Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency

"If everyone knew about this, how many lives could we save?": Do drug suppliers have a role in reducing overdose risk?

Introduction

An unpredictable illicit drug supply is driving high levels of overdose death in North America. Prior research has demonstrated the importance of involving people who use drugs in harm reduction intervention design and implementation. The inclusion of people who supply drugs in these efforts has been scant. We explore this possibility by interviewing persons targeted by a harm reduction educational program designed specifically for people who supply drugs.

Methods

In-person interviews with people who use drugs were conducted in 2022 in Indianapolis, Indiana. We conducted a thematic analysis of data from six interviews with people who were either primarily or secondarily trained through this harm reduction training for people who supply drugs.

Results

Participants described a diverse array of harm reduction strategies, some gained through the targeted education program, which they regularly practiced as they consumed and/or supplied drugs to others. People who supply drugs were regularly identified as key actors capable of widely reducing risk across drug networks. Participants described being motivated by a moral imperative to protect community members, tying the previous loss of friends and loved ones to overdose to their commitments to the safety of others.

Conclusion

This article contributes to the scholarship on the role of people who supply drugs in implementing harm reduction interventions and reducing overdose risk. Better enabling grassroots harm reduction organizations to provide people who supply drugs with harm reduction training and access to harm reduction resources may help to reduce drug-related harms.

Healthcare providers' knowledge and attitudes about overdose prevention sites in Colorado

BACKGROUND

Overdose prevention sites (OPS) are a harm reduction strategy that offer people who use drugs a variety of resources including but not limited to sterile supplies, linkage to healthcare resources, and intervention if an overdose occurs. OPS operate in over 120 countries and evidence has demonstrated they are an effective harm reduction strategy. Despite their success elsewhere, OPS remain federally illegal in the United States and thus there is limited research on their implementation and outcomes in the United States. This study aimed to identify Colorado healthcare providers' knowledge and attitudes about OPS and determine if there is a correlation between healthcare providers with more knowledge about OPS having a more positive attitude about OPS.

METHODS

An electronic survey was distributed to healthcare providers in Colorado. Responses were collected in early 2022 and recorded on a 5-point Likert scale. Mean scores between 1 and 5 were calculated for each participant and analysis of variance methods were used to determine correlating demographic factors. A p value of ≤ 0.05 was used to determine statistical significance of all findings.

RESULTS

This study included 698 participants. A Pearson correlation analysis revealed a strong positive relationship (r = 0.76, p < 0.0001) between provider knowledge and attitudes about OPS. Emergency medicine providers scored the highest in mean knowledge and attitude scores in comparison to all other specialties. Respondents affiliated with a harm reduction center exhibited the highest mean knowledge and attitude scores. Mean knowledge and attitude scores generally rose with respondents' increasing encounters with people who inject drugs in a typical workday, except when reaching nine or more encounters, where a sharp decline occurred.

CONCLUSIONS

Our study highlights the importance of education, exposure to harm reduction strategies, and inter-specialty collaboration in shaping healthcare providers' knowledge and attitudes about OPS. The positive correlation between providers' knowledge and attitudes about OPS suggests that educating healthcare providers on harm reduction strategies, specifically OPS, may lead to reduced stigmatization of OPS among healthcare professionals.

"I Heard of PrEP-I Didn't Think I Needed it." Understanding the Formation of HIV Risk Perception Among People Who Inject Drugs

Uptake of pre-exposure prophylaxis medication (PrEP) to prevent HIV among people who inject drugs (PWID) remains extremely low in the United States. West Virginia's rising HIV incidence and highest drug overdose rate in the nation makes it an important locus for opioid use and HIV risk interaction. In this pilot study we pioneered the use of Cultural Theory among PWID to understand HIV-related risk perception arising from four contrasting modes of social organization. Carried out during an HIV outbreak, we explored PrEP uptake qualitatively as a window onto risk perception. Of the 26 interviewees, 18 were HIV- and despite the medication's free availability from the health center where recruitment took place, none had taken PrEP, half considering they were not at risk. Intimate couples who showed characteristics of 'enclaves' considered the boundary around themselves protective against HIV, creating a safe space or 'invisible risk group'. Higher HIV risk was perceived among those who were housed compared to those living homeless. Beliefs about the causation of the local HIV outbreak and the validity of scientific research corresponded with characteristics of the contrasting modes of social organization and the approach is promising for informing public health interventions among PWID.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Changes in Perceptions of First Responders After Witnessing a Drug Overdose: Individual and Contextual Variations Among People Who Use Opioids in West Virginia

Introduction

Success of opioid overdose interventions involving first responders is dependent on the comfort level that bystanders have with first responders and their willingness to call for assistance. Positive or negative experiences with first responders following witnessing an overdose may influence a person's willingness to call a first responder for assistance in the future.

