Resilience among IDUs: planning strategies to help injection drug users to protect themselves and others from HIV/HCV infections

Alcohol, tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factors

BACKGROUND

Substance use contributes to poor health and increases the risk of mortality in the homeless population. This study assessed the prevalence and risk levels of substance use and associated factors among adults experiencing homelessness in Accra, Ghana.

METHODS

305 adults currently experiencing sheltered and unsheltered homelessness in Accra aged ≥ 18 years were recruited. The World Health Organization's (WHO) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to assess substance use risk levels. Association of high-risk substance use with sociodemographic, migration, homelessness, and health characteristics were assessed using logistic regression.

RESULTS

Nearly three-quarters (71%, n = 216) of the sample had ever used a substance, almost all of whom engaged in ASSIST-defined moderate-risk (55%) or high-risk (40%) use. Survivors of physical or emotional violence (AOR = 3.54; 95% confidence interval [CI] 1.89-6.65, p<.001) and sexual violence (AOR = 3.94; 95%CI 1.85-8.39, p<.001) had significantly higher odds of engaging in high-risk substance use, particularly alcohol, cocaine, and cannabis. The likelihood of engaging in high-risk substance use was higher for men than women (AOR = 4.09; 95%CI 2.06-8.12, p<.001) but lower for those in the middle-income group compared to low-income (AOR = 3.94; 95%CI 1.85-8.39, p<.001).

CONCLUSIONS

Risky substance use was common among adults experiencing homelessness in Accra, and strongly associated with violent victimisation, gender, and income levels. The findings highlight the urgent need for effective and targeted preventive and health-risk reduction strategies to address risky substance use in the homeless population in Accra and similar cities within Ghana and sub-Sahara Africa with a high burden of homelessness.

"It's not just the hit itself": the social practice of injecting drug use among gay and bisexual men in Australia

BACKGROUND

Injecting drug use is purportedly more common among gay and bisexual men (GBM) than the general Australian population. Approaches designed to support the wellbeing of people who inject drugs may not be effective for GBM who inject, due to divergent settings, substances, and/or symbolism. We sought to identify the critical elements shaping injecting among GBM as a social practice and the implications for health and psychosocial wellbeing.

METHODS

We conducted 19 in-depth interviews with GBM in Australia with lifetime experience of injecting drug use, adopting the Frameworks Method for data analysis. Framed by social practice theory, transcripts were coded to delineate the constituent material, competency, and meaning elements of GBM's injecting practices. We developed themes encompassing the dynamic interrelationship between practice elements and wellbeing aspects.

RESULTS

Of 19 participants interviewed (aged 24-60 years), 17 identified as gay, two as bisexual. Injecting histories ranged from 2-32 years; most injected methamphetamine (n = 18). Injecting involved the integration of sexual function with substances and injecting skills in dyadic/communal settings. Beyond traditional harm reduction aspects, 'safe injecting' concerned trustworthiness of fellow practitioners, preventing addiction, and maintaining a solid self-concept. Injecting occurred as a dyadic/communal practice, in which an uneven distribution of materials (substances, sexual capital) and competencies (self-injecting) influenced risk and power dynamics. Pleasurable meanings of belonging, desirability and self-actualisation - gained from communities of practice - conflicted with injecting-related stigma, social dependencies, and fear of harms to body, mind, and sense of self.

CONCLUSION

Injecting is a heterogenous practice, including among GBM. Shifting configurations of its composite elements influence GBM's perceptions and experiences of pleasure, risk, and harms. Efforts to support their wellbeing should take a dyadic/communal approach and seek to rectify the uneven distribution of material and competency elements in these settings.

The discourses of risk of drug users in prison

INTRODUCTION AND OBJECTIVES

In the last twenty years, sociological changes and actions aimed at improving the health of inmates have contributed to decrease the prevalence of infectious diseases and overdoses among prison population. Currently, however, drug addictions treatment penitentiary programs are questioned for lacking of innovation and deficiencies in coverage. In order to investigate this issue we analyzed the discourses of imprisonned people regarding drug use and drug addiction programs.

MATERIALS AND METHODS

We applied a qualitative phenomenological method. We carried out four discussion groups with 29 encarcerated drug users and made an analysis of the discourse about different possitionings towards drug use and drug addiction treatment programs.

RESULTS

From the combination of positions regarding drug use and drug addiction treatment programs emerged three kind of discourses respectively called: a) "reckless", characteristic of people implied in risk practices without taking preventive measures; b) "adventourous", tipical of those that take drugs both keeping the benefits of these practices and controls its negative consequences using prevention measures; c) "prudent", of abstainers or occasionally users that minimize risks and damages.

