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Bromberg DJ, Madden LM, Fraenkel L, Muthulingam D, Rhoades D, Dvoriak S, Dumchev K, Pykalo I, Altice FL. Preferences and decisional considerations relating to opioid agonist therapy among Ukrainian people who use drugs: A conjoint analysis survey. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002725. [PMID: 38277422 PMCID: PMC10817130 DOI: 10.1371/journal.pgph.0002725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/28/2023] [Indexed: 01/28/2024]
Abstract
Scaling up opioid agonist therapies (OAT) is the most effective strategy to control combined HIV and opioid epidemics, especially in Eastern Europe and Central Asia (EECA), where HIV incidence and mortality continue to increase. Patient concerns about OAT, however, have undermined scale-up. The objective of this study is to understand Ukrainian opioid use disorder patient preferences about OAT to guide the development of an evidence-informed decision aid for clinical decision-making. We conducted a conjoint-based choice (CBC) survey. Participants were asked to about their preferences relating to 7 attributes of OAT (cost, dosing frequency, concerns about withdrawal symptoms, adverse side effects, improvements in quality of life, precipitation of withdrawal and legislative requirements to be registered as a drug dependent person) and 20 attribute levels for receiving OAT under differing potential treatment constraints. Data were analyzed using Hierarchical Bayesian models. Using respondent-driven sampling and random sampling, we recruited 2,028 people who inject drugs with opioid use disorder. Relative importance (RIS) and partial-worth utility scores (PWUS) were used to assess preferences for attributes and thresholds within each attribute. Cost and dosing frequency were the most important attributes (RIS = 39.2% and RIS = 25.2%, respectively) to potential patients, followed by concerns about withdrawal symptoms (RIS = 10.8%), adverse side effects (RIS = 9.0%), quality-of-life improvement (RIS = 7.5%), precipitation of euphoria (5.2%) and requirement to be registered as a drug- dependent person (RIS = 3.1%). The monthly cost-threshold for willingness-to-pay was 1,900 UAH ($70 USD). In Ukraine, where both governmental and private OAT clinics have emerged and provide markedly different delivery strategies, preferences are mostly driven by out-of-pocket expenses, despite many patients being willing to pay for OAT. Programmatic demands (flexibility and ease of acquiring medications) remain an important consideration while for a minority, clinical concerns about withdrawal symptoms, adverse side effects and OAT impact on life play a smaller role.
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Affiliation(s)
- Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Lynn M. Madden
- APT Foundation, New Haven, Connecticut, United States of America
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Liana Fraenkel
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Dharushana Muthulingam
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Delaney Rhoades
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Sergii Dvoriak
- European Institute of Public Health Policy, Kyiv, Ukraine
| | | | - Iryna Pykalo
- European Institute of Public Health Policy, Kyiv, Ukraine
| | - Frederick L. Altice
- APT Foundation, New Haven, Connecticut, United States of America
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
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Galvez SJ, Altice FL, Meteliuk A, Ivasiy R, Machavariani E, Farnum SO, Fomenko T, Islam Z, Madden LM. High perceived stress in patients on opioid agonist therapies during rapid transitional response to the COVID-19 pandemic in Ukraine. Front Public Health 2023; 11:1231581. [PMID: 38098837 PMCID: PMC10720365 DOI: 10.3389/fpubh.2023.1231581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/07/2023] [Indexed: 12/17/2023] Open
Abstract
Background The COVID-19 pandemic resulted in marked disruptions in healthcare delivery in Ukraine related to emergency guidance in response to treating opioid use disorder (OUD). Patients with OUD, a group with high levels of comorbid medical and psychiatric disorders, and prescribed opioid agonist therapies (OAT) were rapidly shifted to take-home dosing if they were deemed clinically stable. The impact of these shifts on patient stress and related substance use during the pandemic, however, is unknown. Methods In early May 2020, 269 randomly selected OAT patients in Ukraine were surveyed to assess their stress level and substance use using the validated Perceived Stress Scale and examined correlates of severe perceived stress. Results Overall, 195 (72.5%) met criteria for moderate to severe levels of stress, which was independently correlated with having started OAT within the past 12 months (aOR: 1.33; 95%CI: 1.15-1.55), living in a large metropolitan area (aOR: 1.31; 95%CI: 1.18-1.46), having been asked by others to share their medication (aOR: 1.13; 95%CI: 1.02-1.25), and having an increase of over 10 min in transportation time to get to treatment (aOR: 1.16; 95%CI: 1.04-1.29). Twenty seven (10%) patients felt at high risk of relapse, while 24 (8.9%) patients reported purchasing drugs. Conclusion During a time of great uncertainty soon after emergency guidance to the COVID-19 pandemic, there was extraordinary high levels of perceived stress reported. In response to emergency guidance, OAT patients should be screened for perceived stress and certain subgroups should be targeted for additional psychosocial support.
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Affiliation(s)
- Samy J. Galvez
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | - Frederick L. Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
- Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
- APT Foundation, New Haven, CT, United States
| | - Anna Meteliuk
- Alliance for Public Health of Ukraine, Kyiv, Ukraine
| | - Roman Ivasiy
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | - Eteri Machavariani
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | | | | | - Zahedul Islam
- Alliance for Public Health of Ukraine, Kyiv, Ukraine
| | - Lynn M. Madden
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
- APT Foundation, New Haven, CT, United States
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Owczarzak J, Chien J, Tobin K, Mazhnaya A, Chernova O, Kiriazova T. A qualitative exploration of daily path and daily routine among people in Ukraine who inject drugs to understand associated harms. Subst Abuse Treat Prev Policy 2022; 17:33. [PMID: 35526038 PMCID: PMC9077869 DOI: 10.1186/s13011-022-00465-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals’ movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources.
Methods
This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine.
Results
We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources.
Conclusions
Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks.
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Madden LM, Farnum SO, Bromberg DJ, Barry DT, Mazhnaya A, Fomenko T, Meteliuk A, Marcus R, Rozanova J, Poklad I, Dvoriak S, Altice FL. The development and initial validation of the Russian version of the BASIS-24. Addict Sci Clin Pract 2022; 17:65. [PMID: 36435811 PMCID: PMC9701377 DOI: 10.1186/s13722-022-00343-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/19/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English. METHODS Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R. RESULTS Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA. CONCLUSION Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.
