Risk Factors Associated with HCV Among Opioid-Dependent Patients in a Multisite Study

Factors Associated With Severe Bacterial Infections in People Who Inject Drugs: A Single-center Observational Study

BACKGROUND

People who inject drugs are at increased risk for several bacterial infections such as bacteremia, endocarditis, and osteomyelitis resulting in severe morbidity and high care costs. Limited data exist surrounding the injection drug use practices and behaviors that may increase the risk of these infections.

METHODS

Individuals admitted to a single hospital in New York City with severe bacterial infection, between August 2020 and June 2021, were recruited to partake in an in-depth survey examining potential factors, both demographic and injection drug use behavioral, associated with severe bacterial infections.

RESULTS

Thirty-four participants were recruited with injection drug use-associated severe bacterial infection. The mean age was 36.5 years; 21 (62%) were currently homeless, with 19 (56%) patients admitted for infective endocarditis. The mean length of hospital stay of all participants was 32.2 days; 94% received medication for opioid use disorder while admitted, whereas 35% left before treatment completion with a patient-directed discharge or elopement. Eight-two percent of participants were injected daily in the prior 30 days, with an average of 276 injections per participant. Fifty percent of participants reported requiring multiple sticks per injection event "always" or "very often," with 94% reporting reuse of syringes in the prior month.

CONCLUSIONS

Severe bacterial infections in people who inject drugs resulted in prolonged and complex hospitalization that culminate in suboptimal outcomes despite aggressive measures to engage patients in medication for opioid use disorder. Numerous nonsterile injection drug use practices were identified, indicating a gap in current infection prevention harm reduction messaging.

Opioid agonist treatment for people who are dependent on pharmaceutical opioids

BACKGROUND

There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin.  OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence.

SEARCH METHODS

We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods.

MAIN RESULTS

We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms.

AUTHORS' CONCLUSIONS

There is  very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.

A pilot study of a mixed-method approach to design an ED-based peer mHealth referral tool for HIV/HCV and opioid overdose prevention services

BACKGROUND

The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings.

METHODS

A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated 'patient to peer social network referral program' for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19).

RESULTS

Overall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives.

CONCLUSION

ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

Effect of HCV or HIV infection on mortality among hospitalized persons who used opioids, 2000-2010

Mortality due to opioid misuse and overdose has increased substantially in the United States over the past two decades. The study objective was to describe the causes of death among persons with opioid-related hospitalizations and examine survival by Hepatitis C virus (HCV) or HIV. Opioid-related hospitalization records in Pennsylvania from 2000 to 2010 were linked to death registry files to assess cause of death, and survival from first hospital discharge date to death date, or December 31, 2010. Accelerated failure time models were used to compare survival between persons with and without HCV or HIV diagnoses. Among the 136,416 individuals with an opioid-related hospitalization, 13.0% died over a median of 56 months of follow-up; the most common causes of death were circulatory diseases (26.4%) and drug overdose (23.5%). There were 27,122 (19.9%) and 3662 (2.7%) persons who had an HCV and HIV diagnosis, respectively. Among patients aged ≥20 years, those with HCV had shorter survival time compared to those without HCV, with discrepancies more pronounced at older ages. Patients with HIV also had shorter survival time (time ratio: 0.29 [95% CI: 0.26, 0.34]) compared to without HIV. These findings show that in a cohort of patients with opioid-related hospitalizations, those with HCV or HIV diagnoses have shorter survival. This has public health implications, providing further evidence that medical providers should educate patients who use opioids about the risks of HCV and HIV infection and focus prevention and treatment to decrease mortality among patients hospitalized for opioid use.

Women-Reported Barriers and Facilitators of Continued Engagement with Medications for Opioid Use Disorder

Opioid-related fatalities increased exponentially during the COVID-19 pandemic and show little sign of abating. Despite decades of scientific evidence that sustained engagement with medications for opioid use disorders (MOUD) yields positive psychosocial outcomes, less than 30% of people with OUD engage in MOUD. Treatment rates are lowest for women. The aim of this project was to identify women-specific barriers and facilitators to treatment engagement, drawing from the lived experience of women in treatment. Data are provided from a parent study that used a community-partnered participatory research approach to adapt an evidence-based digital storytelling intervention for supporting continued MOUD treatment engagement. The parent study collected qualitative data between August and December 2018 from 20 women in Western Massachusetts who had received MOUD for at least 90 days. Using constructivist grounded theory, we identified major themes and selected illustrative quotations. Key barriers identified in this project include: (1) MOUD-specific discrimination encountered via social media, and in workplace and treatment/recovery settings; and (2) fear, perceptions, and experiences with MOUD, including mental health medication synergies, internalization of MOUD-related stigma, expectations of treatment duration, and opioid-specific mistrust of providers. Women identified two key facilitators to MOUD engagement: (1) feeling “safe” within treatment settings and (2) online communities as a source of positive reinforcement. We conclude with women-specific recommendations for research and interventions to improve MOUD engagement and provide human-centered care for this historically marginalized population.

