Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain

Examining naloxone access and interest in secondary naloxone distribution on an American Indian Reservation in the Northern Midwest of the United States

Background

Indigenous communities in the United States experience disproportionate rates of overdose morbidity and mortality due to a range of historical traumas and ongoing oppression. Limited health and harm reduction service access on some Tribal lands exacerbate these challenges. To date, little is known about naloxone access on tribal reservation lands.

Methods

We used cross-sectional survey data from community members on the reservation lands of a northern Midwest Tribe in the United States. We explored the prevalence and correlates of recent (past 6-month) naloxone receipt and interest in secondary naloxone distribution among all participants and people who used drugs (PWUD) recently. Correlates included sociodemographics, cultural identity and spirituality, witnessing overdoses, stigma, and drug use characteristics.

Results

Among 227 Indigenous participants, the average age was 45, 62 % were women, 53 % were single, 29 % were not working, 29 % had experienced recent hunger, and 8 % considered themselves homeless. 91 % said that Indigenous spiritual values were important to them. Sixteen percent had witnessed a recent non-fatal overdose, and 6 % had witnessed a fatal one. Twenty-four percent of the overall sample had recently received naloxone, and 40 % of PWUD had received it. Witnessing both fatal (p<0.001) and nonfatal overdoses (p=0.001) were associated with receiving naloxone. Further, 63 % of participants were willing to distribute naloxone.

Conclusions

Innovative strategies to expand naloxone access that are culturally relevant and responsive are needed in Indigenous communities. Cultural connectedness and shared identity are key strengths of Indigenous communities that can potentially be leveraged to implement secondary naloxone distribution programs.

Prenatal cannabis exposure in the clinic and laboratory: What do we know and where do we need to go?

Coincident with the legalisation of cannabis in many nations, rates of cannabis use during pregnancy have increased. Like prior investigations on smoking and alcohol, understanding how prenatal cannabis exposure (PCE) impacts offspring outcomes across the lifespan will be critical for informing choices for pregnant people, clinicians, and policy makers alike. A thorough characterization of the life-long impacts is especially urgent for supporting all of these stakeholders in the decision-making process. While studies in humans bring forth the most direct information, it can be difficult to parse the impact of PCE from confounding variables. Laboratory studies in animal models can provide experimental designs that allow for causal inferences to be drawn, however there can be challenges in designing experiments with external validity in mirroring real-world exposure, as well as challenges translating results from the laboratory back to the clinic. In this literature review, we first highlight what is known about patterns of cannabis use during pregnancy. We then seek to lay out updates to the current understanding of the impact of PCE on offspring development informed by both human and nonhuman animal experiments. Finally we highlight opportunities for information exchange among the laboratory, clinic, and policy, identifying gaps to be filled by future research.

"We're Not Gonna Aid You in Shooting Up": Stigma's Relationship to Harm Reduction in People Who Inject Drugs

BACKGROUND

Harm reduction, when applied to drug use, prioritizes improving patient-centered health outcomes and reducing drug-related harm. In order for harm reduction strategies to be adopted by people who inject drugs (PWID), they need to be promoted, accessible, and accepted in that population and the community-at-large. While PWID face stigma at multiple levels, less is known about how stigma influences uptake and acceptance of harm reduction services and strategies among PWID.

OBJECTIVE

We aim to characterize the stigmatizing experiences PWID have had related to harm reduction and the role of stigma in influencing their acceptance and adoption of harm reduction services and strategies.

DESIGN

A qualitative study using in-person, semi-structured interviews.

PARTICIPANTS

We recruited hospitalized participants, age 18 and over, with a history of injection drug use.

APPROACH

We developed an interview guide asking about various aspects of stigma and participants' experiences with naloxone, syringe service programs, fentanyl test strips, HIV and hepatitis C testing, and any other harm reduction strategies. Key themes were generated using a thematic analysis. We reached thematic saturation at 16 participants.

KEY RESULTS

PWID reported multi-level stigma related to harm reduction from themselves, the public, the healthcare system, and the legal and carceral systems. Themes were grouped into four main categories: internalized, interpersonal, intervention, and structural stigma. Stigma across all of these domains negatively impacted the ability of PWID to access harm reduction resources. Positive, non-stigmatizing experiences from others, such as syringe service programs and peer navigators, countered historically negative experiences and promoted greater education and comfort about using harm reduction resources among PWID.

CONCLUSIONS

To expand the reach of harm reduction services, it is critical to develop interventions that can reduce the stigma against PWID and harm reduction.

"I drink less and that's no small matter": a qualitative descriptive study of a managed alcohol program evaluation in Barcelona

Background: The concurrence of homelessness and alcohol use disorder (AUD) has negative consequences in affected individuals. Managed alcohol programs (MAPs), a harm reduction strategy based on providing regular doses of alcohol to individuals with AUD, have emerged as a potential solution to reduce alcohol-related harms.Objectives: This study examined the impact of a MAP implemented in Barcelona on patterns of alcohol and other psychoactive substance use, health, and quality of life among people who use drugs and were experiencing homelessness. The research also incorporated a gender perspective and focused on individuals who had accessed a residential center.Methods: A descriptive qualitative design was used, employing semi-structured interviews with eight participants who were enrolled in the MAP (three women, five men) and four program professionals. Thematic analysis was used to analyze the resulting data.Results: The domains guiding the study appeared as outcome themes: patterns of use of alcohol and other substances, health, quality of life and impact on female-identified participants. Participants reported improved health due to reduced consumption of alcohol and other substances, better anxiety management, and reconnection to health services. The participants reported enhanced quality of life, including feeling safer, and better use of time, which had been spent on meeting their basic needs. Women reported that a key benefit of the program was living in a sexism-free environment.Conclusion: These results appear to demonstrate that harm reduction strategies prioritizing basic needs and adopting a gender-sensitive perspective can positively impact the health and quality of life of people experiencing homelessness with AUD.

Coverage of cervical cancer prevention interventions among people in Australia who inject drugs

BACKGROUND

The human papillomavirus (HPV) vaccine and regular (i.e., every five years) cervical screening are essential to prevent cervical cancer. Australia has high overall coverage of both interventions but little is known about coverage among people who inject drugs. and known barriers to preventive care among this population may extend to cervical cancer control measures.

METHODS

Data were obtained from the 2023 Illicit Drug Reporting System interviews, in which people who regularly inject drugs participated. The sample was restricted to people with a cervix, with participants aged 25-74 years eligible for the National Cervical Screening Program and participants born after 1980 eligible for HPV vaccination. Age-standardised prevalence ratios were used to compare coverage among this sample to the Australian general population; other results were summarised descriptively.

FINDINGS

Among participants eligible for screening (n = 243), most (96.7 %) reported lifetime uptake, while 70.2 % had been screened during the past five years, which was similar to the general population (prevalence ratio [PR]: 1.14, 95 % confidence interval [CI]: 0.96-1.31). Among those never or overdue for screening (n = 57), one third (31.7 %) were aware that self-sampling is available and barriers to screening varied, with similar numbers reporting personal (e.g., 'I didn't know I needed to'), logistical (e.g., 'I don't have time'), and test-related reasons (e.g., 'the test is uncomfortable/painful'). Among participants eligible for HPV vaccination (n = 99), coverage was 27.2 %, 38 % lower than the general population (PR: 0.62, 95 % CI: 0.39-0.86).

CONCLUSIONS

Cervical screening coverage among this sample of people who inject drugs was similar to the Australian population. Health promotion messaging that focuses on the availability of self-sampling and the importance of regular screening may improve coverage among those overdue for screening. HPV vaccination was lower than the general population, warranting targeted efforts to offer the vaccine to eligible people who inject drugs.

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.

Assessing stigma: Health and social worker regard towards working with people using illicit drugs in Athens, Greece

BACKGROUND

After the 2008 Global Financial Crisis and resulting economic austerity, the rise in illicit drug use engendered an increased need for people who use drugs (PWUD) to access medical care, compounded by the COVID-19 pandemic. Research shows that perceptions of medical staff towards PWUD facilitate or act as a barrier to accessing health care. This study provides a better understanding of health and social work professionals' perceptions by assessing stigma levels towards PWUD in Athens, Greece.

METHODS

This is a mixed-method study. It calculates the stigma score for professionals (n = 60) and the stigma score associated with specific drugs based on the Medical Condition Regard Scale through a quantitative analysis of responses to a semi-structured online survey about attitudes of health and social work professionals towards PWUD. It draws on the qualitative analysis of 12 semi-structured interviews with 16 service managers, providers, and health services advocates working in the charity sector to determine whether perceptions of PWUD affect writing and implementing policy and protocols for services.