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Affiliation(s)
- Lynn M. Madden
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Scott O. Farnum
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
| | - Daniel J. Bromberg
- grid.47100.320000000419368710Yale School of Public Health, Laboratory of Epidemiology and Public Health, 60 College St, New Haven, CT 06510 USA
| | - Declan T. Barry
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06510 USA
- grid.47100.320000000419368710Child Study Center, Yale University School of Medicine, 230 S Frontage Road, New Haven, CT 06519 USA
| | - Alyona Mazhnaya
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- grid.77971.3f0000 0001 1012 5630School of Public Health, National University of Kyiv-Mohyla Academy, Hryhoriya Skovorody Street, Kiev, 2 04655 Ukraine
| | - Tetiana Fomenko
- grid.511905.9ICF Alliance for Public Health, 24 Bulvarno-Kudriavska Street, Kyiv, 01601 Ukraine
| | - Anna Meteliuk
- grid.511905.9ICF Alliance for Public Health, 24 Bulvarno-Kudriavska Street, Kyiv, 01601 Ukraine
| | - Ruthanne Marcus
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Julia Rozanova
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Iurii Poklad
- Chernihiv Regional Narcological Dispensary, 3 Shchorsa Street, Chernihiv, 14005 Ukraine
| | - Sergii Dvoriak
- European Institute of Public Health Policy, 1 Malopidvalna Street, Office 10, Kiev, 01054 Ukraine
| | - Frederick L. Altice
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Yale School of Public Health, Laboratory of Epidemiology and Public Health, 60 College St, New Haven, CT 06510 USA
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- grid.10347.310000 0001 2308 5949Centre of Excellence On Research in AIDS (CERiA), University of Malaya, Malaysia Level 17, Wisma R&DJalan Pantai Baharu, 59990 Kuala Lumpur, Malaysia
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Romero-Mendoza M, Peláez-Ballestas I, Almanza-Avendaño AM, Figueroa E. Structural violence and the need for compassionate use of methadone in Mexico. BMC Public Health 2022; 22:606. [PMID: 35351061 PMCID: PMC8962103 DOI: 10.1186/s12889-022-12955-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Epidemiological data from Mexico have documented an increase in heroin use in the last decade. However, there is no comprehensive care strategy for heroin users, especially those who have been accused of a crime. The objective of this study was to describe the heroin and methadone use of intravenous heroin users of both sexes who have been in jail, to offer evidence for the formulation of health policy. METHODS This study used an ethnographic approach, with open-ended interviews carried out from 2014 to the present. Heroin users of both sexes attending a private methadone clinic in Mexico City were invited to participate. The sample was non-probabilistic. All interviews were audiotaped and transcribed, and narratives were analyzed using thematic analysis. RESULTS Participants in this study were 33 users of heroin, two of them women, who had been in prison. They ranged in age from 33 to 62 years, had used heroin for a period of 13-30 years, and were from three states: Michoacan, Oaxaca, and Mexico City. Three principal categories of analysis were structured: 1. Pilgrimage for help (dynamics of the drama of suffering, pain, and time through health care spaces); 2) methadone use as self-care; and 3) accessibility to methadone treatment. The impossibility of access to methadone treatment is a condition which motivates users in their journey. The dynamics of methadone use are interpreted as a form of self-care and care to avoid substance use. Reducing the psychological, physical, and harmful effects of the substance allows them to perform daily activities. The inability to access treatment leads to a significant effect on users who experience structural violence. CONCLUSION Compassionate methadone treatment and holistic attention should be considered as a way to meet patients' needs and mitigate their suffering, based on public health policy that allows for human rights-based care.
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Affiliation(s)
- Martha Romero-Mendoza
- Instituto Nacional de Psiquiatría Ramón de La Fuente Muñiz, Camino a Xochimilco 101, Col, San Lorenzo Huipulco, CDMX, 144370 Tlalpan, Mexico City, Mexico
| | - Ingris Peláez-Ballestas
- Hospital General de México Dr. Eduardo Liceaga, Dr. Balmis 148, Col. Doctores, CDMX, 06720 Cuauhtémoc, Mexico City, Mexico
| | - Ariagor Manuel Almanza-Avendaño
- Facultad de Ciencias Humanas, Universidad Autónoma de Baja California, Calz. Castellón S/N, Esperanza Conjunto Urbano, 21350 Mexicali, BC Mexico
| | - Emilia Figueroa
- Clínica Integral de Tratamiento Contra Las Adicciones, Adolfo Prieto 1338, Col. Del Valle, Benito Juárez, CDMX, 03100 Mexico City, Mexico
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Lee JO, Yoon Y, Idrisov B, Kiriazova T, Makarenko O, Sereda Y, Bendiks S, Cody K, Schoenberger SF, Nurius PS, Halim N, Flanigan T, Samet JH, Liebschutz J, Lunze K. Violence, HIV Risks, and Polysubstance Use Among HIV-Positive People Who Inject Drugs in Ukraine. AIDS Behav 2021; 25:2120-2130. [PMID: 33385280 PMCID: PMC9184239 DOI: 10.1007/s10461-020-03142-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/28/2022]
Abstract
Violence experience has been consistently associated with HIV risks and substance use behaviors. Although many studies have focused on intimate partner violence (IPV), the role of violence at a structural level (i.e., police abuse) remains relevant for people who inject drugs. This study evaluated the association of IPV and police-perpetrated violence experiences with HIV risk behaviors and substance use in a cohort of HIV-positive people who inject drugs in Ukraine. We also evaluated possible moderation effects of gender and socioeconomic status in the links between violence exposure and HIV risk and polysubstance use behaviors. Data came from the Providence/Boston-CFAR-Ukraine Study involving 191 HIV-positive people who inject drugs conducted at seven addiction treatment facilities in Ukraine. Results from logistic regressions suggest that people who inject drugs and experienced IPV had higher odds of polysubstance use than those who did not experience IPV. Verbal violence and sexual violence perpetrated by police were associated with increased odds of inconsistent condom use. The odds of engaging in polysubstance use were lower for women in relation to police physical abuse. We found no evidence supporting socioeconomic status moderations. Violence experiences were associated with substance use and sexual HIV risk behaviors in this cohort of HIV-positive people who inject drugs in Ukraine. Trauma-informed prevention approaches that consider both individual and structural violence could improve this population's HIV risks.
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Affiliation(s)
- Jungeun Olivia Lee
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th St., Los Angeles, CA, 90089, USA.
| | - Yoewon Yoon
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th St., Los Angeles, CA, 90089, USA
| | - Bulat Idrisov
- Bashkir State Medical University, Ufa, Russia
- Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation, Moscow, Russia
- Moscow Institute of Physics and Technology, Moscow, Russia
| | | | | | | | - Sally Bendiks
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
| | - Kate Cody
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th St., Los Angeles, CA, 90089, USA
| | | | - Paula S Nurius
- School of Social Work, University of Washington, Seattle, WA, USA
| | - Nafisa Halim
- School of Public Health, Boston University, Boston, MA, USA
| | - Timothy Flanigan
- Division of Infectious Disease, Alpert Medical School of Brown University, The Miriam and Rhode Island Hospitals, Brown University, Providence, RI, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Karsten Lunze
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
- School of Medicine, Boston University, Boston, MA, USA
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Kaplowitz E, Truong AQ, Macmadu A, Peterson M, Brinkley-Rubinstein L, Potter N, Green TC, Clarke JG, Rich JD. Fentanyl-related overdose during incarceration: a comprehensive review. HEALTH & JUSTICE 2021; 9:13. [PMID: 34013442 PMCID: PMC8133055 DOI: 10.1186/s40352-021-00138-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 05/05/2021] [Indexed: 06/07/2023]
Abstract
BACKGROUND Fentanyl and related compounds have recently saturated the illicit drug supply in the United States, leading to unprecedented rates of fatal overdose. Individuals who are incarcerated are particularly vulnerable, as the burden of opioid use disorder is disproportionately higher in this population, and tolerance generally decreases during incarceration. METHODS We conduct a systematic search for publications about fentanyl overdoses during incarceration in PubMed and PsycINFO, as well as lay press articles in Google, from January 1, 2013 through March 30th, 2021. RESULTS Not a single fentanyl overdose was identified in the medical literature, but 90 overdose events, comprising of 76 fatal and 103 nonfatal fentanyl overdoses, were identified in the lay press. Among the 179 overdoses, 138 occurred in jails and 41 occurred in prisons, across the country. CONCLUSIONS Fentanyl-related overdoses are occurring in correctional facilities with unknown but likely increasing frequency. In addition to the need for improved detection and reporting, immediate efforts to 1) increase understanding of the risks of fentanyl and how to prevent and treat overdose among correctional staff and residents, 2) ensure widespread prompt availability of naloxone and 3) expand the availability of medications to treat opioid use disorder for people who are incarcerated will save lives.
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Affiliation(s)
- Eliana Kaplowitz
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI, USA.