Severe bacterial infections in people who inject drugs: the role of injection-related tissue damage

Background

In the context of the current U.S. injection drug use epidemic, targeted public health harm reduction strategies have traditionally focused on overdose prevention and reducing transmission of blood-borne viral infections. Severe bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This qualitative study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.

Methods

Qualitative analysis (n = 15) was performed using an in-depth, semi-structured interview of participants admitted to Bellevue Hospital, NYC, with SBI and recent history of injection drug use. Participants were identified through a referral from either the Infectious Diseases or Addition Medicine consultative services. Interviews were transcribed, descriptively coded, and analyzed for key themes.

Results

Participants reported a basic understanding of prevention of blood-borne viral transmission but limited understanding of SBI risk. Participants described engagement in high risk injection behaviors prior to hospitalization with SBI. These practices included polysubstance use, repetitive tissue damage, nonsterile drug diluting water and multipurpose use of water container, lack of hand and skin hygiene, re-use of injection equipment, network sharing, and structural factors leading to an unstable drug injection environment. Qualitative analysis led to the proposal of an Ecosocial understanding of SBI risk, detailing the multi-level interplay between individuals and their social and physical environments in producing risk for negative health outcomes.

Conclusions

Structural factors and injection drug use networks directly impact drug use, injection drug use practices, and harm reduction knowledge, ultimately resulting in tissue damage and inoculation of bacteria into the host and subsequent development of SBI. Effective healthcare and community prevention efforts targeted toward reducing risk of bacterial infections could prevent long-term hospitalizations, decrease health care expenditures, and reduce morbidity and mortality.

Emerging Viral and Bacterial Infections: Within an Era of Opioid Epidemic

The opioid epidemic is a public health crisis that continues to impact healthcare in the United States of America (USA). While changes in opioid prescribing have curbed the medical use of opioids, the increase in nonmedical use, largely driven by injection drug use (IDU), has contributed to the escalating incidence of opioid use disorder (OUD). Furthermore, IDU is associated with high-risk injection practices that can increase the risk of acquiring viral and bacterial infections. Here in this comprehensive review, we aimed to summarize the epidemiology and management of OUD, along with the screening and antimicrobial treatment of associated infections, specifically focused on human immunodeficiency virus, hepatitis C virus, skin and soft tissue infections, endocarditis, and osteomyelitis. Medication-assisted therapy (MAT) and infection guidelines from the USA will be presented.

Hispanic participants in the National Institute on Drug Abuse's Clinical Trials Network: A scoping review of two decades of research

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Hispanics experience multiple structural barriers to adequate substance use treatment.

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Effective interventions for Hispanic populations exist.

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Measurement equivalence and culturally-tailored programs are essential.

Introduction

Hispanics significantly underutilize substance abuse treatment and are at greater risk for poor treatment outcomes and dropout. Two decades of research from the National Drug Abuse Treatment Clinical Trials Network (CTN) offers an opportunity to increase our understanding in how to address the disparities experienced by Hispanics in substance abuse treatment.

Methods

A scoping review was utilized to determine what has been learned from the CTN about Hispanic populations with substance use disorder. A systematic search was conducted within the CTN Dissemination Library and nine databases. Potentially relevant studies were independently assessed by two reviewers for inclusion.

Results

Twenty-four studies were included in the review. Results identified issues in measurement, characteristics of Hispanic substance use, effective interventions, and gaps for future research. Characteristics that interfere with treatment participation were also identified including low employment rates, less likelihood of having insurance, lower rates of internet access, and increased travel time to services, as were treatment issues such as high rates of alcohol and tobacco use. Effective interventions were identified; however, the effectiveness of these interventions may be limited to specific factors.

Conclusions

Despite efforts to improve inclusion of minority populations, Hispanics remain underrepresented in clinical trials. Future research including Hispanic populations should examine measurement equivalence and consider how cultural and historical experiences, as well as patient characteristics, influence utilization of services. Finally, more studies are needed that examine the impact of structural factors that act as barriers to treatment access and engagement and result in significant disparities in treatment outcomes.

