Development of a risk reduction intervention to reduce bacterial and viral infections for injection drug users

Changing the High-Risk Behaviors of Injecting Drug Users in Iran: Application Theory of Planned Behavior

Background

Injection risk behavior is a major predictor of HIV infection. The present study was conducted to survey the effect of educational intervention based on the theory of planned behavior on changing high-risk behaviors (the high-risk behaviors of injecting and behaviors of transmitting blood diseases to others) of injecting drug users under the coverage of addiction harm reduction centers.

Methods

This study is an experimental research on 120 drug addicts in 2021-2022. Two addiction harm reduction centers in Fasa City, Iran, were chosen randomly (one as the test group and the other as the control group). The data collection tool is made up of two parts. The first part is a questionnaire on demographics. The second part is a questionnaire based on the theory of planned behavior, which was made using information from different sources and studies. The training program was set up based on the pretest results and the theory of planned behavior for the test group. Before and six months after the educational intervention, the experimental and control groups filled out the questionnaire. With a significance level of 0.05, the independent t, chi-square, and paired t statistical tests were used to examine the data using the SPSS 22 program.

Results

In the test group, the average age of addicts was 37.42 ± 10.55 years, while in the control group, the average age was 38.36 ± 10.09 years (p=0.244). Six months after the educational intervention, all TPB theory's constructs (knowledge, attitude, subjective norms and perceived behavioral control, behavioral intention, and behavior of injecting drug users) were higher in the test group than in the control group (p=0.001).

Conclusion

The results show the effect of this educational intervention in reducing high-risk behaviors related to injection in injection drug addicts, so it is suggested as a useful method to reduce high-risk injection behaviors in these people.

Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis

BACKGROUND AND AIMS

Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections.

METHODS

We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes.

RESULTS

We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission).

CONCLUSIONS

Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.

Association of skin infections with sharing of injection drug preparation equipment among people who inject drugs

BACKGROUND

Sharing needles and injection drug preparation equipment (IDPE) among people who inject drugs (PWID) are well-established risk factors for viral transmission. Shared needles and IDPE may serve as bacterial niduses for skin and soft tissue infections (SSTI). Given the rising rates of SSTI in PWID, we investigated the association of needle and IDPE sharing on incidence of SSTI in a cohort of PWID.

METHODS

Inpatient PWID (N = 252) were recruited to a randomized controlled trial of an intervention aimed at reducing infections. The primary outcome was self-reported incidence of SSTI one-year post-hospitalization. In this secondary analysis, we assessed two variables: 1) sharing of IDPE alone, 2) sharing needles with or without IDPE, and compared these groups separately to persons who reported no sharing of needles or IDPE via a mixed-effects negative binomial regression model to estimate the effect of baseline sharing behavior on SSTI during follow-up via incidence rate ratios (IRR).

RESULTS

Participant characteristics: 38 years [mean], 58% male, 60% White, 90% primarily injected opioids, 1.58 (± 2.35) mean SSTI in the year prior to baseline. In terms of sharing behavior, 29% didn't share needles or IDPE, 13% shared IDPE only, and 58% shared needles with or without IDPE three months prior to baseline. After adjusting for co-variables, PWID who shared IDPE alone had a 2.2 fold higher IRR of SSTI (95%CI 1.27; 3.85, p = 0.005) and PWID who shared needles with or without IDPE had a 3.31 fold higher IRR of SSTI (95%CI 2.04; 5.37, p < 0.001), compared to those who did not share any equipment. The number of SSTI at baseline was associated with an IRR of 1.20 of SSTI during follow-up (95%CI 1.09; 1.32, p < 0.001).

CONCLUSIONS

In this cohort of hospitalized PWID, we found a significant association between baseline sharing of IDPE alone and of sharing of needles with or without IDPE with one-year incidence of SSTI.

Injecting drug use, the skin and vasculature

Damage to the skin, subcutaneous tissues and blood vessels are among the most common health harms related to injecting drug use. From a limited range of early reports of injecting-related skin and soft tissue damage there is now an increasing literature relating to new drugs, new contaminants and problems associated with unsafe injection practices. Clinical issues range from ubiquitous problems associated with repeated minor localised injection trauma to skin and soft tissue and infections around injection sites, to systemic blood infections and chronic vascular disease. The interplay of limited availability and access to sterile injecting equipment, poor injecting technique, compromised drug purity, drug toxicity and difficult personal and environmental conditions give rise to injection-related health harms. This review of injecting-related skin, soft tissue and vascular damage focuses on epidemiology and causation, clinical examination and investigation, treatment and prevention.

Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs

This article reviews the principles of harm reduction, evidence-based harm reduction strategies such as syringe service programs and supervised injection facilities, and provides approaches to integrating a harm reduction approach into clinical practice. As providers strive to increase capacity to treat underlying substance use disorder, we must also recognize that some people may continue to use drugs. In this setting, providers can still deliver nonjudgmental, individualized care, and advocate for the health and safety of people who inject drugs.

Skin-cleaning among hospitalized people who inject drugs: a randomized controlled trial

AIMS

To test the hypothesis that among hospitalized people who inject drugs (PWID), a brief intervention in skin-cleaning would result in greater reductions in follow-up emergency department (ED) or hospitalization rates compared with a usual care condition.

DESIGN

Randomized, two-group (intervention, n = 128; usual care, n = 124), single-site clinical trial with12-month follow-up.

SETTING

Hospital inpatient services in Boston, Massachusetts, United States.

PARTICIPANTS

People who injected drugs on at least 3 days each week prior to hospital admission (n = 252). Participants averaged 37.9 (± 10.7) years of age; 58.5% were male, 59.3% were white and 61.1% had a diagnosis related to skin infection at enrollment.

INTERVENTION AND COMPARATOR

Intervention was a skin hygiene education and skills-training behavioral intervention [short-term efficacy data on a behavioral intervention (SKIN)] consisting of two education- and skills-based skin-cleaning sessions, one during hospitalization and another 4 weeks later. The comparator was treatment as usual: an informational brochure about substance use treatment options and needle exchange programs in the area and follow-up clinical appointments as arranged by the inpatient medical staff.

MEASUREMENTS

Electronic medical records were reviewed and discharge diagnoses for each ED visit and hospital admission were categorized into injection-related bacterial events (e.g. cellulitis) and non-injection-related events. Negative binomial regression was used to test the intervention effects for the primary outcome and total ED visits, as well as the secondary outcomes, total number of hospitalizations, injection drug use-related (IDU-related) ED visits and IDU-related hospitalizations. We also tested whether the outcomes were moderated by whether the initial hospitalization was IDU-related.

FINDINGS

Of people assigned to SKIN, 66 completed two sessions, 55 completed one session and seven completed zero sessions. Adjusting for baseline covariates, the mean rate of total ED visits in the next 12 months was non-significantly higher [incidence rate ratio (IRR) = 1.13, 95% confidence interval (CI) = 0.96, 1.33, P = 0.152] compared with usual treatment. The intervention did not significantly reduce total hospitalizations or IDU-related hospitalizations. Adjusting for baseline covariates, the mean rate of injection drug use-related ED visits in the next 12 months was lower (IRR = 0.57, 95% CI = 0.35, 0.91, P = 0.019) compared with treatment as usual.

CONCLUSIONS

A skin-cleaning intervention for people who inject drugs delivered during a hospitalization did not significantly reduce either overall emergency department use or hospitalization. There was some evidence that it may have reduced injection drug use-related emergency department visits.

A randomized controlled trial of a brief behavioral intervention to reduce skin and soft tissue infections among people who inject drugs

BACKGROUND

People who inject drugs (PWID) are at high risk for skin and soft tissue infections (SSTIs), but few interventions have targeted their reduction. The goal of the current study was to test the effects of a brief skin and needle hygiene behavioral intervention (SKIN) in a two-group randomized controlled trial with 12-month follow-up.

METHOD

PWID (N = 252) were recruited from inpatient hospital units at a single urban medical center site and randomly assigned to an assessment-only (AO) condition or SKIN, which was a two-session intervention that included psychoeducation, behavioral skills demonstrations, and motivational interviewing. Mixed effects generalized linear models assessed the impact of the intervention on frequency of: 1) self-reported SSTIs, 2) uncleaned skin injections, and 3) injection.

