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Lim J, El-Sheikh M, Buckeridge DL, Panagiotoglou D. Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach. Harm Reduct J 2024; 21:126. [PMID: 38943164 PMCID: PMC11212409 DOI: 10.1186/s12954-024-01037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/14/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID. METHODS We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks. RESULTS The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI. CONCLUSIONS Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Mariam El-Sheikh
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal, QC, H3A 1G1, Canada.
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López-Castro T, Sohler N, Riback L, Bravo G, Ohlendorf E, Ghiroli M, Fox AD. Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care. Harm Reduct J 2024; 21:108. [PMID: 38824597 PMCID: PMC11143655 DOI: 10.1186/s12954-024-01019-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/09/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City. METHODS Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31. RESULTS Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment. CONCLUSIONS Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.
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Affiliation(s)
- Teresa López-Castro
- Department of Psychology, The City College of New York, City University of New York, 160 Convent Avenue, New York, NY, 10031, USA.
| | - Nancy Sohler
- The City University of New York School of Medicine, 160 Convent Avenue, New York, NY, 10031, USA
| | - Lindsey Riback
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Gina Bravo
- Department of Psychology, The City College of New York, City University of New York, 160 Convent Avenue, New York, NY, 10031, USA
| | - Eric Ohlendorf
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Megan Ghiroli
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Aaron D Fox
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA
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Brooks HL, Speed KA, Dong K, Salvalaggio G, Pauly B(B, Taylor M, Hyshka E. Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital. PLoS One 2024; 19:e0297584. [PMID: 38359010 PMCID: PMC10868849 DOI: 10.1371/journal.pone.0297584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/08/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services. METHODS We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program. RESULTS Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears. CONCLUSIONS Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.
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Affiliation(s)
- Hannah L. Brooks
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Kelsey A. Speed
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn Dong
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Ginetta Salvalaggio
- Department of Family Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Bernadette (Bernie) Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - Marliss Taylor
- Streetworks, Boyle Street Community Services, Edmonton, Alberta, Canada
| | - Elaine Hyshka
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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Watson DP, Ray B, Phalen P, Duhart Clarke SE, Taylor L, Swartz J, Gastala N. Fentanyl Exposure and Detection Strategies Utilized by Clinical Trial Participants Seeking Linkage to Opioid Use Disorder Treatment at a Syringe Service Program. J Med Toxicol 2024; 20:13-21. [PMID: 38048033 PMCID: PMC10774457 DOI: 10.1007/s13181-023-00979-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/30/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023] Open
Abstract
INTRODUCTION The USA continues to face a fentanyl-driven overdose epidemic. Prior research has demonstrated users of illicit opioids are concerned about fentanyl exposure and overdose, but the strategies they report using to detect fentanyl's presence lack empirical support. This study compares self-report and biologically detected fentanyl use and investigates overdose risk and risk reduction behaviors among a sample of high-risk people who use opioids. METHODS Structured enrollment interviews conducted as part of a larger clinical trial assessed self-reported fentanyl exposure as well as strategies used to determine believed fentanyl exposure and prevent overdose among 240 participants enrolled at a Chicago, IL syringe service program. Urinalysis measured actual fentanyl exposure. RESULTS Most participants identified as African American (66.7%) and had considerable overdose experience (76.7% lifetime and 48% in the past year). Most also tested positive for fentanyl (93.75%) despite reporting no past year use of fentanyl or fentanyl-adulterated drugs (64.17%). The most utilized approaches reported for identifying fentanyl exposure were stronger effects of the drug (60.7%), sight or taste (46.9%), and being told by someone using the same drugs (34.2%). Few participants (14%) reported using fentanyl test strips. No significant associations were identified between self-report and urinalysis measures or urinalysis results and risk reduction strategies. CONCLUSION This study adds to prior fentanyl exposure risk research. The disconnect between participants' fentanyl detection methods and reported overdose experiences supports the need for more research to identify and understand factors driving access and use of overdose prevention resources and strategies.
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Affiliation(s)
- Dennis P Watson
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA.
| | - Bradley Ray
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Peter Phalen
- Department of Psychiatry, University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA
| | - Sarah E Duhart Clarke
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Lisa Taylor
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA
| | - James Swartz
- Jane Addams College of Social Work, The University of Illinois at Chicago, 1040 W Harrison Street, Chicago, IL, 60607, USA
| | - Nicole Gastala
- Department of Family Medicine, Mile Square Health Centers, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
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Akiba CF, Patel SV, Wenger LD, Morgan-Lopez A, Zarkin GA, Orme S, Davidson PJ, Kral AH, Lambdin BH. Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial. Implement Sci 2023; 18:33. [PMID: 37537665 PMCID: PMC10398915 DOI: 10.1186/s13012-023-01288-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically. METHODS We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness. DISCUSSION This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.
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Affiliation(s)
- Christopher F Akiba
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA.
| | - Sheila V Patel
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Lynn D Wenger
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Antonio Morgan-Lopez
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Gary A Zarkin
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Stephen Orme
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Peter J Davidson
- Department of Medicine, Division Global Public Health, UCSD, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Alex H Kral
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Barrot H Lambdin
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
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Jakubowski A, Fowler S, Fox AD. Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature. Addict Sci Clin Pract 2023; 18:40. [PMID: 37301953 PMCID: PMC10256972 DOI: 10.1186/s13722-023-00394-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD. METHODS We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs. RESULTS SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs. CONCLUSIONS SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.
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Affiliation(s)
- Andrea Jakubowski
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Sabrina Fowler
- Present Address: Ascension St. John Hospital, 22101 Moross Road, Detroit, MI 48236 USA
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461 USA
| | - Aaron D. Fox
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
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Rintoul K, Song E, McLellan-Carich R, Schjelderup ENR, Barr AM. A scoping review of psychiatric conditions associated with chronic pain in the homeless and marginally housed population. FRONTIERS IN PAIN RESEARCH 2023; 4:1020038. [PMID: 37187857 PMCID: PMC10175796 DOI: 10.3389/fpain.2023.1020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
The present review sought to examine and summarise the unique experience of concurrent pain and psychiatric conditions, that is often neglected, within the population of homeless individuals. Furthermore, the review examined factors that work to aggravate pain and those that have been shown to improve pain management. Electronic databases (MEDLINE, EMBASE, psycINFO, and Web of Science) and the grey literature (Google Scholar) were searched. Two reviewers independently screened and assessed all literature. The PHO MetaQAT was used to appraise quality of all studies included. Fifty-seven studies were included in this scoping review, with most of the research being based in the United States of America. Several interacting factors were found to exacerbate reported pain, as well as severely affect other crucial aspects of life that correlate directly with health, within the homeless population. Notable factors included drug use as a coping mechanism for pain, as well as opioid use preceding pain; financial issues; transportation problems; stigma; and various psychiatric disorders, such as post-traumatic stress disorder, depression, and anxiety. Important pain management strategies included cannabis use, Accelerated Resolution Therapy for treating trauma, and acupuncture. The homeless population experiences multiple barriers which work to further impact their experience with pain and psychiatric conditions. Psychiatric conditions impact pain experience and can work to intensify already adverse health circumstances of homeless individuals.
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Affiliation(s)
- Kathryn Rintoul
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Esther Song
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
- Department of Psychiatry, Faculty of Medicine, UBC, Vancouver, BC, Canada
| | - Rachel McLellan-Carich
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Elizabeth N. R. Schjelderup
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Alasdair M. Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
- Correspondence: Alasdair M. Barr
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Rijnink A, Blake D, Groot S, Brough C. Accessing needle exchange services in disasters for remote areas of Aotearoa New Zealand. Harm Reduct J 2022; 19:145. [PMID: 36544156 PMCID: PMC9771773 DOI: 10.1186/s12954-022-00709-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Anne Rijnink
- grid.148374.d0000 0001 0696 9806School of Psychology, Massey University, Wellington, Aotearoa New Zealand
| | - Denise Blake
- grid.267827.e0000 0001 2292 3111School of Health, Te Herenga Waka-Victoria University of Wellington, Wellington, Aotearoa New Zealand
| | - Shiloh Groot
- grid.9654.e0000 0004 0372 3343School of Psychology, University of Auckland, Auckland, Aotearoa New Zealand
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Examining Relational Dimensions of Service Encounters for Disadvantaged People Who Use Drugs. J Addict Nurs 2022; 33:159-167. [DOI: 10.1097/jan.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Holeksa J. Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city. Harm Reduct J 2022; 19:23. [PMID: 35246162 PMCID: PMC8894830 DOI: 10.1186/s12954-022-00602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access. Methods Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy. Results Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission. Conclusion Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.
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Affiliation(s)
- Julie Holeksa
- Department of Social Work, Faculty of Health and Society, Malmö University, Citadellsvägen 7, 211 18, Malmö, Sweden.
