Remote harm reduction services are key solutions to reduce the impact of COVID-19-like crises on people who use drugs: evidence from two independent structures in France and in the USA

BACKGROUND

Harm Reduction (HR) policies for People Who Use Drugs (PWUD) have a significant positive impact on their health. Such approaches limit the spread of infections and reduce opioid overdose mortality. These policies have led to the opening of specialized structures located mainly in big cities and urbanized zones. The COVID-19 pandemic reduced access to HR structures in locations undergoing lockdown. Before the pandemic, HR services in France and in the USA were complemented by the development of remote HR programs: HaRePo (Harm Reduction by Post) for France, implemented in 2011, and NEXT Distro for the USA founded in 2017. These programs are free and specifically designed for people who have difficulties accessing HR tools and counseling in-person. PWUD can access HaRePo program by phone and/or email. NEXT Distro users can access the program through its dedicated website. The aim of the study is to test if and possibly how COVID-19 pandemic and the associated lockdowns have impacted the HR services in both countries.

METHODS

By using t-test comparing the year 2019 with the year 2020, we analyzed how lockdowns impacted the number of new users entering the programs, as well as the numbers of parcels sent and naloxone distributed, by using records of both structures.

RESULTS

We showed that the activity of both programs was significantly impacted by the pandemic. Both show an increase in the number of new users joining the programs (+ 77.6% for HaRePo and + 247.7% for NEXT Distro) as well as for the number of parcels sent per month (+ 42.7% for HaRePo and + 211.3% for NEXT Distro). It shows that remote HR was able to partially compensate for the reduced HR activities due to COVID-19. We also observed that the distribution of naloxone per parcel tends to increase for both structures.

CONCLUSION

With the ability to reach PWUD remotely, HaRePo and NEXT Distro were particularly effective at maintaining service continuity and scaling up services to meet the needs of PWUD during the COVID-19 pandemic. By studying two independent structures in France and in the USA sharing similar objectives (remote HR), we showed that this approach can be a key solution to crises that impact classical HR structures despite various differences in operating procedures between countries.

NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe service program

Background

Despite proven health benefits, harm reduction services provided through in-person syringe services programs (SSPs) and pharmacies are largely unavailable to most people who inject drugs (PWID). Internet-based mail-delivered harm reduction services could overcome barriers to in-person SSPs. This manuscript describes Needle Exchange Technology (NEXT) Harm Reduction, the first formal internet-based mail delivery SSP in the US.

Methods

We examined the trajectory of NEXT's growth between February 2018 and August 2021. Descriptive statistics were used to characterize program participants. All analysis were run using STATA statistical software.

Results

Over the course of 42 months, 1,669 unique participants enrolled in NEXT. The program distributed 1,648,162 total syringes with a median of 79,449 syringes per month. Most participants ordered multiple times (61%); 31% had more 5 or more orders (upper range = 48 orders). The total number of syringes per month and total number of first-time syringe orders per month increased steadily over time, particularly after the onset of the COVID-19 pandemic.

Conclusions

The online platform and mail-delivery model appears successful in reaching PWID at high risk for harms from IDU. Changes to state laws and additional funding support are needed to make mail-delivery harm reduction more widely available throughout the US.

Participants of a mail delivery syringe services program are underserved by other safe sources for sterile injection supplies

BACKGROUND

In the United States, accessing sterile injection supplies remains challenging for many people who inject drugs (PWID). Although women are less likely to inject drugs than men, women who do inject are disproportionately affected by IDU-related complications. Needle Exchange Technology (NEXT), the first formal online accessed mail delivery syringe services program (SSP) in the US, may overcome access barriers. We evaluated whether NEXT was reaching women participants and people without access to other safe sources of sterile injection supplies.

METHODS

This cross-sectional study examined NEXT participants who enrolled in the mail-delivery SSP from February 2018 through March 2021. All NEXT participants completed an online questionnaire during enrollment, which included sociodemographic and clinical characteristics and injection-related risk factors (including prior sources of sterile injection supplies). Multivariable logistic regression (MVR) was used to examine associations between gender and prior use of safe sources of injection supplies (i.e., SSPs or pharmacies).

RESULTS

1,032 participants received injection supplies. Median age was 34 and participants were mostly cis-gendered women (55%) and white (93%). 34% reported infection with HCV; women were more likely to report HCV infection than men (38% vs 28%; p < 0.01). 68% of participants acquired injection supplies from less safe sources. Few participants exclusively used safe sources for injection supplies (26%). In adjusted MVR analysis, women participants had significantly lower odds than men of having exclusively used safe sources for injection supplies (adjusted OR 0.71, 95% CI 0.52, 0.98).

CONCLUSION

Our findings suggest that NEXT services are utilized by women and people without prior access to sterile injection supplies. Women participants were less likely than men to have exclusively used safe sources for sterile injection supplies. Future research should explore women's preference for mail-delivery over in-person SSPs and determine whether online accessed mail delivery services can reach other underserved populations of PWID.

NEXT Harm Reduction: An Online, Mail-Based Naloxone Distribution and Harm-Reduction Program

Needle EXchange Technology (NEXT) Harm Reduction is an online, mail-based platform designed for sending (1) naloxone kits to people at risk for overdose and (2) sterile syringes and other equipment directly to people who otherwise cannot access safe supplies. From its inception in 2017 through the end of 2019, NEXT Harm Reduction sent naloxone kits to 3609 individuals and 1230 packages of sterile syringes and supplies and received 335 reports of overdose reversals using naloxone provided by NEXT Harm Reduction and its affiliates.