RESULTS

Stigma towards PWUD exists amongst health and social work professionals in Athens. Professionals who have worked with PWUD for longer periods of time, professionals who have had specific training on working with PWUD, and professionals who feel that they have the necessary training to work with PWUD all demonstrated a higher stigma score than those reporting the opposite. Cannabis and opioids were associated with lower stigma scores while shisha had the highest level of stigma associated with it. Finally, professional environments are not conducive to alleviating stigma as the lack of training specific to stigma, the lack of professional supervision, and worker burn-out are key barriers faced by professionals in their everyday practice.

CONCLUSIONS

Reducing and eliminating stigma towards PWUD among health and social workers requires immediate action. Measures to be taken include: introducing training programs focused on stigma towards PWUD to healthcare providers, social workers, lawyers, police, the media; increasing professional supervision on field work for health and social workers; introducing low barrier health care and specialist units. Peers and field-focused organisations should meaningfully participate in drug and alcohol policymaking, program development, and implementation.

Characterizing people who inject drugs with no history of opioid agonist therapy uptake in Iran: Results from a national bio-behavioural surveillance survey in 2020

Injection drug use is the primary driver of the human immunodeficiency virus HIV epidemic in Iran. We characterized people who inject drugs (PWID) living in Iran who had never received opioid agonist therapy (OAT) and examined barriers to OAT uptake. We recruited 2,684 PWID with a history of drug injection in the previous 12 months using a respondent-driven sampling approach from 11 geographically dispersed cities in Iran. The primary outcome was no lifetime uptake history of OAT medications. The lifetime prevalence of no history of OAT uptake among PWID was 31.3%, with significant heterogeneities across different cities. In the multivariable analysis, younger age, high school education or above, no prior incarceration history, and shorter length of injecting career was significantly and positively associated with no history of OAT uptake. Individual-level barriers, financial barriers, and system-level barriers were the main barriers to receiving OAT. PWID continue to face preventable barriers to accessing OAT, which calls for revisiting the OAT provision in Iran.

Receipt of Opioid Agonist Treatment in provincial correctional facilities in British Columbia is associated with a reduced hazard of nonfatal overdose in the month following release

BACKGROUND

In many jurisdictions, policies restrict access to Opioid Agonist Treatment (OAT) in correctional facilities. Receipt of OAT during incarceration is associated with reduced risk of fatal overdose after release but little is known about the effect on nonfatal overdose. This study aimed to examine the association between OAT use during incarceration and nonfatal overdose in the 30 days following release.

METHODS AND FINDINGS

Using linked administrative healthcare and corrections data for a random sample of 20% of residents of British Columbia, Canada we examined releases from provincial correctional facilities between January 1, 2015 -December 1, 2018, among adults (aged 18 or older at the time of release) with Opioid Use Disorder. We fit Andersen-Gill models to examine the association between receipt of OAT in custody and the hazard of nonfatal following release. We conducted secondary analyses to examine the association among people continuing treatment initiated prior to their arrest and people who initiated a new episode of OAT in custody separately. We also conducted sex-based subgroup analyses. In this study there were 4,738 releases of 1,535 people with Opioid Use Disorder. In adjusted analysis, receipt of OAT in custody was associated with a reduced hazard of nonfatal overdose (aHR 0.55, 95% CI 0.41, 0.74). This was found for prescriptions continued from community (aHR 0.49, 95%CI 0.36, 0.67) and for episodes of OAT initiated in custody (aHR 0.58, 95%CI 0.41, 0.82). The effect was greater among women than men.

CONCLUSIONS

OAT receipt during incarceration is associated with a reduced hazard of nonfatal overdose after release. Policies to expand access to OAT in correctional facilities, including initiating treatment, may help reduce harms related to nonfatal overdose in the weeks following release. Differences in the effect seen among women and men indicate a need for gender-responsive policies and programming.

Factors associated with hepatitis C treatment uptake among females of childbearing age in New South Wales, Australia: A population-based study

INTRODUCTION

Females of childbearing age with hepatitis C virus (HCV) face increased marginalisation with intersecting, sex-specific barriers to direct acting antiviral (DAA) therapy. We assessed the factors associated with uptake of DAA therapy among females of childbearing age, including those with evidence of recent drug dependence.

METHODS

HCV notifications in New South Wales, Australia (1995-2017) were linked to opioid agonist therapy (OAT), hospitalisations, incarcerations, perinatal, HIV notifications, deaths and prescription databases. Recent drug dependence was defined as hospitalisation due to injectable drugs or receipt of OAT occurring in the DAA era (2016-2018). Logistic regression was used to analyse factors associated with DAA uptake among females of childbearing age (18-44), including those with recent drug dependence.

RESULTS

Among 57,467 people with evidence of chronic HCV in the DAA era (2016-2018), 20,161 (35%) were female, including 33% (n = 6563/20,161) of childbearing age (18-44). Among all females of childbearing age (n = 6563) and those with evidence of recent drug dependence (n = 2278/6563, 35%), DAA uptake was lower among those who had given birth in the DAA era (vs. no birth record, all females of childbearing age; aOR: 0.74, 95% CI 0.61, 0.89; those with recent drug dependence; aOR 0.69, 95% CI 0.51, 0.93) and Aboriginal and Torres Strait Islander peoples (all females of childbearing age; aOR 0.81, 95% CI 0.71, 0.93; those with recent drug dependence aOR 0.75, 95% CI 0.62, 0.90).

CONCLUSION

Females of childbearing age should be considered a key population for DAA therapy. Enhancing antenatal and postnatal HCV care may be critical in the pursuit towards elimination.

Experiences of stigma and subsequent reduced access to health care among women who inject drugs

INTRODUCTION

Research into stigma and injecting drug use has typically involved predominantly male participants, with limited research about the unique experience of women who inject drugs.

METHODS

This study used survey methods to assess reduced access to health care due to stigma among a sample of women who inject drugs. Women (n = 232) completed a survey as part of a broader national study of people who inject drugs.

RESULTS

Only 46 (19.9%) women reported that they had not experienced any injecting drug use-related stigma in the past year and most commonly noted 'sometimes' experiencing injecting-related stigma (36.8%) with more than 75% of women reporting that health workers had treated them negatively because of their injecting drug use. Most women undertook strategies to prevent experiencing stigma, such as not disclosing drug use to a health worker (81.3%), not attending follow-up appointments (76.7%) and delaying accessing health care (76.8%). Women with lower levels of personal wellbeing, who had experienced poorer treatment by health workers, had engaged in greater past month injecting, were employed and identified as lesbian, gay, bisexual, transgender or queer (LGBTQ) reported more reduced access to health care.

DISCUSSION AND CONCLUSIONS

Stigma has concerning health care implications for women who inject drugs and this research highlights the importance of understanding the impact of stigma in impeding health care access. Public health interventions should focus on addressing the systemic factors that reduce health care access for women who inject and take account of the impact of stigma in diminishing the quality and accessibility of health care for this group.

Introducing the Harm Reduction Collaboration Framework for Policy, Systems, and Environmental Change

A revised way of thinking is essential for promoting harm reduction strategies and reducing the negative implications of injection drug use (IDU). Despite the growth of harm reduction approaches in the United States, there is limited guidance for designing and implementing multi-sector efforts that address the external determinants that promote and facilitate IDU. Current frameworks fail to acknowledge the individual's role and influence in multi-sector change. To address the multifaceted nature of IDU, we must address the complex relationship between people who inject drugs (PWID) and their external environment. As part of a community-academic partnership, a framework was developed to address the gaps in current theoretical models and community practice. Our Harm Reduction Collaboration Framework (HRCF) accepts PWID as key stakeholders and presents a practical framework in which PWID and community organizations partner in decision making to influence policy, systems, and environmental change. We provide examples of two organizations that have made substantive changes in implementing harm reduction strategies in their communities by utilizing the HRCF.

Factors associated with hepatitis C testing, treatment, and current hepatitis C infection among men and women who inject drugs: The ETHOS engage study

BACKGROUND

Evaluating gender-specific trends in hepatitis C virus (HCV) treatment uptake among men and women who inject drugs is crucial for ensuring equitable progress towards HCV elimination. This study aimed to quantify differences in testing, treatment, and current HCV infection between men and women who inject drugs.