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Salazar ZR, Vincent L, Figgatt MC, Gilbert MK, Dasgupta N. Research led by people who use drugs: centering the expertise of lived experience. Subst Abuse Treat Prev Policy 2021; 16:70. [PMID: 34544478 PMCID: PMC8454046 DOI: 10.1186/s13011-021-00406-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Research collaborations between people who use drugs (PWUD) and researchers are largely underutilized, despite the long history of successful, community-led harm reduction interventions and growing health disparities experienced by PWUD. PWUD play a critical role in identifying emerging issues in the drug market, as well as associated health behaviors and outcomes. As such, PWUD are well positioned to meaningfully participate in all aspects of the research process, including population of research questions, conceptualization of study design, and contextualization of findings. MAIN BODY We argue PWUD embody unparalleled and current insight to drug use behaviors, including understanding of novel synthetic drug bodies and the dynamics at play in the drug market; they also hold intimate and trusting relationships with other PWUD. This perfectly situates PWUD to collaborate with researchers in investigation of drug use behaviors and development of harm reduction interventions. While PWUD have a history of mistrust with the medical community, community-led harm reduction organizations have earned their trust and are uniquely poised to facilitate research projects. We offer the North Carolina Survivors Union as one such example, having successfully conducted a number of projects with reputable research institutions. We also detail the fallacy of meaningful engagement posed by traditional mechanisms of capturing community voice. As a counter, we detail the framework developed and implemented by the union in hopes it may serve as guidance for other community-led organizations. We also situate research as a mechanism to diversify the job opportunities available to PWUD and offer a real-time example of the integration of these principles into public policy and direct service provision. CONCLUSION In order to effectively mitigate the risks posed by the fluid and volatile drug market, research collaborations must empower PWUD to play meaningful roles in the entirety of the research process. Historically, the most effective harm reduction interventions have been born of the innovation and heart possessed by PWUD; during the current overdose crisis, there is no reason to believe they will not continue to be.
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Affiliation(s)
- Zach R Salazar
- North Carolina Survivors Union, 1116 Grove Street, Greensboro, NC, 27403, USA.
| | - Louise Vincent
- North Carolina Survivors Union, 1116 Grove Street, Greensboro, NC, 27403, USA
| | - Mary C Figgatt
- Injury Prevention Research Center, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | | | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
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Figgatt MC, Salazar ZR, Vincent L, Carden-Glenn D, Link K, Kestner L, Yates T, Schranz A, Joniak-Grant E, Dasgupta N. Treatment experiences for skin and soft tissue infections among participants of syringe service programs in North Carolina. Harm Reduct J 2021; 18:80. [PMID: 34330297 PMCID: PMC8324443 DOI: 10.1186/s12954-021-00528-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Bacterial and fungal infections, such as skin and soft tissue infections (SSTIs) and infective endocarditis (IE), are increasing among people who use drugs in the United States. Traditional healthcare settings can be inaccessible and unwelcoming to people who use drugs, leading to delays in getting necessary care. The objective of this study was to examine SSTI treatment experiences among people utilizing services from syringe services programs. This study was initiated by people with lived experience of drug use to improve quality of care. METHODS We conducted a cross-sectional survey among participants of five syringe services programs in North Carolina from July through September 2020. Surveys collected information on each participant's history of SSTIs and IE, drug use and healthcare access characteristics, and SSTI treatment experiences. We examined participant characteristics using counts and percentages. We also examined associations between participant characteristics and SSTI history using binomial linear regression models. RESULTS Overall, 46% of participants reported an SSTI in the previous 12 months and 10% reported having IE in the previous 12 months. Those with a doctor they trusted with drug use-related concerns had 27 fewer (95% confidence interval = - 51.8, - 2.1) SSTIs per every 100 participants compared to those without a trusted doctor. Most participants with a SSTI history reported delaying (98%) or not seeking treatment (72%) for their infections. Concerns surrounding judgment or mistreatment by medical staff and self-treating the infection were common reasons for delaying or not seeking care. 13% of participants used antibiotics obtained from sources other than a medical provider to treat their most recent SSTI. Many participants suggested increased access to free antibiotics and on-site clinical care based at syringe service programs to improve treatment for SSTIs. CONCLUSIONS Many participants had delayed or not received care for SSTIs due to poor healthcare experiences. However, having a trusted doctor was associated with fewer people with SSTIs. Improved access to non-judgmental healthcare for people who use drugs with SSTIs is needed. Expansion of syringe services program-based SSTI prevention and treatment programs is likely a necessary approach to improve outcomes among those with SSTI and IE.
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Affiliation(s)
- Mary C Figgatt
- Injury Prevention Research Center, University of North Carolina At Chapel Hill, 725 Martin Luther King Jr. Blvd, CB #7505, Chapel Hill, NC, 27599, USA.
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina At Chapel Hill, 170 Rosenau Hall, CB #740, Chapel Hill, NC, 27599, USA.
| | - Zach R Salazar
- North Carolina Survivors Union, 1116 Grove Street, Greensboro, NC, 27403, USA
| | - Louise Vincent
- North Carolina Survivors Union, 1116 Grove Street, Greensboro, NC, 27403, USA
| | | | - Kelly Link
- Community Hope Alliance, 2012 N Fayetteville St, Asheboro, NC, 27203, USA
| | - Lauren Kestner
- Center for Prevention Services, 1117 E Morehead St #200, Charlotte, NC, 28204, USA
| | - Tyler Yates
- Guilford County Solution To the Opioid Problem, 1601 Walker Ave, Greensboro, NC, 27403, USA
| | - Asher Schranz
- Division of Infectious Disease, Department of Medicine, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth Joniak-Grant
- Injury Prevention Research Center, University of North Carolina At Chapel Hill, 725 Martin Luther King Jr. Blvd, CB #7505, Chapel Hill, NC, 27599, USA
| | - Nabarun Dasgupta
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina At Chapel Hill, 170 Rosenau Hall, CB #740, Chapel Hill, NC, 27599, USA
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Hartney E, Barnard DK, Richman J. Development of Best Practice Guidelines for Primary Care to Support Patients Who Use Substances. J Prim Care Community Health 2021; 11:2150132720963656. [PMID: 33176537 PMCID: PMC7675907 DOI: 10.1177/2150132720963656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION People who use substances often mistrust the primary care system, impeding access. OBJECTIVES To build on research clarifying how to improve patients' feelings of safety, through co-creating best practice guidelines with physicians and patient representatives. METHODS After obtaining Research Ethics Board approval, this qualitative study engaged 22 participants including patients, physicians, and health system partners. We held a series of workshops, co-facilitated by patients and researchers, corresponding to 3 phases of the research: (1) establishment of cultural safety processes for participants during the workshops; (2) a facilitated, collaborative world café to develop guideline content; (3) validation of best practice guidelines. An implementation plan was developed and implemented. Finally, an external peer review was conducted by McGill University. RESULTS Best practices guidelines were developed giving the patient perspective on how to enhance primary care, as follows: (1) become trauma informed; (2) consider your clinical environment; (3) build a network; (4) supply an array of resources; (5) co-create a long-term treatment plan; (6) help me to stay healthy; (7) ensure timely access to specialized medical and surgical care; (8) be an advocate; (9) ask for feedback; (10) follow up. Resources were developed and disseminated. CONCLUSION The best practice guidelines reflect the patients' perspectives on common challenges patients have encountered, which impede their access to primary care. They support primary care physicians in providing more effective services to this challenging population of patients.
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Dányi E, Csák R. Drug places and spaces of problematisation: the melancholy case of a Hungarian needle exchange programme. DRUGS AND ALCOHOL TODAY 2021. [DOI: 10.1108/dat-12-2020-0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper aims to explore multiple problematisation processes through a former needle exchange programme run by Kék Pont (a non-governmental organisation) in the 8th district of Budapest. By presenting a collage of ethnographic stories, this paper attempts to preserve tacit knowledge associated with the programme and thereby keep its office alive as a “drug place”, the operation of which was made impossible in 2014.
Design/methodology/approach
Drawing on the insights of Foucauldian governmentality studies and actor-network theory, this paper focusses on drug use as a problem in its spatial-material settings. Based on ethnographic fieldwork, the contribution traces multiple problematisation processes and related infrastructures.
Findings
From the needle exchange programme’s perspective, drug use is not a singular problem but the effect of multiple problematisation processes. Although those processes are often in conflict with each other, the question is not which one is right, but how social workers manage to hold them together. It is a fragile achievement that requires years of training and ongoing negotiation with local actors. By eliminating Kék Pont’s 8th district office, the Hungarian Government did not only hinder harm reduction in the area but it had also rendered tacit knowledge associated with the needle exchange programme as a “drug place” inaccessible.
Originality/value
The paper is a melancholy intervention – an attempt to preserve tacit knowledge that had accumulated at the needle exchange programme. The retelling of ethnographic stories about this “drug place” is one way of ensuring that other drug policies remain imaginable.