RESULTS

Participants were 58.3 % male, 59.5 % White, and averaged 38 years of age. SKIN participants had 35 % fewer SSTIs compared to AO (p = .179), a difference of nearly one infection per year. The mean rate of uncleaned skin injections was about 66 % lower (IRR = 0.34, 95 % CI 0.20; 0.59, p < .001) among SKIN participants compared to AO. Almost one-third of participants reported no injection over follow-up and the mean rate of injection during follow-up was about 39 % lower (IRR = 0.61; 95 % CI 0.36; 1.02, p = .058) among persons randomized to SKIN than AO.

CONCLUSIONS

The SKIN intervention reduced uncleaned skin injections but did not reduce SSTIs significantly more than a control condition. Brief interventions can improve high-risk practices among PWID and lead to clinically meaningful outcomes.

Risk factors for leg ulceration in people who inject drugs: A cross-sectional study

AIMS AND OBJECTIVES

The aim of this study was to assess, for the first time in a hard-to-reach population, the risk factors for leg ulceration among PWID, with the objective of making improvements to prevention and care.

BACKGROUND

An estimated 4.8 million people globally inject drugs with potential for injecting-related harm. Skin and vein damage associated with drug injecting is increasing. Leg ulceration is a chronic condition which in the UK has a prevalence of 15% among people who have injected drugs (PWID) compared with 1% in the general population. Glasgow has the highest rate of problematic drug use in Scotland with approximately 13,900 individuals, about 50% of whom are thought to inject. However, the reasons for high prevalence of leg ulceration among PWID are unknown. To support improvements in prevention and care, the dearth of evidence around risk factors for leg ulceration in PWID needs to be addressed.

DESIGN

A cross-sectional survey of 200 current and former injectors recruited from drug services in Glasgow, Scotland, to measure skin problems, leg ulceration and injecting habits is reported following STROBE guidelines. Logistic regression modelling examined whether demographics and injecting habits predicted leg ulceration.

RESULTS

The likelihood of leg ulceration was increased for those who injected in the groin and the leg. Additionally, injecting in the groin and leg were associated with having a DVT.

CONCLUSION

The primary risk factors for leg ulceration in PWID are injecting in the groin and the legs and these are clinically linked to deep vein thrombosis. Injecting into the femoral vein is increasingly common practice for PWID and healthcare practitioners should advise injectors of the increased risk of leg ulceration and DVT and discourage injecting into these areas.

A randomized clinical trial of a theory-based fentanyl overdose education and fentanyl test strip distribution intervention to reduce rates of opioid overdose: study protocol for a randomized controlled trial

Background

Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs.

Methods

Residents of Rhode Island aged 18–65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses.

Discussion

If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose.

Trial registration

ClinicalTrials.gov NCT04372238. Registered on 01 May 2020

Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care

In the United Kingdom, increases in premature mortality among the intersecting populations of people made homeless and people who inject drugs map onto the implementation and solidification of fiscal austerity policies over the past decade, rather than drug market fluctuations and trends as in North America. In this context, it is crucial to explore how poverty, multi-morbidity and care delay interplay in exacerbating vulnerability to mortality among an aging population of people who use illicit drugs. The mixed methods Care & Prevent study generated survey data with 455 PWID and in-depth qualitative interviews with a subsample (n = 36). Participants were recruited though drug treatment services and homeless hostels in London from October 2017-June 2019. This paper focuses on qualitative findings, analysed thematically and contextualised in relation to the broader survey sample. Survey participants report an extensive history of rough sleeping (78%); injecting-related bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts emphasise engagement with the medical system as a 'last resort', with admission to hospital in a critical or a "near death" condition common. For many severe physical pain and debility were normalised, incorporated into the day to day. In a context of everyday violence and marginalisation, avoidance of medical care can have a protective impetus. Translation of cultural safety principles to care for people who inject drugs in hospital settings offers transformative potential to reduce serious health harms among this population.

Geographically Diverse Clusters of Nontoxigenic Corynebacterium diphtheriae Infection, Germany, 2016-2017

From 2016 through the middle of 2017, the German Consiliary Laboratory on Diphtheria noted an increase in nontoxigenic Corynebacterium diphtheriae isolates submitted from cities in northern Germany. Many patients for whom epidemiologic data were available were homeless, alcohol or drug abusers, or both. After performing routine diagnostics and multilocus sequence typing (MLST), we analyzed isolates of sequence type (ST) 8 and previously submitted isolates by whole-genome sequencing. Results were analyzed for phylogenetic relationship by core genome MLST (cg-MLST) and whole-genome single-nucleotide polymorphism profiles. Next-generation sequencing–based cg-MLST revealed several outbreak clusters caused by ST8; the geographic focus was in the metropolitan areas of Hamburg and Berlin. To achieve enhanced analytical depth, we used additional cg-MLST target genes and genome-wide single-nucleotide polymorphisms. We identified patient characteristics and detected transmission events, providing evidence that nontoxigenic C. diphtheriae infection is a potential public health threat in industrialized countries.