METHOD

ETHOS Engage is an observational cohort study of people who inject drugs attending drug treatment clinics and needle and syringe programs in Australia recruited from May 2018-September 2019 (wave 1) and November 2019-April 2021 (wave 2). Participants completed a questionnaire including self-reported HCV testing and treatment history and underwent point-of-care HCV RNA testing (Xpert® HCV Viral Load Fingerstick). Logistic regression was used to compare the factors associated with self-reported HCV testing and treatment and current HCV infection for men and women who inject drugs.

RESULTS

Among 2,395 participants enrolled in ETHOS Engage, 66% (n = 1,591) were men, 33% (n = 786) women, and <1% (n = 18) did not identify as a man or woman. HCV testing history and current infection were similar among men and women. Among men or women ever eligible for HCV treatment (ever chronic HCV) (n = 1,242), women were less likely to report a history of HCV treatment compared to men (227/352, 64% vs. 631/890, 71%; p = 0.03). Among women, those aged <45 were less likely to report HCV testing (aOR: 0.57, 95%CI: 0.36, 0.90), treatment (aOR: 0.47, 95%CI: 0.29, 0.77), and more likely to have HCV infection (aOR: 1.48, 95%CI: 1.00, 2.20) CONCLUSION: Among women, those of childbearing age (<45) were less likely to report testing and treatment and were more likely to have current HCV infection. Women <45 years old should be a priority population for HCV care. Services that interface with these women should be optimised to enhance HCV testing and treatment.

Barriers to access to hepatitis C treatment with direct-acting antivirals in people who inject drugs in the community setting

Barriers to access to hepatitis C treatment with direct-acting antivirals in people who inject drugs in the community setting. Qualitative study with prison population. Hepatitis C (HCV) treatments with direct-acting antiviral therapy (DAA) are an easy and effective option among people who inject drugs (PWID). However, difficulties in accessing and monitoring treatment in community services and dropouts on release from prison are detected among PWID. For this reason, the aim of the study is to know the access barriers in the diagnosis and treatment of HCV in community health services. An exploratory qualitative study was carried out through semi-structured interviews with 33 PWID recruited in a pre-trial detention prison in Barcelona. The information obtained was analysed using grounded theory. Among PWID sub-population entering prison, personal barriers are related to intense drug use, lack of interest and ignorance of HCV infection and treatment, as well as being in a situation of social exclusion. In relation to health providers, they reported receiving little information, the existence of language barriers in migrants, not receiving screening and treatment proposals, and having poor interactions with some professionals. Systemic barriers were expressed related to the health system circuit being complicated, perceiving little comprehensive care and lack of community support. It is recommended to intensify prevention and treatment campaigns, promoting drug substitution programmes than current ones, improve health education, make the diagnosis and treatment process more flexible, and promote social policies and holistic care for greater coverage of the needs of PWID.

What may encourage or deter health services utilization by people living with or at the risk of HIV/AIDS in special health centers? Qualitative evidence from a stigmatized community

BACKGROUND

Behavioral Diseases Counseling Centers (BDCCs) and Vulnerable Women's Counseling Centers (VWCCs) in Iran are the main peripheral centers that offer educational, counseling, diagnostic, preventive, curative and protective services to individuals living with or at high risk of contracting HIV/AIDS and female sex workers respectively. Due to the social stigma surrounding HIV in Iran, this study aims to identify the factors that may hinder or encourage HIV/AIDS patients and women with risky sexual behaviors from visiting these centers.

METHODS

Conducted in 2023, this qualitative study involved individuals visiting BDCCs and VWCCs in two western provinces of Iran, Ilam and Kermanshah. The study participants included 21 health staff members working in BDCCs and VWCCs and 20 HIV/AIDS patients and vulnerable women with unsafe sexual behaviors referring to these centers. Purposive, snowball and maximum variation sampling techniques were applied to interview the participants. Interviews were conducted between January 5th and May 21st, 2023, using a semi-structure guideline. Interviews were transcribed and content analysis approach was applied to analyze data using MAXQDA20 software.

RESULTS

According to the findings, the barriers and facilitators of visiting specialized centers for HIV/AIDS patients and vulnerable women were categorized into three main categories, 10 subcategories and 35 sub-subcategories including: Medical and operational processes (4 subcategories and 12 sub-subcategories), mutual interactions between the personnel and visitors (people living with and at the risk of getting HIV/AIDS) (3 subcategory and 13 sub-subcategories), and physical characteristics of the centers (3 subcategories and 10 sub-subcategories).

CONCLUSIONS

To improve the performance of BDCCs and VWCCs and encourage people living with and at the risk of contracting HIV/AIDS to visit these centers regularly, health policy makers should consider modifying clinical processes, physical features, personnel behaviors and visitors' concerns raised by the interviewees and the issues identified in this study.

Gender and Drug Use Discrimination Among People Who Inject Drugs: An Intersectional Approach Using the COSINUS Cohort

Purpose

Injection drug use is strongly associated with stigmatization by loved ones, healthcare providers, and society in general. This stigmatization can have negative consequences on the health of people who inject drugs (PWID) and limit their access to care. Women who inject drugs face greater stigma than men because of gendered social norms and the intersectional effect between gender and drug use identities. For this analysis, we aimed to study discrimination - which is closely linked to stigmatization - experienced by PWID, considering the intersectionality between drug use discrimination and gender discrimination in the French context.

Methods

We used data from the COSINUS cohort study, conducted between June 2016 and May 2019 in four French cities. We selected 427 of the 665 PWID who regularly injected drugs enrolled in COSINUS, at three months of follow-up, and performed multivariable logistic regression to identify factors associated with self-reported drug use discrimination.

Results

Women comprised 20.6% of the study sample. Sixty-nine percent of the participants declared drug use discrimination and 15% gender discrimination. In the multivariable regression analysis, PWID who had hurried injection out of fear of being seen were almost twice as likely to have experienced drug use discrimination (OR [95% CI]: 1.77 [1.15, 2.74], p = 0.010). Likewise, women experiencing gender discrimination were almost three times as likely to have experienced drug use discrimination (OR [95% CI]: 2.84 [1.07,7.56], p=0.037).

Conclusion

Women who inject drugs experienced gender and drug use intersectional discrimination. This could be a reason for the low attendance rates of women in healthcare settings. In addition, discrimination negatively impacted injection drug use practices (eg, hurried injection), particularly for people with unstable housing who injected in public spaces. We recommend introducing adapted services in healthcare facilities for women who inject drugs, and creating a favorable social and physical environment for all PWID in order to improve their health and access to care.

"I don't think of it as a shelter. I say I'm going home": a qualitative evaluation of a low-threshold shelter for women who use drugs

BACKGROUND

In 2021-2022, encampments in a downtown Boston neighborhood reached record heights, increasing the visibility of drug use and homelessness in the city. In response, the city planned a "sweep" (i.e., eradication of encampments) and requested support from social services and medical providers to pilot low-threshold shelters. Low-threshold shelters reduce barriers to staying in traditional congregate shelters with more flexible regulations, longer-term bed assignments, and secured storage for contraband (e.g., drugs, weapons) instead of forced disposal. One homeless service provider opened a harm reduction-focused shelter for women who use drugs. This report describes the low-threshold shelter design and program evaluation.

METHODS

This program evaluation had two primary aims: (1) to examine guests' beliefs about shelter policies and practices; and (2) to understand the staff's experiences working in a low-threshold model. We conducted semi-structured qualitative interviews with 16 guests and 12 staff members during the summer 2022. Interviews were thematically analyzed.

RESULTS

Guests expressed overwhelming approval for the shelter's policies, which they stated supported their autonomy, dignity, and safety. They emphasized the staff's willingness to build relationships, thus demonstrating true commitment to the guests. Guests highlighted the value of daytime access to the shelter, as it granted them autonomy over their time, reduced their substance use, and helped them build relationships with staff and other guests. The co-directors and staff designed the shelter quickly and without US models for reference; they turned to international literature, local harm reduction health care providers, and women living in encampments for guidance on the shelter policies. The staff were passionate and committed to the health and stability of the guests. Most staff found value in the low-threshold model, though some were challenged by it, believing it enabled drug use and did not require the guests to "get better."

CONCLUSIONS

This evaluation indicates the value of low-threshold, harm reduction shelters as alternatives to traditional models. While these shelters do not mitigate the need for overarching housing reform, they are important measures to meet the needs of women experiencing unsheltered homelessness who face intersectional oppression.