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Watson DP, Swartz JA, Robison-Taylor L, Mackesy-Amiti ME, Erwin K, Gastala N, Jimenez AD, Staton MD, Messmer S. Syringe service program-based telemedicine linkage to opioid use disorder treatment: protocol for the STAMINA randomized control trial. BMC Public Health 2021; 21:630. [PMID: 33789642 PMCID: PMC8010496 DOI: 10.1186/s12889-021-10669-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/22/2021] [Indexed: 01/28/2023] Open
Abstract
Background A key strategy for mitigating the current opioid epidemic is expanded access to medications for treating opioid use disorder (MOUD). However, interventions developed to expand MOUD access have limited ability to engage opioid users at higher levels of overdose risk, such as those who inject opioids. This paper describes the study protocol for testing STAMINA (Syringe Service Telemedicine Access for Medication-assisted Intervention through NAvigation), an intervention that engages high-risk opioid users at community-based syringe service programs (SSP) and quickly links them to MOUD using a telemedicine platform. Methods This randomized control trial will be conducted at three SSP sites in Chicago. All participants will complete an initial assessment with a provider from a Federally Qualified Health Center who can prescribe or refer MOUD services as appropriate. The control arm will receive standard referral to treatment and the intervention arm will receive immediate telemedicine linkage to the provider and (depending on the type of MOUD prescribed) provided transportation to pick up their induction prescription (for buprenorphine or naltrexone) or attend their intake appointment (for methadone). We aim to recruit a total of 273 participants over two years to provide enough power to detect a difference in our primary outcome of MOUD treatment linkage. Secondary outcomes include treatment engagement, treatment retention, and non-MOUD opioid use. Data will be collected using structured interviews and saliva drug tests delivered at baseline, three months, and six months. Fixed and mixed effects generalized linear regression analyses and survival analysis will be conducted to compare the probabilities of a successful treatment linkage between the two arms, days retained in treatment, and post-baseline opioid and other drug use. Discussion If successful, STAMINA’s telemedicine approach will significantly reduce the amount of time between SSP clients’ initial indication of interest in the medication and treatment initiation. Facilitating this process will likely lead to stronger additional treatment- and recovery-oriented outcomes. This study is also timely given the need for more rigorous testing of telemedicine interventions in light of temporary regulatory changes that have occurred during the COVID-19 pandemic. Trial registration ClinicalTrials.gov (Clinical Trials ID: NCT04575324 and Protocol Number: 1138–0420). Registered 29 September 2020. The study protocol is also registered on the Open Science Framework (DOI 10.17605/OSF.IO/4853 M).
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Affiliation(s)
- Dennis P Watson
- Lighthouse Institute, Chestnut Health Systems, 221 W Walton St, Chicago, IL, 60610, USA.
| | - James A Swartz
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison St, Chicago, IL, 60607, USA
| | - Lisa Robison-Taylor
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois College of Medicine at Chicago, 818 S Wolcott Ave, Chicago, IL, 60612, USA
| | - Mary Ellen Mackesy-Amiti
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St, Chicago, IL, 60612, USA
| | - Kim Erwin
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, 1220 S. Wood Street, Chicago, IL, 60612, USA
| | - Nicole Gastala
- Mile Square Health Centers, Department of Family Medicine, University of Illinois College of Medicine at Chicago, 1220 S Wood Street, Chicago, IL, 60608, USA
| | - Antonio D Jimenez
- Community Outreach Intervention Projects, University of Illinois - Chicago, School of Public Health, 1603 W. Taylor, Chicago, IL, 60612, USA
| | - Monte D Staton
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois College of Medicine at Chicago, 818 S Wolcott Ave, Chicago, IL, 60612, USA
| | - Sarah Messmer
- Departments of Academic Internal Medicine and Pediatrics, University of Illinois Chicago, 840 S Wood St, Chicago, IL, 60612, USA
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Urbanoski K, Pauly B, Inglis D, Cameron F, Haddad T, Phillips J, Phillips P, Rosen C, Schlotter G, Hartney E, Wallace B. Defining culturally safe primary care for people who use substances: a participatory concept mapping study. BMC Health Serv Res 2020; 20:1060. [PMID: 33228650 PMCID: PMC7685616 DOI: 10.1186/s12913-020-05915-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/10/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND People who use substances experience high levels of substance-related stigma, both within and outside of health care settings, which can prevent people from help-seeking and contribute further to health inequities. Recognizing and respecting how political, social, economic, and historical conditions influence health and health care, cultural safety, with origins in addressing Indigenous racism, is a potential strategy for mitigating stigma and marginalization in health care. Using a participatory research approach, we applied the concept of cultural safety to develop a model of safe primary care from the perspective of people who use substances. METHODS People who use or used substances were involved in all phases of the research and led data collection. Study participants (n = 75) were 42.5 years old on average; half identified as female and one quarter as Indigenous. All were currently using or had previous experience with substances (alcohol and/or other drugs) and were recruited through two local peer-run support agencies. Concept mapping with hierarchical cluster analysis was used to develop the model of safe primary care, with data collected over three rounds of focus groups. RESULTS Participants identified 73 unique statements to complete the focus prompt: "I would feel safe going to the doctor if …" The final model consisted of 8 clusters that cover a wide range of topics, from being treated with respect and not being red-flagged for substance use, to preserving confidentiality, advocacy for good care and systems change, and appropriate accommodations for anxiety and the effects of poverty and criminalization. CONCLUSIONS Developing a definition of safe care (from the patient perspective) is the necessary first step in creating space for positive interactions and, in turn, improve care processes. This model provides numerous concrete suggestions for providers, as well as serving as starting point for the development of interventions designed to foster system change.
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Affiliation(s)
- Karen Urbanoski
- Technology Enterprise Facility, Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada.
- School of Public Health and Social Policy, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada.
| | - Bernadette Pauly
- Technology Enterprise Facility, Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
- School of Nursing, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
| | - Dakota Inglis
- Technology Enterprise Facility, Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
| | - Fred Cameron
- SOLID Outreach Society, 1056 N Park St, Victoria, BC, V8T 1C6, Canada
| | - Troy Haddad
- SOLID Outreach Society, 1056 N Park St, Victoria, BC, V8T 1C6, Canada
| | - Jack Phillips
- SOLID Outreach Society, 1056 N Park St, Victoria, BC, V8T 1C6, Canada
| | - Paige Phillips
- SOLID Outreach Society, 1056 N Park St, Victoria, BC, V8T 1C6, Canada
| | - Conor Rosen
- Umbrella Society for Addictions and Mental Health, 415 Dunedin St #8, Victoria, BC, V8T 5G8, Canada
| | - Grant Schlotter
- SOLID Outreach Society, 1056 N Park St, Victoria, BC, V8T 1C6, Canada
| | - Elizabeth Hartney
- Centre for Health Leadership and Research, Royal Roads University, 2005 Sooke Road, Victoria, BC, V9B 5Y2, Canada
| | - Bruce Wallace
- Technology Enterprise Facility, Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
- School of Social Work, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
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Värmå Falk M, Strömdahl S, Ekström AM, Kåberg M, Karlsson N, Dahlborn H, Hammarberg A. A qualitative study of facilitators and barriers to participate in a needle exchange program for women who inject drugs. Harm Reduct J 2020; 17:84. [PMID: 33092595 PMCID: PMC7579804 DOI: 10.1186/s12954-020-00425-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women who inject drugs (WWID) show higher levels of injecting risk behaviour compared to men, putting them at risk of contracting HIV and hepatitis C (HCV). Compared to men, WWID are also less present in harm reduction programs such as needle exchange programs (NEP). The aim of this study is to investigate reasons for, and barriers to, participation in NEP among WWID in Sweden, and to identify measures that could be taken to strengthen the program and increase participation among WWID. METHOD In-depth interviews (IDIs) were conducted with 20 WWID who had participated in the Stockholm NEP for at least six months and was over 18 years old. IDIs were audio recorded and transcribed et verbatim. Qualitative content analysis was used to identify themes. RESULTS The need for sterile injection equipment was identified as the main driver to join and remain in the NEP program. Continuous participation in the NEP was further driven by easy access to a multitude of health-related services. The most valued service was the sexual and reproductive health services (SRHR), allowing participants to access contraceptives, cervical cancer screening and sexually transmitted infections testing (STI-testing). NEP staffs' respectful treatment of participants further contributed to program participation. However, participants also expressed a number of concerns around NEP participation, which created barriers to joining. These included losing custody or visitation rights to children, male partner jealousy and violence, unwillingness to spend time in the waiting area and fear of receiving positive HIV/HCV test results. Practical barriers included limited opening hours and travel distance to the NEP. To strengthen the program, most participants requested additional SRHR services. Most participants also proposed some form of "women only" access to the NEP, to strengthen the feeling of the NEP as a safe space. CONCLUSION This study identified factors that may increase uptake of NEP among WWID. Additional SRHR services and "women only" access are recommended to be implemented and evaluated as part of NEP. These findings may inform and improve the current scale-up of NEPs in Sweden to ensure equal access to services.
