From opiates to methamphetamine: building new harm reduction responses in Jakarta, Indonesia

Barriers to enrolling in voluntary treatment programs in Malaysia: a study of women who use methamphetamine (WWUM)

Women with substance use disorders (SUDs) have been widely reported to face barriers in seeking treatment. We sought to identify barriers that prevented women who use methamphetamine (WWUM) from accessing the decade-old Voluntary Treatment Centers (VTCs) in Malaysia. A total of 153 WWUM who were undergoing rehabilitation for methamphetamine use at a compulsory drug detention center (CDDC) were recruited for this cross-sectional study. Data were collected by canvasing a structured questionnaire through face-to-face meetings. Of the total sample, 131 (86%) were Malays, with a mean age of 32.1 years. The commonly cited treatment barriers were the belief that methamphetamine use was not problematic (42%), not knowing how to seek treatment (38%), feeling embarrassed to seek treatment (33%), the lack of family support (24%), and the long waiting time for enrollment (23%). Logistic analyses indicated that a longer duration of use increased the odds of not acknowledging methamphetamine use as a problem while older participants had lower odds of holding a similar view. A longer duration of use also increased the odds of claiming treatment was not needed but lowered the odds of asserting a lack of confidence in treatment. Furthermore, Malays had higher odds of lacking family support in seeking treatment while being employed lowered the odds of not wanting treatment. Addressing these concerns will hopefully encourage higher participation of WWUM in voluntary treatment programs.

The utilization and delivery of safer smoking practices and services: a narrative synthesis of the literature

BACKGROUND

Providing sterile drug smoking materials to people who use drugs can prevent the acquisition of infectious diseases and reduce overdose risk. However, there is a lack of understanding of how these practices are being implemented and received by people who use drugs globally.

METHODS

A systematic review of safer smoking practices was conducted by searching PubMed, PsycInfo, Embase for relevant peer-reviewed, English-language publications from inception or the availability of online manuscripts through December 2022.

RESULTS

Overall, 32 peer-reviewed papers from six countries were included. 30 studies exclusively included people who use drugs as participants (n = 11 people who use drugs; generally, n = 17 people who smoke drugs, n = 2 people who inject drugs). One study included program staff serving people who use drugs, and one study included staff and people who use drugs. Sharing smoking equipment (e.g., pipes) was reported in 25 studies. People who use drugs in several studies reported that pipe sharing occurred for multiple reasons, including wanting to accumulate crack resin and protect themselves from social harms, such as police harassment. Across studies, smoking drugs, as opposed to injecting drugs, were described as a crucial method to reduce the risk of overdose, disease acquisition, and societal harms such as police violence. Ten studies found that when people who use drugs were provided with safer smoking materials, they engaged in fewer risky drug use behaviors (e.g., pipe sharing, using broken pipes) and showed improved health outcomes. However, participants across 11 studies reported barriers to accessing safer smoking services. Solutions to overcoming safer smoking access barriers were described in 17 studies and included utilizing peer workers and providing safer smoking materials to those who asked.

CONCLUSION

This global review found that safer smoking practices are essential forms of harm reduction. International policies must be amended to help increase access to these essential tools. Additional research is also needed to evaluate the efficacy of and access to safer smoking services, particularly in the U.S. and other similar countries, where such practices are being implemented but have not been empirically studied in the literature.

People with lived and living experience of methamphetamine use and admission to hospital: what harm reduction do they suggest needs to be addressed?

INTRODUCTION

People who use substances may access hospital services for treatment of infections and injuries, substance use disorder, mental health issues and other reasons. Our aim was to identify the experiences, issues and recommendations of people who use methamphetamine and have accessed hospital services.

METHODS

Of the 114 people with lived and living experience of methamphetamine use recruited for a mixed-methods study conducted in southwestern Ontario, Canada, 104 completed the qualitative component. Interviews were conducted from October 2020 to April 2021. Participants were asked open-ended questions and the responses were analyzed using an ethnographic thematic approach.

RESULTS

Negative patient-staff interactions included stigma and a lack of understanding of addiction and methamphetamine use, leading to distrust, avoidance of hospital care and reduced help-seeking and health care engagement. The consequences can be infections, unsafe needle use, discharge against medical advice and withdrawal. Almost all participants were in favour of in-hospital harm reduction strategies including safe consumption services, provision of sterile equipment and sharps containers, and withdrawal support. Clinical implications include education to reduce knowledge gaps about methamphetamine use and addiction and address stigma, which could facilitate the introduction of harm reduction strategies.

CONCLUSION

Although the strategies identified by participants could promote a safer care environment, improving therapeutic relationships through education of health care providers and hospital staff is an essential first step. The addition of in-hospital harm reduction strategies requires attention as the approach remains uncommon in hospitals in Canada.

High levels of interest in access to free safer smoking equipment to reduce injection frequency among people who inject drugs in Seattle, Washington

Background

Drug use route transition interventions promote safer consumption by facilitating a switch from injection to safer routes such as smoking or oral consumption.