Purpose

The objective of this study was to examine changes in bystanders' perceptions of first responders following witnessing an overdose attended by emergency medical services or a law enforcement official. It specifically explored perception changes among a sample of individuals residing in Appalachia who use prescription opioids nonmedically.

Methods

Individuals from West Virginia who used prescription opioids nonmedically were interviewed to examine changes in perceptions of first responders following witnessing an overdose. The analytic sample (N = 50) consisted of participants who witnessed an overdose for which 911 was called and stayed until a first responder arrived. Chi-square contingency tables and ANOVA were conducted to assess relationships between individual and contextual characteristics with changes in perceptions.

Results

Findings indicate that the majority (63%) had improved perceptions of first responders, 6% had diminished perceptions, and 24% were unchanged. Changes in perceptions varied by income, presence during substance use, and prior concerns about first responders.

Implications

Individuals who reported experiencing a positive interaction with first a responder after witnessing an overdose may be more likely to call 911 during an overdose and support other interventions by first responders (e.g., referral to syringe service programs or treatment with medications for opioid use disorder).

"That's why we're speaking up today": exploring barriers to overdose fatality prevention in Indianapolis' Black community with semi-structured interviews

BACKGROUND

Opioid overdose deaths are of great concern to public health, with over one million lives lost since 1999. While many efforts have been made to mitigate these, Black communities continue to experience a greater burden of fatalities than their white counterparts. This study aims to explore why by working with Black community members in Indianapolis through semi-structured interviews.

METHODS

Semi-structured one-on-one in-depth interviews were conducted in spring and summer of 2023 with Black residents (N = 23) of zip codes 46202, 46205, 46208, and 46218 in Indianapolis. Ten interview questions were used to facilitate conversations about opioid overdoses, recovery, fatality prevention tools such as calling 911 and naloxone, law enforcement, and racism. Data were analyzed using grounded theory and thematic analysis.

RESULTS

Interviews revealed access barriers and intervention opportunities. Racism was present in both. Mental access barriers such as stigma, fear, and mistrust contributed to practical barriers such as knowledge of how to administer naloxone. Racism exacerbated mental barriers by adding the risk of race-based mistreatment to consequences related to association with substance use. Participants discussed the double stigma of substance use and being Black, fear of being searched in law enforcement encounters and what would happen if law enforcement found naloxone on them, and mistrust of law enforcement and institutions that provide medical intervention. Participants had favorable views of interventions that incorporated mutual aid and discussed ideas for future interventions that included this framework.

CONCLUSIONS

Racism exacerbates Blacks' mental access barriers (i.e., help-seeking barriers), which, in turn, contribute to practical barriers, such as calling 911 and administering naloxone. Information and resources coming from people within marginalized communities tend to be trusted. Leveraging inter-community relationships may increase engagement in opioid overdose fatality prevention. Interventions and resources directed toward addressing opioid overdose fatalities in Black communities should use mutual aid frameworks to increase the utilization of the tools they provide.

Prenatal substance use in the rural and Appalachian state: Project WATCH study 2020-2022

PURPOSE

To examine the prevalence, patterns, and correlates of prenatal substance use in the rural Appalachian state of West Virginia (WV).

METHODS

Population-based cohort (Project WATCH) of all women (N = 34,309) who gave birth between February 2020 and June 2022. A composite substance use variable included 9 categories: "no substance use," "opioids," "cannabis," "sedatives/hypnotics," "stimulants," "opioids and cannabis," "opioids and stimulants," "cannabis and stimulants," and "opioids, cannabis, and stimulants." These data were gathered through self-report, medical records, and/or positive drug screen at labor and delivery.

FINDINGS

12.4% of women used one or more substances (opioids, cannabis, stimulants, and sedatives/hypnotics) during their current pregnancy. The mean age of women using cannabis was 25.34 (SD = 5.31), stimulants was 28.88 (SD = 5.62), and opioid was 30.19 (SD = 4.78). White women were more likely to use opioids (aOR = 2.19, 95% CI 1.46, 3.28) and less likely to use cannabis (aOR = 0.39, 95% CI 0.34, 0.44) compared to minority racial groups. Women with cannabis use were more likely to live in urban versus rural regions (aOR = 1.47, 95% CI 1.33, 1.62). The odds of using any type of substance(s) were significantly higher in women who smoked (aOR range 4.17-30.85), had Medicaid (aOR range 1.52-7.65), and those receiving inadequate prenatal care (aOR range 1.96-16.83).

CONCLUSIONS

In this rural Appalachian state, 1 in 8 women used 1 or more substances (opioids, cannabis, stimulants, and/or sedatives/hypnotics) during pregnancy and the type of substance used varied by sociodemographic and health-related factors. These factors should inform state-level strategies and initiatives to address the substance use crisis for this population.