- Center of Biomedical Research Excellence on Opioids and Overdose , The Rhode Island Hospital , RI, Providence, USA.
| | - Ashley Q Truong
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alexandria Macmadu
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Meghan Peterson
- Division of General Internal Medicine, Albert Einstein College of Medicine, New York City, NY, USA
| | - Lauren Brinkley-Rubinstein
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI, USA
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - Traci C Green
- Center of Biomedical Research Excellence on Opioids and Overdose , The Rhode Island Hospital , RI, Providence, USA
- The Heller School of Social Policy and Management, Brandeis University, Waltham, MA, USA
- Department of Emergency Medicine , Brown School of Medicine , RI, Providence, USA
| | | | - Josiah D Rich
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI, USA
- Center of Biomedical Research Excellence on Opioids and Overdose , The Rhode Island Hospital , RI, Providence, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Grella CE, Ostile E, Scott CK, Dennis M, Carnavale J. A Scoping Review of Barriers and Facilitators to Implementation of Medications for Treatment of Opioid Use Disorder within the Criminal Justice System. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 81:102768. [PMID: 32446130 DOI: 10.1016/j.drugpo.2020.102768] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Policies aimed at addressing the high rates of opioid overdose have prioritized increasing access to medications for treatment of opioid use disorder (MOUD). Numerous barriers exist to providing MOUD within the criminal justice system and/or to justice-involved populations. The aim of this study was to conduct a scoping review of the peer-reviewed literature on implementation of MOUD within criminal justice settings and with justice-involved populations. METHODS A systematic search process identified 53 papers that addressed issues pertaining to implementation barriers or facilitators of MOUD within correctional settings or with justice-involved populations; these were coded and qualitatively analyzed for common themes. RESULTS Over half of the papers were published outside of the U.S. (n = 28); the most common study designs were surveys or structured interviews (n = 20) and qualitative interviews/focus groups (n = 18) conducted with correctional or treatment staff and with incarcerated individuals. Four categories of barriers and facilitators were identified: institutional, programmatic, attitudinal, and systemic. Institutional barriers typically limited capacity to provide MOUD to justice-involved individuals, which led to programmatic practices in which MOUD was not implemented following clinical guidelines, often resulting in forcible withdrawal or inadequate treatment. These programmatic practices commonly led to aversive experiences among justice-involved individuals, who consequently espoused negative attitudes about MOUD and were reluctant to seek treatment with MOUD following their release to the community. Facilitators of MOUD implementation included increased knowledge and information from training interventions and favorable prior experiences with individuals being treated with MOUD among correctional and treatment staff. Few systemic facilitators to implementing MOUD with justice-involved individuals were evident in the literature. CONCLUSION Barriers to implementing MOUD in criminal justice settings and/or with justice-involved populations are pervasive, multi-leveled, and inter-dependent. More work is needed on facilitators of MOUD implementation.
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Affiliation(s)
- Christine E Grella
- Chestnut Health Systems, 221 W. Walton St., Chicago, IL 60610, USA. (CORRESPONDING AUTHOR).
| | - Erika Ostile
- Carnevale Associates LLC, 4 Belinder Rd., Gaithersburg, MD 20878, USA..
| | - Christy K Scott
- Chestnut Health Systems, 221 W. Walton St., Chicago, IL 60610, USA..
| | - Michael Dennis
- Chestnut Health Systems, 448 Wylie Dr., Normal, IL 61761, USA..
| | - John Carnavale
- Carnevale Associates LLC, 4 Belinder Rd., Gaithersburg, MD 20878, USA..
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9
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Gruß I, Firemark A, Mayhew M, McMullen CK, DeBar LL. Taking opioids in times of crisis: Institutional oversight, chronic pain and suffering in an integrated healthcare delivery system in the U.S. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:62-68. [PMID: 31536957 PMCID: PMC6893145 DOI: 10.1016/j.drugpo.2019.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Opioid treatment for chronic pain has garnered heightened public attention and political pressure to control a devastating public health crisis in the United States (U.S.). Resulting policy changes, together with ongoing public and political attention, have pushed health care systems and providers to lower doses or deprescribe and taper patients off opioids. However, little attention has been paid to the impact of such practice changes on patients who had relied on opioid treatment to manage their chronic pain. The aim of this article is to explore experiences with opioid-related care under aggressive tapering efforts and concomitant heightened monitoring and institutional oversight among patients with chronic pain in an integrated delivery system through in-depth interviews. METHODS We interviewed 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. These patients had been prescribed opioids as part of their treatment regimens and taken opioids closely monitored by their health care providers. We followed the framework method for coding and analysing transcripts using NVivo 12. RESULTS The experiences of these patients during this period of change can be understood through three interconnected themes: (1) many patients taking opioids experience debilitating physical side effects; (2) navigating opioid treatment contributes to significant emotional distress among many patients with chronic pain and; (3) the quality of patients' relationship with their primary care provider can be negatively affected by negotiations regarding long-term opioid treatment for chronic pain. CONCLUSION We highlight the importance of utilizing communication approaches that are patient-centered and include shared decision making during the tapering and/or deprescribing processes of opioids and ensuring alternative pain treatments are available to patients with chronic pain.
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Affiliation(s)
- Inga Gruß
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Alison Firemark
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Meghan Mayhew
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Carmit K McMullen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate, Portland, OR 97227, United States.
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466, United States.
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Rhodes T, Azbel L, Lancaster K, Meyer J. The becoming-methadone-body: on the onto-politics of health intervention translations. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:1618-1636. [PMID: 31310008 PMCID: PMC7700701 DOI: 10.1111/1467-9566.12978] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In this paper, we reflect on health intervention translations as matters of their implementation practices. Our case is methadone treatment, an intervention promoted globally for treating opioid dependence and preventing HIV among people who inject drugs. Tracing methadone's translations in high-security prisons in the Kyrgyz Republic, we notice the multiple methadones made possible, what these afford, and the onto-political effects they make. We work with the idea of the 'becoming-methadone-body' to trace the making-up of methadone treatment and its effects as an intra-action of human and nonhuman substances and bodies. Methadone's embodied effects flow beyond the mere psycho-activity of substances incorporating individual bodies, to material highs and lows incorporating the governing practices of prisoner society. The methadone-in-practice of prisoner society is altogether different to that imagined as being in translation as an intervention of HIV prevention and opioid treatment, and has material agency as a practice of societal governance. Heroin also emerges as an actor in these relations. Our analysis troubles practices of 'evidence-based' intervention and 'implementation science' in the health field, by arguing for a move towards 'evidence-making' intervention approaches. Noticing the onto-politics of health intervention translations invites speculation on how intervening might be done differently.
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Affiliation(s)
- Tim Rhodes
- London School of Hygiene and Tropical Medicine, UK
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Lyuba Azbel
- London School of Hygiene and Tropical Medicine, UK
- Yale School of Medicine, Yale University, Connecticut, USA
| | - Kari Lancaster
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Jaimie Meyer
- Yale School of Medicine, Yale University, Connecticut, USA
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Owczarzak J, Nguyen TQ, Mazhnaya A, Phillips SD, Filippova O, Alpatova P, Zub T, Aleksanyan R. Outcome evaluation of a "common factors" approach to develop culturally tailored HIV prevention interventions for people who inject drugs. Drug Alcohol Depend 2019; 199:18-26. [PMID: 30981045 PMCID: PMC6537906 DOI: 10.1016/j.drugalcdep.2019.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Current models of HIV prevention intervention dissemination involve packaging interventions developed in one context and training providers to implement that specific intervention with fidelity. Providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally-generated solutions. Moreover, such interventions may not reflect local drug markets and drug use practices that contribute to HIV risk. PURPOSE This paper examines whether provider-developed interventions based on common factors of effective, evidence-based behavioral interventions led to reduction in drug-related HIV risk behaviors at four study sites in Ukraine. METHODS We trained staff from eight nongovernmental organizations (NGOs) to develop HIV prevention interventions based on a common factors approach. We then selected four NGOs to participate in an outcome evaluation. Each NGO conducted its intervention for at least N = 130 participants, with baseline and 3-month follow-up assessments. RESULTS At three sites, we observed reductions in the prevalence of both any risk in drug acquisition and any risk in drug injection. At the fourth site, prevalence of any risk in drug injection decreased substantially, but the prevalence of any risk in drug acquisition essentially stayed unchanged. CONCLUSIONS The common factors approach has some evidence of efficacy in implementation, but further research is needed to assess its effectiveness in reducing HIV risk behaviors and transmission. Behavioral interventions to reduce HIV risk developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority.
