Prescription opioid injection among young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose

Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites

BACKGROUND

Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD.

METHODS

This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework.

RESULTS

The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]).

CONCLUSION

As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.

Infectious Diseases Among People Experiencing Homelessness: A Systematic Review of the Literature in the United States and Canada, 2003-2022

Homelessness increases the risk of acquiring an infectious disease. We conducted a systematic review of the literature to identify quantitative data related to infectious diseases and homelessness. We searched Google Scholar, PubMed, and SCOPUS for quantitative literature published from January 2003 through December 2022 in English from the United States and Canada. We excluded literature on vaccine-preventable diseases and HIV because these diseases were recently reviewed. Of the 250 articles that met inclusion criteria, more than half were on hepatitis C virus or Mycobacterium tuberculosis. Other articles were on COVID-19, respiratory syncytial virus, Staphylococcus aureus, group A Streptococcus, mpox (formerly monkeypox), 5 sexually transmitted infections, and gastrointestinal or vectorborne pathogens. Most studies showed higher prevalence, incidence, or measures of risk for infectious diseases among people experiencing homelessness as compared with people who are housed or the general population. Although having increased published data that quantify the infectious disease risks of homelessness is encouraging, many pathogens that are known to affect people globally who are not housed have not been evaluated in the United States or Canada. Future studies should focus on additional pathogens and factors leading to a disproportionately high incidence and prevalence of infectious diseases among people experiencing homelessness.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Behavioral Intervention for Nonmedical Use of Prescription Drugs Among Adolescents and Young Adults: A Narrative Review

The nonmedical use of prescription drugs (NMUPD) is a public health crisis. In 2020, more Americans died of drug overdose than in any prior year, and the nonmedical use of opioids and other prescription drugs contributed significantly to that total. Young adults and adolescents report the highest rates of NMUPD, relative to other age groups. This article provides a narrative review of interventions for young adults and adolescents to prevent NMUPD, including interventions directed at the individual, family or other small group, and community. The interventions reviewed included those that were delivered in person and via technology.

Hepatitis C virus risk among young people who inject drugs

Background

Injection drug use (IDU) is the leading risk factor for hepatitis C virus (HCV) transmission in the U.S. While the general risk factors for HCV transmission are known, there is limited work on how these factors interact and impact young people who inject drugs (YPWID).

Methods

Project data were drawn from a study of 539 New York City (NYC) residents ages 18-29 who were recruited via Respondent-Driven Sampling and, reported past-month non-medical use of prescription opioids and/or heroin. Analyses are based on a subsample of 337 (62%) who reported injecting any drug in the past 12 months. All variables were assessed via self-report, except HCV status, which was established via rapid antibody testing. Integrating the observed statistical associations with extant literature on HCV risk, we also developed a qualitative system dynamics (SD) model to use as a supplemental data visualization tool to explore plausible pathways and interactions among key risk and protective factors for HCV.

Results

Results showed a 31% HCV antibody prevalence with an overall incidence of 10 per 100 person-years. HCV status was independently correlated with having shared cookers with two or more people (AOR = 2.17); injected drugs 4–6 years (AOR = 2.49) and 7 or more years (AOR = 4.95); lifetime homelessness (AOR = 2.52); and having been incarcerated two or more times (AOR = 1.99). These outcomes along with the extant literature on HCV risk were used to develop the qualitative SD model, which describes a causal hypothesis around non-linearities and feedback loop structures underlying the spread of HCV among YPWID.

Conclusions

Despite ongoing harm reduction efforts, close to a third of YPWID in the community sample have been exposed to HCV, have risks for injection drug use, and face challenges with structural factors that may be preventing adequate intervention. The qualitative SD model explores these issues and contributes to a better understanding of how these various risk factors interact and what policies could potentially be effective in reducing HCV infections.

Trends and age-related disparities in opioid use disorder treatment admissions for adolescents and young adults

BACKGROUND

Treatment of opioid use disorder (OUD) in adolescents and young adults is imperative to reduce the risk of overdose and other opioid-related harms. Limited information has been published about national trends in health disparities including utilization, access to medication for opioid use disorder (MOUD), and treatment retention of adolescents and young adults with OUD.

METHODS

This secondary data analysis tested for trends and age-related disparities in national OUD treatment admissions, as well as length of stay (defined as continuous enrollment in some form of treatment at a program) and planned use of MOUD for adolescents (age 12-17) and young adults (age 18-24) using the Treatment Episode Data Set from 2008 to 2017. The study also used data from the National Survey on Drug Use and Health to identify population prevalence of OUD and presentation to OUD treatment in adolescents and young adults compared to older adults (age 25+).