An evaluation of the Compassion, Inclusion, and Engagement initiative: learning from PWLE and communities across British Columbia

BACKGROUND

The Compassion, Inclusion and Engagement initiative (CIE) was a social contact intervention that operated in British Columbia between 2015 and 2021. The primary objective of CIE was to increase the participation of people with lived experience of substance use (PWLE) in the planning, design, implementation, and evaluation of harm reduction supports and services.

CASE PRESENTATION

CIE used the developmental evaluation methodology outcome mapping to define and measure progress towards its goals. Developmental evaluation emphasizes learning in contrast to other forms of evaluation which are often more focused on determining the value or success of a project or programme based on predetermined criteria. Outcome mapping is a relational practice which acknowledges that change is achieved by an initiative's partners and the role of the initiative is to provide access to resources, ideas and opportunities that can facilitate and support change.

CONCLUSIONS

Through the implementation and evaluation of CIE, it became clear that directly supporting PWLE facilitated more meaningful and lasting change than solely working to improve the health and social services that supported them. The impacts of the CIE initiative extend far beyond the outcomes of any of the dialogues it facilitated and are largely the result of an increase in social capital. CIE engagements created the opportunity for change by inviting people most affected by the toxic drug supply together with those committed to supporting them, but their ability to bring about systemic change was limited. Both PWLE and service providers noted the lack of support to attend CIE engagements, lack of support for actions that came from those engagements, and lack of PWLE inclusion in decision-making by health authorities as limiting factors for systemic change. The lack of response at a systemic level often resulted in PWLE carrying the burden of responding to toxic drug poisonings, often without resources, support, or compensation.

The motives and methods of methamphetamine and 'heroin' co-use in West Virginia

BACKGROUND

Opioid and methamphetamine co-use is increasing across the USA with overdoses involving these drugs also rising. West Virginia (WV) has led the US in opioid overdose death rates since at least 2013 and rising co-use of methamphetamine with opioids has played a greater role in deaths over the last 5 years.

METHODS

This study used rapid ethnography to examine methods and motivations behind opioids and methamphetamine co-use from the viewpoint of their consumers. Participants (n = 30) were people who injected heroin/fentanyl also using methamphetamine who participated in semi-structured interviews.

RESULTS

We found multiple methods of co-using opioids and methamphetamine, whether alternately or simultaneously and in varying order. Most prioritized opioids, with motives for using methamphetamine forming three thematic categories: 'intrinsic use', encompassing both inherent pleasure of combined use greater than using both drugs separately or for self-medication of particular conditions; 'opioid assisting use' in which methamphetamine helped people manage their existing heroin/fentanyl use; and 'reluctant or indifferent use' for social participation, reflecting methamphetamine's low cost and easy availability.

CONCLUSIONS

Methamphetamine serves multiple functions among people using opioids in WV. Beliefs persist that methamphetamine can play a role in preventing and reversing opioid overdose, including some arguments for sequential use being protective of overdose. 'Reluctant' uptake attests to methamphetamine's social use and the influence of supply. The impact on overdose risk of the many varied co-use patterns needs further investigation.

'The High Five Club': Social Relations and Perspectives on HIV-Related Stigma During an HIV Outbreak in West Virginia

In the United States, HIV outbreaks are occurring in areas most affected by the opioid epidemic, including West Virginia (WV). Cultural Theory contends that multiple cultures co-exist within societies distinguished by their differing intensities of rules or norms of behavior ('grid') or degree of group allegiance/individual autonomy ('group'). Accordingly, we would expect that perceptions about HIV, including stigma, correspond with individuals' grid/group attributes. To explore this, we conducted qualitative interviews with people who inject drugs (PWID) recruited from a WV syringe service program. This paper focuses on our unexpected findings on stigma during a coinciding HIV outbreak. PWID living homeless identified as belonging to a 'street family'. Its members were mutually distrustful and constrained by poverty and drug dependence but despite their conflicts, reported openness between each other about HIV + status. Interviewees living with HIV perceived little enacted stigma from peers since the local outbreak. Contrasting stigmatizing attitudes were attributed to the town's mainstream society. The 'High Five' (Hi-V) Club, expressing defiance towards stigmatizing behavior outside the street family, epitomized the tensions between a desire for solidary and mutual support and a fatalistic tendency towards division and distrust. Fatalism may hinder cooperation, solidarity and HIV prevention but may explain perceived reductions in stigma.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Optimization of Prescription Drug Monitoring Program to Overcome Opioid Epidemic in West Virginia

The development of the Prescription Drug Monitoring Program (PDMP) led to an innovation in the healthcare organization system (HCOs). The PDMP system has been utilized in different states at various organizational levels in an effort to achieve improved health outcomes, reduce the number of prescription drug overdoses, and lighten the economic burden that follows. However, during the implementation of PDMP, there were several barriers and limitations that were discovered. Those barriers impeded the process of utilization of PDMP, such as the complex user interface and lack of training for healthcare providers. The purpose of this paper was to examine the advances and limitations in the utilization and implementation of PDMP in the US healthcare industry and develop strategies for effective use of PDMP in West Virginia.

