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Lemain L, Lever D, Therene-Mouden C, Verdeau R, Barais M, Guillou-Landreat M. Chemsex Among Men Having Sex with Men: A Scoping Review on Management, Support, and Harm Reduction Strategies. JOURNAL OF SEX RESEARCH 2024:1-11. [PMID: 39093301 DOI: 10.1080/00224499.2024.2377592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Chemsex defines the practice of sexual activity under the influence of psychoactive substances, mainly by Men who have Sex with Men (MSM). This activity can be associated with negative health consequences, yet there are no recommendations to guide management of individuals who engage in chemsex. The aim of this scoping review was to identify and describe the existing treatments (pharmacological or not) and risk/harm reduction strategies for MSM who engage in chemsex. This scoping review was performed using PubMed and Embase databases and according to the PRISMA Extension for Scoping Review criteria. Overall, 19 studies were included in the review. Among these studies, four main themes were identified: management and harm reduction strategies, key actors involved in managing MSM who engage in chemsex, perceived barriers to care and the role of pre-exposure prophylaxis, and medical information sought by MSM who engage in chemsex. This scoping review concludes with the need to develop multidisciplinary approaches to improve communication about chemsex, and to design interventional studies that target MSM who engage in chemsex.
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Affiliation(s)
- Loic Lemain
- Addictology Service, University Hospital of Brest, Université de Bretagne occidentale
- ER 7479 SPURBO, University of Western Brittany
| | - Delphine Lever
- Addictology Liaison, University Hospital of Brest, CHU de Brest
| | | | - Romain Verdeau
- Department of General Practice, University of Western Brittany
| | - Marie Barais
- ER 7479 SPURBO, University of Western Brittany
- Department of General Practice, University of Western Brittany
| | - Morgane Guillou-Landreat
- ER 7479 SPURBO, University of Western Brittany
- Addictology Liaison, University Hospital of Brest, CHU de Brest
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2
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Pozo-Herce PD, Martínez-Sabater A, Sanchez-Palomares P, Garcia-Boaventura PC, Chover-Sierra E, Martínez-Pascual R, Gea-Caballero V, Saus-Ortega C, Ballestar-Tarín ML, Karniej P, Baca-García E, Juárez-Vela R. Effectiveness of Harm Reduction Interventions in Chemsex: A Systematic Review. Healthcare (Basel) 2024; 12:1411. [PMID: 39057554 PMCID: PMC11275498 DOI: 10.3390/healthcare12141411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/05/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
The phenomenon of chemsex has emerged as an essential public health issue in recent years. This systematic review aimed to investigate currently available harm reduction strategies and to evaluate the efficacy of the corresponding interventions. METHODS A systematic review of the scientific literature related to harm and risk reduction strategies and the effectiveness of chemsex interventions. Between January 2024 and May 2024, the articles were retrieved from the electronic databases Pubmed, Web of Science, Scopus, PsycInfo, Cochrane, Dialnet, CUIDEN, and SciELO. The review protocol was registered in the PROSPERO database (registration number CRD42024508953). The inclusion criteria were as follows: (I) original studies published in peer-reviewed journals, (II) studies exploring harm reduction interventions for chemsex, and (III) studies reflecting the efficacy of harm reduction interventions for chemsex. Two reviewers independently selected articles by title, abstract, and full paper review and extracted data. Two authors described the selected studies and assessed their methodological quality. RESULTS The systematic review comprised six scientific papers that met the selection criteria and were obtained from five countries. Although a limited number of studies were included, it was observed that they presented a medium-high methodological quality. Programs evaluated interventions to reduce harm from chemsex, such as a web-based intervention that improved self-efficacy to refuse risky behaviors and accept HIV testing. The studies suggested that peer-led programs can be effective, especially with facilitators who have experienced chemsex dependence. CONCLUSION Harm reduction strategies in chemsex are effective and should be promoted by health professionals. Interventions should be accessible, personalized, and non-judgmental to provide appropriate care and support, ensuring a comprehensive and effective public health response.
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Affiliation(s)
- Pablo Del Pozo-Herce
- Department of Psychiatry, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (P.D.P.-H.); (E.B.-G.)
- Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, 28040 Madrid, Spain
- School of Nursing, Fundación Jiménez Díaz, Madrid Autonomous University, 28049 Madrid, Spain;
| | - Antonio Martínez-Sabater
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Facultat d’Infermeria i Podologia, University of Valencia, 46010 Valencia, Spain; (A.M.-S.); (R.M.-P.); (M.L.B.-T.)