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Affiliation(s)
- Malin Värmå Falk
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden.
| | - Susanne Strömdahl
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Kåberg
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden
- Division of Infection and Dermatology, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Niklas Karlsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Stockholm, Sweden
| | - Helena Dahlborn
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden
| | - Anders Hammarberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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Soares NSA, Fernandes MA, Ribeiro HKP, Rocha DDM, Ribeiro ÍAP. Harm reduction in primary healthcare: an integrative review of care strategies. Rev Esc Enferm USP 2020; 54:e03591. [PMID: 32965442 DOI: 10.1590/s1980-220x2018051803591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 09/30/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To analyze the evidence available in the literature on harm reduction actions developed by primary healthcare. METHOD Integrative literature review carried out in the databases MEDLINE, CINAHL, SCOPUS, Web of ScienceTM and LILACS. RESULTS Seventeen (17) primary studies published from 2008 to 2017 were included in this review. Care strategies for harm reduction included maintenance treatment with methadone, therapy with opioid agonists, needle and syringe distribution programs and the creation of rooms for supervised drug consumption. Health professionals were essential for consolidating inclusion strategies, possessing skills to listen without judgment and prejudice. CONCLUSION Harm reduction care strategies have been disseminated in different countries and healthcare levels, aiming toward safe practice and quality, effective and risk-free care actions.
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Marsella O, Forchuk C, Oudshoorn A. Exploring harm reduction among Canadian Veterans experiencing homelessness. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2020. [DOI: 10.3138/jmvfh-2019-0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: In Canada, Veteran homelessness is an increasing concern. It is estimated that approximately 2,950 Veterans experienced homelessness in 2016. Some may also have substance use disorders, which has been linked to loss of housing and homelessness many years after exiting military service. A strategy that facilitates housing stability and reduces the harms of substance use is harm reduction. This study explored how Veterans who have experienced homelessness perceive and experience harm reduction. Methods: This study was a secondary analysis of data collected from the Canadian Model for Housing and Support of Veterans Experiencing Homelessness study that evaluated a Veteran-specific housing model in four Canadian cities. In the primary study, 78 participants received housing and related programming intervention. Focus groups with Veterans occurred at each of the four housing sites from 2012 to 2014. Across all sites, 24 Veterans attended both the 2012 and 2013 focus groups. A total of 39 Veterans attended the final focus groups in 2014. The authors conducted a thematic analysis of Veteran focus group data where data were extracted from transcripts and organized into themes. Results: Various themes emerged from the data including (1) regimented structure, (2) understanding both worlds, (3) congruent recovery journeys, (4) location close enough to services, far enough from harm, and (5) harm reduction is housing stability and housing stability is harm reduction. These themes represent the interface between military culture and homeless culture. Overall, Veterans considered harm reduction as an essential component of housing. Discussion: This study has shown that harm reduction may be part of the solution to ending Veteran homelessness in Canada. The findings of this study may inform how Veteran housing and substance use needs are addressed. Additional research is needed to explore further how harm reduction can be effectively incorporated into Housing First for Veterans.
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Affiliation(s)
- Olivia Marsella
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Cheryl Forchuk
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Abe Oudshoorn
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
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Impact of overdose prevention sites during a public health emergency in Victoria, Canada. PLoS One 2020; 15:e0229208. [PMID: 32438390 PMCID: PMC7242015 DOI: 10.1371/journal.pone.0229208] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 01/31/2020] [Indexed: 11/19/2022] Open
Abstract
The primary objective of this study was to examine the impacts associated with implementation of overdose preventions sites (OPSs) in Victoria, Canada during a declared provincial public health overdose emergency. A rapid case study design was employed with three OPSs constituting the cases. Data were collected through semi-structured interviews with 15 staff, including experiential staff, and 12 service users. Theoretically, we were informed by the Consolidated Framework for Implementation Research. This framework, combined with a case study design, is well suited for generating insight into the impacts of an intervention. Zero deaths were identified as a key impact and indicator of success. The implementation of OPSs increased opportunities for early intervention in the event of an overdose, reducing trauma for staff and service users, and facilitated organizational transitions from provision of safer supplies to safer spaces. Providing a safer space meant drug use no longer needed to be concealed, with the effect of mitigating drug related stigma and facilitating a shift from shame and blame to increasing trust and development of relationships with increased opportunities to provide connections to other services. These impacts were achieved with few new resources highlighting the commitment of agencies and harm reduction workers, particularly those with lived experience, in achieving beneficial impacts. Although mitigating harms of overdose, OPSs do not address the root problem of an unsafe drug supply. OPSs are important life-saving interventions, but more is needed to address the current contamination of the illicit drug supply including provision of a safer supply.
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Wallace B, van Roode T, Pagan F, Phillips P, Wagner H, Calder S, Aasen J, Pauly B, Hore D. What is needed for implementing drug checking services in the context of the overdose crisis? A qualitative study to explore perspectives of potential service users. Harm Reduct J 2020; 17:29. [PMID: 32398090 PMCID: PMC7216532 DOI: 10.1186/s12954-020-00373-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/28/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The current illicit drug overdose crisis within North America and other countries requires expanded and new responses to address unpredictable and potentially lethal substances, including fentanyl analogues, in the unregulated drug market. Community-wide drug checking is being increasingly explored as one such public health response. We explored how drug checking could be implemented as a potential harm reduction response to the overdose crisis, from the perspective of potential service users. METHODS The research was guided by the Consolidated Framework for Implementation Research (CFIR). We conducted a qualitative, pre-implementation study to inform development and implementation of drug checking services that are acceptable to people who use substances and meet their needs. University and community researchers conducted 27 in-depth interviews with potential service users at prospective drug checking sites. We inductively developed emerging themes to inform the implementation of drug checking services within the five domains of the CFIR, and identified the most relevant constructs. RESULTS Implementing community drug checking faces significant challenges within the current context of criminalization and stigmatization of substance use and people who use/sell drugs, and trauma experienced by potential service users. Participants identified significant risks in accessing drug checking, and that confidential and anonymous services are critical to address these. Engaging people with lived experience in the service can help establish trust. The relative advantage of drug checking needs to outweigh risks through provision of accurate results conveyed in a respectful, non-judgemental way. Drug checking should provide knowledge relevant to using and/or selling drugs and informing one's own harm reduction. CONCLUSIONS For service users, the extent to which the implementation of drug checking can respond to and mitigate the risks of being criminalized and stigmatized is critical to the acceptability and success of community drug checking. The culture and compatibility of the service, setting and staff with harm reduction principles and practices is essential.
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Affiliation(s)
- Bruce Wallace
- Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada. .,School of Social Work, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada.
| | - Thea van Roode
- Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada
| | - Flora Pagan
- Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada
| | - Paige Phillips
- SOLID Outreach Society, 1056 North Park St, Victoria, BC, Canada
| | - Hailly Wagner
- SOLID Outreach Society, 1056 North Park St, Victoria, BC, Canada
| | - Shane Calder
- AVI Health & Community Services, 3rd Floor - Access Health Centre 713 Johnson St, Victoria, BC, Canada
| | - Jarred Aasen
- Lantern Services, 820 Cormorant St, Victoria, BC, Canada
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada.,School of Nursing, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada
| | - Dennis Hore
- Department of Chemistry, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada.,Department of Computer Science, University of Victoria, PO Box 1700, STN CSC, Victoria, BC, Canada
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O'Keefe-Markman C, Lea KD, McCabe C, Hyshka E, Bubela T. Social values for health technology assessment in Canada: a scoping review of hepatitis C screening, diagnosis and treatment. BMC Public Health 2020; 20:89. [PMID: 31959155 PMCID: PMC6971980 DOI: 10.1186/s12889-020-8190-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/09/2020] [Indexed: 02/06/2023] Open
Abstract
Background Health care system decision makers face challenges in allocating resources for screening, diagnosis and treatment of hepatitis C. Approximately 240,000 individuals are infected with the hepatitis C virus (HCV) in Canada. Populations most affected by HCV include Indigenous people, people who inject drugs, immigrants and homeless or incarcerated populations as well as those born between 1946 and 1965. Curative but expensive drug regimens of novel direct acting antivirals (DAAs) are available. We aim to identify social values from academic literature for inclusion in health technology assessments. Methods We conducted a scoping review of academic literature to identify and analyze the social values and evidence-based recommendations for screening, diagnosis and treatment of HCV in Canada. After applying inclusion/exclusion criteria, we abstracted: type of intervention(s), population(s) affected, study location, screening methods, diagnostics and treatments. We then abstracted and applied qualitative codes for social values. We extracted social value statements and clustered them into one of 4 categories: (1) equity and justice, (2) duty to provide care, (3) maximization of population benefit, and (4) individual versus community interests. Results One hundred and eighteen articles met our inclusion criteria on screening, diagnosis and treatment of HCV in Canada. Of these, 54 (45.8%) discussed screening, 4 (3.4%) discussed diagnosis and 60 (50.8%) discussed treatment options. Most articles discussed the general population and other non-vulnerable populations. Articles that discussed vulnerable populations focused on people who inject drugs. We coded 1243 statements, most of which fell into the social value categories of equity and justice, duty to provide care and maximization of population benefit. Conclusion The academic literature identified an expanded set of social values to be taken into account by resource allocation decision makers in financially constrained environments. In the context of hepatitis C, authors called for greater consideration of equity and justice and the duty to provide care in making evidence-based recommendations for screening, diagnosis and treatment for different populations and in different settings that also account for individual and community interests.
