the combined effort of community members, healthcare professionals, policymakers and researchers in order to prevent and treat opioid misuse.

Gang Involvement and Drug Use Histories Among People Who Inject Drugs in California: A Retrospective Analysis

We examined whether gang membership history was associated with earlier age of first drug use, first drug injection, and shorter time to injection (TTI) drug use among people who inject drugs (PWID). PWID ( N = 438) were interviewed in California (2011-2013). Surveys addressed demographics, current/former drug use practices, gang membership, and parental drug use. Multivariate analyses were conducted to identify whether gang membership history was associated with age at first drug use, first injection drug use, and TTI. Gang membership was reported by 23% of sample. Gang membership history was associated with earlier ages of first drug use (–1.35 years; 95% confidence interval [CI]= [−0.50, −2.20]), age at first injection (–1.89 years; 95% CI = [0.00, −3.78]), but not TTI. Gang involvement facilitates drug use including earlier age of first injection drug use.

Factors Associated with Frequency of Recent Initiation of Others into Injection Drug Use Among People Who Inject Drugs in Los Angeles and San Francisco, CA, USA, 2016-17

Objective: Drug injection initiation is often assisted by a person who injects drugs (PWID). How often PWID provide this assistance has not been examined. We examine frequency of injection initiation assistance and factors associated with high (4+) and low frequency (1-3) initiation assistance as compared to no initiation assistance among PWID. Methods: Participants were 979 Californian PWID. PWID were interviewed about providing injection initiation assistance in the last 6 months among other items. Multinomial regression analysis was used to examine factors associated with levels of frequency of injection initiation assistance. Results: Among participants, 132 (14%) had initiated 784 people into injection (mean = 5.94 [standard deviation = 20.13]; median = 2, interquartile range = 1,4) in the last 6 months. PWID engaged in high frequency initiation (26% of sample) assisted 662 new initiates (84% of total). Using multinomial regression analysis with no initiating as the referent group, we found that high frequency initiating was statistically associated with higher injection frequency, having a paying sex partner, taking someone to a shooting gallery, and providing injection assistance. Lower frequency initiation was statistically associated with having a paying sex partner, illegal income source, and providing injection assistance. Conclusion: Differences between high and low frequency initiators were not found. Sex work and assisting with drug injection were linked to initiating others. Individual-level interventions that reduce this behavior among PWID and structural interventions such as safe consumption sites and opioid medication treatments that interrupt the social process of injection initiation should be considered as ways to reduce injection initiations.

Navigating social norms of injection initiation assistance during an overdose crisis: A qualitative study of the perspectives of people who inject drugs (PWID) in Vancouver, Canada

Despite the proliferation of fentanyl and fentanyl-adulterated opioids in North America, the impacts of this drug market change on injection initiation processes have not been examined. With the aim of informing structural interventions to address injection initiation and related harms, we explore how people who inject drugs (PWID) in Vancouver, Canada understand and navigate social norms of initiating others into injecting within the context of an overdose crisis. In-depth qualitative interviews were conducted with 19 PWID who reported helping someone inject for the first time. Participants were recruited from two cohort studies of PWID. Participants articulated moral dilemmas about assisting others with injecting. While participants described a 'moral code' prohibiting assisting injection-naïve individuals, this code was not the sole consideration shaping social action around injection initiation. Rather, PWID exercised agency about whether and how to assist novice injectors within the context of constraining and enabling social norms around practicing interpersonal responsibility. Changes to the drug market heightened feelings of moral culpability and criminal liability among PWID who assisted others into injection, given that injecting heightened initiates' risk of overdose. These concerns operated in tension with the aim of protecting novice injectors from harms associated with an increasingly potent and unpredictable drug supply by providing them with injection assistance, education and supervision. Our analysis of how PWID practice interpersonal responsibility helps conceptualise how 'moral codes' prohibiting initiation assistance are managed and negotiated amidst structural vulnerability. Structural interventions reducing the vulnerability of novice injectors should be prioritized, including the implementation of supervised injection sites allowing for assisted injection, Good Samaritan laws, and policy changes conducive to a safer drug supply.

Opioid agonist treatment and the process of injection drug use initiation

BACKGROUND

Opioid agonist treatment (OAT) is an effective biomedical intervention to manage opioid use disorder among persons who inject drugs (PWID). Preliminary evidence suggests that OAT may also disrupt the social communicability of injection drug use (IDU) practices by established PWID. We therefore aim to investigate the association between OAT enrollment and initiating others into IDU among PWID in Vancouver, Canada.

