The Risk Environment of Heroin Use Initiation: Young Women, Intimate Partners, and "Drug Relationships"

Dual-substance use disorder couples: An integrative review and proposed theoretical model

Committed romantic relationships between two individuals with Substance Use Disorder (or dual-SUD couples) are prevalent. Dual-SUD couples have poor treatment engagement and outcomes. Research has established a reciprocal link between relationship dynamics (e.g., conflict, intimacy) and substance use. Thus, the couple's relationship presents a distinct social context for both partner's substance use. Dual-SUD couples face unique challenges due to substance use being a shared behavior that may serve as a rewarding source of compatibility, closeness, and short-term relationship satisfaction despite it being at the cost of other alternative sources of substance-free reinforcement. Yet, treatment options for these couples are scarce. Dual-maladaptive health behaviors (e.g., dual-substance use) are challenging to treat; however, theory and preliminary research suggests that transformation of couple's joint motivation toward adaptive health behavior change may result in a more satisfying relationship and improved treatment outcomes for both individuals. The current paper reviews the extant literature on dual-SUD couples from theoretical, empirical, and treatment research and proposes an expanded paradigm regarding how we understand dual-SUD couples with the aim of informing basic research and treatment development.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Why Young Women Who Use Opioids Are at Risk for Rape: The Impact of Social Vulnerabilities and Sexually Coercive Drug Using Contexts

This study tests a theoretically informed model to understand why women who use opioids (WWUO) are at risk of rape while using drugs. Structured interviews were conducted with 168 WWUO. Three domains were hypothesized to increase risk: the sexually coercive context of drug use, women's social vulnerability, and drug use severity. Logistic regression examined the odds of being raped by domain. One-third of WWUO had been raped while using drugs. The sexually coercive context and social vulnerability domains significantly increased women's odds of being raped. Prevention efforts should target social and contextual factors.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs

BACKGROUND

People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored.

METHODS

We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%.

RESULTS

In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point.

CONCLUSION

Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

"They're not doing enough.": women's experiences with opioids and naloxone in Toronto

BACKGROUND

Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone access landscape, there is a need for up-to-date research on Canadian women's experiences with opioids. Studies on Canadian take-home naloxone programs are promising, but research beyond these programs is limited. Our study is the first to focus on women's experiences and perspectives on the opioid crisis in Ontario, Canada's most populous province, since the opioid crisis began in 2010.

OBJECTIVE

Our objective was to address research knowledge gaps involving Canadian women with criminal justice involvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioid overdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts, especially involving naloxone, are meeting their needs.

METHODS

We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women with experience of opioid use. They were recruited through the study's community partner in Toronto. Participants provided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadian government's responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysis was conducted to determine major themes within the data.

RESULTS

Thematic analysis identified seven major concerns despite significant differences in participant life and opioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counter in 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to 2016. The portability, dosage form, and effects of naloxone are important considerations for women who use opioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadian government's response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needs and views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma, addiction management, and housing.

CONCLUSIONS

Participants experienced with naloxone use found it to be useful in preventing fatal overdose, however many of their needs with regards to physical, mental, and social health, housing, harm reduction, and access to opioid treatment remained unmet.

Kentucky Women's Justice Community Opioid Innovation Network (JCOIN): A type 1 effectiveness-implementation hybrid trial to increase utilization of medications for opioid use disorder among justice-involved women

The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities.

A prospective cohort study of risk behaviours, retention and loss to follow-up over 5 years among women and men in a needle exchange program in Stockholm, Sweden

BACKGROUND

Needle exchange programs (NEP) are important in reducing risk behaviours among people who inject drugs (PWID), also exposed to HIV and hepatitis C (HCV) through injecting drug use (IDU). Women (WWID) compared to men who inject drugs (MWID), are particularly vulnerable with complex needs, however less is known about their risk determinants and NEP outcomes.

METHODS

In an open prospective NEP cohort, 697 WWID and 2122 MWID were followed, 2013-2018. Self-reported socio/drug-related determinants for receptive injection (needle/syringe and paraphernalia) and sexual risk behaviours at enrolment, lost to follow-up (LTFU) and probability of retention, were assessed for both groups. Multivariable logistic regression (adjusted odds ratios, aOR) for enrolment and Poisson regression (adjusted incidence rate ratios, aIRR) for LTFU, were used. Cumulative NEP-retention probability was analysed using a six- and 12-month scenario.