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Affiliation(s)
| | - Kristina Dawn Lea
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Christopher McCabe
- Institute of Health Economics, Edmonton, AB, Canada.,Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, AB, Canada.,Inner City Health and Wellness, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Tania Bubela
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
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Magwood O, Leki VY, Kpade V, Saad A, Alkhateeb Q, Gebremeskel A, Rehman A, Hannigan T, Pinto N, Sun AH, Kendall C, Kozloff N, Tweed EJ, Ponka D, Pottie K. Common trust and personal safety issues: A systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness. PLoS One 2019; 14:e0226306. [PMID: 31887152 PMCID: PMC6936789 DOI: 10.1371/journal.pone.0226306] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/22/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Persons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness. METHODS We searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings. FINDINGS Our search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement. CONCLUSIONS Individuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.
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Affiliation(s)
- Olivia Magwood
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Victoire Kpade
- Faculty of Medicine, McGill University Montreal, QC, Canada
| | - Ammar Saad
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Qasem Alkhateeb
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Akalewold Gebremeskel
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Asia Rehman
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Terry Hannigan
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Nicole Pinto
- Department of Population Medicine, University of Guelph, Guelph, ON, Canada
| | - Annie Huiru Sun
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Claire Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine & School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health and Department of Psychiatry and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Emily J. Tweed
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - David Ponka
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Family Medicine & School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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‘It's our safe sanctuary’: Experiences of using an unsanctioned overdose prevention site in Toronto, Ontario. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:135-140. [DOI: 10.1016/j.drugpo.2019.09.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 01/18/2023]
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Abstract
The rate of overdose related to the use of licit and illicit opioids has drastically increased over the last decade in the United States. The epicenter has been West Virginia with the highest rates of overdoses accounting for 41.5 deaths per 100 000 people among the 33 091 deaths in 2015. The purpose of this research was to examine and analyze the cause of the opioid epidemic and subsequent responses to it in the state of West Virginia. This study conducted a literature review using 37 references that were published between the years 2009 and 2018, complemented with a semistructured interview. The number of people injecting drugs has increased from 36% in 2005 to 54% in 2015. The total US cost of prescription opioid abuse in 2011 has been estimated at $25 billion, and criminal justice system costs to $5.1 billion. The reasons for this opioid epidemic incidence in West Virginia have been a combination of sociocultural factors, a depressed economy, lack of education, and a high rate of prescribing and dispensing of prescription opioids.
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Abstract
This report documents a successful intervention by a community-based naloxone distribution program in San Francisco. The program and its partner organizations, working with participants who use drugs, first identified the appearance of illicitly made fentanyl and increased outreach and naloxone distribution. Distribution of naloxone and reported use of naloxone to reverse opioid-involved overdoses increased significantly while the number of opioid-involved and fentanyl-involved overdose deaths did not. Community-based programs that provide training and naloxone to people who use drugs can serve as an early warning system for overdose risk and adaptively respond to the rapidly changing overdose risk environment.
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Glick JL, Christensen T, Park JN, McKenzie M, Green TC, Sherman SG. Stakeholder perspectives on implementing fentanyl drug checking: Results from a multi-site study. Drug Alcohol Depend 2019; 194:527-532. [PMID: 30551090 DOI: 10.1016/j.drugalcdep.2018.10.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND The opioid epidemic is one of the greatest public health crises of our times, driven increasingly by synthetic opioids such as fentanyl in the heroin supply. The implementation of drug checking in community settings has the potential to reduce the burden of fatal overdose, provide harm reduction education around safer drug consumption, and increase health access among people who use drugs (PWUD). To inform program development, we explored stakeholder opinions on drug checking technologies and implementation considerations. METHODS This study, from the larger FORECAST study, utilized semi-structured in-depth interviews (n = 32) with a range of stakeholders in Baltimore, Boston, and Providence, many of whom were service providers. Stakeholders represented various roles and levels in organization types including harm reduction, public health, peer groups, and advocates. Interviews were audio recorded and transcribed. Data were coded using a priori codes; the coded text was analyzed for key themes. RESULTS Stakeholders responded positively to drug checking technology, though they shared apprehensions regarding service implementation. Primary topics requiring consideration included: utility in fentanyl endemic areas, trust and rapport between providers and PWUD, legality and policy concerns. Additional considerations included: technology accuracy, cost, ease of distribution, and service delivery setting. CONCLUSIONS Stakeholders overwhelmingly supported the concept of drug checking with the goals of providing needed risk reduction information and resources to PWUD and serving as a point for greater engagement in services. Programs need to be tailored to local circumstances. Law enforcement buy-in and policy change will be critical aspects of providing drug checking services.
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Affiliation(s)
- Jennifer L Glick
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 749, Baltimore, MD, 21205, USA.
| | - Tricia Christensen
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 163, Baltimore, MD, USA
| | - Ju Nyeong Park
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 163, Baltimore, MD, USA
| | | | - Traci C Green
- Rhode Island Hospital, Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 163, Baltimore, MD, USA
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Abstract
The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.
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Sheltering risks: Implementation of harm reduction in homeless shelters during an overdose emergency. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 53:83-89. [DOI: 10.1016/j.drugpo.2017.12.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 12/01/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022]
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30
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Goodin A, Fallin-Bennett A, Green T, Freeman PR. Pharmacists' role in harm reduction: a survey assessment of Kentucky community pharmacists' willingness to participate in syringe/needle exchange. Harm Reduct J 2018; 15:4. [PMID: 29370808 PMCID: PMC5785823 DOI: 10.1186/s12954-018-0211-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/19/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pharmacists' role in harm reduction is expanding in many states, yet there are limited data on pharmacists' willingness to participate in harm reduction activities. This study assessed community pharmacists' willingness to participate in one harm reduction initiative: syringe/needle exchange. METHODS In 2015, all Kentucky pharmacists with active licenses were emailed a survey that examined attitudes towards participation in syringe/needle exchange. Response frequencies were calculated for community pharmacist respondents. Ordinal logistic regression estimated the impact of community pharmacist characteristics and attitudes on willingness to provide clean needles/syringes to people who inject drugs and to dispose of used syringes/needles, where both dependent variables were defined as Likert-type questions on a scale of 1 (not at all willing) to 6 (very willing). RESULTS Of 4699 practicing Kentucky pharmacists, 1282 pharmacists responded (response rate = 27.3%); the majority (n = 827) were community pharmacists. Community pharmacists were divided on willingness to provide clean needles/syringes, with 39.1% not willing (score 1 or 2 of 6) and 30% very willing (score 5 or 6 of 6). Few were willing to dispose of used needles/syringes, with only 18.7% willing. Community pharmacists who agreed that pharmacists could have significant public health impact by providing access to clean needles expressed 3.56 times more willingness to provide clean needles (95% CI 3.06-4.15), and 2.04 times more willingness to dispose of used needles (95% CI 1.77-2.35). Chain/supermarket pharmacists (n = 485, 58.6% of community pharmacies) were 39% less likely to express willingness to dispose of used needles (95% CI 0.43-0.87) when compared with independent community pharmacists (n = 342, 41.4% of community pharmacies). Independent pharmacists reported different barriers (workflow) than their chain/supermarket pharmacist colleagues (concerns of clientele). CONCLUSIONS Kentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.
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Affiliation(s)
- Amie Goodin
- College of Pharmacy, Pharmaceutical Outcomes and Policy, University of Florida, 1225 Center Drive, HPNP 2320, Gainesville, FL, 32610, USA.
| | | | - Traci Green
- Emergency Medicine, Injury Prevention Research Center, College of Medicine, Brown University, Providence, RI, USA
| | - Patricia R Freeman
- Pharmacy Practice and Science, Center for the Advancement of Pharmacy Practice, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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Barbour K, McQuade M, Brown B. Students as effective harm reductionists and needle exchange organizers. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2017; 12:15. [PMID: 28302153 PMCID: PMC5356241 DOI: 10.1186/s13011-017-0099-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Needle exchange programs are safe, highly effective programs for promoting health among people who inject drugs. However, they remain poorly funded, and often illegal, in many places worldwide due to fear and stigma surrounding drug use. Continued advocacy, education, and implementation of new needle exchanges are thus essential to improve public health and reduce structural inequality. COMMENTARY We argue that students, and especially professional and graduate students, have the potential to play an important role in advancing harm reduction. Students benefit from the respect given to the professions they are training to enter, which gives them leverage to navigate the political hurdles often faced by needle exchange organizers, especially in areas that presently lack services. In addition, due to their relative simplicity, needle exchanges do not require much of the licensing, clinical knowledge, and infrastructure associated with more traditional student programs, such as student-run free medical clinics. Students are capable of learning harm reduction cultural approaches and techniques if they remain humble, open-minded, and seek the help of the harm reduction community. Consequently, students can generate tremendous benefits to their community without performing beyond their appropriate clinical limitations. Students benefit from organizing needle exchanges by gaining applied experience in advocacy, organization-building, and political finesse. Working in a needle exchange significantly helps erode stigma against multiple marginalized populations. Students in health-related professions additionally learn clinically-relevant knowledge that is often lacking from their formal training, such as an understanding of structural violence and inequality, root causes of substance use, client-centered approaches to health services, and interacting with clients as peers, rather than through the standard hierarchical medical interaction. CONCLUSION We therefore encourage students to learn about and consider organizing needle exchanges during their training. Our experience is that students can be successful in developing sustainable programs which benefit their clients, the broader harm reduction movement, and themselves alike.