The experiences of people who inject drugs of skin and soft tissue infections and harm reduction: A qualitative study

BACKGROUND

Bacterial skin and soft tissue infections (SSTI) among people who inject drugs (PWID) are considered a public health concern. There is a lack of qualitative research examining the lived experience of PWID who have had SSTI. This paper explores PWID views and experiences of their SSTI, their perceptions on the causes of their SSTI and their harm reduction (HR) behaviours. The implications for HR service delivery and practice will be discussed.

METHODS

Between October 2015-January 2016, 22 in-depth interviews were conducted with PWID who had experienced a SSTI within the past year. Interviewees were recruited from an injecting equipment provision service and a drug treatment service in Glasgow and Edinburgh respectively. The interview transcripts were transcribed verbatim and underwent thematic analysis.

RESULTS

We found that the experience of SSTI can cause strong negative feelings, including panic and stigma and that there was limited knowledge of SSTI prior to first hand experience. The awareness of the unacceptable social and physical consequences of SSTI fostered a sense of personal responsibility and agency which led to the introduction or improved HR uptake. However, when PWID were struggling to inject or when their physical and political environments were compromised there was an increased risk for SSTI and reduced effectiveness of HR.

CONCLUSION

Compared to HCV and HIV, SSTI as an injecting related harm has received less policy attention. Policy makers need to address SSTI HR within enabling environments, such as 'safer environment interventions'. It is recommended that peer based support, improved NSP provision and medically supervised injecting facilities are needed to deliver SSTI HR.

Both localized and systemic bacterial infections are predicted by injection drug use: A prospective follow-up study in Swedish criminal justice clients

Background

Both skin and soft tissue infections (SSTI) and systemic bacterial infections are common in people who inject drugs (PWID), but data on incidence and risk factors are lacking. We compared registered diagnoses for such infections in Swedish criminal justice clients with regard to injecting drug use.

Methods

Baseline interview data from the Swedish Prison and Probation Service on drug use in PWID and non-PWID with problematic alcohol use were linked to follow-up data from national Swedish registers on hospital diagnoses and/or death. Associations between drug use and later diagnosis of SSTI and systemic bacterial infection (septicemia or bacterial infection of the heart, bone/joints or central nervous system) were analyzed by Cox regression.

Results

Incidence rates of SSTI was 28.3 per 1,000 person-years for PWID (n = 2,444) and 10.0 for non-PWID with problematic alcohol use (n = 735). Incidence rates of systemic bacterial infection was 9.1 per 1,000 person-years for PWID and 2.7 per 1,000 person-years for non-PWID. Injection drug use was associated with a significantly increased risk of bacterial infections, for main drugs heroin (SSTI: Hazard ratio [HR] 2.45; systemic infection: HR 2.75), amphetamine (SSTI: HR 1.60; systemic infection: HR 2.19), and polysubstance use (SSTI: HR 1.92; systemic infection: HR 2.01). In relation to injection use of amphetamine and polysubstance use, PWID mainly using heroin had higher risk of SSTI.

Conclusions

Injection drug use predicted both SSTI and systemic bacterial infection, with a particularly high risk of SSTI in PWID mainly using heroin. The results imply the need for increased attention to bacterial infections among PWID, in terms of clinical management, prevention and research.

Behavioral characteristics and injection practices associated with skin and soft tissue infections among people who inject drugs: A community-based observational study

BACKGROUND

People who inject drugs (PWID) are at increased risk for bacterial skin and soft tissue infections (SSTIs). Although SSTIs pose significant health risks, little is known about their prevalence and characteristics in the population of PWID in the United States. This study investigates whether behavioral factors related to skin and equipment hygiene and tissue-damaging injection practices are associated with recent SSTIs among PWID.

METHODS

Active PWID were recruited using targeted sampling in San Francisco in 2011-2013. Interviewers collected information on behavioral risk factors of past-month self-reported SSTIs. Inferential analyses used multivariate logistic regression methods (i.e., generalized linear model) to characterize risk factors for past-month SSTIs.