[Women drug-users in outpatient treatment: a qualitative study from a gender and community mental health perspective]

Women drug-users face significant challenges in accessing and adhering to outpatient treatment. However, this issue has been underexplored. The study aims to understand the experiences of a group of women undergoing drug use treatment. Between March and December 2021, a qualitative phenomenological interpretative study was carried out through semi-structured interviews with 16 women attending a drug-dependence care center in Catalonia, Spain. Data were processed through content analysis. The results indicate that, despite perceiving a positive impact of the treatment, women experience vulnerabilities related to stigmatization, lack of social support, and insufficient coverage of specific needs, impacting therapeutic follow-up. The findings emphasize the need to enhance resources for specialized care and promote a social support network where women drug-users actively participate.

Evidence of telescoping in females across two decades of US treatment admissions for injection drug use: 2000-2020

Background

People who inject drugs (PWID) have an increased risk of soft tissue infection, drug overdose and death. Females may be particularly vulnerable due to barriers to substance use disorder (SUD) treatment entry, stigma, and telescoping, or the greater severity in substance use-related comorbidity and consequences despite a shorter history of use. We set out to identify sex differences in United States injection drug use (IDU).

Methods

The Treatment Episode Dataset-Admission (2000-2020) provided data to identify PWID undergoing their initial SUD treatment admission. Mann-Whitney U test, chi-square, and Spearman correlations were used for ordinal variables, categorical variables, and to assess similarity of male/female trends over the 21 years, respectively. The probabilistic index (PI) and Cramer's V provided effect sizes for Mann-Whitney U tests and chi-square tests, respectively.

Results

A total of 13,612,978 records existed for cases entering their initial treatment. Mapping to a history of IDU left 1,458,695 (561,793 females). Females had a higher prevalence among PWID across all 21 years; IDU trends were essentially identical between males and females (r = 0.97). Females endorsed beginning their primary substance later in life (PI = 0.47, p < 0.0001) and entered treatment after a shorter period of substance use (PI = 0.57, p < 0.0001).

Conclusions

We saw evidence of telescoping among PWID with a SUD entering their initial episode of treatment. Interventions should be implemented prior to the transition to IDU, and this window of opportunity is shortened in females. Utilizing gender-responsive treatment options may be a way to increase treatment-seeking earlier in the disease course.

Negative changes in illicit drug supply during COVID-19: Associations with use of overdose prevention and health services among women sex workers who use drugs (2020-2021)

BACKGROUND

Women sex workers are a highly criminalized population who are over-represented amongst people who use drugs (PWUD) and face gaps in overdose prevention and harm reduction services. British Columbia, Canada continues to face a pronounced drug poisoning crisis of the illicit drug supply, which has intensified during the COVID-19 pandemic. Our objective was to examine the prevalence and structural correlates of experiencing negative changes in illicit drug supply (e.g., availability, quality, cost, or access to drugs) amongst women sex workers who use drugs during the first year of the COVID-19 pandemic.

METHODS

Cross-sectional questionnaire data were drawn from a prospective, community-based cohort of women sex workers in Vancouver (AESHA) from April 2020 to 2021. Bivariate and multivariable logistic regression was used to investigate structural correlates of negative changes in drug supply during COVID-19 among sex workers who use drugs.

RESULTS

Among 179 sex workers who use drugs, 68.2% reported experiencing negative changes to drug supply during COVID-19, 54.2% recently accessed overdose prevention sites, and 44.7% reported experiencing recent healthcare barriers. In multivariable analysis adjusted for injection drug use, women who reported negative changes in illicit drug supply had higher odds of experiencing recent healthcare barriers (AOR 2.28, 95%CI 1.12-4.62); those recently accessing overdose prevention sites (AOR 1.75, 95%CI 0.86-3.54) faced marginally higher odds also.

CONCLUSIONS

Over two-thirds of participants experienced negative changes to illicit drug supply during the first year of the COVID-19 pandemic. The association between experiencing negative changes in the illicit drug supply and accessing overdose prevention services highlights the agency of women in taking measures to address overdose-related risks. Highly criminalized women who experience structural barriers to direct services are also vulnerable to fluctuations in the illicit drug supply. Attenuating health consequences requires interventions tailored to sex workers' needs.

Life-time HIV testing among people who inject drugs in Iran: results from the National Rapid Assessment and Response survey

Background

HIV testing is recommended for people who inject drugs (PWID). The aim of this study was to determine the prevalence of lifetime HIV testing among PWID and to better understand the predictors for HIV testing in a convenience sample across Iran.

Materials and methods

This study is a secondary analysis of Iran's National Rapid Assessment and Response survey conducted between October 2016 and March 2017. Analysis includes the 999 people who reported injecting drugs across the capital cities of 21 provinces. Data were collected by using the venue-based application of the Time Location Sampling (TLS) frame. Chi-square tests were used to examine the difference between HIV testing across different quantitative variables. Logistic regression was used to determine the predictors of life-time HIV testing. Analysis was performed using STATA V.12 software with a significance level of 95%.

Results

Most participants were male (n = 902, 93.50%), and over half (n = 555, 59.17%) were older than 35 years old. About one-third, (n = 326, 38%) of people interviewed were single and another one-third (n = 251, 29%) reported being divorced. Over two-thirds of participants (n = 678, 69.78%) in this study reported lifetime HIV testing. The results from a multiple variable logistic regression showed people with a university education were more likely to have been previously tested for HIV than illiterate people (OR = 18.87, 95%CI 2.85-124.6, value of p = 0.002). Those individuals who reported ever receiving methadone treatment were 2.8 times more likely to have been tested for HIV than individuals without methadone treatment experience (OR = 2.89, 95%CI 1.53-5.42, value of p < 0.001). Needle syringe sharing in last month, was negatively associated with life-time HIV testing (OR = 0.29, 95%CI 0.17-0.48, value of p < 0.001).

Conclusion

Despite Iran's wide availability and access to counseling services for HIV testing in key populations, the proportion of PWID being tested for HIV could be improved. Developing effective strategies to increase people's understanding and awareness of the importance of and need for HIV prevention and familiarity with HIV testing sites is an essential step in increasing HIV testing for this population. Studies on more recent HIV testing are required to better assess and understand the frequency of HIV testing among PWID in Iran.

Mental Health, Environmental, and Socioeconomic Geographic Factors of Severe Drug Addiction: Analysis of Rehabilitation Center Data in Indonesia

Background

A growing number of recent literatures have attempted to document the factors related to drug use in different contexts, but limited studies analyzed the factors related to patient's severity level.

Objective

We aimed to examine the correlates of behavioral, environmental, socioeconomic, geographic factors, and severe drug addiction.

Methods

We used a sample of 6790 people who use drugs (PWUD) from rehabilitation centers during 2019 to 2020 in Indonesia. Data were obtained from Drugs Rehabilitation Information System (SIRENA) by the Indonesian National Narcotics Agency (BNN) during 2019 to 2020. SIRENA used the adapted version of WHO's Addiction Severity Index (ASI), which assesses patient's addiction severity level and relevant factors. A composite of the ASI factors is classified as "poor" or "serious" if its score is 4 or higher. The data was analyzed using logistic regression model to estimate correlations of severe drug addiction.

Results

We found a high prevalence (65.08%) of our sample reported having severe drug addiction, which needed intervention and support. Poor psychiatric condition (OR = 4.02, CI: 2.97-5.44), serious work-related issue (OR = 2.10, 1.75-2.51), poor medical condition (OR = 2.01, 1.32-3.06), and serious family and social problems (OR = 2.56, 2.15-3.05) were significantly associated with severe drug addiction. Male users had higher odds of severe drug addiction (OR = 1.81, 1.55-2.20), compared to female counterparts. Patients in urban areas had higher odds of severe drug addiction (OR = 1.19, 1.1-1.3) than those in rural. Those in less developed regions (eg, Sumatera, Kalimantan, and Sulawesi) had higher odds of severe drug addiction (OR = 2.33, 1.9-2.9), compared to those in the most developed region (eg, Java and Bali).

Conclusion

This evidence can help policymakers in refining the harm reduction policies in Indonesia and other countries with similar settings.

Impacts of intergenerational substance use and trauma among black women involved in the criminal justice system: A longitudinal analysis

INTRODUCTION

Intergenerational substance use and trauma disproportionately impact racialized women. Yet, how these factors impact outcomes in women involved in the criminal justice system is understudied.

METHODS

Using data from 443 participants in the Black Women in a Study of Epidemics, we assessed the impact of intergenerational substance use and trauma on participant drug use and open Child Protective Services (CPS) cases over 18 months. In repeated-measures logistic regression, intergenerational substance and trauma were independent variables, while participants' drug use at each follow-up and any open CPS case (s) served as separate dependent variables. Models were adjusted for criminal justice involvement, age, marital status, education, childhood guardian, number of children, and prior year homelessness.