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Affiliation(s)
- Kyle Barbour
- UC Irvine School of Medicine, Irvine; Orange County Needle Exchange Program (OCNEP), Santa Ana, USA.
| | - Miriam McQuade
- UC Irvine School of Medicine, Irvine; Orange County Needle Exchange Program (OCNEP), Santa Ana, USA
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Trend Analyses of Users of a Syringe Exchange Program in Philadelphia, Pennsylvania: 1999-2014. AIDS Behav 2016; 20:2922-2932. [PMID: 27066985 DOI: 10.1007/s10461-016-1393-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This study examines trends of injection drug users' (IDUs) use of a Philadelphia, Pennsylvania, syringe exchange program (SEP) from 1999 to 2014, including changes in demographics, drug use, substance abuse treatment, geographic indicators, and SEP use. Prevention Point Philadelphia's SEP registration data were analyzed using linear regression, Pearson's Chi square, and t-tests. Over time new SEP registrants have become younger, more racially diverse, and geographically more concentrated in specific areas of the city, corresponding to urban demographic shifts. The number of new registrants per year has decreased, however syringes exchanged have increased. Gentrification, cultural norms, and changes in risk perception are believed to have contributed to the changes in SEP registration. Demographic changes indicate outreach strategies for IDUs may need adjusting to address unique barriers for younger, more racially diverse users. Implications for SEPs are discussed, including policy and continued ability to address current public health threats.
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Clarke K, Harris D, Zweifler JA, Lasher M, Mortimer RB, Hughes S. The Significance of Harm Reduction as a Social and Health Care Intervention for Injecting Drug Users: An Exploratory Study of a Needle Exchange Program in Fresno, California. SOCIAL WORK IN PUBLIC HEALTH 2016; 31:398-407. [PMID: 27167664 PMCID: PMC5129746 DOI: 10.1080/19371918.2015.1137522] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Infectious disease remains a significant social and health concern in the United States. Preventing more people from contracting HIV/AIDS or Hepatitis C (HCV), requires a complex understanding of the interconnection between the biomedical and social dimensions of infectious disease. Opiate addiction in the US has skyrocketed in recent years. Preventing more cases of HIV/AIDS and HCV will require dealing with the social determinants of health. Needle exchange programs (NEPs) are based on a harm reduction approach that seeks to minimize the risk of infection and damage to the user and community. This article presents an exploratory small-scale quantitative study of the injection drug using habits of a group of injection drug users (IDUs) at a needle exchange program in Fresno, California. Respondents reported significant decreases in high risk IDU behaviors, including sharing of needles and to a lesser extent re-using of needles. They also reported frequent use of clean paraphernalia. Greater collaboration between social and health outreach professionals at NEPs could provide important frontline assistance to people excluded from mainstream office-based services and enhance efforts to reduce HIV/AIDS or HCV infection.
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Affiliation(s)
- Kris Clarke
- a Department of Social Work , California State University , Fresno , California , USA
| | - Debra Harris
- a Department of Social Work , California State University , Fresno , California , USA
| | - John A Zweifler
- b Department of Family & Community Medicine , University of California, San Francisco, Fresno Medical Education Program , Fresno , California , USA
| | - Marc Lasher
- b Department of Family & Community Medicine , University of California, San Francisco, Fresno Medical Education Program , Fresno , California , USA
| | - Roger B Mortimer
- b Department of Family & Community Medicine , University of California, San Francisco, Fresno Medical Education Program , Fresno , California , USA
| | - Susan Hughes
- b Department of Family & Community Medicine , University of California, San Francisco, Fresno Medical Education Program , Fresno , California , USA
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Barman-Adhikari A, Begun S, Rice E, Yoshioka-Maxwell A, Perez-Portillo A. Sociometric network structure and its association with methamphetamine use norms among homeless youth. SOCIAL SCIENCE RESEARCH 2016; 58:292-308. [PMID: 27194667 PMCID: PMC4873723 DOI: 10.1016/j.ssresearch.2016.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 01/05/2016] [Accepted: 01/22/2016] [Indexed: 05/25/2023]
Abstract
Homeless youths' social networks are consistently linked with their substance use. Social networks influence behavior through several mechanisms, especially social norms. This study used sociometric analyses to understand whether social norms of drug use behaviors are clustered in network structures and whether these perceived norms (descriptive and injunctive) influence youths' drug use behaviors. An event-based approach was used to delineate boundaries of the two sociometric networks of homeless youth, one in Los Angeles, CA (n = 160) and the other in Santa Monica, CA (n = 130). Network characteristics included centrality (i.e., popularity) and cohesiveness (location in dense subnetworks). The primary outcome was recent methamphetamine use. Results revealed that both descriptive and injunctive norms influenced methamphetamine use. Network cohesion was found to be associated with perception of both descriptive and injunctive norms in both networks, however in opposite directions. Network interventions therefore might be effective if designed to capitalize on social influence that naturally occurs in cohesive parts of networks.
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Affiliation(s)
| | - Stephanie Begun
- School of Social Work, University of Denver, Denver, CO, USA.
| | - Eric Rice
- School of Social Work, University of Southern California, Los Angeles, CA, USA.
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Pauly BB, Gray E, Perkin K, Chow C, Vallance K, Krysowaty B, Stockwell T. Finding safety: a pilot study of managed alcohol program participants' perceptions of housing and quality of life. Harm Reduct J 2016; 13:15. [PMID: 27156564 PMCID: PMC4860766 DOI: 10.1186/s12954-016-0102-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 01/21/2016] [Indexed: 12/01/2022] Open
Abstract
Background There is a higher prevalence of alcohol use and severe alcohol dependence among homeless populations. The combination of alcohol use and lack of housing contributes to increased vulnerability to the harms of substance use including stigma, injury, illness, and death. Managed alcohol programs (MAPs) administer prescribed doses of alcohol at regular intervals to people with severe and chronic alcohol dependence and homelessness. As a pilot for a larger national study of MAPs, we conducted an in-depth evaluation of one program in Ontario, Canada. In this paper, we report on housing and quality of life outcomes and experiences of the MAP participants and staff. Methods We conducted a pilot study using mixed methods. The sample consisted of 38 people enrolled in or eligible for entry into a MAP who completed a structured quantitative survey that included measures related to their housing and quality of life. All of the participants self-identified as Indigenous. In addition, we conducted 11 in-depth qualitative interviews with seven MAP residents and four program staff and analyzed the interviews using constant comparative analysis. The qualitative analysis was informed by Rhodes’ risk environment framework. Results When compared to controls, MAP participants were more likely to retain their housing and experienced increased safety and improved quality of life compared to life on the streets, in jails, shelters, or hospitals. They described the MAP as a safe place characterized by caring, respect, trust and a nonjudgmental approach with a sense of family and home as well as opportunities to reconnect with family members. Conclusions The MAP was, as described by participants, a safer environment and a home with feelings of family and a sense of community that countered stigma, loss, and dislocation with potential for healing and recovery. The MAP environment characterized by caring, respect, trust, a sense of home, “feeling like family”, and the opportunities for family and cultural reconnections is consistent with First Nations principles for healing and recovery and principles of harm reduction.