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Affiliation(s)
- J Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House Room 739, Baltimore, MD, 21205-1996, USA; Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
| | - TQ Nguyen
- Departments of Mental Health and Biostatistics, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Hampton House 800, Baltimore, MD, 21205, USA; Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
| | - A Mazhnaya
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205-1996, USA; Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
| | - SD Phillips
- Department of Anthropology, Indiana University, Student Building 130, 701 E. Kirkwood Ave, Bloomington, IN, 47405, USA
| | - O Filippova
- Department of Sociology, V.N. Karazin Kharkiv National University, 6 Svobody Sq, Office 351, Kharkiv, Ukraine
| | - P Alpatova
- Institute of Social-Humanitarian Research, V.N. Karazin Kharkiv National University, 6 Svobody Sq, Office 351, Kharkiv, Ukraine
| | - T Zub
- Department of Sociology, V.N. Karazin Kharkiv National University, 6 Svobody Sq, Office 351, Kharkiv, Ukraine
| | - R Aleksanyan
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Ave, Milwaukee, WI, 53202, USA
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Bahji A. An Epidemic of Incompetence: A Critical Review of Addictions Curriculum in Canadian Residency Programs. MEDEDPUBLISH 2019; 8:3. [PMID: 38089260 PMCID: PMC10712642 DOI: 10.15694/mep.2019.000003.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
This article was migrated. The article was marked as recommended. In Canada and the United States, the rising number of apparent opioid-related deaths have given to the aptly-named opioid epidemic. Despite the criticism physicians have received for their role in opioid overprescribing, physicians may very well be in the position to vanquish the opioid epidemic. While the importance of the importance of Addictions training in psychiatry and other disciplines has been recognized in Canada at a national level, training resources are scarce and difficult to implement, even when delivered in online formats. Many have speculated that the delivery of high-quality Addictions training has been hampered by multiple roadblocks endemic to the Canadian medical education system, particularly stigma towards individuals with substance use disorders. In navigating the winds of change in the Competency-Based Medical Education (CBME) era, it remains unclear how Addictions will be embraced. To date, there are no defined addictions competencies in the Canadian CBME infrastructure, despite the critical findings of the Association of Faculties of Medicine report in 2017, which was generated in response to the opioid epidemic. Despite these challenges, those who struggle with addiction can lead full, happy, productive lives if they have the right resources. With time, we can only hope that the increasing visibility of addiction will translate to improved training and curricula for the next generation of physicians.
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Zelenev A, Shea P, Mazhnaya A, Meteliuk A, Pykalo I, Marcus R, Fomenko T, Prokhorova T, Altice FL. Estimating HIV and HCV prevalence among people who inject drugs in 5 Ukrainian cities using stratification-based respondent driven and random sampling. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 67:91-101. [PMID: 30503695 DOI: 10.1016/j.drugpo.2018.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 08/14/2018] [Accepted: 09/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ukraine, a country of 45.5 million people, has one of the most volatile HIV and HCV epidemics in the world. In this paper, we estimate the prevalence of HIV and HCV among PWID in five Ukrainian cities. METHODS A cross-sectional study was conducted in 2014-2015, based on stratified hybrid sampling with random and respondent driven sampling in five cities: Kyiv, Odesa, Mykolaiv, Dnipro and Lviv. Using data on HIV and HCV antibody testing from 1613 respondents, we evaluate selection bias in the sampling methods by analyzing spatial and network patterns of sampling processes. We develop and apply inverse probability weights in order to estimate the HIV and HCV prevalence in each city, as well as in the overall sample. FINDINGS The aggregate HIV prevalence for the five cities is 35.1% (95% CI: 29.5%-38.5%) but this varied considerably by city: in Kyiv the HIV prevalence is 26.6% (95% CI: 20.3.8%-33.4%), in Odesa - 38.2% (95% CI: 29.8% and 47.1%), in Mykolaiv - 42.0% (95% CI: 34.3%-49.2%), in Dnipro - 58.8% (95% CI: 52.2%-65.8%), and in Lviv 24.6% (95% CI: 18.8%-30.8%). The aggregate HCV prevalence estimate for the five cities is 58.6% (95% CI: 54.9%-61.7%). The highest HCV prevalence is estimated in Kyiv - 84.8% (95% CI: 78.5%-90.1%). HCV prevalence in Odesa is the lowest and estimated to be 36.5% (95% CI: 29.5%-45.1%), in Mykolaiv - 49.1% (95% CI: 41.5%-57.0%), in Dnipro - 56.1% (95% CI: 50.3%-63.4%) and in Lviv 38.5% (95% CI: 31.8%-45.0%). CONCLUSIONS Monitoring behavioral and health outcomes of PWID on a regular basis is necessary for determining prevention and treatment priorities for HIV and HCV infections in Ukraine and elsewhere. The heterogeneity of the local epidemics provides insights into the best prevention and treatment strategies to be deployed in low-resource settings.
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Affiliation(s)
- Alexei Zelenev
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA.
| | - Portia Shea
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA
| | - Alyona Mazhnaya
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624 N Broadway, Baltimore, MD 21205, USA
| | - Anna Meteliuk
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine
| | - Iryna Pykalo
- Ukrainian Institute on Public Health Policy, Mala Zhytomyrska St, 5, Kyiv, 01001, Ukraine
| | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA
| | - Tatiana Fomenko
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine
| | - Tatiana Prokhorova
- ICF Alliance for Public Health in Ukraine, 5 Dilova str. Building 10A, Kyiv 03150, Ukraine
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, 06510, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, 06510, USA
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Zelenev A, Shea P, Mazhnaya A, Rozanova J, Madden L, Marcus R, Altice FL. Assessment of barrier severity and willingness to enter opioid agonist treatment among people who inject drugs in Ukraine. Drug Alcohol Depend 2018; 190:82-88. [PMID: 29990648 PMCID: PMC6292439 DOI: 10.1016/j.drugalcdep.2018.05.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers. METHODS A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT. RESULTS The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT. CONCLUSIONS Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine.
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Affiliation(s)
- Alexei Zelenev
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.
| | - Portia Shea
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Alyona Mazhnaya
- ICF Alliance for Public Health in Ukraine. 5 Dilova str. Building 10A, Kyiv 03150, Ukraine; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society. 624 N Broadway, Baltimore, MD 21205, USA
| | - Julia Rozanova
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Lynn Madden
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; APT Foundation, New Haven, CT, USA
| | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
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Rozanova J, Morozova O, Azbel L, Bachireddy C, Izenberg JM, Kiriazova T, Dvoryak S, Altice FL. Perceptions of Health-Related Community Reentry Challenges among Incarcerated Drug Users in Azerbaijan, Kyrgyzstan, and Ukraine. J Urban Health 2018; 95:508-522. [PMID: 29728898 PMCID: PMC6095752 DOI: 10.1007/s11524-018-0256-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Facing competing demands with limited resources following release from prison, people who inject drugs (PWID) may neglect health needs, with grave implications including relapse, overdose, and non-continuous care. We examined the relative importance of health-related tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in Ukraine, Azerbaijan, and Kyrgyzstan. A proxy measure of whether participants identified a task as applicable (easy or hard) versus not applicable was used to determine the importance of each task. Correlates of the importance of health-related reentry tasks were analyzed using logistic regression, with a parsimonious model being derived using Bayesian lasso method. Despite all participants having substance use disorders and high prevalence of comorbidities, participants in all three countries prioritized finding a source of income, reconnecting with family, and staying out of prison over receiving treatment for substance use disorders, general health conditions, and initiating methadone treatment. Participants with poorer general health were more likely to prioritize treatment for substance use disorders. While prior drug injection and opioid agonist treatment (OAT) correlated with any interest in methadone in all countries, only in Ukraine did a small number of participants prioritize getting methadone as the most important post-release task. While community-based OAT is available in all three countries and prison-based OAT only in Kyrgyzstan, Kyrgyz prisoners were less likely to choose help staying off drugs and getting methadone. Overall, prisoners consider methadone treatment inapplicable to their pre-release planning. Future studies that involve patient decision-making and scale-up of OAT within prison settings are needed to better improve individual and public health.