RESULTS

On average, participants were aged 35 years, 64 % had never married, and 44 % were raised by both parents. Two-thirds of women (67 %) reported intergenerational substance use (≥1 parent and/or grandparent with alcohol/drug problems), while only 13 % reported intergenerational trauma. Each increase in the number of parents/grandparents with drug/alcohol problems was associated with 30 % increased odds of participants' drug use (aOR 1.30, 95 % CI: 1.07,1.57) and 40 % increased odds of having an open CPS case (aOR 1.40, 95 % CI: 1.11, 1.78). The association of intergenerational trauma and CPS cases was attenuated with sociodemographic/contextualizing factors.

CONCLUSIONS

Intergenerational substance use and trauma are associated with negative outcomes. Our findings highlight the need for substance use treatment to address the pervasive generational effects of substance use and trauma faced by racialized women in the criminal justice system.

Racial disparities in use of syringe service programs in King County, WA: a comparison of two cross-sectional surveys

BACKGROUND

Syringe service programs (SSPs) provide tools to people who inject drugs (PWID) to prevent overdose, reduce the risk of HIV and HCV infection, and reduce injection frequency. While effective, previous research suggests that SSPs may not adequately reach some marginalized or particularly vulnerable subpopulations of PWID.

METHODS

To identify disparities in SSP use, data from two cross-sectional surveys conducted in King County, Washington were compared: a survey of SSP clients and a community survey of PWID in King County. It was hypothesized that Black PWID, women, and gender minorities would be underrepresented in the SSP survey relative to the general population of PWID.

RESULTS

SSP clients identified as White at a significantly higher rate than the community sample of PWID (p = 0.030). Black (p < 0.001), American Indian/Alaska Native (p < 0.001), Latinx/Hispanic (p = 0.009), and Native Hawaiian/ Pacific Islander PWID (p = 0.034) were underrepresented in the SSP client survey. The gender of SSP clients was similar to the distribution seen in the community sample of PWID (p = 0.483).

CONCLUSIONS

Black PWID are underrepresented in Seattle-area SSPs, consistent with studies in other large US cities. Both nationally and in Seattle, overdose deaths have been increasing among Black PWID, and harm reduction strategies are vital to reversing this trend. SSPs should explore and test ways to be more accessible to minority populations.

Social Networks, Stigma, and Hepatitis C Care Among Women Who Inject Drugs: Findings from A Community Recruited Sample

This study explores the role of perceived HCV stigma and social networks on HCV care among people who inject drugs (PWID) of both sexes, and solely among women who inject drugs (WWID). Data were from 269 HCV positive PWID, community-recruited through street-based outreach in Baltimore, MD. We defined HCV stigma based on participants' perceptions of treatment by others and their need to conceal their HCV status. Among WWID, HCV stigma was linked with decreased odds of undergoing liver disease staging (aOR = 0.33, 95% CI: 0.13,0.85) or to have attempted to get the HCV cure (aOR = 0.39, CI: 0.16,0.97), these associations were not evident in the overall sample with both sexes. Social network characteristics were significant correlates of HCV care in the overall sample, and these associations were stronger among WWID. WWID with more HCV positive social network members had higher odds of an HCV-related healthcare visit in the prior 12 months (aOR = 4.28, CI: 1.29,14.17) and to have undergone liver disease staging (aOR = 2.85, CI: 1.01,8.05). WWID with more social network members aware of the HCV cure were more likely to report an attempt at obtaining the HCV cure (aOR = 5.25, CI: 1.85,14.89). Our results suggest complexity in the role of social networks and stigma on HCV care.

Daily opioid and stimulant co-use and nonfatal overdoses in the context of social disadvantage: Findings on marginalized populations

OBJECTIVE

Opioids and stimulants are increasingly implicated in overdose deaths, particularly among minoritized groups. We examined daily opioid and cocaine co-use, nonfatal overdoses, and naloxone carrying among minoritized people who inject drugs (PWID).

METHODS

The study derived data from 499 PWID in Baltimore City, MD, recruited using street-based outreach between 2016 and 2019. Participants reported overdoses; sociodemographic characteristics; and use of nonmedical prescription opioids, heroin, cocaine, and naloxone.

RESULTS

Among the participants, the mean age was 46, 34 % were female, 64 % self-identified as Black, and 53 % experienced recent homelessness. Black PWID, compared to White PWID, were as likely to use opioids and cocaine daily but were 61 % less likely to have naloxone. After controlling for sociodemographic characteristics, women (aOR:1.88, 95%CI: 1.14, 3.11), persons experiencing homelessness (aOR:3.07, 95%CI: 1.79, 5.24), and those who experienced a recent overdose (aOR:2.14, 95%CI: 1.29, 3.58) were significantly more likely to use opioids and any form of cocaine every day. In a subanalysis of only female PWID, females engaged in sex work (aOR:2.27, 95%CI: 1.02, 5.07) and females experiencing recent homelessness (aOR:5.82, 95%CI: 2.50, 13.52) were significantly more likely to use opioids and cocaine daily. Furthermore, females (aOR:1.69, 95%CI:1.03, 2.77), persons experiencing homelessness (aOR:1.94, 95%CI:1.16, 3.24), and those with higher educational attainment (aOR:2.06, 95%CI:1.09, 3.91) were more likely to often/always carry naloxone, while Black PWID were less likely to have naloxone (aOR:0.39, 95%CI:0.22, 0.69).

CONCLUSIONS

These findings highlight the need for targeted naloxone distribution and other harm-reduction interventions among minoritized groups in urban areas.

Implementing buprenorphine prolonged-release injection using a health at the margins approach for transactional sex-workers

Background

Access to prescribed interventions and retention in treatment services are associated with improved health outcomes and reduced premature mortality rates for people living with opioid use disorder (OUD). In Leeds, transactional sex-workers frequently cycled in and out of treatment for OUD such that they never reached a level of engagement that permitted opportunities to meet their healthcare or housing needs. Barriers to accessing care provision include an itinerant lifestyle, difficulties with travel at unpredictable hours, impacting upon adherence to medication regimens including daily supervised consumption.

Objectives

To use a co-produced, "health at the margins" approach, to reach the sex-working population in Leeds, and support informed choices about the potential to receive buprenorphine prolonged-release injection (BPRI) as a treatment option for OUD.

Methods

BPRI was introduced using a theory of change model and improvements in sex-worker care delivery was reviewed. Strategies included buprenorphine micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based and trauma-informed approach.

Results

Benefits of BPRI included removal of the need for daily pharmacy visits, reducing the risk of diversion, improved medication adherence, stability and engagement with treatment and supportive services.

Conclusion

BPRI may offer an additional option for pharmacological interventions for people with OUD where there may be increased barriers to accessing treatment for example due to sex-working. Strategies for effective BPRI include micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based approach.

Intersections between syndemic conditions and stages along the continuum of overdose risk among women who inject drugs in Mexicali, Mexico

BACKGROUND

Research on women who inject drugs is scarce in low- and middle-income countries. Women experience unique harms such as sexism and sexual violence which translate into negative health outcomes. The present work aims to provide insight into the experiences of women who inject drugs at the US-Mexico border to identify social and health-related risk factors for overdose to guide harm reduction interventions across the Global South.

METHODS

We recruited 25 women ≥ 18 years of age accessing harm reduction and sexual health services at a non-governmental harm reduction organization, "Verter", in Mexicali, Mexico. We employed purposeful sampling to recruit women who inject drugs who met eligibility criteria. We collected quantitative survey data and in-depth interview data. Analyses of both data sources involved the examination of descriptive statistics and thematic analysis, respectively, and were guided by the syndemic and continuum of overdose risk frameworks.

RESULTS

Survey data demonstrated reports of initiating injection drug use at a young age, experiencing homelessness, engaging in sex work, being rejected by family members, experiencing physical violence, injecting in public spaces, and experiencing repeated overdose events. Interview data provided evidence of stigma and discrimination toward women, a lack of safe spaces and support systems, risk of overdose-related harms, sexual violence, and the overall need for harm reduction services.

CONCLUSION

Women who inject drugs in Mexicali describe experiences of violence, overdose, and public injecting. Women are particularly vulnerable in the Mexicali context, as this area faces a noticeable lack of health and social services. Evidenced-based harm reduction strategies such as safe consumption sites and overdose prevention strategies (e.g., naloxone distribution and training) may benefit this population. Evidence from local organizations could help close the gap in service provision in low-resource settings like Mexico, where government action is almost nonexistent.