METHODS

Preventing Injecting by Modifying Existing Responses (PRIMER; NIDA DP2-DA040256-01) is a prospective multi-cohort study seeking to identify structural interventions that reduce the risk that PWID initiate others into IDU. The present analysis was conducted using data from a participating cohort of PWID in Vancouver, Canada, between December 2014 and May 2017. Multivariable logistic regression models were built to assess the association between reporting active (i.e., within the past six months) OAT enrollment and assisting others in injection initiation. A final model was determined using a manual stepwise approach whereby covariates were excluded if their removal altered the coefficient of interest by <5%.

RESULTS

Participants (n = 1740) were predominantly male (62.3%); 35.1% reported daily injecting (n = 611); 860 (49.4%) reported active OAT enrollment, and 80 (4.6%) reported recently providing injection initiation assistance. In a multivariable model, participants who reported active OAT enrollment had significantly lower odds of recently providing injection initiation assistance (Adjusted Odds Ratio = 0.52, 95% Confidence Interval: 0.31-0.87, P = 0.01).

CONCLUSION

Results suggest a protective association between OAT and the expansion of IDU practices among vulnerable populations, suggesting its potential use as 'addiction treatment as prevention.'

You can't do this job when you are sober: Heroin use among female sex workers and the need for comprehensive drug treatment programming in Kenya

AIMS

Globally, women who use drugs often practice sex work and experience multiple health and social harms that complicate their drug treatment needs. In East Africa, understanding the emergence of heroin use among women is critical in efforts to build effective drug treatment programming, including the ongoing scale-up of medication-assisted treatment (MAT). We explored heroin use among women engaged in sex work in Kenya to inform services.

METHODS

In a qualitative study of 45 female sex workers reporting substance use in Kisumu, Kenya, 32 reported lifetime heroin use and comprise the focus of this analysis. Semi-structured interviews explored histories of substance use and sex work and health programming needs. Thematic analysis focused on the contexts and meanings of heroin use.

RESULTS

Among 32 women, median age was 28 (range: 18-37). Women commonly smoked cocktails containing heroin while using alcohol and other drugs prior to sex work. Most women perceived heroin to engender "morale" and "courage" to engage in sex work and "fight" potentially abusive clients. Sex work reinforced drug use in ways that both managed and created new risks.

CONCLUSIONS

Drawing on the concept of "paradoxical autonomy," we suggest that heroin use engenders new forms of autonomy allowing women to support themselves in conditions of uncertainty, yet does not enable them to entirely overcome their vulnerabilities. Drug treatment programs for sex workers should address the situated logics of substance use in contexts of sexual risk, including patterns of poly-substance use that may render MAT inappropriate for some women who use heroin.

"Another Person Was Going to Do It": The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region

Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.

Gender differences in the provision of injection initiation assistance: a comparison of three North American settings

AIM

Individuals experience differential risks in their initiation into drug injecting based on their gender. Data suggest women are more likely to be injected after their initiator and to share injection equipment. Little is known, however, regarding how gender influences the risk that people who inject drugs (PWID) may assist others into injection initiation. We therefore sought to investigate the role of "initiator" gender in the provision of injection initiation assistance across multiple settings.

METHODS

We employed data from PReventing Injecting by Modifying Existing Responses (PRIMER), a multi-cohort study investigating factors influencing injection initiation assistance provision. Data were drawn from three cohort studies of PWID in San Diego, USA (STAHR II); Tijuana, Mexico (El Cuete IV); and Vancouver, Canada (VDUS). Site-specific logistic regression models were fit, with lifetime provision of injection initiation assistance as the outcome and gender as the independent variable.

RESULTS

Overall, 3.2% (24/746) of the women and 4.6% (63/1367) of the men reported providing injection initiation assistance. In Tijuana, men were more than twice as likely to have provided injection initiation assistance after controlling for potential confounders (adjusted odds ratio = 2.17, 95% confidence interval: 1.22-3.84). Gender was not significantly associated with providing injection initiation assistance in other sites.

CONCLUSION

We identified that being male in Tijuana, specifically, was associated with providing injection initiation assistance, which could inform targeted outreach aimed at reducing the influence of PWID populations on non-injectors in this site. This will likely require that existing interventions address gender- and site-specific factors for effectiveness.