- Care Research Group (INCLIVA), Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | | | | | - Elena Chover-Sierra
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Facultat d’Infermeria i Podologia, University of Valencia, 46010 Valencia, Spain; (A.M.-S.); (R.M.-P.); (M.L.B.-T.)
- Internal Medicine, Consorci Hospital Universitari de Valencia, 46014 Valencia, Spain
| | - Raquel Martínez-Pascual
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Facultat d’Infermeria i Podologia, University of Valencia, 46010 Valencia, Spain; (A.M.-S.); (R.M.-P.); (M.L.B.-T.)
- Care Research Group (INCLIVA), Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | - Vicente Gea-Caballero
- Research Group Community Health and Care, Faculty of Health Sciences, International University of Valencia, 46002 Valencia, Spain;
| | - Carles Saus-Ortega
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Facultat d’Infermeria i Podologia, University of Valencia, 46010 Valencia, Spain; (A.M.-S.); (R.M.-P.); (M.L.B.-T.)
- Nursing School La Fe, Adscript Centre, University of Valencia, 46026 Valencia, Spain
- Research Group GREIACC, Health Research Institute La Fe, 46016 Valencia, Spain
| | - María Luisa Ballestar-Tarín
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Facultat d’Infermeria i Podologia, University of Valencia, 46010 Valencia, Spain; (A.M.-S.); (R.M.-P.); (M.L.B.-T.)
- Nursing Department, Jaume I University, 12006 Castellón, Spain;
| | - Piotr Karniej
- Faculty of Finance and Management, WSB MERITO University in Wroclaw, 53-609 Wroclaw, Poland;
| | - Enrique Baca-García
- Department of Psychiatry, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (P.D.P.-H.); (E.B.-G.)
- Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, 28040 Madrid, Spain
| | - Raúl Juárez-Vela
- Research Group in Care, Department of Nursing, Faculty of Health Sciences, University of La Rioja, 26006 Logroño, Spain;
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Hawkinson DE, Witzel TC, Gafos M. Exploring practices to enhance benefits and reduce risks of chemsex among gay, bisexual, and other men who have sex with men: A meta-ethnography. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104398. [PMID: 38555721 DOI: 10.1016/j.drugpo.2024.104398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Chemsex is the intentional combining of specific drugs with sex, primarily by gay, bisexual, and other men who have sex with men (GBMSM), to enhance intimacy, pleasure, and prolong sexual sessions. Practices vary across geographic and social settings. Participants report benefits and risks of chemsex. Studies have previously reviewed chemsex practices and harm reduction interventions separately. This review aims to examine both together by describing and understanding practices that men employ to navigate the perceived benefits and risks of chemsex. METHODS We conducted a systematic meta-ethnographic review of published qualitative literature, screening titles, abstracts, and full texts on defined inclusion and exclusion criteria. Using reciprocal and refutational translation techniques, we analysed study participants' (first-order) and researchers' (second-order) accounts of benefit-enhancing and risk-reducing chemsex practices. Finally, we employed line-of-argument synthesis techniques to develop our own higher-level interpretations (third-order constructs) of these chemsex practices. RESULTS Our search yielded 6356 records, from which, we included 23 articles in our review. Most studies were conducted in high-income Western countries. Across studies, participants acted at the individual, interpersonal, and community levels to enhance benefits and reduce risks, which made up our third-order constructs. Eight themes emerged from first- and second-order constructs to describe these practices, which included personal preparation, personal boundaries, biomedical measures, structured use of drugs, leaning on partners, injecting practices, group organising, watching out for others, and teaching and learning. Contextual factors like trust, agency, access, stigma, and setting moderated whether and how participants engaged in these practices, and if practices enhanced benefits or reduced risks. CONCLUSION Health promotion programmes and research focused on chemsex must account for the benefits and the risks that GBMSM associate with this type of sexualised drug use and target the moderating factors that shape the practices they employ to navigate these benefits and risks.