The qualitative part of this paper was a literature review. The paper referred to several peer-reviewed studies and research articles from several reliable resources, which were reached by databases or Google Scholar. A total of 44 articles were reviewed for this study.

The implementation of the PDMP was influenced by benefits and barriers. This article reviewed several studies in general that demonstrated positive outcomes from the implementation of PDMP, including a reduced number of prescription drug overdoses, coordinated care for patients, and improved health outcomes. However, the barriers and limitations were not neglected, which mainly include integration of PDMP into the electronic health record (EHR) system, lack of training for the providers, and lack of basic standards for the use of PDMP.

Although the new health reforms encouraged the adaption of PDMP among providers, data reporting and data interpretation still remain major concerns for assessing the health outcomes of PDMP implementation.

Compassion, stigma, and professionalism among emergency personnel responding to the opioid crisis: An exploratory study in New Hampshire, USA

OBJECTIVE

Drug overdoses are the leading cause of death in the United States for those under 50 years of age, and New Hampshire has been disproportionately affected, resulting in increased encounters with the emergency response system. The ensuing impact on emergency personnel has received little attention. The present study aimed to explore the experiences and perspectives of emergency personnel responding to the opioid crisis in NH, with a focus on their views toward people who use opioids.

METHODS

Thirty-six emergency personnel (emergency department clinicians, n = 18; emergency medical service providers, n = 6; firefighters, n = 6; and police officers, n = 6) in 6 New Hampshire counties were interviewed about their experiences responding to overdoses and their perspectives on individuals who use opioids. Directed content analysis was used to identify themes in the transcribed, semistructured interviews. The results were reviewed for consensus.

RESULTS

Several categories of themes were identified among emergency personnel's accounts of their overdose response experiences and perspectives, including varied degrees of compassion and stigma toward people who use opioids; associations between compassion or stigma and policy- and practice-related themes, such as prehospital emergency care and the role of emergency departments (EDs); and primarily among personnel expressing compassion, a sense of professional responsibility that outweighed personal biases.

CONCLUSIONS

Despite the magnitude of the ongoing opioid crisis, some emergency personnel in New Hampshire have sustained or increased their compassion for people who use opioids. Others' perspectives remain or have become increasingly stigmatizing. The associations of compassion and stigma with various policy- and practice-related themes warrant further investigation.

Communicating During an HIV Outbreak Among People Who Inject Drugs-West Virginia 2019

In 2019, the West Virginia Bureau for Public Health (WV BPH), Cabell-Huntington Health Department (CHHD), and CDC collaborated to respond to an HIV outbreak among people who inject drugs (PWID). CDC, WV BPH, and CHHD formed a cross-agency communications team to establish situational awareness, identify knowledge gaps, and establish key audiences for messages, including the general population, PWID, and clinical and social service providers. The team disseminated up-to-date information about the outbreak, and prioritized messages addressing stigma related to drug use, syringe services programs, and HIV. Messages were continually updated to address the evolving situation and to resonate with local values. Messages were disseminated via advertisements, local news media, and directly to PWID, people experiencing homelessness, and providers. The response supplemented CHHD's assets, including strong relationships and community knowledge, with staff capacity and expertise from state and federal agencies. This collaborative approach is a useful model to address communication needs.

The fourth wave of the US opioid epidemic and its implications for the rural US: A federal perspective

The current opioid epidemic in the United States has been characterized as having three waves: prescription opioid use, followed by heroin use, and then use of synthetic opioids (e.g., fentanyl), with early waves affecting a population that was younger, less predominantly male, and more likely to be Caucasian and rural than in past opioid epidemics. A variety of recent data suggest that we have entered a fourth wave which can be characterized as a stimulant/opioid epidemic, with mental illness co-morbidities being more evident than in the past. Stimulant use has introduced new complexities in terms of behavioral consequences (e.g., neurological deficits, suicidal ideation, psychosis, hostility, violence), available treatments, and engagement into services. These compound existing issues in addressing the opioid epidemic in rural areas, including the low density of populations and the scarcity of behavioral health resources (e.g., fewer credentialed behavioral health professionals, particularly those able to prescribe Buprenorphine). Considerations for addressing this new wave are discussed, along with the drawbacks of a wave perspective and persistent concerns in confronting drug abuse such as stigma.