Beliefs, attitudes and experiences of virtual overdose monitoring services from the perspectives of people who use substances in Canada: a qualitative study

BACKGROUND

Solitary use of substances is a risk factor for substance use-related mortality. Novel e-health harm reduction interventions such as virtual overdose monitoring services (VOMS) have emerged in North America to improve access to emergency overdose support for people who use substances (PWUS). To date, little research has been published, and the perspectives of PWUS are needed to inform evaluation and policy efforts.

OBJECTIVE

To explore the beliefs, values and perceptions of PWUS around using and accessing VOMS in Canada.

METHODS

A qualitative study following grounded theory methodology was conducted. Using existing peer networks, purposive and snowball sampling was conducted to recruit PWUS (≥ 18 years) with previous experience with VOMS. Thematic analysis was used to analyze twenty-three interviews. Several methods were employed to enhance rigor, such as independent data coding and triangulation.

RESULTS

Twenty-three one-on-one telephone interviews of PWUS with previous experience with VOMS were completed and analyzed. The following themes emerged: (1) feelings of optimism around VOMS to save lives; (2) privacy/confidentiality was highly valued due to stigma and fear of arrest; (3) concerns with reliable cell phones negatively impacting VOMS uptake; (4) concerns around emergency response times, specifically in rural/remote communities; (5) desire for trusting relationships with VOMS operators; (6) importance of mental health supports and referrals to psychosocial services; and (7) possible limited uptake due to low public awareness of VOMS.

CONCLUSION

This qualitative study provided novel insights about the VOMS from the perspectives of PWUS. PWUS generally felt optimistic about the potential of VOMS as a suitable harm reduction intervention, but several potential barriers around accessing VOMS were identified that may limit uptake. Future research is warranted.

Women who use drugs: engagement in practices of harm reduction care

BACKGROUND

Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada.

METHODS

Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction.

FINDINGS

Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection.

CONCLUSION

The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

Between Care and Control: Examining Surveillance Practices in Harm Reduction

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

The impact of the COVID-19 pandemic on people who inject drugs accessing harm reduction services in an rural American state

Background

The impact of public health policies during the COVID-19 pandemic on people who inject drugs (PWID) has varied across regions. In other countries, recent research has shown that PWID access to harm reduction services, despite rapid adaptations, has been negatively impacted. Our study describes these impacts in a rural state.

Methods

We conducted semi-structured interviews with PWID, community partners, and healthcare providers in the rural state of Maine (USA). We explored how changes made during the pandemic impacted access to harm reduction services, including basic services (i.e., shelter), syringe service programs, safe drug supply, low barrier treatment, and peer support. Interviews were analyzed using the framework method to apply Penchansky’s model of access, with Saurman’s modification, which includes six dimensions of access—accessibility, availability, acceptability, affordability, accommodation, awareness.

Results

We interviewed thirty-six stakeholders (N = 9 community partners, N = 9 healthcare providers, N = 18 PWID). Policies such as mobile outreach expansion, mail delivery of equipment, and relaxed telemedicine regulations facilitated accessibility to syringe service programs and low barrier buprenorphine treatment. Public health policies, such as social distancing and screening policies, reduced contact, which subsequently reduced acceptability and awareness of many services. Elimination of the one-for-one needle exchange in some areas increased, acceptability (i.e., perception of service), and affordability for PWID. However, some areas actually began enforcing a one-for-one needle exchange policy, which reduced affordability, acceptability, and awareness of services.

Conclusions

Changes resulting from the COVID-19 pandemic have impacted all dimensions of access to harm reduction services among PWID. While some barriers to harm reduction services were unavoidable during the pandemic, we found that specific policy decisions mitigated service barriers, while other policies exacerbated them. Relaxing needle exchange policies were particularly helpful in facilitating access to harm reduction services by giving community organizations flexibility to adapt to the evolving needs of PWID. These results can inform policies and service delivery to optimally mitigate the negative impacts on PWID during, and beyond, the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00660-2.

Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs

BACKGROUND

Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID.

METHODS

We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization.

RESULTS

Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder.

DISCUSSION

Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.

Helping Women Suffering from Drug Addiction: Needs, Barriers, and Challenges

Statistical data on the use of various psychoactive substances indicate a narrowing of previous differences in substance use between men and women. Data from studies conducted among women suffering from drug addiction are increasingly published, with the authors highlighting the specific needs of this group and the difficulties that women with addiction problems encounter. The current study aimed to identify the barriers and needs of this audience, both when seeking help and during treatment. The method used in the study was secondary content analysis. To identify publications describing the barriers and needs of women suffering from drug addiction, we searched the PubMed database to find publications that met the adopted research objective. We set the data search period to the last ten years to examine the timeliness of the issue under study. The search yielded 199 research reports. Twenty-three articles describing 21 studies were included in the final analysis. The selected publications dealt with the difficulties and challenges faced by women with addiction problems. Barriers to accessing treatment for this group, the needs, and the challenges of helping women suffering from addiction were identified. Results showed that the barriers are mainly stigma but also deficits in the therapeutic offerings for this group. The primary need was identified as the introduction of appropriate drug policies, and the challenges, unfortunately, are the still-reported gender inequalities. To improve the situation of women, regular attention to these issues and the need to include them in national health strategies is essential.

The impact of the COVID-19 pandemic on harm reduction services in Catalonia: the experience of people who use drugs and harm reduction professionals

BACKGROUND

Harm reduction services and professionals have had to reorganise and adapt to COVID-19 prevention measures while still ensuring health and social services for people who use drugs (PUD).

OBJECTIVE

To assess the impact of the COVID-19 pandemic on PUD and on the professionals who provide harm reduction services.

METHODS

A qualitative, exploratory, multicentre design was used. Two focus groups were held with harm reduction professionals, and 40 individual semi-structured interviews were undertaken with PUD in various harm reduction services in Catalonia. Interviews and focus group discussions were transcribed and analysed using thematic content analysis.

RESULTS

Harm reduction services adapted to the pandemic situation by employing methods such as reducing opening hours and closing drop in areas, along with health protection measures such as access control, which in turn led to stress among both professionals and service users. Despite the changes implemented, PUD continued to have access to sterile drug use equipment and methadone treatment. In addition, those who were not in treatment were able to access it rapidly. Regarding their emotional state, the PUD reported that it was worse during the pandemic than before the lockdown, with women affected to a greater extent than men. The harm reduction professionals reported difficulties in managing service users' compliance with the security measures at the beginning of the lockdown and having had to focus primarily on providing food and shelter for the PUD.

CONCLUSIONS

It is important to keep PUD in mind and maintain a harm reduction perspective when implementing confinement measures in situations such as those experienced during the COVID pandemic. Guaranteeing that PUD have their basic needs such as food, hygiene and shelter covered is key.

COVID-19 and the opportunity for gender-responsive virtual and remote substance use treatment and harm reduction services

The COVID-19 pandemic has increased the uptake of virtual and remote service delivery in the substance use field, which was previously uncommon. This swift uptake of virtual services provides an opportunity to improve service design to meet the diverse needs of women and gender-diverse people. Such services have the potential to better meet the needs of women and gender-diverse people by allowing for increased choice, control, and autonomy, enabling empowerment, facilitating greater considerations of power relations, violence, childcare responsibilities, and fostering greater inclusion of trans and non-binary people. This commentary aims to identify how virtual and remote delivery of substance use treatment and harm reduction services can be gender-responsive. We highlight the role gender transformative services play in meeting the unique needs of women and gender-diverse people who use drugs both during and after the COVID-19 pandemic. By using the unique window of opportunity COVID-19 has created to develop and deliver gender-transformative programs, we can help address the detrimental gaps in service accessibility and effectiveness that have persistently been experienced by women and gender-diverse people who use drugs.

Behavior change after fentanyl testing at a safe consumption space for women in Northern Mexico: A pilot study

BACKGROUND

Fentanyl has led to an increased number of overdose deaths in North America. Testing substances for fentanyl may be a harm reduction strategy to prevent overdose. Little is known about behavior change after fentanyl testing and the attitudes around fentanyl knowledge and testing along the US-Mexico border in the context of a safe consumption site.

METHODS

This was a pilot quantitative and qualitative study with 30 women who use drugs at an unsanctioned safe consumption site in Mexicali, Mexico. Women participated in a quantitative survey, a semi-structured interview, and fentanyl testing of substances. Injection behavior was observed after fentanyl testing results were provided. Qualitative data were collected to explore the meanings participants attributed to fentanyl and fentanyl testing.