Frequency and factors associated with providing injection initiation assistance in Tallinn, Estonia

Injection drug use is expanding in numerous regions in the world. Persons who inject drugs (PWID) play an important role encouraging new persons into injecting, by providing injection initiation assistance ("assisting" behaviors) and stimulating interest in injection ("promoting" behaviors).

OBJECTIVES

To describe the prevalence of assisting and promoting behaviors, and to identify factors associated with assisting, among PWID in Tallinn, Estonia.

METHODS

In 2016, PWID were recruited through respondent-driven sampling (RDS), interviewed, and HIV tested. RDS weights were used to estimate the prevalence of assisting and promoting behaviors and, in multivariable regression modeling, to identify factors associated with assisting.

RESULTS

Among 299 PWID recruited, 13.7% had ever assisted a non-PWID with their first injection. Regarding past-six-month promoting behaviors: 9.4% talked positively about injecting to non-PWID, 16.2% injected in front of non-PWID, and 0.6% offered to help with a first injection. Significant predictors of ever assisting with a first injection included: gender (men: aOR 6.31, 95% CI 2.02-19.74); age (30 years or younger: aOR 3.89, 95% CI 1.40-10.16); receptive sharing of syringes or needles (aOR 4.73, 95% CI 1.32-16.98); ever testing for HIV (aOR 8.44, 95% CI 1.15-62.07); and having peers who helped someone with their first injection (aOR 3.44, 95% CI 1.31-9.03).

CONCLUSION

Demographic and drug-use related factors are associated with having initiated someone into injecting. Interventions targeting PWID and non-PWID are needed to prevent injection initiation.

A fragmented code: The moral and structural context for providing assistance with injection drug use initiation in San Diego, USA

BACKGROUND

Injection drug use initiation is shaped by social networks and structural contexts, with people who inject drugs often assisting in this process. We sought to explore the norms and contexts linked to assisting others to initiate injection drug use in San Diego, USA, to inform the development of structural interventions to prevent this phenomenon.

METHODS

We undertook qualitative interviews with a purposive sample of people who inject drugs and had reported assisting others to initiate injection (n = 17) and a sub-sample of people who inject drugs (n = 4) who had not reported initiating others to triangulate accounts. We analyzed data thematically and abductively.

RESULTS

Respondents' accounts of providing initiation assistance were consistent with themes and motives reported in other contexts: of seeking to reduce harm to the 'initiate', responding to requests for help, fostering pleasure, accessing resources, and claims that initiation assistance was unintentional. We developed analysis of these themes to explore initiation assistance as governed by a 'moral code'. We delineate a fragmented moral code which includes a range of meanings and social contexts that shape initiation assistance. We also show how assistance is happening within a structural context that limits discussion of injection drug use, reflecting a prevailing silence on drug use linked to stigma and criminalization.

CONCLUSIONS

In San Diego, the assistance of others to initiate injection drug use is governed by a fragmented moral code situated within particular social norms and contexts. Interventions that address the social and structural conditions shaped by and shaping this code may be beneficial, in tandem with efforts to support safe injection and the reduction of injection-related harms.

Transition from First Drug Use to Regular Injection among People Who Inject Drugs in Iran

BACKGROUND

The study aimed to evaluate the interval between first drug use and regular injection and factors associated with transition from first injection into premature regular injection among people who inject drugs (PWIDs).

METHODS

In a multicenter cross-sectional study, we recruited 400 PWIDs using snowball sampling. Age of first drug use, age of initiation of regular injection, and demographic and behavioral data were collected using face to face interview. Premature transition to regular injection was defined as initiation of regular injection within the five years of first injection. Data were analyzed using bivariate and multivariate logistic regression survey analysis.

FINDINGS

The mean age of first drug use and age of initiation of regular injection was 29.87 ± 6.54 years, respectively. Having history of sexual abuse in childhood [adjusted odds ratio (AOR) = 3.1], history of imprisonment (AOR = 3.4), use of heroin as the first drug (AOR = 4.3), and doing the first injection at friends' houses (AOR = 2.2) or in ruins (AOR = 2.2) significantly increased the chance of premature transition to regular injection, while being a female decreased the chance of premature transition to regular injection (AOR = 0.4). Compared to curiosity, being friend with a drug user (AOR = 0.4), having withdrawal symptoms (AOR = 0.2), and low cost of injection (AOR = 0.3) at the first occasion of drug injection reduced the chance of premature transition to regular injection.

CONCLUSION

New interventions to prevent injection initiation among drug users are needed and should be integrated in harm reduction programs.