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Affiliation(s)
- Julia Rozanova
- Section of Infectious Diseases, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT, 06510, USA.
| | - Olga Morozova
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Lyuba Azbel
- London School of Hygiene & Tropical Medicine, London, UK
| | - Chethan Bachireddy
- University of California in San Francisco School of Medicine, San Francisco, CA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Jacob M Izenberg
- University of California in San Francisco School of Medicine, San Francisco, CA, USA
| | | | - Sergiy Dvoryak
- Academy of Labor, Social Relations and Tourism, Kyiv, Ukraine
| | - Frederick L Altice
- Section of Infectious Diseases, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT, 06510, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Centre of Excellence of Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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16
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Iakunchykova O, Meteliuk A, Zelenev A, Mazhnaya A, Tracy M, Altice FL. Hepatitis C virus status awareness and test results confirmation among people who inject drugs in Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 57:11-17. [PMID: 29655101 PMCID: PMC5994183 DOI: 10.1016/j.drugpo.2018.03.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 03/11/2018] [Accepted: 03/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Among the estimated 340,000 people who inject drugs (PWID) in Ukraine, HCV prevalence is approximately 70%. As HCV treatment availability increases, an assessment of the HCV treatment cascade is needed to guide HCV prevention and treatment strategies. METHODS Opioid dependent PWID were interviewed and tested for HIV and HCV in five Ukrainian cities from January 2014 to March 2015. Logistic regression was used to examine the independent correlates of two cascade steps: a) anti-HCV positive status awareness; b) chronic HCV confirmation; and of c) annual HCV testing for PWID. RESULTS Among 1613 PWID, 1002 (62.1%) had anti-HCV positive test result, of which 568 (56.7%) were aware of it before the study and 346 (34.5%) reported previous confirmatory testing for chronic HCV. Independent correlates of being aware they had anti-HCV positivity included: current [AOR: 3.08; 95%CI: 2.16-4.40] or prior [AOR: 1.85; 95%CI: 1.27-2.68] opioid agonistic treatment (OAT) experience, relative to no prior OAT, living in Lviv [AOR: 0.50; 95%CI: 0.31-0.81] or Odesa [AOR: 2.73; 95%CI: 1.51-4.93] relative to Kyiv and being aware of having HIV [AOR: 4.10; 95%CI: 2.99-5.62]. Independent correlates of confirming HCV infection among those who were aware of their anti-HCV positive status included: current OAT [AOR: 2.00; 95%CI: 1.24-3.23], relative to prior OAT, the middle income category [AOR: 1.74, 95%CI: 1.15-2.63], relative to the lowest, and receiving ART [AOR: 4.54; 95%CI: 2.85-7.23]. Among 1613 PWID, 918 (56.9%) were either HCV negative or not aware of their HCV positive status, of which 198 (21.6%) reported recent anti-HCV test (during last 12 month). Recent anti-HCV test in this group was associated with current [AOR: 7.17; 95%CI: 4.63-11.13] or prior [AOR: 2.24; 95%CI: 1.32-3.81] OAT experience, relative to no prior OAT. CONCLUSION Encouraging PWID to participate in OAT may be an effective strategy to diagnose and link PWID who are HCV positive to care. Among HIV negative participants, regular HCV testing may be ensured by participation in OAT. More studies are needed to assess HCV treatment utilization among PWID in Ukraine and OAT as a possible way to retain them in treatment.
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Affiliation(s)
- Olena Iakunchykova
- School of Public Health, Department of Epidemiology and Biostatistics, State University of New York at Albany, Albany, NY, USA.
| | | | - Alexei Zelenev
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Alyona Mazhnaya
- ICF Alliance for Public Health, Kyiv, Ukraine; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
| | - Melissa Tracy
- School of Public Health, Department of Epidemiology and Biostatistics, State University of New York at Albany, Albany, NY, USA
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS (CERiA), Kuala Lumpur, Malaysia
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Makarenko I, Mazhnaya A, Marcus R, Pykalo I, Madden L, Filippovich S, Dvoriak S, Altice FL. Concurrent drug injection during opioid agonist treatment among people who inject drugs in Ukraine. J Subst Abuse Treat 2018; 87:1-8. [PMID: 29471921 PMCID: PMC5826566 DOI: 10.1016/j.jsat.2018.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/06/2018] [Accepted: 01/08/2018] [Indexed: 12/24/2022]
Abstract
Ongoing drug use during opioid agonist treatment (OAT) negatively affects treatment and health outcomes, and increases treatment dropout. This study aimed to examine correlates of concurrent illicit drug use among OAT patients in Ukraine. A random sample of 434 patients currently on OAT receiving buprenorphine (BMT) or methadone maintenance treatment (MMT) from five cities in Ukraine were assessed for factors associated with self-reported concurrent illicit drug use during OAT using a multivariable logistic regression. Among 434 OAT patients, 100 (23%) reported concurrent drug injecting in the previous 30 days; 28% of these were injecting ≥20 days. While 100 (100%) of these injected opioids, 24 (24%) injected stimulants; 40 (40%) met criteria for polysubstance use disorder that included opioids, stimulants and alcohol. Independent correlates of concurrent drug injection included: being on MMT vs. BMT (aOR = 2.8, 95%CI = 1.4-5.8), lower OAT dosage (aOR = 1.7, 95%CI = 1.1-2.7), more severe addiction severity (aOR = 2.3, 95%CI = 1.4-3.8), younger age of injection initiation (aOR = 2.3, 95%CI = 1.3-3.9), and presence of alcohol use disorder (aOR = 2.1, 95%CI = 1.3-3.5); participants living with parents were negatively associated with concurrent drug injection. Concurrent drug use was prevalent among OAT patients in Ukraine indicating the urgent needs for tailored interventions and changes in OAT program design and implementation. Results highlight the importance of prescribing an adequate OAT dosage, and discrepancies between MMT and BMT programs in Ukraine addressing needs of OAT patients with specific characteristics such as severe opioid and alcohol dependence.
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Affiliation(s)
- Iuliia Makarenko
- ICF Alliance for Public Health, Kyiv, Ukraine; Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.
| | - Alyona Mazhnaya
- ICF Alliance for Public Health, Kyiv, Ukraine; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Iryna Pykalo
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Lynn Madden
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; APT Foundation, New Haven, CT, USA
| | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine; Academy of Labor, Social Relations and Tourism, Kyiv, Ukraine
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
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Marcus R, Bojko MJ, Mazhnaya A, Makarenko I, Filippovych S, Dvoriak S, Altice FL, Springer SA. A qualitative assessment of attitudes about and preferences for extended-release naltrexone, a new pharmacotherapy to treat opioid use disorders in Ukraine. J Subst Abuse Treat 2018; 86:86-93. [PMID: 29415856 PMCID: PMC5808584 DOI: 10.1016/j.jsat.2018.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 01/03/2018] [Accepted: 01/03/2018] [Indexed: 12/23/2022]
Abstract
Numerous individual barriers, including negative attitudes toward opioid agonist therapies (OAT), have undermined HIV prevention efforts in Ukraine where the epidemic is concentrated in people who inject drugs (PWID). The recent availability of extended-release naltrexone (XR-NTX), an opioid antagonist, provides new opportunities for treatment and prevention, but little is known about patient preferences. We conducted qualitative analysis using focus groups (FG) of PWID recruited based on OAT experience: currently, previously, and never on OAT in five Ukrainian cities. FG included 199 PWID in 25 focus groups. Focus group transcripts were coded and analyzed using a modified grounded theory approach to identify common themes and domains related to attitudes about and preferences for XR-NTX, relative to other treatments. Interest in XR-NTX was supported if supervised opioid withdrawal and psychological support were assured. Other factors supporting XR-NTX included a focus on younger PWID early in their injection career and motivated for recovery. Perceptions of recovery included not receiving psychoactive medications like methadone or buprenorphine. With more information, XR-NTX could be a viable option for PWID in Ukraine, especially if concerns regarding withdrawal and psychological support are adequately addressed.