DISCUSSION

Encarcerated population accept drug use practices based on three risk discourses. The present study shows out that, in order to increase the effectiveness of drug policies in prison, drug treatement programs goals must be adapted to drug users particular economization of risk strategies.

Exploration of Associations Between Early Maladaptive Schemas, Impaired Emotional Regulation, Coping Strategies and Resilience in Opioid Dependent Poly-Drug Users

BACKGROUND

Early Maladaptive Schema (EMS) are self-beliefs regarding oneself, others and the world, developed in childhood as the result of cumulative negative experiences (Young, 1993). High levels of EMS are present in the opioid using population along with high levels of emotional dysregulation and maladaptive coping alongside traits of resilience.

OBJECTIVES

The study explored the associations between EMS in relation to emotional dysregulation, maladaptive coping, adaptive coping and resilience between a clinical group composed of opioid dependent polydrug users attending a facility for opioid substitution treatment (n = 52) and a healthy comparison group (n = 70).

METHODS

A cross-sectional design was used to compare group differences using MANOVAs, and multiple regression analysis identified associations between EMS and emotional dysregulation, coping and resilience.

RESULTS

The groups significantly differed in relation to emotional dysregulation, maladaptive coping, adaptive coping and resilience. Specific EMS were significant independent predictors in regards to high emotional dysregulation, maladaptive coping, adaptive coping and resilience.

CONCLUSION

EMS appear to have a significant impact on emotional dysregulation, coping and resilience. Clinical implications suggest that EMS should be addressed when treating opioid dependent polydrug users.

Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial

BACKGROUND

Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment.

OBJECTIVES

To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control.

DESIGN

A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London.

SETTING

NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016.

PARTICIPANTS

Current PWID, aged ≥ 18 years.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control).

MAIN OUTCOME MEASURES

Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability.

RESULTS

A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported.

CONCLUSIONS

As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs.

FUTURE WORK

The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female.

LIMITATIONS

Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.

Is there room for resilience? A scoping review and critique of substance use literature and its utilization of the concept of resilience

Research in the area of illicit substance use remains preoccupied with describing and analyzing the risks of people who use drugs (PWUD), however more recently there has been a drive to use a strengths-based or resilience approach as an alternative to investigating drug use. This leads us to ask: what can be known about PWUD from the point of view of resilience? The objective of this scoping review is to analyze how the concept of resilience is defined, operationalized, and applied in substance use research. Popular health, social science, psychology, and inter-disciplinary databases namely: SCOPUS, PUBMED, PsycINFO, and Sociological Abstracts were searched. Studies were selected if they used the concept of resilience and if substance use was a key variable under investigation. A total of 77 studies were identified which provided a definition of resilience, or attempted to operationalize (e.g., via scales) the concept of resilience in some manner. Data were charted and sorted using key terms and fundamental aspects of resilience. The majority of studies focus on youth and their resistance to, or engagement in, substance use. There is also a small but growing area of research that examines recovery from substance addiction as a form of resilience. Very few studies were found that thoroughly investigated resilience among PWUD. Consistently throughout the literature drug use is presented as a 'risk factor' jeopardizing one's ability to be resilient, or drug use is seen as a 'maladaptive coping strategy', purporting one's lack of resilience. Currently, substance use research provides a substantial amount of information about the internal strengths that can assist in resisting future drug use; however there is less information about the external resources that play a role, especially for adults. Though popular, outcome-based conceptualizations of resilience are often static, concealing the potential for developing resilience over time or as conditions change. Studies of resilience among PWUD predominantly concentrate on health-related behaviours, recovery-related factors or predefined harm reduction strategies. Indeed, overall, current conceptualizations of resilience are too narrow to recognize all the potential manifestations of resilience practices in the daily lives of individuals who actively use drugs.

The case of a needle exchange policy debate in Fresno, California

Needle exchange is one of the most effective public health interventions to prevent the transmission of infectious disease by injecting drug users. Despite the preponderance of scientific evidence, US federal funding for needle exchange programmes has been banned since 1988. This prohibition has resulted in the lack of a centralised policy on needle exchange and has given birth to a patchwork of diverse practices and regulations throughout the nation. This article focuses on how various local players interpreted the meaning of needle exchange through the debate on an unauthorised site in Fresno, California. In exploring a specific context, this study delineates the narratives used to outline competing views about needle exchange and to offer a snapshot of how the issue of widespread injecting drug use was handled in an impoverished and socially conservative region of the United States.