Young people who use drugs engaged in harm reduction programs in New York City: Overdose and other risks

BACKGROUND

Little is known about the engagement of young people who use drugs (PWUD) in harm reduction programs (HRPs), and few studies have included non-opioid users and non-injectors. While HRPs have effectively engaged PWUD, young people are under-represented in their services.

METHODS

The Injection Drug Users Health Alliance Citywide Study (IDUCS) is the largest community-based study of PWUD in HRPs in the US. From 2014-2015, 2421 HRP participants across New York City (NYC) completed a cross-sectional survey. We investigated differences in socio-demographics, service utilization, and risk behaviors between young (aged 18-30) and older participants and examined factors associated with overdose among young participants.

RESULTS

The study included 257 young participants. They were significantly more likely than older participants to be white, educated, uninsured, unstably housed or homeless, and have a history of incarceration and residential drug treatment. They were more likely to report recent overdose but less likely to report knowledge of naloxone. Young participants also had higher rates of alcohol, marijuana, benzodiazepine, and injection drug use, and related risk behaviors such as public injection. Factors associated with past year overdose among young participants included experiencing symptoms of psychological distress (AOR=9.71), being unstably housed or homeless (AOR=4.39), and utilizing detox (AOR=4.20).

CONCLUSIONS

Young PWUD who access services at HRPs in NYC differ significantly from their older counterparts. New York City and other urban centers that attract young PWUD should consider implementing harm reduction oriented services tailored to the unique needs of young people.

Abstract S4-03: Exome sequencing reveals clinically actionable mutations in the pathogenesis and metastasis of triple negative breast cancer

Triple negative breast cancer (TNBC) represents a particularly aggressive and difficult to treat form of breast cancer. No specific genetic alterations have been described as characteristic of the disease, with the exception of association with BRCA1/2, EGFR, and KRAS mutations. In this study, we sought to define clinically actionable mutations in untreated metastatic tumors as well as compare the mutational status of metastatic samples with germ-line and primary tumors using whole exome sequencing.

We prospectively enrolled 38 patients with newly diagnosed metastatic TNBC and collected matched specimens of germ-line DNA, primary tumor and metastatic tumor. Median DFI from time of initial primary diagnosis to recurrence was 18 months (IQR = 1-24 months) and 9 patients presented with de novo metastatic disease. 34/38 patients went on to receive first-line treatment with nab-paclitaxel, carboplatin, and bevacizumab and ORR/PFS/OS are available.

Sites of TNBC metastatic tissue (n = 31) included: liver (10), chest wall (13), non-regional lymph nodes (4), and lung (4). 7 patients had inadequate metastatic tumor for sequencing. We performed whole-exome sequencing for all samples using the Agilent solution-based system of exon capture, which uses RNA baits to target all protein coding genes (CCDS database), as well as ∼700 human miRNAs from miRBase (v13). In all, we generated over 10 GB of sequencing data using high throughput sequencing on the Illumina platform.

We observed striking genetic heterogeneity among the metastatic and primary tumors. There was no single driver mutation that was common to the metastatic tumors indicating the diverse genetic pathways that contribute to metastasis. Early analysis suggests that mutations in APC and MTOR occur more frequently in metastatic tumors than in primary tumors. Nonsense mutations of ER were detected in both primary and metastatic tumors but not in germ-line DNA. EGFR and HER2 mutations were not found in any of the primary or metastatic TNBC samples.

This data provides the most comprehensive genetic portrait of metastatic and primary TNBC to date, and represents a significant first step in identifying the genetic causes of the disease, drivers of recurrence, and potential therapeutic targets. Full results, including the primary versus metastatic tumor mutational analysis will be presented.

This study was funded by a Susan G. Komen Grant SAC 100001.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S4-03.

Consumer attitudes about opioid addiction treatment: a focus group study in New York City

OBJECTIVE

To develop effective programs for people who are opioid dependent and to impact the opioid epidemic in New York City, it is crucial to monitor attitudes about opioid addiction treatments among opioid users who have experienced barriers to engagement and retention in addiction treatment.

DESIGN

The authors conducted a qualitative study using focus groups.

METHODS

Six focus groups in three needle exchanges in New York City were audio recorded, transcribed, and systematically coded. The authors report on the main themes related to the study objectives.

PARTICIPANTS

Participants of each needle exchange who were opioid dependent and had some knowledge of both methadone and buprenorphine were eligible.

RESULTS

There were four main findings. Participants felt the following: 1) buprenorphine is an appropriate option for those heroin users who are motivated to stop using, 2) they have less control over their addiction treatment with methadone than they would have with buprenorphine, 3) buprenorphine treatment is not accessible to many New York City residents who would benefit from this treatment, and 4) lack of access to buprenorphine treatment is a cause of treatment-related diversion.

CONCLUSIONS

Both methadone maintenance and buprenorphine treatment opportunities are necessary to address the diverse treatment needs of opioid-dependent people in New York City. However, the current medical model of buprenorphine treatment may be too restrictive for some opioid-dependent people and may be contributing to the use of illicit buprenorphine. New models to deliver buprenorphine treatment may address these problems.