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Affiliation(s)
- Drew E Hawkinson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - T Charles Witzel
- Institute for Global Health, University College London, Gower Street, London, WC1E 6BT, United Kingdom; Center of Excellence in Research on Gender, Sexuality and Health, Mahidol University, 999 Phutthamonthon Sai 4 Rd, Nakhon Pathom, Thailand
| | - Mitzy Gafos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
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Nyman F. Reshaping the narrative: Tracing the historical trajectory of HIV/AIDS, gay men, and public health in Sweden. PLoS One 2024; 19:e0298630. [PMID: 38386666 PMCID: PMC10883528 DOI: 10.1371/journal.pone.0298630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
The human immunodeficiency virus (HIV) emerged as an endemic health crisis in the United States during the early 1980s. Initially labelled a "gay disease" due to its prevalence among gay men, the spread of HIV led to widespread fear and moral panic, as there was limited medical knowledge on preventing its transmission. While HIV is often associated with Sub-Saharan Africa, this article focuses on Sweden, a pioneering nation that became the first to achieve the remarkable Joint UNAIDS/WHO 90-90-90 continuum in addressing the epidemic. However, despite this significant milestone, the punitive legislation and attitudes prevalent in Sweden have had a counterproductive effect on curbing the virus's spread. Drawing upon a comprehensive triangulation of various data and sources on the evolution of public policy in Sweden, this article argues for the urgent need to reduce stigma surrounding HIV and AIDS. By undertaking further measures to combat stigmatisation, we not only have the potential to prevent the spread of HIV but also significantly enhance the quality of life for individuals living with the virus. An essential step in this journey is to eliminate the legally-enforced mandatory disclosure of one's HIV status, which would mark a tremendous victory for all those affected. With limited evidence to support the effectiveness of criminalisation and penal laws, no longer being viewed as criminals for non-disclosure would be a monumental achievement, positively transforming the lives of people living with HIV and fostering a more inclusive and supportive society.
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Affiliation(s)
- Fredrik Nyman
- Department of Psychology and Social Work, Mid Sweden University, Östersund, Jämtland, Sweden
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Nyman F, Jellesma FC. Prevention of HIV in the MSM Population: A Cultural-Historical Comparison of Sweden and the Netherlands. JOURNAL OF HOMOSEXUALITY 2024; 71:28-55. [PMID: 35895000 DOI: 10.1080/00918369.2022.2103870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The aim of this article is to compare the cultural-historical events and decisions regarding how to deal with the higher risks of HIV in MSM, and more specifically, gay populations in Sweden and the Netherlands. A narrative literature was used, based on 46 scientific articles and 20 additional semi-scientific resources. The themes of the arrival of HIV and AIDS, blood donations, offender/victim, the balance of risks with respect to the statistical probabilities and the human factor, and finally, prevention were discussed. It is concluded that certain context-specific historical events (the Dutch Bloody Sunday and the Swedish gay sauna ban) and culturally determined processes (trust in others in the Netherlands, and disapproval of casual sex in Sweden) have led to some important differences in how HIV and AIDS and the higher risks for gay men and MSM have been dealt with. In the Netherlands, there is a stronger protective attitude when it comes to the freedom and autonomy of MSM both when it comes to decisions about sexual behavior and to sharing any positive HIV status. In Sweden, on the other hand, there is a stronger tendency to enforce informing others of their HIV status. In both countries, despite efforts to prevent this, HIV has increased stigma for gay men and other MSM.
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Affiliation(s)
- Fredrik Nyman
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
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Marques Oliveira P, Sousa Reis C, Vieira-Coelho MA. Getting Inside the Mind of Gay and Bisexual Men Who Have Sex with Men with Sexualized Drug Use - A Systematic Review. INTERNATIONAL JOURNAL OF SEXUAL HEALTH : OFFICIAL JOURNAL OF THE WORLD ASSOCIATION FOR SEXUAL HEALTH 2023; 35:573-595. [PMID: 38601804 PMCID: PMC10903597 DOI: 10.1080/19317611.2023.2260372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/13/2023] [Indexed: 04/12/2024]
Abstract
Objectives Sexualized Drug Use (SDU) consists of using any drug purposely before or during sex with the intent of modifying sex experiences. SDU is especially practiced among Gay and Bisexual Men who have Sex with Men (GBMSM). This study aims to review the relevant literature to identify and summarize the reasons reported by GBMSM to engage in SDU. Methods A systematic review of the literature using PubMed/Medline, Scopus, Google Scholar, and PsycINFO, comprising qualitative and quantitative papers published between 2010 and 2022, was conducted with a narrative synthesis of the findings. PRISMA guidelines were followed. Results Our search identified 1400 publications, of which 23 were included. Reasons to engage in SDU were aggregated as follows: (1) Enhancing sexual sensations and performance, (2) Achieving hedonic mental and emotional states, (3) Tackling negative thoughts and feelings, and (4) Social motivations. Different sample methods and ways of asking for motivations may limit the internal validity of these conclusions. Conclusion Both individual and social factors are involved in the decision to engage in SDU. SDU practices should not be medicalized, however therapeutic support if needed should provide multidisciplinary, pleasure-centered, harm-reducing care interventions, specifically designed for these minorities of GBMSM.