More than just someone to inject drugs with: Injecting within primary injection partnerships

BACKGROUND

Studies have shown intimate injection partners engage in higher rates of syringe and injecting equipment sharing. We examined the drug use context and development of injection drug use behaviors within intimate injection partnerships.

METHODS

In-depth interviews (n=18) were conducted with both members of nine injecting partnerships in Sydney, Australia. Content analysis identified key domains related to the reasons for injecting with a primary injection partner and development of drug injection patterns.

MAIN FINDINGS

Most partnerships (n=5) were also sexual; three were blood-relatives and one a friend dyad. The main drug injected was heroin (66%) with high rates of recent sharing behaviors (88%) reported within dyads. Injecting within a primary injection partnership provided perceived protection against overdose events, helped reduce stress, increased control over when, where, and how drugs were used, and promoted the development of an injecting pattern where responsibilities could be shared. Unique to injecting within primary injection partnerships was the social connection and companionship resulted in a feeling of fulfillment while also blinding one from recognizing risky behavior.

CONCLUSIONS

Findings illuminated the tension between protection and risks within primary injection partnerships. Primary injection partnerships provide a potential platform to expand risk reduction strategies.

L, Latimer W. Gender differences in planning ability and hepatitis C virus among people who inject drugs

Hepatitis C virus (HCV) is primarily spread through risky injection practices, including sharing needles, cookers, cottons, rinse water, and the practice of backloading. An important aspect of harm reduction for people who inject drugs (PWID) is to identify factors that contribute to safer injection. Planning ability may influence risky injection practices and gender differences in factors that drive injection practices indicate a need to examine associations between planning and injection behaviors in men versus women. Data from the NEURO-HIV Epidemiologic Study was restricted to those who had ever injected in their lifetime (n=456). Impaired planning ability was assessed with the Tower of London and defined as a standardized total excess move score below the 10th percentile. We used logistic regression to estimate the gender-specific adjusted odds ratios (AOR) and 95% confidence intervals (CI) for associations between impaired planning, each injection practice, and biologically-confirmed HCV. Impaired planning ability was associated with sharing needles (AOR=2.93, 95% CI: 1.33, 6.47), cookers (AOR=3.13, 95% CI: 1.22, 8.02), cottons (AOR=2.89, 95% CI: 1.23, 6.78), rinse water (AOR=2.43, 95% CI: 1.15, 5.14), and backloading (AOR=2.68, 95% CI: 1.26, 5.70) and HCV (AOR=3.42, 95% CI: 1.03, 11.38) among men. Planning ability was not significantly associated with the injection behaviors or HCV among women, suggesting that other factors likely contribute to risky injection practices. Interventions to promote harm reduction among PWID should ascertain and strengthen planning ability. Women may have additional barriers to practicing safe injection beyond impaired planning abilities, which should also be addressed.

Sustained drug use changes after hepatitis C screening and counseling among recently infected persons who inject drugs: a longitudinal study

BACKGROUND

Notification of hepatitis C virus (HCV) positive status is known to have short-term impacts on subsequent alcohol, drug use and injection behaviors among persons who inject drugs (PWID). It remains to be established whether postscreening behavioral changes extend over time for PWID and whether screening test notification has behavioral impacts among HCV-negative PWID. This study sought to longitudinally assess substance use and injection behaviors after HCV status notification among HCV seroconverters and HCV-negative PWID.

METHODS

Initially HCV-seronegative PWID (n = 208) were followed prospectively between 2004 and 2011 in Montreal, Canada. Semiannual screening visits included blood sampling and an interview-administered questionnaire assessing substance use and injection behaviors. Multivariable generalized estimating equation analyses were conducted to assess substance use and behavior changes over time and compare changes between HCV seroconverters and HCV-seronegative participants while adjusting for baseline characteristics.

RESULTS

Of the 208 participants (83% male; mean age, 34.7 years, mean follow-up time, 39 months), 69 (33.2%) seroconverted to HCV. A linear decrease in syringe sharing behavior was observed over time after HCV and status notification, whereas a 10% decrease for each additional 3 months of follow-up was observed for injection cocaine and heroin use among HCV seroconverters but not among HCV-seronegative PWID (P < .05). No significant changes were observed in alcohol use.

CONCLUSIONS

Our results indicate that notification of HCV-positive status is associated with reduced injection drug use among seroconverters. Among PWID deemed seronegative after screening, there is no sustained trend for change in risk behavior.