RESULTS

At NEP enrolment, injection risk behaviours among WWID were associated with: younger age; homelessness; amphetamine-IDU; non-participation in opioid substitution therapy (OST); history of custody and among MWID: lower education level; cohabitation; homelessness, being a tenant; amphetamine-IDU; non-participation in OST; history of being sectioned, HIV-negative and HCV-positive. Condomless sex among WWID was associated with: younger age; lower education-level; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; being HIV-negative and HCV-positive and among MWID: younger age; married; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; history of custody, prison and being HIV-negative. WWID had higher NEP-retention levels compared to MWID over time. Being LTFU among WWID was associated with being HIV-negative and reporting injection risk behaviours and among MWID, younger age, non-participation in OST, being HIV-negative and having protected sex.

CONCLUSIONS

Despite better NEP compliance among WWID, high injection and sexual risk behaviours in both gender-subgroups, especially in intimate relationships, suggests ongoing HCV and HIV-infection risks. Subgroup-variation in the NEP continuum of care warrants more gender-disaggregated research and tailoring gender-sensitive services may improve prevention, health and retention outcomes.

Ethnoepidemiology and mental health: insights from Latin America

In this essay, I explore methodological as well as theoretical implications of an ethno-epidemiological approach, aiming to integrate research findings in mental health into new conceptual models. With this objective, I first evaluate the roots and uses of the term “ethnoepidemiology” to designate three research strategies for scientific knowledge production: type I (studies of sociocultural risk factors and ethnically defined risk groups); type II (studies of lay models of distribution and occurrence of illness in populations); type III (ethnographic studies of projects and areas of epidemiologic research). As an illustration, selected methodological features of three studies in which I have participated are presented and discussed. I then elaborate upon methodological developments derived from this experience of doing research, generating new models for transcultural transdisciplinary research of mental health practices. Lastly, I comment on some broad implications of studying mental health problems from an integrated ethnographical and epidemiological point of view, in diverse and deeply unequal societies such as those of contemporary Latin America.

Risk perception, changing social context, and norms prevent transition to regular injection among people who smoke heroin

BACKGROUND

There is a lack of research examining what prevents people who smoke heroin from transitioning to regular injection. This qualitative study aims to improve understanding of environmental influences preventing people who smoke heroin from transitioning to regular injection.

METHODS

In-depth, semi-structured interviews (n = 15) were conducted with people who currently smoked heroin but never injected (n = 10) and those who injected on a few occasions but did not transition to regular injection (n = 5) in Northern Ireland. Multiple recruitment strategies were utilized to generate a community-based sample. Interviews were thematically analysed.

MAIN FINDINGS

Participants identified two main, interconnected influences preventing transition to injecting heroin. Firstly, resistance towards injecting was rooted in micro level perceptions of risks primarily arising from meso level social interactions with people who inject drugs and, to a lesser extent, harm reduction agencies. Secondly, participants identified meso and macro environments defined as changing social contexts and normative beliefs surrounding the acceptability of injecting within their drug-using social networks, facilitated by expanding heron markets, negative interactions with people who inject drugs and new groups of people choosing to smoke heroin due to perceptions of injection risks.

CONCLUSIONS

Findings illuminate environmental influences surrounding and shaping drug consumption practices. Harm reduction strategies should develop and implement safer smoking rooms, community and peer interventions, and improve accessibility to opioid substitution therapy and low threshold outreach services to prevent transitioning to regular heroin injecting.

You can't do this job when you are sober: Heroin use among female sex workers and the need for comprehensive drug treatment programming in Kenya

AIMS

Globally, women who use drugs often practice sex work and experience multiple health and social harms that complicate their drug treatment needs. In East Africa, understanding the emergence of heroin use among women is critical in efforts to build effective drug treatment programming, including the ongoing scale-up of medication-assisted treatment (MAT). We explored heroin use among women engaged in sex work in Kenya to inform services.

METHODS

In a qualitative study of 45 female sex workers reporting substance use in Kisumu, Kenya, 32 reported lifetime heroin use and comprise the focus of this analysis. Semi-structured interviews explored histories of substance use and sex work and health programming needs. Thematic analysis focused on the contexts and meanings of heroin use.