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Affiliation(s)
- Ruthanne Marcus
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA.
| | - Martha J Bojko
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | | | | | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA; Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Sandra A Springer
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
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Rozanova J, Marcus R, Taxman FS, Bojko MJ, Madden L, Farnum SO, Mazhnaya A, Dvoriak S, Altice FL. Why People Who Inject Drugs Voluntarily Transition Off Methadone in Ukraine. QUALITATIVE HEALTH RESEARCH 2017; 27:2057-2070. [PMID: 28942704 DOI: 10.1177/1049732317732307] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Methadone maintenance therapy (MMT) treats opioid use disorder among people who inject drugs (PWID). To understand why PWID may voluntarily discontinue MMT, we analyzed data from 25 focus groups conducted in five Ukrainian cities from February to April 2013 with 199 participants who were currently, previously, or never on MMT. Using constant comparison method, we uncovered three themes explaining why PWID transition off MMT: (a) purposeful resistance to rigid social control associated with how MMT is delivered and to power asymmetries in provider-patient relationships, (b) self-management of a PWID's "wounded identity" that is common in socially stigmatized and physically sick persons-MMT serves as a reminder of their illness, and (c) the quest for a "normal life" uninterrupted by daily MMT site visits, harassment, and time inefficiencies, resources, and social capital. Focusing on holistic principles of recovery would improve addiction treatment and HIV prevention in Ukraine and globally.
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Affiliation(s)
| | | | - Faye S Taxman
- 2 George Mason University, Washington, District of Columbia, USA
| | | | - Lynn Madden
- 1 Yale University, New Haven, Connecticut, USA
- 4 APT Foundation, New Haven, Connecticut, USA
| | | | | | - Sergii Dvoriak
- 6 Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L Altice
- 1 Yale University, New Haven, Connecticut, USA
- 4 APT Foundation, New Haven, Connecticut, USA
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Dumchev K, Dvoryak S, Chernova O, Morozova O, Altice FL. Retention in medication-assisted treatment programs in Ukraine-Identifying factors contributing to a continuing HIV epidemic. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 48:44-53. [PMID: 28800420 PMCID: PMC5603251 DOI: 10.1016/j.drugpo.2017.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/31/2017] [Accepted: 05/02/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Opioid agonist treatments (OAT) are widely-used, evidence-based strategies for treating opioid dependence and reducing HIV transmission. The positive benefits of OAT are strongly correlated with time spent in treatment, making retention a key indicator for program quality. This study assessed patient retention and associated factors in Ukraine, where OAT was first introduced in 2004. METHODS Data from clinical records of 2916 patients enrolled in OAT at thirteen sites from 2005 to 2012 were entered into an electronic monitoring system. Survival analysis methods were used to determine the probability of retention and its correlates. RESULTS Twelve-month retention was 65.8%, improving from 27.7% in 2005, to 70.9% in 2011. In multivariable analyses, the correlates of retention were receiving medium and high doses of medication (compared to low doses, dropout aHR=0.57 for both medium and high doses), having not been tested for HIV and tuberculosis (compared to not being tested, dropout aHR=4.44 and 3.34, respectively), and among those who were tested-a negative TB test result (compared to receiving a positive test result, dropout aHR=0.67). CONCLUSION Retention in Ukrainian OAT programs, especially in recent years, is comparable to other countries. The results confirm the importance of adequate OAT dosing (≥60mg of methadone, ≥8mg of buprenorphine). Higher dosing, however, will require interventions that address negative attitudes toward OAT by patients and providers. Interruption of OAT, in the case developing tuberculosis, should incorporate continuity of OAT for TB patients through integrated care delivery systems.
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Affiliation(s)
| | - Sergii Dvoryak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Olena Chernova
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Olga Morozova
- Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
| | - Frederick L Altice
- Yale University School of Medicine and School of Public Health, New Haven, CT, USA
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Marcus R, Makarenko I, Mazhnaya A, Zelenev A, Polonsky M, Madden L, Filippovych S, Dvoriak S, Springer SA, Altice FL. Patient preferences and extended-release naltrexone: A new opportunity to treat opioid use disorders in Ukraine. Drug Alcohol Depend 2017; 179:213-219. [PMID: 28806638 PMCID: PMC5599372 DOI: 10.1016/j.drugalcdep.2017.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Scaling up HIV prevention for people who inject drugs (PWID) using opioid agonist therapies (OAT) in Ukraine has been restricted by individual and structural factors. Extended-release naltrexone (XR-NTX), however, provides new opportunities for treating opioid use disorders (OUDs) in this region, where both HIV incidence and mortality continue to increase. METHODS Survey results from 1613 randomly selected PWID from 5 regions in Ukraine who were currently, previously or never on OAT were analyzed for their preference of pharmacological therapies for treating OUDs. For those preferring XR-NTX, independent correlates of their willingness to initiate XR-NTX were examined. RESULTS Among the 1613 PWID, 449 (27.8%) were interested in initiating XR-NTX. Independent correlates associated with interest in XR-NTX included: being from Mykolaiv (AOR=3.7, 95% CI=2.3-6.1) or Dnipro (AOR=1.8, 95% CI=1.1-2.9); never having been on OAT (AOR=3.4, 95% CI=2.1-5.4); shorter-term injectors (AOR=0.9, 95% CI 0.9-0.98); and inversely for both positive (AOR=0.8, CI=0.8-0.9), and negative attitudes toward OAT (AOR=1.3, CI=1.2-1.4), respectively. CONCLUSIONS In the context of Eastern Europe and Central Asia where HIV is concentrated in PWID and where HIV prevention with OAT is under-scaled, new options for treating OUDs are urgently needed. FINDINGS here suggest that XR-NTX could become an option for addiction treatment and HIV prevention especially for PWID who have shorter duration of injection and who harbor negative attitudes to OAT. Decision aids that inform patient preferences with accurate information about the various treatment options are likely to guide patients toward better, patient-centered treatments and improve treatment entry and retention.