Methods

We performed a descriptive analysis using data from questions about "free, clean equipment for smoking" heroin, methamphetamine and/or crack from the Seattle 2018 National HIV Behavioral Surveillance survey of people who inject drugs (N = 555). We estimated the proportion of respondents with access to free safer smoking equipment, and among these participants, the proportion who reported that this access reduced their injection frequency. Among respondents without access to free safer smoking equipment, we described the proportion who were interested in getting access, and whether they thought this access would reduce their injection frequency.

Results

Among participants who reported prior year heroin (n = 495), methamphetamine (n = 372), or crack (n = 88) injection, 11%, 11% and 12% reported access to free safer smoking equipment, respectively. Of those with access, the proportion that reported that access reduced their injection frequency ranged from 12% to 44%. Among participants without access, 28% who used heroin, 45% who used methamphetamine, and 49% who used crack were interested in access. Of interested participants, a majority reported that they thought this access would reduce their frequency of injection.

Conclusions

Access to free safer smoking equipment was limited. Many participants were interested in getting free safer smoking equipment and reported that this access may reduce their injection frequency. Safer smoking equipment is a harm reduction strategy that should be available to reduce risks from opioid and stimulant injection.

Different phases of ATS use call for different interventions: a large qualitative study in Europe

BACKGROUND

Amphetamine-type stimulants (ATS) are globally widely used. Scientific literature generally defines four phases of substance use (initiation, continuation, increase and decrease); however, there is limited understanding of what influences these different phases of ATS use. The ATTUNE study investigated which factors shape individual phases of use, or ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use.

METHODS

Qualitative, semi-structured interviews (n = 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily.

RESULTS

Amphetamine and MDMA were the most commonly used ATS. Yet, types of ATS used differed between the countries. We found that people who use ATS have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation, decrease and sometimes dependence. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of ATS, phase or country.

CONCLUSIONS

These findings demonstrate that tailor-made interventions are needed for the diverse types of people who use ATS and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.

Decolonizing harm reduction

In this essay, I show that notwithstanding the undeniable colonial origins of punitive drug policies around the world, such policies have figured in nationalist projects and populist platforms in various postcolonial states, and today they are viewed as local responses to the 'drug problem.' Instead, it is harm reduction and other efforts to reform drug policies that are seen as a colonial, or Western, imposition. I argue that to overcome such perceptions, there is a need to decolonize harm reduction alongside decolonizing drug policies. I conclude by offering recommendations toward this move, including involving Global South actors in leadership positions within the harm reduction movement, supporting pilot harm reduction programs in postcolonial states, and highlighting local scholarship.

Treatment Barriers Associated with Amphetamine-Type Stimulant (ATS) Use in Malaysia

People who use amphetamine-type stimulant (ATS) are known to face barriers in seeking treatment. We sought to identify these barriers and gender differences in barriers (if any) faced by them. A convenience sample of 386 respondents who use ATS was recruited from five formal drug rehabilitation centers for this cross-sectional study. The majority were male (83%), with 17% being female. The barriers most frequently cited by both men and women were: the perception that ATS use needed no treatment, fears of community discrimination, peer influence, and long waiting time to get into a treatment programme. One-third of the sample held that the mandated treatment programmes were ineffective, based on past experience. In terms of male-female differences, long waiting time discouraged significantly more women than men, whereas more men than women asserted that formal treatment programmes were ineffective. We also found no significant differences in barriers faced by ATS users and those using ATS with other illicit substances. Outreach initiatives to minimize the impact of treatment barriers, coupled with offering separate treatment protocols and facilities, will encourage people who use ATS to seek treatment voluntarily.

"Shabu is different": Extrajudicial killings, death penalty, and 'methamphetamine exceptionalism' in the Philippines

BACKGROUND

This paper articulates and problematises the 'exceptionalism' in the way shabu (crystal methamphetamine) is framed in political and popular discourse in the Philippines, and how these framings have informed and enabled the drug regime in the country, creating a 'state of exception' and justifying the killing-whether extrajudicially or through the death penalty-of people associated with the particular drug.

METHODS

Two case studies are presented in this paper to demonstrate how political and civil society actors treat shabu, drawing on official statements, journalistic reportage, and published articles from various sources as empirical material, and using a problematisation framework to guide analysis.

DISCUSSION

'Methamphetamine exceptionalism' pervades public discourse in the Philippines, creating a social and political environment that is permissive for, if not outright supportive of, draconian measures particular toward people associated with shabu. Such views are rooted in the perception that shabu is especially dangerous as opposed to other drugs, thereby posing an exceptional threat to the body politic.

CONCLUSION

This paper underscores the importance of nuance in constructing and interrogating the objects of drug policy, given that different drugs are treated differently. Policy and communication interventions must therefore specifically address the ways in which shabu has been framed to justify not only Duterte's deadly drug war, but other such wars throughout the region.