RESULTS

Among 32 women, median age was 28 (range: 18-37). Women commonly smoked cocktails containing heroin while using alcohol and other drugs prior to sex work. Most women perceived heroin to engender "morale" and "courage" to engage in sex work and "fight" potentially abusive clients. Sex work reinforced drug use in ways that both managed and created new risks.

CONCLUSIONS

Drawing on the concept of "paradoxical autonomy," we suggest that heroin use engenders new forms of autonomy allowing women to support themselves in conditions of uncertainty, yet does not enable them to entirely overcome their vulnerabilities. Drug treatment programs for sex workers should address the situated logics of substance use in contexts of sexual risk, including patterns of poly-substance use that may render MAT inappropriate for some women who use heroin.

Partner Relationships and Injection Sharing Practices among Rural Appalachian Women

BACKGROUND

The role of relationships in initiating and maintaining women's risk behaviors has been established. However, understanding factors that may underlie partner relationships and women's risky drug use, particularly in rural contexts, is limited. This study is the first to examine the association between injecting partners and women's risky injection practices as a function of relationship power perception.

METHODS

Female participants were recruited from three rural jails in the Appalachian region. Women were selected randomly, provided informed consent, and screened for study eligibility criteria. This cross-sectional analysis focuses on women who inject drugs during the year before entering jail (n = 199).

MAIN FINDINGS

Approximately three-quarters (76%) reported having a recent main male sexual partner with a history of injection drug use. Although having a risky partner independently increased the likelihood of women reporting shared injection practices, perceptions of relationship power significantly moderated the effect on shared needle (adjusted odds ratio, 0.02; 95% CI, 0.003-0.23; p = .001) and shared works (adjusted odds ratio, 0.17; 95% CI, 0.03-0.95; p = .04) use.

CONCLUSIONS

This interaction indicated that, for women who inject drugs with a recent injecting male partner, greater perception of relationship power was associated with a decreased likelihood of shared injection practices. Implications for clinical assessment and intervention are discussed.

Social-structural factors influencing periods of injection cessation among marginalized youth who inject drugs in Vancouver, Canada: an ethno-epidemiological study

BACKGROUND

Injection drug use is associated with HIV and hepatitis C transmission, overdose, and other preventable harms. These harms are heightened for structurally vulnerable injection drug-using populations, as their social conditions pose barriers to safer injecting. Previous research on injection cessation has largely focused on adult drug-using populations. Little qualitative work has examined the social, structural, and environmental factors that shape periods of injection cessation among youth and young adults. Such research is essential to understanding how we can best reduce harms among this vulnerable population as they move in and out of periods of injection cessation.

METHODS

We conducted 22 semi-structured, qualitative interviews with street-involved young people who use drugs (SY), focused on characterizing their transitions into periods of injection cessation and perceived barriers to injection cessation. Adopting an ethno-epidemiological approach, participants who had experienced at least 6 months of injection cessation were purposively recruited from an ongoing prospective cohort study of SY in Vancouver, Canada to participate in qualitative interviews. Qualitative interview findings were triangulated with the findings of a longitudinal program of ethnographic research with SY in this setting. This ethno-epidemiological approach allowed for a more robust exploration of contextual factors surrounding drug use patterns than would be possible through traditional epidemiological methods alone.

RESULTS

Findings indicate that periods of injection cessation were influenced by access to harm reduction-informed youth-focused services, transitions in route of administration (e.g., from injecting methamphetamine to the smoking of methamphetamine), and the provision of housing and social supports (e.g., from friends, family, and care providers). Conversely, participants indicated that inadequate social supports and, for some, abstinence-focused treatment methods (e.g., 12-step programs), impeded efforts to cease injecting.

CONCLUSIONS

To reduce harms, it is imperative to reorient attention toward the social, structural, and spatial contexts that surround injection drug use and shape periods of injection cessation for SY. There is an urgent need for more comprehensive youth-focused services for those engaged in injection drug use, and further study of innovative means of engaging youth.

Commentary on Sacks-Davis et al. (2016): Quantifying the risk environment-effect modification and precision population health

Substance use epidemiology focuses increasingly on the risk environment; however, few studies quantify the differential impacts of physical, social and structural environments on population health risk factors and outcomes. To do so, researchers studying the effects of the risk environment on drug-related harms should consider effect modification analyses.