RESULTS

The self-reported prevalence of lifetime, past-year, and past-month SSTI was 70%, 29%, and 11%, respectively. Several factors were significantly associated with past-month SSTIs in bivariate analysis, including injecting nonpowder drugs (odds ratio [OR] = 3.57; 95% confidence interval [CI] = 1.23, 10.35; P = .01), needle-licking before injection (OR = 3.36; 95% CI = 1.28, 8.81; P = .01), injecting with someone else's preused syringe/needle (OR = 7.97; 95% CI = 2.46, 25.83; P < .001), being injected by another person (OR = 2.63; 95% CI = 1.02, 6.78; P = .04), infrequent skin cleaning before injection (OR = 2.47; 95% CI = 1.00, 6.10; P = .04), and frequent injections (P = .02). In multivariate analysis, only syringe/needle sharing (adjusted OR = 6.38; 95% CI = 1.90, 21.46) remained statistically significant.

CONCLUSION

SSTIs are common among PWID. These data highlight the importance of clinical and public health screening efforts to reduce SSTIs. Needle exchange programs may be good venues for SSTIs screening and treatment.

Tailoring a brief intervention for illicit drug use and alcohol use in Irish methadone maintained opiate dependent patients: a qualitative process

BACKGROUND

The World Health Organization (WHO) recommend the tailoring of a brief intervention (BI) programme of research to ensure that it is both culturally and contextually appropriate for the country and the environment in which it is being tested. The majority of BI research has been conducted with non-opioid dependent participants. The current study developed a tailored BI for illicit drug use and alcohol use to a methadone maintained opioid dependent polydrug using cohort of patients.

METHODS

Focus groups with staff and one-to-one qualitative interviews with patients guided the tailoring of all intervention materials for use in a subsequent cluster randomised controlled trial (RCT). This was done to make them contextually appropriate to an opioid dependent cohort and culturally appropriate to Ireland. Thematic analyses were utilised.

RESULTS

The BI was modified to ensure its compatibility with the culture of an Irish drug using population, with elements of motivational interviewing (MI) and personalised feedback incorporated. Example scripts of a screening and BI were included, as was an algorithm to facilitate clinicians during a session. Modifications to the 'Substance Use Risk' cards included weighting the severity of the problems, writing the language in the first person to personalise the feedback and including tick boxes so as to further highlight the relevant risk factors for individual patients. Photographs of key risk factors were included to display pictorially risks for illiterate or semi-literate patients. Examples of the interaction of particular substances with methadone were of particular importance to this group. Modifications of the 'Pros and Cons of Substance Use/Reasons to Quit or Cut Down' included additional categories such as addiction, crime and money that were salient to this cohort. The manual was used to standardise training across trial sites.

CONCLUSION

The research team was faithful to WHO recommendations to tailor BI programmes that are culturally and contextually appropriate to the treatment cohort and clinical environment. Outcome data from the cluster RCT have demonstrated that the tailored intervention was effective.

Barriers to practicing risk reduction strategies among people who inject drugs

INTRODUCTION AND AIMS

People who inject drugs (PWID) engage in practices that put them at risk for various infections and overdose. The primary aim of this study was to examine common barriers to engaging in two risk reduction practices - cleaning one's skin at the injection site and always using new needles to inject - among heroin injectors in Denver, CO.

METHOD

In 2010, 48 PWIDs were recruited through street outreach and completed a structured interview that included questions on the frequency of specific risk reduction practices (skin cleaning and using new needles) and barriers associated with these practices.

RESULTS

Though many of the reported barriers were similar across the two practices, the most common barriers associated with skin cleaning included being in withdrawal and not being prepared with materials prior to injection. Fear of being arrested and being in withdrawal were most frequently reported for using new needles. Multivariate and t-test analyses demonstrated that individuals who skin cleaned and used new needles more frequently reported less barriers to these practices.

CONCLUSIONS

Participants reported a number of barriers to risk reduction, including those that are within the personal control of the injector, barriers that are consequences of addiction or psychological problems, and those that are structural or a function of the risk environment. Statistical analysis found that PWIDs who were more likely to skin clean and use new needles reported less barriers. Addressing barriers when intervening with PWID appears important to increase the success of risk reduction interventions.