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Affiliation(s)
- Pedro Marques Oliveira
- Department of Biomedicine, Pharmacology and Therapeutics Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Cláudia Sousa Reis
- Department of Psychiatry and Mental Health, University Hospital Centre of São João, Porto, Portugal
| | - Maria Augusta Vieira-Coelho
- Department of Biomedicine, Pharmacology and Therapeutics Unit, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Psychiatry and Mental Health, University Hospital Centre of São João, Porto, Portugal
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Hage K, van de Kerkhof M, Boyd A, Carson JM, Newsum AM, Matser A, van der Valk M, Brinkman K, Arends JE, Lauw FN, Rijnders BJA, van Eeden A, Martinello M, Matthews GV, Schinkel J, Prins M. Screening for Hepatitis C Virus Reinfection Using a Behaviour-Based Risk Score among Men Who Have Sex with Men with HIV: Results from a Case-Control Diagnostic Validation Study. Pathogens 2023; 12:1248. [PMID: 37887764 PMCID: PMC10610046 DOI: 10.3390/pathogens12101248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
We assessed the predictive capacity of the HCV-MOSAIC risk score, originally developed for primary early HCV infection, as a screening tool for HCV reinfection in 103 men who have sex with men (MSM) with HIV using data from the MOSAIC cohort, including MSM with HIV/HCV-coinfection who became reinfected (cases, n = 27) or not (controls, n = 76) during follow-up. The overall predictive capacity of the score was assessed using the area under the receiver operating characteristic (AUROC) curve. The effects of covariates on the receiver operating characteristic (ROC) curve were assessed using parametric ROC regression. The score cut-off validated for primary early infection (≥2.0) was used, from which the sensitivity and specificity were calculated. The AUROC was 0.74 (95% confidence interval (CI) = 0.63-0.84). Group sex significantly increased the predictive capacity. Using the validated cut-off, sensitivity was 70.4% (95%CI = 49.8-86.2%) and specificity was 59.2% (95%CI: 47.3-70.4%). External validation from a cohort of 25 cases and 111 controls, all MSM with HIV, resulted in a sensitivity of 44.0% (95%CI = 24.4-65.1) and specificity of 71.2% (95%CI = 61.8-79.4). The HCV-MOSAIC risk score may be useful for identifying individuals at risk of HCV reinfection. In sexual health or HIV-care settings, this score could help guide HCV-RNA testing in MSM with a prior HCV infection.
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Affiliation(s)
- Kris Hage
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
- Infectious Diseases, Amsterdam UMC Location, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Infectious Diseases, Amsterdam Institute for Infection and Immunity, 1105 AZ Amsterdam, The Netherlands
| | - Marita van de Kerkhof
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
- Stichting SBOH, 3528 BB Utrecht, The Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
- Stichting HIV Monitoring (SHM), 1105 BD Amsterdam, The Netherlands
| | - Joanne M. Carson
- The Kirby Institute, University of New South Wales, Sydney 2052, Australia
| | - Astrid M. Newsum
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
- Infectious Diseases, Amsterdam Institute for Infection and Immunity, 1105 AZ Amsterdam, The Netherlands
| | - Amy Matser
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
- Infectious Diseases, Amsterdam Institute for Infection and Immunity, 1105 AZ Amsterdam, The Netherlands
| | - Marc van der Valk
- Infectious Diseases, Amsterdam Institute for Infection and Immunity, 1105 AZ Amsterdam, The Netherlands
- Stichting HIV Monitoring (SHM), 1105 BD Amsterdam, The Netherlands
| | - Kees Brinkman
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis (OLVG), 1091 AC Amsterdam, The Netherlands
| | - Joop E. Arends
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht (UMCU), 3584 CX Utrecht, The Netherlands
- Department of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Fanny N. Lauw
- Department of Internal Medicine, Medical Centre Jan van Goyen, 1075 HN Amsterdam, The Netherlands
| | - Bart J. A. Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Arne van Eeden
- Department of Internal Medicine, DC Klinieken Oud Zuid, 1075 BG Amsterdam, The Netherlands
| | | | - Gail V. Matthews
- The Kirby Institute, University of New South Wales, Sydney 2052, Australia
| | - Janke Schinkel
- Medical Microbiology and Infection Prevention, Amsterdam UMC Location, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
- Infectious Diseases, Amsterdam Institute for Infection and Immunity, 1105 AZ Amsterdam, The Netherlands