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Affiliation(s)
- Bernadette Bernie Pauly
- Scientist Centre for Addictions Research of BC, University of Victoria, Victoria, BC, Canada.
| | - Erin Gray
- School of Social Work, MacEwan University, Edmonton, Canada
| | | | - Clifton Chow
- Centre for Addictions Research of BC, Victoria, Canada
| | - Kate Vallance
- Centre for Addictions Research of BC, Victoria, Canada
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Olsen A, Higgs P, Maher L. A review of qualitative research inDrug and Alcohol Review. Drug Alcohol Rev 2015; 34:474-476. [DOI: 10.1111/dar.12307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Anna Olsen
- National Centre of Epidemiology and Population Health; The Australian National University; Canberra Australia
| | - Peter Higgs
- National Drug Research Institute, Faculty of Health Sciences; Curtin University; Melbourne Australia
| | - Lisa Maher
- The Kirby Institue, Faculty of Medicine; The Universsity of New South Wales; Sydney Australia
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Trust and people who inject drugs: The perspectives of clients and staff of Needle Syringe Programs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 27:138-45. [PMID: 26394538 DOI: 10.1016/j.drugpo.2015.08.018] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 05/20/2015] [Accepted: 08/24/2015] [Indexed: 11/21/2022]
Abstract
AIMS Interest in health-care related trust is growing with the recognition that trust is essential for effective therapeutic encounters. While most trust-related research has been conducted with general patient groups, the experiences of people who inject drugs cannot be understood without acknowledging the critical role social stigma plays in shaping (mis)trust, both generally and in regards to health services specifically. This study examined the experiences of trust among clients and staff of Needle and Syringe Programs (NSPs) in one area of Sydney, Australia. METHOD In-depth interviews with 12 NSP staff and 31 NSP clients were conducted. Analysis was informed by a five component model of trust, with particular emphasis on the notion of "global trust" as encompassing experiences of stigma and other negative social processes related to injecting drug use. Participant experiences of trust in NSPs were compared with those within other drug-related health services. Particular attention was paid to understanding the relationship between 'identity' (as a drug user) and 'legitimacy' (as a service user) and the centrality of this relationship to the experience of global trust for PWID. RESULTS Notions of identity and legitimacy were inextricably bound up with the stigmatisation of drug use, shaping participants' experiences and accounts of trust in NSPs and drug treatment services. Client participants reported high levels of trust in NSPs, especially when compared with drug treatment services, describing being treated like "any other person" even when negotiating 'sensitive' issues. NSP staff participants described the establishment of trust as not only underpinning their work with clients but as something that required ongoing renewal and demonstration. CONCLUSION "Global trust" assists us to better understand the complex experiences shaping PWID decisions to engage with and trust health services. The high levels of trust reported between client and NSP need to be recognised as a valuable resource for the delivery of effective health care for people who inject drugs, including encouraging behaviours to support the prevention of blood-borne viruses.
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McNeil R, Small W. 'Safer environment interventions': a qualitative synthesis of the experiences and perceptions of people who inject drugs. Soc Sci Med 2014; 106:151-8. [PMID: 24561777 PMCID: PMC4133147 DOI: 10.1016/j.socscimed.2014.01.051] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/13/2014] [Accepted: 01/31/2014] [Indexed: 01/08/2023]
Abstract
There is growing acknowledgment that social, structural, and environmental forces produce vulnerability to health harms among people who inject drugs (PWID), and safer environment interventions (SEI) have been identified as critical to mitigating the impacts of these contextual forces on drug-related harm. To date, however, SEIs have been under-theorized in the literature, and how they minimize drug-related risks across intervention types and settings has not been adequately examined. This article presents findings from a systematic review and meta-synthesis of qualitative studies reporting PWID's experiences with three types of SEIs (syringe exchange programmes, supervised injection facilities and peer-based harm reduction interventions) published between 1997 and 2012. This meta-synthesis sought to develop a comprehensive understanding of SEIs informed by the experiences of PWID. Twenty-nine papers representing twenty-one unique studies that included an aggregate of more than 800 PWID were included in this meta-synthesis. This meta-synthesis found that SEIs fostered social and physical environments that mitigated drug-related harms and increased access to social and material resources. Specifically, SEIs: (1) provided refuge from street-based drug scenes; (2) enabled safer injecting by reshaping the social and environmental contexts of injection drug use; (3) mediated access to resources and health care services; and, (4) were constrained by drug prohibition and law enforcement activities. These findings indicate that it is critical to situate SEIs in relation to the lived experiences of PWID, and in particular provide broader environmental support to PWID. Given that existing drug laws limit the effectiveness of interventions, drug policy reforms are needed to enable public health, and specifically SEIs, to occupy a more prominent role in the response to injection drug use.
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Affiliation(s)
- Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
| | - Will Small
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Impact of supervised drug consumption services on access to and engagement with care at a palliative and supportive care facility for people living with HIV/AIDS: a qualitative study. J Int AIDS Soc 2014; 17:18855. [PMID: 24629844 PMCID: PMC3955762 DOI: 10.7448/ias.17.1.18855] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 01/02/2014] [Accepted: 02/12/2014] [Indexed: 11/28/2022] Open
Abstract
Introduction Improvements in the availability and effectiveness of highly active antiretroviral therapy (HAART) have prolonged the lives of people living with HIV/AIDS. However, mortality rates have remained high among populations that encounter barriers to accessing and adhering to HAART, notably people who use drugs. This population consequently has a high burden of illness and complex palliative and supportive care needs, but is often unable to access these services due to anti-drug policies and discrimination. In Vancouver, Canada, the Dr. Peter Centre (DPC), which operates a 24-bed residential HIV/AIDS care facility, has sought to improve access to palliative and supportive care services by adopting a comprehensive harm reduction strategy, including supervised injection services. We undertook this study to explore how the integration of comprehensive harm reduction services into this setting shapes access to and engagement with care. Methods Qualitative interviews were conducted with 13 DPC residents between November 2010 and August 2011. Interviews made use of a semistructured interview guide which facilitated discussion regarding how the DPC Residence's model of care (a) shaped healthcare access, (b) influenced healthcare interactions and (c) impacted drug use practices and overall health. Interview transcripts were analysed thematically. Results Participant accounts highlight how the harm reduction policy altered the structural-environmental context of healthcare services and thus mediated access to palliative and supportive care services. Furthermore, this approach fostered an atmosphere in which drug use could be discussed without the risk of punitive action, and thus increased openness between residents and staff. Finally, participants reported that the environmental supports provided by the DPC Residence decreased drug-related risks and improved health outcomes, including HAART adherence and survival. Conclusions This study highlights how adopting comprehensive harm reduction services can serve to improve access and equity in palliative and supportive care for drug-using populations.
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McNeil R, Small W, Lampkin H, Shannon K, Kerr T. "People knew they could come here to get help": an ethnographic study of assisted injection practices at a peer-run 'unsanctioned' supervised drug consumption room in a Canadian setting. AIDS Behav 2014; 18:473-85. [PMID: 23797831 DOI: 10.1007/s10461-013-0540-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
People who require help injecting are disproportionately vulnerable to drug-related harm, including HIV transmission. North America's only sanctioned SIF operates in Vancouver, Canada under an exemption to federal drug laws, which imposes operating regulations prohibiting assisted injections. In response, the Vancouver Area Network of Drug Users (VANDU) launched a peer-run unsanctioned SIF in which trained peer volunteers provide assisted injections to increase the coverage of supervised injection services and minimize drug-related harm. We undertook qualitative interviews (n = 23) and ethnographic observation (50 h) to explore how this facility shaped assisted injection practices. Findings indicated that VANDU reshaped the social, structural, and spatial contexts of assisted injection practices in a manner that minimized HIV and other health risks, while allowing people who require help injecting to escape drug scene violence. Findings underscore the need for changes to regulatory frameworks governing SIFs to ensure that they accommodate people who require help injecting.
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Affiliation(s)
- Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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The burgeoning HIV/HCV syndemic in the urban Northeast: HCV, HIV, and HIV/HCV coinfection in an urban setting. PLoS One 2013; 8:e64321. [PMID: 23691197 PMCID: PMC3653872 DOI: 10.1371/journal.pone.0064321] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 04/14/2013] [Indexed: 01/16/2023] Open
Abstract
Introduction Despite recommendations for generation-based HCV and once lifetime HIV screening, thousands of individuals in the U.S. still remain untested and undiagnosed. This cross-sectional study examines the correlates of HCV and HIV monoinfection and HIV/HCV coinfection in an urban Northeast setting. Methods Utilizing an electronic database from a mobile medical clinic in New Haven, CT from January 2003 to July 2011, 8,311 individuals underwent structured health assessment and screening for HIV and HCV. Results HIV [N = 601 (8.0%)] and HCV [N = 753 (10.1%)] infection were identified, and 197 (26.1%) of the 753 with HCV were coinfected with HIV. Both monoinfection and coinfection status were independently correlated with crack cocaine use and increasing age. HIV/HCV coinfection was correlated with men having sex with men (MSM) (AOR = 38.53, p<0.0080), shooting gallery use (AOR = 3.06, p<0.0070), and not completing high school (AOR = 2.51, p<0.0370). HCV monoinfection correlated with health insurance (AOR = 2.16, p<0.0020), domestic violence (AOR = 1.99, p<0.0070), and being Hispanic (AOR = 2.63, p<0.0001), while HIV monoinfection correlated with having had syphilis (AOR = 2.66, p<0.0001) and being Black (AOR = 1.73, p = 0.0010). Conclusions Though HIV and HCV share common transmission risk behaviors, independent correlates with viral infection status in an urban Northeast setting are distinct and have important implications for surveillance, healthcare delivery, disease prevention, and clinical care.