RESULTS

Half of the substances tested positive for fentanyl (n=15, 50%), and all of them were in samples of black tar heroin. Among those participants who tested positive for fentanyl, 7 (47%) subsequently used less of the intended substance, 1 did not use the intended substance, and 7 (47%) did not change their behavior (i.e., used as originally intended). In qualitative interviews, a predominant theme was a description of fentanyl as dangerous and deadly and fentanyl testing as being helpful for modifying drug use behaviors. However, participants recognized that there could be no change in behavior following a positive fentanyl test in the context of not being able to find substances free of fentanyl.

CONCLUSION

We observed mixed results related to behavior change after women's intended substance for use tested positive for fentanyl. Fentanyl testing was acceptable to women, but behavior change was hampered by the inability to find substances free of fentanyl. Further research is needed to maximize the potential of fentanyl testing as a harm reduction tool especially in the context of a changing drug supply.

“Returning to Ordinary Citizenship”: A Qualitative Study of Chinese PWUD’s Self-Management Strategies and Disengagement Model of Identity

How PWUD (people who use drugs) live under drug governance is an important research question. This study adopts a qualitative research method to explore how PWUD in China self-manage after perceiving the dilemma of incomplete citizenship and the social pressure brought by drug control arrangements. Through analysis of 130 PWUD’s files and in-depth interviews with 10 interviewees (from the 24 preliminary interviews), this study found that PWUD developed action strategies of hidden mobility (spatial isolation), disconnection of past experiences (time isolation), instrumental actions, as well as narrative strategies of reframing themselves as ordinary citizens with attempts of reversing identity disadvantages. Further, PWUD’s self-management strategies manifest as a disengagement model in which the actors (PWUD, not rehabilitation agencies) do not intend to develop integrative positive identities through dispersed, practiced behavioral strategies, but attempt to return to pre-addiction, non-socially exclusionary citizenship experiences. The disengagement model and its negative effect on PWUD’s social integration help us reflect on the current implementation of rehabilitation projects and institutional settings of drug governance.

The impact of social network dynamics on engagement in drug use reduction programs among men and women who use drugs

BACKGROUND

Cross-sectional studies have shown strong relationships between social network characteristics and substance use disorder (SUD) treatment engagement. The current study examined associations between longitudinal changes in egocentric social networks of male and female people who use drugs (PWUD) and engagement in drug use reduction programs, broadly defined as either formal SUD treatment or self-help groups.

METHOD

Using data from an HIV prevention and care study in Baltimore, MD, this study categorized PWUD into those who engaged and did not engage in any drug use reduction programs over two follow-ups during a one-year observation window. The study used multivariate logistic generalized estimating equations (GEE) to examine associations between network composition and stability measures and drug use reduction program engagement, stratified by gender.

RESULTS

Of the 176 subjects participating in drug use reduction programs at baseline, 56.3% remained engaged at one year. Among both male and female respondents, higher turnover into non-kin networks was associated with increased odds of engagement in drug use reduction programs (AOR 1.4; 95% CI: 1.1-1.9, AOR 1.3; 95% CI: 1.0-1.8, respectively). For males, retention of intimate partner networks was associated with increased odds of program engagement (AOR 2.9; 95% CI: 1.1-7.6); for females, higher turnover into kin networks was associated with decreased odds of engagement (AOR 0.8; 95% CI: 0.5-1.0).

CONCLUSION

Evaluation of associations between social network characteristics and drug use reduction program engagement appears to benefit from longitudinal analyses that are stratified by gender. Efforts to improve retention in formal SUD treatment or self-help groups might consider intervening through social networks, perhaps by increasing overall levels of social support.

Setting foot in private spaces: extending the hepatitis C cascade of care to automatic needle/syringe dispensing machines, a mixed methods study

Background

Global commitment to achieving hepatitis C virus (HCV) elimination has enhanced efforts in improving access to direct-acting antiviral (DAA) treatments for people who inject drugs (PWID). Scale-up of efforts to engage hard-to-reach groups of PWID in HCV testing and treatment is crucial to success. Automatic needle/syringe dispensing machines (ADMs) have been used internationally to distribute sterile injecting equipment. ADMs are a unique harm reduction service, affording maximum anonymity to service users. This paper explores the feasibility and acceptability of extending the HCV cascade of care to sites where ADMs are located.

Methods

The ADM users into Treatment (ADMiT) study was undertaken in a metropolitan region in Sydney, Australia. This mixed methods study involved analysis of closed-circuit television footage, ethnographic methods (fieldwork observation and in-depth interviews) and structured surveys. Researchers and peers conducted fieldwork and data collection over 10 weeks at one ADM site, including offering access to HCV testing and treatment.

Results

Findings from 10 weeks of fieldwork observations, 70 survey participants and 15 interviews highlighted that there is scope for engaging with this population at the time they use the ADM, and enhanced linkage to HCV testing and treatment may be warranted. Most survey participants reported prior HCV testing, 61% in the last 12 months and 38% had received HCV treatment. However, fieldwork revealed that most people observed using the ADM were not willing to engage with the researchers. Field work data and interviews suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement.

Discussion

Enhanced linkage to HCV testing and treatment for people who use ADMs may be warranted. However, data suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement. The current study raises important public health questions about the need to ensure interventions reflect the needs of affected communities, including their right to remain anonymous.

Scoping Review of Best Practice Guidelines for Care in the Labor and Birth Setting of Pregnant Women Who Use Methamphetamines

OBJECTIVE

To use a scoping review to explore the existing literature on best practice guidelines for safe, dignified, and compassionate care in the labor and birth setting for pregnant women who use methamphetamines.

DATA SOURCES

We conducted a systematic search for articles and best practice guidelines from health-related databases (MEDLINE; CINAHL; and the Web of Science, including the Core Collection and Social Science Citation Index, PsycInfo, Women's Studies International, and Sociological Abstracts) and gray literature. Search terms included substance use disorder, methamphetamine, childbirth, and labor and delivery.

STUDY SELECTION

We included English-language, peer-reviewed reports of primary research, systematic reviews, and practice guidelines from credible databases and organizations published between 1991 and 2020. We screened 1,297 resources and agreed to review 156 articles and 16 gray literature resources in the full-text analysis. Nine of the 156 articles and 16 gray literature resources met the inclusion criteria.

DATA EXTRACTION

We used the Joanna Briggs Institute review guidelines (2015) criteria for extraction of the following data: author(s); year of publication; type of study; objectives; country of origin; study population and sample size (if applicable); inclusion of best practice guidelines for the labor and birth setting; care approaches specific to safety, dignity, compassion; and the targeted substance(s) discussed (e.g., methamphetamine, opioids, etc.). We further documented the phenomena of interest to determine if articles or best practice guidelines included safe, dignified, and compassionate care approaches specific to pregnant women who use methamphetamine.

DATA SYNTHESIS

We summarized the best practice guidelines, which included universal screening, assessment, and management of analgesia during labor, as well as broad guidance regarding the inclusion of a multidisciplinary health care team. Safe, dignified, and compassionate care approaches were focused on communication, shared decision making, and the provision of nonjudgmental care. Although evidence about substance use during the childbearing years is increasing, stronger evidence for clinical care approaches in the labor and birth setting is needed, inclusive of all stakeholder perspectives.

CONCLUSION

The articles and best practice guidelines reviewed provided broad clinical recommendations that were applicable to pregnant women who use methamphetamine. However, we did not find a complete comprehensive best practice guideline for labor and birth that was specific, was solution focused, and delineated a safe, dignified, and compassionate care approach.

Vulnerability, Risk and Harm for People Who Use Drugs and Are Engaged in Transactional Sex: Learning for Service Delivery

Against a backdrop of high levels of drug related harms in Scotland, this research aimed to inform training development to aid the upskilling of the workforce to support people who use drugs and are involved in transactional sex. Sixteen qualitative interviews were conducted with participants recruited across four health board areas and a range of services covering sexual health and/or harm reduction. Interviews explored initiation, frequency, and the nature of transactional sex; drug use, and experience of services. A thematic analysis was undertaken. Vulnerability was a key emerging theme when discussing drug use, sexual behavior, and service use. Vulnerability increased risk of a range of harms from sexual assault to injecting harms and overdose. Participants were often, but not always, introduced to drugs and transactional sex by someone who had power over them or was more experienced in drug use and/or sex. High risk drug use was evident in terms of polydrug use, consuming large quantities of drugs, sharing crack pipes/injecting equipment. There is a need for information and services to reduce the risk of harm from drugs, sexual violence, and unprotected sex as well as non-judgmental, trauma aware services. The workforce needs to be skilled to recognize and manage these potentially complex syndemics.