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Affiliation(s)
- Ruthanne Marcus
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA.
| | | | | | - Alexei Zelenev
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Maxim Polonsky
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | | | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Sandra A Springer
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven CT, USA; Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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Willingness to pay for opioid agonist treatment among opioid dependent people who inject drugs in Ukraine. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017. [PMID: 28628853 DOI: 10.1016/j.drugpo.2017.05.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In the context of decreasing external and limited Ukrainian governmental funding for opioid agonist treatments (OAT) for opioid dependent people who inject drugs in Ukraine, information on sustainable financial models is needed. METHODS Data on 855 opioid dependent people who inject drugs (PWID) were drawn from a cross-sectional nationwide survey of 1613 PWID. They comprised 434 participants who were receiving OAT and 421 who were on OAT in the past or have never been on OAT and were interested in receiving the treatment. Multivariate logistic regression was used to examine factors associated with willingness-to-pay (WTP) for OAT, stratified by OAT experience. Variation in the price which respondents were willing to pay for OAT and its effect on their monthly income among PWID with different OAT experience were assessed as a continuous variable using one-way ANOVA and Kruskal-Wallis test. RESULTS Overall, 378 (44%) expressed WTP for OAT. Factors independently associated with WTP differed by OAT experience. Among those using OAT, independent predictors of WTP included: city (Dnipro - aOR=1.9; 95%CI=1.1-4.8 and Lviv - (aOR=2.2; 95%CI=1.1-4.8) compared to those elsewhere in Ukraine), higher income (aOR=1.8; 95%CI=1.2-2.7) and receiving psychosocial counseling (aOR=1.8; 95%CI=1.2-2.7). Among those who had previously been on OAT, positive attitude towards OAT (aOR=1.3; 95%CI=1.1-1.6) and family support of OAT (aOR=2.5; 95%CI=1.1-5.7) were independently associated with WTP. Among PWID who had never been on OAT, being male (aOR=2.2; 95%CI=1.1-4.2), younger age (aOR=1.9; 95%CI=1.2-3.2), higher income (aOR=2.0; 95%CI=1.2-3.4) and previous unsuccessful attempts to enter OAT (aOR=2.3; 95%CI=1.1-4.7) were independently associated with WTP. PWID were willing to commit a large percentage of their monthly income for OAT, which, however, varied significantly based on OAT experience: current OAT: 37% of monthly income, previous OAT: 53%, and never OAT: 60% (p-value=0.0009). CONCLUSIONS WTP for OAT was substantial among PWID in Ukraine, supporting the implementation of self-pay or co-payment programs. Such strategies, however, must remain affordable, provide better access to OAT, and consider specific needs of PWID.
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Wood EF, Werb D, Beletsky L, Rangel G, Cuevas Mota J, Garfein RS, Strathdee SA, Wagner KD. Differential experiences of Mexican policing by people who inject drugs residing in Tijuana and San Diego. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 41:132-139. [PMID: 28111221 DOI: 10.1016/j.drugpo.2016.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/29/2016] [Accepted: 12/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Research among people who inject drugs (PWIDs) in the USA and Mexico has identified a range of adverse health impacts associated with policing of PWIDs. We employed a mixed methods design to investigate how PWIDs from San Diego and Mexico experienced policing in Tijuana, and how these interactions affect PWIDs behavior, stratifying by country of origin. METHODS In 2012-2014, 575 PWIDs in San Diego, 102 of whom had used drugs in Mexico in the past six months, were enrolled in the STAHR-II study, with qualitative interviews conducted with a subsample of 20 who had recently injected drugs in Mexico. During this period, 735 PWIDs in Tijuana were also enrolled in the El Cuete-IV study, with qualitative interviews conducted with a subsample of 20 recently stopped by police. We calculated descriptive statistics for quantitative variables and conducted thematic analysis of qualitative transcripts. Integration of these data involved comparing frequencies across cohorts and using qualitative themes to explain and explore findings. RESULTS Sixty-one percent of San Diego-based participants had been recently stopped by law enforcement officers (LEOs) in Mexico; 53% reported it was somewhat or very likely that they would be arrested while in Mexico because they look like a drug user. Ninety percent of Tijuana-based participants had been recently stopped by LEOs; 84% reported it was somewhat or very likely they could get arrested because they look like a drug user. Participants in both cohorts described bribery and targeting by LEOs in Mexico. However, most San Diego-based participants described compliance with bribery as a safeguard against arrest and detention, with mistreatment being rare. Tijuana-based participants described being routinely targeted by LEOs, were frequently detained, and reported instances of sexual and physical violence. Tijuana-based participants described modifying how, where, and with whom they injected drugs in response; and experienced feelings of stress, anxiety, and powerlessness. This was less common among San Diego-based participants, who mostly attempted to avoid contact with LEOs in Mexico while engaging in risky injection behavior. CONCLUSION Experiences of discrimination and stigma were reported by a larger proportion of PWIDs living in Mexico, suggesting that they may be subject to greater health harms related to policing practices compared with those residing in the USA. Our findings reinforce the importance of efforts to curb abuse and align policing practices with public health goals in both the US and Mexico.
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Affiliation(s)
- Emily F Wood
- Interdisciplinary Social Psychology Ph.D. Program, University of Nevada, Reno, United States
| | - Dan Werb
- Division of Global Public Health, University of California, San Diego, United States
| | - Leo Beletsky
- Northeastern University School of Law & Bouve College of Health Sciences, Division of Global Public Health, University of California, San Diego, United States
| | - Gudelia Rangel
- Comisión de Salud Fronteriza México-EEUU, Sección México, Tijuana, Mexico; Department of Migrant Health, Secretaría de Salud, México DF, Mexico
| | - Jazmine Cuevas Mota
- Division of Global Public Health, University of California, San Diego, United States
| | - Richard S Garfein
- Division of Global Public Health, University of California, San Diego, United States
| | - Steffanie A Strathdee
- Division of Global Public Health, University of California, San Diego, United States
| | - Karla D Wagner
- School of Community Health Sciences, University of Nevada, Reno, United States.
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Altice FL, Azbel L, Stone J, Brooks-Pollock E, Smyrnov P, Dvoriak S, Taxman FS, El-Bassel N, Martin NK, Booth R, Stöver H, Dolan K, Vickerman P. The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia. Lancet 2016; 388:1228-48. [PMID: 27427455 PMCID: PMC5087988 DOI: 10.1016/s0140-6736(16)30856-x] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.
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Affiliation(s)
- Frederick L Altice
- School of Medicine and School Public Health, Yale University, New Haven, CT, USA.
| | - Lyuba Azbel
- Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jack Stone
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | | | - Pavlo Smyrnov
- ICF International Alliance for Public Health, Kiev, Ukraine
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | - Faye S Taxman
- Department of Criminology, Law and Society, George Mason University, Fairfax, VA, USA
| | | | - Natasha K Martin
- School of Social and Community Medicine, Bristol University, Bristol, UK; Division of Global Public Health, University of California San Diego, San Diego, CA, USA
| | - Robert Booth
- Department of Psychiatry, University of Colorado, Denver, CO, USA
| | - Heino Stöver
- Institute of Addiction Research, Frankfurt University of Applied Sciences, Frankfurt, Germany
| | - Kate Dolan
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Peter Vickerman
- School of Social and Community Medicine, Bristol University, Bristol, UK
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Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine. Drug Alcohol Depend 2016; 165:213-20. [PMID: 27370527 PMCID: PMC5094181 DOI: 10.1016/j.drugalcdep.2016.06.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/10/2016] [Accepted: 06/11/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Coverage with opioid agonist treatments (OAT) that include methadone and buprenorphine is low (N=8400, 2.7%) for the 310,000 people who inject drugs (PWID) in Ukraine. In the context of widespread negative attitudes toward OAT in the region, patient-level interventions targeting the barriers and willingness to initiate OAT are urgently needed. METHODS A sample of 1179 PWID with opioid use disorder not currently on OAT from five regions in Ukraine was assessed using multivariable logistic regression for independent factors related to willingness to initiate OAT, stratified by their past OAT experience. RESULTS Overall, 421 (36%) PWID were willing to initiate OAT. Significant adjusted odds ratios (aOR) for covariates associated with the willingness to initiate OAT common for both groups included: higher injection frequency (previously on OAT: aOR=2.7; never on OAT: aOR=1.8), social and family support (previously on OAT: aOR=2.0; never on OAT: aOR=2.0), and positive attitude towards OAT (previously on OAT: aOR=1.3; never on OAT: aOR=1.4). Among participants previously on OAT, significant correlates also included: HIV-negative status (aOR=2.6) and depression (aOR=2.7). Among participants never on OAT, however, living in Kyiv (aOR=4.8) or Lviv (aOR=2.7), previous imprisonment (aOR=1.5), registration at a Narcology service (aOR=1.5) and recent overdose (aOR=2.6) were significantly correlated with willingness to initiate OAT. CONCLUSIONS These findings emphasize the need for developing interventions aimed to eliminate existing negative preconceptions regarding OAT among PWID with opioid use disorder in Ukraine, which should be tailored to meet the needs of specific characteristics of PWID in geographically distinct setting based upon injection frequency, prior incarceration, and psychiatric and HIV status.