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Vanbaelen T, Rotsaert A, Van Landeghem E, Nöstlinger C, Vuylsteke B, Platteau T, Herrijgers C, Reyniers T. Do pre-exposure prophylaxis (PrEP) users engaging in chemsex experience their participation as problematic and how can they best be supported? Findings from an online survey in Belgium. Sex Health 2023; 20:424-430. [PMID: 37487323 DOI: 10.1071/sh23037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Chemsex involves the use of psychoactive drugs in a sexual context and is a growing phenomenon among men who have sex with men (MSM) and pre-exposure prophylaxis (PrEP) users. Investigating how its negative consequences can be avoided is important. The objective of this study was to explore the perceived impact of chemsex, the willingness to reduce chemsex activities and associated risks and preferred interventions to do so among PrEP users. METHODS We analysed data from an online survey among PrEP users in Belgium. Chemsex was assessed in two questionnaires distributed between September 2020 and January 2022. RESULTS A total of 326 participants completed the baseline questionnaire, and 186 the follow-up questionnaire. About one in three participants (36.5%, 119/326) reported engaging in chemsex, and half of those (49.6%, 59/119) were willing to reduce chemsex-related risks. The most preferred strategies for reducing risks were online support via an app (37.3%, 22/59) and face-to-face counselling with a health care professional (30.5%, 18/59). Among those reporting recent chemsex in the follow-up questionnaire, about one in five (21.9%, 14/64) wanted to reduce or stop chemsex activities. About 23.4% (15/64) also reported experiencing negative consequences of chemsex on their health, social or professional life. CONCLUSION Our findings show that one in four PrEP users engaging in chemsex experienced negative consequences of these activities and about one in five was willing to reduce or stop chemsex activities. We recommend embedding comprehensive chemsex support in the PrEP package of care and developing novel tools and interventions in order to reach maximum impact.
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Affiliation(s)
- T Vanbaelen
- Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium; and Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - A Rotsaert
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - E Van Landeghem
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - C Nöstlinger
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - B Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - T Platteau
- Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - C Herrijgers
- Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
| | - T Reyniers
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium
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Vock F, Johnson-Ferguson L, Bechtiger L, Stulz N, von Felten J, Eisner M, Hepp U, Ribeaud D, Shanahan L, Quednow BB. Substance use in sexual minority youth: prevalence in an urban cohort. Child Adolesc Psychiatry Ment Health 2023; 17:109. [PMID: 37716977 PMCID: PMC10505308 DOI: 10.1186/s13034-023-00657-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/08/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Little comparative data on substance use (SU) between sexual minority youth (SMY) and heterosexual youth (HET) is available. This study compares the prevalence of SU in an urban cohort between SMY and HET and evaluates demographic and psychosocial predictors of SU. METHODS Data came from a prospective-longitudinal cohort study in an urban setting (N = 1297). SU and psychosocial variables such as internalizing symptoms, self-control, sensation-seeking, bullying-victimization, subjective stress, leisure activities, and peer influences were assessed with self-reports at age 17 and 20. SU was stratified by sex and sexual attraction, and the groups were compared using regression models, with demographic and psychosocial variables included as covariates. RESULTS SMY- and HET-youth displayed differences in a number of psychosocial variables. Overall, SMY- and HET-youth differed in their 12-months prevalence of SU: At age 17, SMY-females had significantly higher rates of SU than HET-females for cannabis (aOR = 2.14, p = 0.04), ecstasy/MDMA (aOR = 4.29, p = 0.01), and hallucinogens (aOR = 5.59, p = 0.02). At age 20, SMY-females had significantly higher rates of SU than HET-females for tobacco (aOR = 2.06, p = 0.03), cannabis (aOR = 2.24, p = 0.004), ecstasy/MDMA (aOR = 3.93, p < 0.001), stimulants (aOR = 3.45, p = 0.002), and hallucinogens (aOR = 6.65, p < 0.001). SMY-males reported significantly lower rates for tobacco and cannabis than HET-males at age 17. At age 20, they reported significantly higher rates for the use of ecstasy/MDMA (aOR = 2.30, p = 0.04) and hallucinogens (aOR = 2.43, p = 0.03). CONCLUSIONS Given that psychosocial variables were significant covariates of SMY-status and SU, our results underline the importance of accounting for these when explaining differences in SU between adolescents. While differentiation by sex is established in most studies, such standardized comparisons are lacking with regards to sexual identities. But knowledge about SU of SMY is critical for designing effective interventions. This is especially true for SMY-females: Thus, SU in SMY-females early in life needs to be explored more thoroughly and addressed with adequate prevention measures.