Sex Differences in Injection Drug Risk Behaviors Among Hospitalized Persons

OBJECTIVES

As opioid use increases, it remains important to assess factors that contribute to injection drug risk behaviors, as sharing needles and other drug use equipment contributes to the spread of human immunodeficiency virus and hepatitis C virus. Such risks may differ by sex and injecting with others. The current study examined factors that contribute to increased injection drug risk separately for men and women.

METHODS

People who inject drugs were recruited at an academic safety-net hospital that reported recent injection drug use. Two main injection outcomes were assessed: (1) human immunodeficiency virus drug risk behaviors as assessed by the Risk Assessment Battery and (2) the number of times participants injected drugs with a needle used by someone else. For each outcome, different models for women and men were conducted to detect differences by sex.

RESULTS

Both men and women were more likely to inject with a needle used by someone else if they used drugs within a sexual relationship (incidence rate ratio (IRR) = 14.61, P < 0.01; IRR = 7.17, P < 0.05). Being employed was associated with lower risk assessment battery scores among men, and lower mean rates of using a needle used by someone else among women (IRR = 0.22, P < 0.05). Women with post-traumatic stress disorder (PTSD) and men with higher depression scores had higher rates of injecting with a needle used by someone else.

CONCLUSIONS

People who inject drugs who are in intimate relationships report higher injection drug risk behaviors. We found benefits to employment among both men and women. Identifying factors associated with increased injection risk behaviors can be useful for creating interventions tailored by sex.

Use of community healthcare and overdose in the 30 days following release from provincial correctional facilities in British Columbia

BACKGROUND

Interruptions in healthcare services contribute to an elevated risk of overdose in the weeks following release from incarceration. This study examined the association of use of community healthcare with nonfatal and fatal overdose in the 30 days following release.

METHODS

We conducted a retrospective cohort study using linked administrative data from a random sample of 20% of the population of British Columbia. We examined releases from provincial correctional facilities between January 1, 2015-December 1, 2018. We fit multivariate Andersen-Gill models to examine nonfatal overdoses after release from incarceration and applied Standard Cox regression for analyses of fatal overdoses.

RESULTS

There were a combined 16,809 releases of 6721 people in this study. At least one overdose occurred in 2.8% of releases. A community healthcare visit preceded the first nonfatal overdose in 86.4% of releases with a nonfatal overdose event. Only 48.4% of people who had a fatal overdose used community healthcare. In adjusted analysis, people who had used community healthcare had a higher hazard of healthcare-attended nonfatal overdose (aHR 2.83 95% CI 2.13, 3.78) and lower hazard of fatal overdose (aHR 0.58, 95%CI 0.28, 1.19).

CONCLUSIONS

Community healthcare visits after release from custody may be an important opportunity to provide overdose prevention and harm reduction supports. Policies and resourcing are needed to facilitate better connection to primary healthcare during the transition to community. Providers in community should be equipped to offer care to people who have recently experienced incarceration in a way that is accessible, acceptable and trauma-informed.

"I would rather do it myself": injection initiation and current injection patterns among women who inject drugs in Tijuana, Mexico

BACKGROUND

Women who inject drugs (WWID) experience unique risks and adverse health outcomes related to injection initiation and patterns of injection drug use. However, there is limited information on injection initiation experiences and injection patterns among women and the protective strategies employed to limit injection-related harms, especially in low- and middle-income settings. Therefore, this study sought to explore injection initiation and current injection patterns (e.g., relying on someone else to inject) among women who inject drugs and engage in sex work in Tijuana, Mexico.

METHODS

Semistructured in-depth interviews were conducted with 30 WWID on the following topics: injection initiation, current injection patterns, places where women inject, and protective strategies (i.e., risk reduction). All interviews were audio-recorded, transcribed, and de-identified. An inductive thematic analysis was conducted to identify and compare common themes and patterns across participants.

RESULTS

The interviews revealed that the vast majority of study participants were first initiated by another person who injects drugs (PWID), often a male sexual partner. However, the majority of the women transitioned to become self-injectors in order to avoid risks associated with relying on others for injection, including overdose, interpersonal violence, sexual abuse, and wounds. Those who relied on others indicated that they would prefer to inject themselves without assistance from others if they were able to.

CONCLUSIONS

The narratives uncovered in this study reveal the importance of multiple risk environments in shaping perceived risks associated with injection drug use among women in Tijuana, Mexico. Specifically, the interviews elucidate the connection between interpersonal relationships with other PWID and protective strategies used to minimize risk and harm. These findings highlight the need for women-centered harm reduction programs to facilitate the development of safer drug use environments among WWID in Tijuana, Mexico.

Gender-specific associations between psychological distress and injecting risk behaviours among people who inject drugs in Montreal, Canada

BACKGROUND

Psychological distress is common among people who inject drugs (PWID) and may be associated with HCV-related risk behaviours. Previous studies have documented increased vulnerability to both psychological distress and HCV infection among female relative to male PWID. It is, however, unclear whether behavioural responses to distress differ by gender. This study estimated gender-specific associations between psychological distress and i) binge drug injection, and ii) sharing of injection materials.

METHODS

Data were drawn from HEPCO, a longitudinal cohort study involving three-monthly interviews with active PWID in Montreal, Canada. Past-month psychological distress was assessed with the Kessler (K10) scale, categorized for descriptive analyses as minimal (score 10-15), moderate (16-21), high (22-29), or severe (30-50). Binge was defined as injecting large quantities of drugs until participants could no longer continue (past 3 months). Sharing was defined as injection with previously-used needles or equipment (past 3 months). Generalized additive models were fit to estimate smooth, nonlinear associations between K10 scores and risk behaviours, by gender. Models were adjusted for known determinants of drug-related harms and included random intercepts to model within-subject correlation.

RESULTS

805 individuals (82% male) provided 8158 observations (2011-2020). High to severe levels of distress were common and more frequent among women (55% vs 37%). Among men, the odds of binge and sharing monotonically and non-linearly increased with increasing scores of psychological distress. Associations for binge among women were attenuated relative to men but nevertheless increased with distress, albeit in a linear fashion. Sharing was not associated with distress among women.

CONCLUSION

Psychological distress was differentially associated with injecting risk behaviours among men and women who inject drugs. Assessment of distress may provide novel prevention opportunities for select PWID. Further investigation into gender differences is warranted to inform development and tailoring of interventions.

Substance use among sexual minorities in the US - Linked to inequalities and unmet need for mental health treatment? Results from the National Survey on Drug Use and Health (NSDUH)

BACKGROUND

Sexual minorities (SM) have specific substance use patterns and show elevated rates of substance use and substance use disorders. We investigated the potential association between substance use - including chemsex drug use - among SM adults in the United States (US) and social inequality, with an additional focus on disparities in unmet need for mental health treatment.

METHODS

A secondary cross-sectional data analysis was performed using National Survey on Drug Use and Health (NSDUH) data from 2015 to 2017 and including 126,463 individuals with 8241 identifying as SM. Multivariable logistic regression models were implemented to quantify disparities in substance use, to calculate the effect of sociodemographic variables on substance use, and to examine associations with socioeconomic vulnerability.

FINDINGS

SM showed higher odds of past-year substance use and lifetime chemsex drug use. All SM except for bisexual men exhibited higher odds of past-month binge drinking relative to heterosexuals. Bisexual women had higher odds for use of all analysed substances relative to heterosexual women. Being older and being a woman were shown to be protective factors. Urbanity, being uninsured, and unmet need for mental health treatment were associated with significantly higher odds of substance use, chemsex drug use and binge drinking. A link was established between drug use and health indicators, with higher odds of drug use for lower health ratings. SM experienced significantly higher levels of socioeconomic vulnerability. Higher vulnerability indices were associated with increased odds for drug use.

INTERPRETATION

This study is among the first nationally representative samples that analysed the link between sociodemographic factors and unmet need for mental health treatment and substance use in SM. It emphasises the multifactorial aetiology of substance use exposure, highlights the underlying mechanisms for substance use among SM while underscoring disparities among them. Approaches tailored to SM subgroups may be needed to address comorbidities and negative health outcomes of substance use in the long-term. However, critical gaps in the literature remain and large-scale studies inclusive of SM individuals are needed to present causal links.

FUNDING

Gillings Fellowship SYOG054 to ARU.