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Factors associated with physical and sexual violence by police among people who inject drugs in Ukraine: implications for retention on opioid agonist therapy. J Int AIDS Soc 2016; 19:20897. [PMID: 27435717 PMCID: PMC4951533 DOI: 10.7448/ias.19.4.20897] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 04/11/2016] [Accepted: 04/24/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction Ukraine's volatile HIV epidemic, one of the largest in Eastern Europe and Central Asia, remains concentrated in people who inject drugs (PWID). HIV prevalence is high (21.3% to 41.8%) among the estimated 310,000 PWID. Opioid agonist therapy (OAT) is the most cost-effective HIV prevention strategy there, yet OAT services are hampered by negative attitudes and frequent harassment of OAT clients and site personnel by law enforcement. This paper examines the various types of police violence that Ukrainian PWID experience and factors associated with the different types of violence, as well as the possible implications of police harassment on OAT retention. Methods In 2014 to 2015, we conducted a cross-sectional survey in five Ukrainian cities with 1613 PWID currently, previously and never on OAT, using a combination of respondent-driven sampling, as well as random sampling. We analysed correlates of police violence by multiple factors, including by gender, and their effects on duration of OAT retention. Self-reported physical and sexual violence by police were the two primary outcomes, while retention on OAT was used as a secondary outcome. Results Overall, 1033 (64.0%) PWID reported being physically assaulted by police, which was positively correlated with currently or previously being on OAT (69.1% vs. 60.2%; p<0.01). HIV prevalence rates were higher in those receiving OAT than those not on OAT (47.6% vs. 36.1%; p<0.01). Police violence experiences differed by sex, with men experiencing significantly more physical violence, while women experienced more sexual violence (65.9% vs. 42.6%; p<0.01). For PWID who had successfully accessed OAT, longer OAT retention was significantly correlated both with sexual assault by police and fewer non-fatal overdoses. Conclusions Police violence is a frequent experience among PWID in Ukraine, particularly for those accessing OAT, an evidence-based primary and secondary HIV prevention strategy. Police violence experiences, however, were different for men and women, and interventions with police that address these sexual differences and focus on non-violent interactions with PWID to improve access and retention on OAT are crucial for improving HIV prevention and treatment goals for Ukraine.
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Police, Law Enforcement and HIV. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.4.21260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Bojko MJ, Mazhnaya A, Marcus R, Makarenko I, Islam Z, Filippovych S, Dvoriak S, Altice FL. The Future of Opioid Agonist Therapies in Ukraine: A Qualitative Assessment of Multilevel Barriers and Ways Forward to Promote Retention in Treatment. J Subst Abuse Treat 2016; 66:37-47. [PMID: 27211995 PMCID: PMC4919997 DOI: 10.1016/j.jsat.2016.03.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 02/03/2016] [Accepted: 03/13/2016] [Indexed: 12/22/2022]
Abstract
Opioid agonist therapies (OAT) to treat opioid addiction in people who inject drugs (PWID) began in Ukraine in 2004. Scale-up of OAT, however, has been hampered by both low enrollment and high attrition. To better understand the factors influencing OAT retention among PWID in Ukraine, qualitative data from 199 PWIDs were collected during 25 focus groups conducted in five Ukrainian cities from February to April 2013. The experiences of PWID who were currently or previously on OAT or currently trying to access OAT were analyzed to identify entry and retention barriers encountered. Transcribed data were analyzed using a grounded theory approach. Individual beliefs about OAT, particularly misaligned treatment goals between clients and providers, influenced PWID's treatment seeking behaviors. Multiple programmatic and structural issues, including inconvenient hours and treatment site locations, complicated dosing regimens, inflexible medication dispensing guidelines, and mistreatment by clinic and medical staff also strongly influenced OAT retention. Findings suggest the need for both programmatic and policy-level structural changes such as revising legal regulations covering OAT dispensing, formalizing prescription dosing policies and making OAT more available through other sites, including primary care settings as a way to improve treatment retention. Quality improvement interventions that target treatment settings could also be deployed to overcome healthcare delivery barriers. Additional patient education and medical professional development around establishing realistic treatment goals as well as community awareness campaigns that address the myths and fears associated with OAT can be leveraged to overcome individual, family and community-level barriers.
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Affiliation(s)
- Martha J Bojko
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.
| | | | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | | | | | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA; Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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Mukherjee TI, Wickersham JA, Desai MM, Pillai V, Kamarulzaman A, Altice FL. Factors associated with interest in receiving prison-based methadone maintenance therapy in Malaysia. Drug Alcohol Depend 2016; 164:120-127. [PMID: 27207155 PMCID: PMC5592792 DOI: 10.1016/j.drugalcdep.2016.04.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/25/2016] [Accepted: 04/30/2016] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Methadone maintenance therapy (MMT) is crucial for HIV prevention and treatment in people who inject opioids. In Malaysia, a large proportion of the prison population is affected by both HIV and opioid use disorders. This study assessed individual preferences and factors associated with interest in receiving MMT among male prisoners meeting criteria for opioid dependence in Malaysia. METHODS A convenience sample of 96 HIV-positive and 104 HIV-negative incarcerated men who met pre-incarceration criteria for opioid dependence was interviewed using a structured questionnaire to examine participant characteristics and attitudes toward MMT. Factors associated with interest in prison-based MMT initiation were identified using logistic regression analysis. RESULTS Among all participants, 85 (42.5%) were interested in receiving MMT within prison. Independent correlates of interest in prison-based MMT were being previously married (AOR=4.15, 95% CI: 1.15, 15.02), previously incarcerated (AOR=5.68, 95% CI: 1.54, 21.02), depression (AOR=3.66, 95% CI: 1.68, 7.98), daily heroin use in the 30days prior to incarceration (AOR=5.53, 95% CI: 1.65, 18.58), and more favorable attitudes toward MMT (AOR=19.82, 95% CI: 6.07, 64.74). CONCLUSIONS Overall, interest in receiving prison-based MMT was low, and was associated with adverse social, mental health, and drug use consequences. Incarceration provides a unique opportunity to initiate MMT for those who need it, however, optimal scale-up efforts must be systemic and address modifiable factors like improving attitudes toward and motivation for MMT. Informed or shared decision-making tools may be useful in improving expectations and acceptability of MMT.
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Affiliation(s)
- Trena I. Mukherjee
- Yale School of Public Health, Department of Chronic Disease Epidemiology, New Haven, CT, USA
| | - Jeffrey A. Wickersham
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA,Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mayur M. Desai
- Yale School of Public Health, Department of Chronic Disease Epidemiology, New Haven, CT, USA
| | - Veena Pillai
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adeeba Kamarulzaman
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA,Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L. Altice
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA,Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia,Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT, USA,Corresponding author at: Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, 135 College St., Suite 323, New Haven, CT, USA., (F.L. Altice)
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Kolind T, Duke K. Drugs in prisons: Exploring use, control, treatment and policy. DRUGS-EDUCATION PREVENTION AND POLICY 2016. [DOI: 10.3109/09687637.2016.1153604] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Torsten Kolind
- Centre for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, Bygn 1322, Aarhus C 8000, Denmark,
| | - Karen Duke
- Drug and Alcohol Research Centre, Middlesex University, The Burroughs, Hendon, London NW4, UK
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