RESULTS

OUD treatment admissions significantly decreased over the decade by 63% (z = 2.61, p < .01) for adolescents and 13% (z = 2.25, p < .01) for young adults. The rate of planned MOUD at intake increased from 1.1% to 3.0% for adolescents but did not achieve significance. MOUD was more commonly recommended in young adults across the time period (13.5 to 21.8%, z = 2.24, p < .01). Treatment length of stay did not change significantly for adolescents, but did increase for young adults from 2008 to 2017 in the 91+ (19.9-23.9%, z = 2.22, p < .01) and 181+ days (9.7-12.5%, z = 2.26, p < .01) categories. Relative to older adults, the percent of people with OUD presenting for OUD treatment is significantly lower for adolescents (44.6% vs. 3.6%, OR = 0.05, p < .05) and young adults (44.6% vs. 22.2%, OR = 0.36, p < .05). Among those who initiated treatment, lower rates occurred of planned MOUD for adolescents (93% vs. 2%, OR = 0.002, p < .05) and young adults (93% vs. 56%, OR = 0.10, p < .05).

CONCLUSIONS

A significant unmet need exists for OUD treatment and recommendation of MOUD in adolescents and young adults with OUD. These trends are concerning given increasing rates of opioid-related emergency room admissions and deaths during the same time period. Federal and state funders should examine adolescent and young adult's services separately from older adults (25+) to reduce age-related access disparities and ensure adequate MOUD treatment capacity.

Hepatitis C Virus Exposure and Infection in the Perinatal Period

BACKGROUND

Hepatitis C virus infection is a leading cause of blood-borne hepatitis disease worldwide. Hepatitis C is a silent liver disease that, without treatment, leads to late-onset complications, including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma, in 10-40% of patients.

OBJECTIVE

This study aimed to review the epidemiology, clinical features, diagnosis, treatment, and prevention of hepatitis C among perinatally exposed children.

METHODS

Public databases, including MEDLINE and PubMed, and websites from the Centers for Disease Control and Prevention, the Food and Drug Administration, the World Health Organization, and the National Institutes of Health were searched for relevant articles published between 2006 and 2021.

RESULTS

The prevalence of hepatitis C has increased among women of childbearing age in the United States and is associated with risk factors, such as intravenous drug use, health inequities, and low socioeconomic background. Infants born to hepatitis C virus-infected mothers have a 6% risk of vertical transmission, and among those infected, 75% will develop chronic hepatitis C and late complications. However, hepatitis C-exposed infants are frequently lost to follow-up, and those infected have delayed diagnosis and treatment and are at high risk for late-onset complications. Direct- acting antivirals and the establishment of effective treatment guidelines cure hepatitis C virus infections.

CONCLUSION

Hepatitis C predominantly affects underserved communities. Early screening of mothers and infants is critical for the diagnosis, treatment, and prevention of chronic infections and lateonset complications. New policies are needed to address hepatitis C health care inequities affecting mothers and infants in the United States.

Injecting Alone: Practices and Preferences among People Who Inject Drugs in New York City

Injecting alone is a suspected risk factor for opioid overdose death among people who inject drugs (PWID). Better understanding of PWID's injecting practices and preferences could guide pragmatic harm reduction and overdose prevention interventions. We investigated injection practices and preferences among PWID attending syringe services programs (SSPs). We surveyed 108 PWID with opioid use disorder from 3 New York City SSPs between November 2020 and August 2021 to ascertain harm reduction service preferences. This secondary analysis examined injection behavior preferences, reasons for these preferences, and self-reported non-fatal lifetime overdoses. Slightly more participants preferred injecting alone (56%) than with someone present (44%), but most in both groups inject alone most of the time (97% vs 52%, p &lt; 0.01). Commonly reported reasons for preferring to inject alone were privacy (82%) and not wanting to be judged (78%), whereas many preferred to inject with others to have someone present in case of overdose (92%), for camaraderie (69%), and to share drugs (65%). Those preferring to inject alone (vs. with someone present) self-reported higher mean number of lifetime overdoses (3.1 vs 2.6), but differences were not statistically significant. In conclusion, most participants injected alone regardless of preference. While not associated with prior non-fatal overdose, injection preference likely carries risk for future overdose. Participants preferred injecting alone to avoid shame or injecting with others in case of overdose, which can inform public health interventions that support both preferences. Reducing stigma while facilitating rapid overdose response can mitigate the risk of fatal overdose.

Coordinating Systems of Care for HIV and Opioid Use Disorder: A Systematic Review of Enablers and Barriers to Integrated Service Access, and Systems and Tools Required for Implementation

Individuals who have HIV who also use drugs experience increased age-matched morbidity and mortality in comparison with those with HIV who do not use drugs. A systematic review was conducted to describe models of integrated HIV and opioid use disorder (OUD) services, enablers of and barriers to integrated service access, and the coordinated systems and tools at the state and service delivery levels required for implementation. Database searches yielded 235 candidate articles, of which 22 studies met the inclusion criteria. Analysis found that integrated programs operated with minimal coordinated policy and systems guidance at the state level. Service delivery systems and tools used for integration, including use of integrated protocols, risk assessment tools, case management tools, and referral systems, were similar across integration models. Concerted efforts to coordinate state-level systems and develop supportive policies, guidelines, and standardized tools may facilitate integration at the service delivery level.

Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida

INTRODUCTION

Syringe services programs (SSPs) are evidence-based HIV prevention programs for people who inject drugs. However, not all SSPs operate evidence-based syringe distribution models, such as needs-based distribution. This study aims to provide preliminary evidence from the IDEA SSP on changes in injection risk behaviors over time, and to examine factors, including syringe coverage, associated with injection risk behavior trajectories over time under a one-for-one syringe distribution model.

METHODS

We used a prospective observational study design to generate a cohort of SSP clients who completed three behavioral assessments at SSP service visits between December 2016 and January 2020 (N = 115). The study used generalized estimating equations (GEE) to examine the relationship between covariate measures and the primary outcomes. The primary outcomes were 1) sharing of any injection equipment (e.g. syringes, needles, cookers, cottons) in the previous 30 days (yes/no) and 2) reusing of needles/syringes in the previous 30 days (yes/no).

RESULTS

Men were more likely to report reusing syringes (aRR = 1.15, 95% CI: 1.01-1.37) and those who reported injecting in public were less likely to report reusing syringes (aRR = 0.90, 95% CI: 0.82-0.99). HCV-positive clients had a 62% reduction in sharing injection equipment and those who reported public injection had a 62% increase in sharing injection equipment over time. Most importantly, increasing syringe coverage was associated with a decrease in both sharing injection equipment (aRR = 0.42, 95% CI: 0.25-0.72) and reusing syringes (aRR = 0.79, 95% CI: 0.66-0.95).

CONCLUSION

This study provides preliminary evidence of reductions in injection-related risk behaviors from the IDEA SSP and highlights potential high priority groups, such as people experiencing homelessness, that may need additional intervention. In addition, improving syringe coverage among SSP clients may be an important factor in reducing behaviors that place individuals at risk for contracting HIV and HCV.

Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis

The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.

Adverse Childhood Experiences Predict Early Initiation of Opioid Use Behaviors

Introduction: Although a substantial body of research documents a relationship between traumatic stress in childhood and the initiation of substance use later in the life course, only limited research has examined potential linkages between adverse childhood experiences (ACEs) and the initiation of non-medical prescription opioid use and other opioid use behaviors. The present study contributes to this growing body of work by investigating the association of childhood trauma with early initiation of a series of opioid use behaviors. Methods: New York City young adults (n = 539) ages 18-29 who reported non-medical use of prescription opioids or heroin use in the past 30 days were recruited using Respondent-Driven Sampling in 2014-16. Ten ACEs were assessed via self-report with the ACE Questionnaire. Associations between number of ACEs and self-reported ages of initiating seven opioid use behaviors (e.g., non-medical prescription opioid use, heroin use, heroin injection) were estimated with multivariable logistic regression. Results: Eighty nine percent of participants reported at least one ACE, and 46% reported four or more ACEs, a well-supported threshold indicating elevated risk for negative health consequences. Every increase of one trauma was associated with a 12-23% increase in odds of early initiation across the seven opioid use behaviors. Findings also document that the mean age at initiation increased with increasing risk severity across the behaviors, contributing to evidence of a trajectory from opioid pill misuse to opioid injection. Discussion: Increasing number of childhood traumas was associated with increased odds of earlier initiation of multiple opioid misuse behaviors. In light of prior research linking earlier initiation of substance use with increased substance use severity, present findings suggest the importance of ACEs as individual-level determinants of increased opioid use severity. Efforts to prevent onset and escalation of opioid use among at-risk youth may benefit from trauma prevention programs and trauma-focused screening and treatment, as well as increased attention to ameliorating upstream socio-structural drivers of childhood trauma.

"Caballo": risk environments, drug sharing and the emergence of a hepatitis C virus epidemic among people who inject drugs in Puerto Rico

BACKGROUND

Sharing drug injection equipment has been associated with the transmission of HCV among PWID through blood contained in the cooker and cotton used to prepare and divide up the drug solution. While epidemiologists often subsume this practice under the sharing of "ancillary equipment," more attention should be paid to the fact that indirect sharing takes place within the process of joint drug acquisition and preparation.

METHODS

We employed an ethnographic approach observing active PWID (N = 33) in four rural towns in Puerto Rico in order to document drug sharing arrangements involved in "caballo", as this practice is locally known. We explored partners' motivation to engage in drug sharing, as well as its social organization, social roles and existing norms.

FINDINGS

Findings suggest that drug sharing, is one of the main drivers of the HCV epidemic in this population. Lack of financial resources, drug packaging, drug of choice and the desire to avoid the painful effects of heroin withdrawal motivates participants' decision to partner with somebody else, sharing injection equipment-and risk-in the process. Roles are not fixed, changing not only according to caballo partners, but also, power dynamics.

CONCLUSION

In order to curb the HCV epidemic, harm reduction policies should recognize the particular sociocultural contexts in which people inject drugs and make decisions about risk. Avoiding sharing of injection equipment within an arrangement between PWID to acquire and use drugs is more complex than assumed by harm reduction interventions. Moving beyond individual risk behaviors, a risk environment approach suggest that poverty, and a strict drug policy that encourage users to carry small amounts of illicit substances, and a lack of HCV treatment among other factors, contribute to HCV transmission.