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Affiliation(s)
| | - Lydia Johnson-Ferguson
- Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
- Department of Psychology, Clinical and Developmental Psychology, University of Zurich, Zurich, Switzerland
- Experimental and Clinical Pharmacopsychology, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Laura Bechtiger
- Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
- Department of Psychology, Clinical and Developmental Psychology, University of Zurich, Zurich, Switzerland
| | - Niklaus Stulz
- Integrated Psychiatric Services Psychiatry Winterthur - Zürcher Unterland, Winterthur, Switzerland
| | - Joh von Felten
- Milchjugend, LGBTQ+ Youth Organization, Zurich, Switzerland
| | - Manuel Eisner
- Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
- Institute of Criminology, University of Cambridge, Cambridge, UK
| | - Urs Hepp
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Denis Ribeaud
- Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
| | - Lilly Shanahan
- Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
- Department of Psychology, Clinical and Developmental Psychology, University of Zurich, Zurich, Switzerland
| | - Boris B Quednow
- Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
- Experimental and Clinical Pharmacopsychology, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
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Gautam K, Paudel K, Jacobs J, Wickersham JA, Ikhtiaruddin WM, Azwa I, Saifi R, Lim SH, Shrestha R. An mHealth-Delivered Sexual Harm Reduction Tool (PartyPack) for Men Who Have Sex With Men in Malaysia: Usability Study. JMIR Form Res 2023; 7:e48113. [PMID: 37616034 PMCID: PMC10485720 DOI: 10.2196/48113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/27/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Chemsex-the use of psychoactive drugs to enhance the sexual experience-is an increasing phenomenon globally. Despite the increasing burden and associated harms of chemsex, evidence-based interventions (ie, behavioral and pharmacological) for chemsex users are nonexistent. OBJECTIVE In this study, we assessed the usability and acceptability of a mobile health (mHealth)-delivered safer chemsex package ("PartyPack") as a sexual harm reduction strategy among men who have sex with men in Malaysia-a setting where chemsex is becoming increasingly prevalent. METHODS This study is part of a larger smartphone app-based intervention (ie, JomPrEP; University of Connecticut) designed to improve access to HIV prevention services among Malaysian men who have sex with men. A total of 50 participants were recruited from the Greater Kuala Lumpur region of Malaysia to use the JomPrEP app, which included a feature allowing participants to order PartyPack, for 30 days (March-April 2022). The usability and acceptability of the PartyPack were assessed using self-report, app analytics, and exit interviews (n=20). RESULTS Overall, 8% (4/50) of participants reported having engaged in chemsex in the past 6 months; however, engagement in condomless sex (34/50, 68%) and group sex (9/50, 18%) was much higher. A total of 43 (86%) participants ordered PartyPack, of which 27 (63%) made multiple orders during the 30 days. Most participants (41/43, 95%) reported being satisfied with the PartyPack order feature in the app, with 91% (39/43) indicating the order and tracking process was easy. Thematic data exploration further revealed important information for understanding (eg, items included in the package, use of mHealth platform to order package, and discreetness of the PartyPack box and order and delivery) and refining the logistical preferences (eg, using branded items and allowing customization during order). CONCLUSIONS Our findings provide strong evidence of the usability and acceptability of a mHealth-delivered safer chemsex package as a potential sexual harm reduction tool among this underserved population. Replication in a study with a larger sample size to test the efficacy of the PartyPack is warranted.
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Affiliation(s)
- Kamal Gautam
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Kiran Paudel
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Jerome Jacobs
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Jeffrey A Wickersham
- AIDS Program, Yale School of Medicine, New Haven, CT, United States
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wan Mohd Ikhtiaruddin
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Iskandar Azwa
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Rumana Saifi
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sin How Lim
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Roman Shrestha
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
- AIDS Program, Yale School of Medicine, New Haven, CT, United States
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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11
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Card KG, Shen T, Barath J, Sang J, Lal A, Moore DM, Lachowsky NJ. Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver. AIDS Behav 2023:10.1007/s10461-023-04036-w. [PMID: 36943600 DOI: 10.1007/s10461-023-04036-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/23/2023]
Abstract
This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.