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Pauly BB, Reist D, Belle-Isle L, Schactman C. Housing and harm reduction: what is the role of harm reduction in addressing homelessness? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 24:284-90. [PMID: 23623720 DOI: 10.1016/j.drugpo.2013.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 03/11/2013] [Accepted: 03/15/2013] [Indexed: 10/26/2022]
Abstract
Homelessness and drug use often overlap and the harms of substance use are exacerbated by homelessness. Responding to the twin problems of homelessness and substance use is an important aspect of strategies to end homelessness. The introduction and development of ten year plans to end homelessness in North America heralds a new era of systemic responses to homelessness. Central to many of these plans is the adoption of 'Housing First' as a policy response. Housing First focuses directly on housing people regardless of current patterns of substance use. As such, harm reduction is a key principle of Housing First. In this paper, we examine Housing First as an example of the integration of housing and harm reduction and then put forth a community level policy framework to further promote the integration of harm reduction as part of a response to homelessness. Drawing on Rhodes' risk environment framework and current evidence of Housing First and harm reduction, we describe four key policy areas for action: (1) social inclusion policies; (2) adequate and appropriate supply of housing; (3) on demand harm reduction services and supports and (4) systemic and organizational infrastructure. We conclude by identifying areas for future research.
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Klein MB, Rollet KC, Saeed S, Cox J, Potter M, Cohen J, Conway B, Cooper C, Côté P, Gill J, Haase D, Haider S, Hull M, Moodie E, Montaner J, Pick N, Rachlis A, Rouleau D, Sandre R, Tyndall M, Walmsley S. HIV and hepatitis C virus coinfection in Canada: challenges and opportunities for reducing preventable morbidity and mortality. HIV Med 2012; 14:10-20. [PMID: 22639840 DOI: 10.1111/j.1468-1293.2012.01028.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2012] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Hepatitis C virus (HCV) has emerged as an important health problem in the era of effective HIV treatment. However, very few data exist on the health status and disease burden of HIV/HCV-coinfected Canadians. METHODS HIV/HCV-coinfected patients were enrolled prospectively in a multicentre cohort from 16 centres across Canada between 2003 and 2010 and followed every 6 months. We determined rates of a first liver fibrosis or endstage liver disease (ESLD) event and all-cause mortality since cohort enrolment and calculated standardized mortality ratios compared with the general Canadian population. RESULTS A total of 955 participants were enrolled in the study and followed for a median of 1.4 (interquartile range 0.5-2.3) years. Most were male (73%) with a median age of 44.5 years; 13% self-identified as aboriginal. There were high levels of current injecting drug and alcohol use and poverty. Observed event rates [per 100 person-years; 95% confidence interval (CI)] were: significant fibrosis (10.21; 8.49, 12.19), ESLD (3.16; 2.32, 4.20) and death (3.72; 2.86, 4.77). The overall standardized mortality ratio was 17.08 (95% CI 12.83, 21.34); 12.80 (95% CI 9.10, 16.50) for male patients and 28.74 (95% CI 14.66, 42.83) for female patients. The primary causes of death were ESLD (29%) and overdose (24%). CONCLUSIONS We observed excessive morbidity and mortality in this HIV/HCV-coinfected population in care. Over 50% of observed deaths may have been preventable. Interventions aimed at improving social circumstances, reducing harm from drug and alcohol use and increasing the delivery of HCV treatment in particular will be necessary to reduce adverse health outcomes among HIV/HCV-coinfected persons.
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Affiliation(s)
- M B Klein
- Department of Medicine, Divisions of Infectious Diseases/Immunodeficiency, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada.
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McNeil R, Guirguis-Younger M, Dilley LB, Aubry TD, Turnbull J, Hwang SW. Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis. BMC Public Health 2012; 12:312. [PMID: 22545586 PMCID: PMC3355019 DOI: 10.1186/1471-2458-12-312] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/30/2012] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Homeless and marginally housed persons who use alcohol and/or illicit drugs often have end-of-life care needs that go unmet due to barriers that they face to accessing end-of-life care services. Many homeless and marginally housed persons who use these substances must therefore rely upon alternate sources of end-of-life care and support. This article explores the role of harm reduction services in end-of-life care services delivery to homeless and marginally housed persons who use alcohol and/or illicit drugs. METHODS A qualitative case study design was used to explore end-of-life care services delivery to homeless and marginally housed persons in six Canadian cities. A key objective was to explore the role of harm reduction services. 54 health and social services professionals participated in semi-structured qualitative interviews. All participants reported that they provided care and support to this population at end-of-life. RESULTS Harm reduction services (e.g., syringe exchange programs, managed alcohol programs, etc.) were identified as a critical point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs. Where possible, harm reduction services facilitated referrals to end-of-life care services for this population. Harm reduction services also provided end-of-life care and support when members of this population were unable or unwilling to access end-of-life care services, thereby improving quality-of-life and increasing self-determination regarding place-of-death. CONCLUSIONS While partnerships between harm reduction programs and end-of-life care services are identified as one way to improve access, it is noted that more comprehensive harm reduction services might be needed in end-of-life care settings if they are to engage this underserved population.
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Affiliation(s)
- Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | | | - Laura B Dilley
- Faculty of Education, Simon Fraser University, Surrey, BC, Canada
| | - Tim D Aubry
- School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey Turnbull
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Inner City Health, Ottawa, ON, Canada
| | - Stephen W Hwang
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
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Needle exchange and the geography of survival in the South Bronx. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2012; 23:295-302. [PMID: 22417824 DOI: 10.1016/j.drugpo.2012.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 01/13/2012] [Accepted: 01/20/2012] [Indexed: 11/23/2022]
Abstract
This paper explores the position of needle exchange programmes (NEPs) in the "geography of survival" in the South Bronx neighbourhood of New York City. Stemming the spread of HIV through the provision of sterile injecting equipment, needle exchange promotes the survival of injection drug users (IDUs) in the starkest sense; yet NEPs also attract a diverse population of service users whose attendance is not necessarily related to drugs. This paper locates NEPs among a larger constellation of social services accessed by residents of poor neighbourhoods, including injection drug users, the homeless, the hungry, and those in need of medical services or just safe space. Drawing on ethnographic and interview data from a needle exchange in the South Bronx, I describe how both IDUs and others employed the organisation to make ends meet, elaborating four "off-label" usages of needle exchange: as a place to obtain basic necessities, as a source of income, as a safe space, and as a site of social contact. As harm reduction in the United States moves towards an increasingly clinical model of care, this paper considers these latent functions of needle exchange within the context of a larger struggle over the content and meaning of harm reduction services. By themselves, NEPs are clearly an unsatisfactory solution to the economic and political circumstances that drive a variety of individuals through their doors; yet, in a country that lacks a comprehensive welfare system, needle exchange arguably represents an important thread within a social safety net that is being woven from the ground up. This study may be used to argue for a (re)expanded mission for harm reduction in the United States, in the face of constant moves to narrow its mandate and reduce its budget.
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ISLAM MMOFIZUL, REID SHARONE, WHITE ANN, GRUMMETT SARA, CONIGRAVE KATHERINEM, HABER PAULS. Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic. Drug Alcohol Rev 2011; 31:114-5; author reply 116-7. [DOI: 10.1111/j.1465-3362.2011.00390.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schwartländer B, Stover J, Hallett T, Atun R, Avila C, Gouws E, Bartos M, Ghys PD, Opuni M, Barr D, Alsallaq R, Bollinger L, de Freitas M, Garnett G, Holmes C, Legins K, Pillay Y, Stanciole AE, McClure C, Hirnschall G, Laga M, Padian N. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 2011; 377:2031-41. [PMID: 21641026 DOI: 10.1016/s0140-6736(11)60702-2] [Citation(s) in RCA: 385] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.
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MacNeil J, Pauly B. Impact: a case study examining the closure of a large urban fixed site needle exchange in Canada. Harm Reduct J 2010; 7:11. [PMID: 20500870 PMCID: PMC2903567 DOI: 10.1186/1477-7517-7-11] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 05/25/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION In 2008, one of the oldest fixed site needle exchanges in a large urban city in Canada was closed due to community pressure. This service had been in existence for over 20 years. CASE DESCRIPTION This case study focuses on the consequences of the switch to mobile needle exchange services immediately after the closure and examines the impact of the closure on changes in risk behavior related to drug use, needle distribution and access to services The context surrounding the closure was also examined. DISCUSSION AND EVALUATION After the closure of the fixed site exchange, access to needle exchange services decreased as evidenced by the sharp decline in numbers of clients reached, and the numbers of needles distributed and collected monthly. Reports related to needle reuse and selling of syringes suggest changes in risk behaviors. Thousands of needles remain unaccounted for in the community. To date, a new fixed site has not been found. CONCLUSION Closing the fixed site needle exchange had an adverse effect on already vulnerable clients and reduced access to comprehensive harm reduction services. While official public policy supports a fixed site, politicization of the issue has meant a significant setback for harm reduction with reduced potential to meet public health targets related to reducing the spread of blood borne diseases. This situation is unacceptable from a public health perspective.
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Affiliation(s)
- Joan MacNeil
- School of Nursing, University of Victoria, P.O. Box 1700, Victoria, BC, V8W 2Y2, Canada
| | - Bernadette Pauly
- School of Nursing, University of Victoria, P.O. Box 1700, Victoria, BC, V8W 2Y2, Canada
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