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Affiliation(s)
- Kiffer G Card
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.
| | - Tian Shen
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Justin Barath
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Jordan Sang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Allan Lal
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - David M Moore
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Nathan J Lachowsky
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
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12
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Íncera-Fernández D, Román FJ, Moreno-Guillén S, Gámez-Guadix M. Understanding Sexualized Drug Use: Substances, Reasons, Consequences, and Self-Perceptions among Men Who Have Sex with Other Men in Spain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2751. [PMID: 36768116 PMCID: PMC9916109 DOI: 10.3390/ijerph20032751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/28/2023] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
Sexualized drug use (SDU) has been identified as a health risk factor among gay, bisexual, and other men who have sex with men (GBMSM). This study aimed to analyze the associations between SDU frequency and a broad set of substances, motives, consequences, and self-perceptions. Sampling was conducted through an online survey. The final sample consisted of 185 GBMSM aged between 18 and 78 years old (mean age = 38.38, SD = 11.52) who engaged in SDU. We analyzed the frequency of SDU in terms of practicing it "once," "moderately" ("once a month or less" or "a few times a month"), or "frequently" (from "once a week" to "daily") during the previous 18 months. A questionnaire was administered through which sociodemographic variables, substances, reasons, consequences, and self-perceptions of SDU practice were analyzed. Participants who did so frequently were significantly more likely to use mephedrone, methamphetamine, and GHB/GBL than those who performed SDU less often (large effect sizes). In addition, habitual SDU was associated with motivations to achieve pleasurable emotions and sensations and manage negative feelings. Health implications, such as blackout moments, were also significantly related to frequent SDUs. Finally, those who practiced frequent SDU perceived it as a severe problem and wanted to control it. These data indicate the importance of raising awareness of chemsex as a public health problem among GBMSM. Specific identification, education, and prevention programs need to be strengthened to reduce the incidence of the most undesirable implications of SDU among GBMSM.
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Affiliation(s)
- Daniel Íncera-Fernández
- Department of Biological and Health Psychology, Autonomous University of Madrid, 28049 Madrid, Spain
| | - Francisco J. Román
- Department of Biological and Health Psychology, Autonomous University of Madrid, 28049 Madrid, Spain
| | - Santiago Moreno-Guillén
- Department of Medicine and Medical Specialties, University of Alcalá de Henares, 28801 Alcalá de Henares, Spain
| | - Manuel Gámez-Guadix
- Department of Biological and Health Psychology, Autonomous University of Madrid, 28049 Madrid, Spain
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13
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Kinnman E, Herder T, Björkman P, Månsson F, Agardh A. HIV self-testing for men who have sex with men in Sweden. A cross-sectional study concerning interest to use HIV self-tests. Glob Health Action 2022; 15:2021631. [PMID: 35289717 PMCID: PMC8928837 DOI: 10.1080/16549716.2021.2021631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background HIV self-testing (HIVST) has been found to have high acceptability among men who have sex with men (MSM) internationally and might contribute to increase testing frequencies, but many countries, including Sweden, lack policies for using HIVST. Objective To examine interest to use and willingness to pay for HIVST, and associated factors, among MSM attending HIV testing venues in Sweden. Method This cross-sectional study analyzed data from a self-administered survey, consisting of 33 questions, collected at six HIV testing venues in Sweden in 2018. The sample consisted of sexually active men who have sex with men, aged ≥ 18 years, and not diagnosed with HIV. Data were analyzed descriptively and by univariable and multivariable logistic regression. Result Among 663 participants (median age 33 years), 436 respondents (65.8%) expressed interest to use HIVST. Among those interested, less than half, 205 (47.0%), were willing to pay for HIVST. Being interested in HIVST was found to be negatively associated with being in the 55 years or older age group (AOR 0.31, CI 0.14–0.71), and having had syphilis, rectal chlamydia, or rectal gonorrhea in the preceding 12 months (AOR 0.56, CI 0.32–0.99). In the sample of MSM interested in HIVST, willingness to pay was positively associated with being in the age groups 35–44 years (AOR 2.94, CI 1.40–6.21), 45–54 years (AOR 2.82, CI 1.16–6.90), and 55 years or above (AOR 3.90, CI 1.19–12.81), and negatively associated with being single (AOR 0.56, CI 0.36–0.88). Conclusion This study found high interest for HIVST in a sample of MSM in Sweden. However, HIVST offered at a cost is likely to negatively affect uptake among MSM broadly, compared with free availability.
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Affiliation(s)
- Elin Kinnman
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Tobias Herder
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Per Björkman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Fredrik Månsson
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Anette Agardh
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Herrijgers C, Platteau T, Vandebosch H, Poels K, Florence E. Using Intervention Mapping to Develop an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Development and Usability Study. JMIR Res Protoc 2022; 11:e39678. [PMID: 36542451 DOI: 10.2196/39678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/25/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chemsex refers to the intentional use of drugs before or during sex among men who have sex with men (MSM). Engaging in chemsex has been linked to significant negative impacts on physical, psychological, and social well-being. However, no evidence-based support tools have addressed either these harms or the care needs of MSM who engage in chemsex. OBJECTIVE The purpose of this paper was to describe the development of a mobile health intervention (named Budd) using the intervention mapping protocol (IMP). Budd aims to support and inform MSM who participate in chemsex, reduce the negative impacts associated with chemsex, and encourage more reasoned participation. METHODS The IMP consists of 6 steps to develop, implement, and evaluate evidence-based health interventions. A needs assessment was carried out between September 2, 2019, and March 31, 2020, by conducting a literature study and in-depth interviews. Change objectives were selected based on these findings, after which theory-based intervention methods were selected. The first version of the intervention was developed in December 2020 and pilot-tested between February 1, 2021, and April 30, 2021. Adjustments were made based on the findings from this study. A separate article will be dedicated to the effectiveness study, conducted between October 15, 2021, and February 24, 2022, and implementation of the intervention. The Budd app went live in April 2022. RESULTS Budd aims to address individual factors and support chemsex participants in applying harm reduction measures when taking drugs (drug information, drug combination tool, and notebook), preparing for participation in a chemsex session (articles on chemsex, preparation tool, and event-specific checklist), planning sufficient time after a chemsex session to recover (planning tool), seeking support for their chemsex participation (overview of existing local health care and peer support services, reflection, personal statistics, and user testimonials), taking HIV medication or pre-exposure prophylaxis in a timely manner during a chemsex session (preparation tool), and contacting emergency services in case of an emergency and giving first aid to others (emergency information and personal buddy). CONCLUSIONS The IMP proved to be a valuable tool in the planning and development of the Budd app. This study provides researchers and practitioners with valuable information that may help them to set up their own health interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/39678.
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Affiliation(s)
- Corinne Herrijgers
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Tom Platteau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Heidi Vandebosch
- Department of Communication Studies, University of Antwerp, Antwerpen, Belgium
| | - Karolien Poels
- Department of Communication Studies, University of Antwerp, Antwerpen, Belgium
| | - Eric Florence
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
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15
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Ivsins A, Fleming T, Barker A, Mansoor M, Thakarar K, Sue K, McNeil R. The practice and embodiment of "goofballs": A qualitative study exploring the co-injection of methamphetamines and opioids. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 107:103791. [PMID: 35830749 PMCID: PMC10894463 DOI: 10.1016/j.drugpo.2022.103791] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/03/2022] [Accepted: 07/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Polysubstance use is common among people who use drugs, including the co-use of stimulants and opioids. Research suggests the practice of simultaneous co-injection of methamphetamines and opioids, often referred to as "goofballs", is increasing. As a relatively unique drug use practice, little qualitative research currently exists on goofball injecting. This study explores the practice and embodied experiences of goofball injecting. METHODS This article draws on in-depth interviews conducted across two qualitative studies undertaken in Vancouver, Canada's Downtown Eastside neighbourhood examining changing dynamics in relation to stimulant use and experiences with an overdose prevention site-based safer supply intervention, respectively. Interviews containing discussions of goofball use (n=29) were extracted from each study and merged into a single qualitative dataset. Data were analysed thematically and focused on the practices and embodied experiences of goofball injection. RESULTS Our analysis uncovered how goofball injection represented a complex drug use practice driven by the desire to achieve particular embodied experiences not attainable by using either drug individually. We identified three distinct practices of goofball use: 1) to alter or enhance the effects of opioids; 2) to alter or enhance the effects of methamphetamines; and 3) to balance out the effects of both drugs. CONCLUSION Our study fills an important gap in the polysubstance use literature specifically exploring the co-injection of methamphetamines and opioids. Our findings highlight the need to implement and expand interventions and services attentive to polysubstance use and the role of pleasure in drug taking practices, including expanding non-medicalized opioid and stimulant safer supply initiatives across North America.
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Affiliation(s)
- Andrew Ivsins
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Taylor Fleming
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Allison Barker
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Manal Mansoor
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Kinna Thakarar
- Maine Medical Center/Tufts University School of Medicine. 41 Donald B Dean Drive, South Portland ME 04106, United States
| | - Kimberly Sue
- School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
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