A systematic scoping review of research on Black participants in the National Drug Abuse Treatment Clinical Trials Network

Black individuals experience a disproportionate burden of substance-related disabilities and premature death relative to other racial/ethnic groups, highlighting the need for additional research. The National Drug Abuse Treatment Clinical Trials Network (CTN), a research platform for multisite behavioral, pharmacological, and integrated trials designed to evaluate the effectiveness of substance use treatments in community settings with diversified patient populations, provides a wealth of research knowledge on substance use. Although CTN trials have enrolled over 5,000 Black individuals since its inception in 2000, there has been no synthesis of the findings, discussion of the implications, or suggestions for future research for Black individuals. Members of the Minority Interest Group of the CTN conducted a scoping review of published research on Black participants in CTN trials. Studies were included if the sample was more than 75% Black and/or specific findings pertaining to Black participants were reported. The review yielded 50 articles, with studies that mostly focused on baseline characteristics, followed by substance use treatment outcomes, HIV/risky sex behaviors, retention, comorbid conditions and measurement issues. This review highlighted the importance of several issues that are critical to understanding and treating substance misuse among Black people, such as the characteristics of Black people entering treatment, measurement equivalence, and engaging/retaining adolescents and young adults in treatment. There is still a continued need to identify the most effective treatments for Black individuals who use substances. The CTN offers several untapped opportunities to further advance research on Black individuals who use substances (e.g., secondary analyses of publicly available data). (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Hepatitis C infection and psychiatric burden in two imprisoned cohorts: Young offenders and opioid-maintained prisoners

Prisoners constitute a considerable gap in the hepatitis C virus (HCV) tested population. The present study examined HCV prevalence in imprisoned opioid-maintained patients (OMT-P) and adolescents and young adults (AYA, 14-26 years). In addition, HCV testing and treatment provision, knowledge of HCV status and psychiatric comorbidity were assessed. Data collection took place in six Austrian prisons. Participants were N = 133 for OMT-P (78% male, mean age 35.7 years) and N = 71 for AYA (100% male, mean age 19.8 years). Analysis of HCV serology was conducted. Psychiatric comorbidity and addiction severity were assessed applying standardized questionnaires and interviews. Antibodies were detected in 74.4% of OMT-P, and in 45.0% HCV infection was confirmed. Only one AYA was infected with HCV. None of the participants was receiving treatment for HCV. Eleven percent of OMT-P (50.7% of AYA) did not know their HCV status, and 14.3% of OMT-P (36.6% of AYA) had not been tested in prison. Among OMT-P, lifetime IDU [OR = 330.33, CI = 25.91-4433.20] and age at first IDU [OR = 0.90, CI = 0.82-0.98] significantly predicted HCV status. In both samples, a high prevalence of affective disorders was observed. Despite the high prevalence of HCV among opioid-dependent detainees, the unique opportunities for comprehensive testing and treatment of HCV are substantially underutilized. This is in stark contrast to the UN Basic Principles for the Treatment of Prisoners.

Risk factors for hepatitis C seropositivity among young people who inject drugs in New York City: Implications for prevention

Background

Hepatitis C virus (HCV) infection remains a significant problem in the United States, with people who inject drugs (PWID) disproportionately afflicted. Over the last decade rates of heroin use have more than doubled, with young persons (18–25 years) demonstrating the largest increase.

Methods

We conducted a cross-sectional study in New York City from 2005 to 2012 among young people who injected illicit drugs, and were age 18 to 35 or had injected drugs for ≤5 years, to examine potentially modifiable factors associated with HCV among young adults who began injecting during the era of syringe services.

Results

Among 714 participants, the median age was 24 years; the median duration of drug injection was 5 years; 31% were women; 75% identified as white; 69% reported being homeless; and 48% [95% CI 44–52] had HCV antibodies. Factors associated with HCV included older age (adjusted odds ratio [AOR], 1.99 [1.52–2.63]; p<0.001), longer duration of injection drug use (AOR, 1.68 [1.39–2.02]; p<0.001),more frequent injection (AOR, 1.26 [1.09–1.45]; p = 0.001), using a used syringe with more individuals (AOR, 1.26 [1.10–1.46]; p = 0.001), less confidence in remaining uninfected (AOR, 1.32 [1.07–1.63]; p<0.001), injecting primarily in public or outdoors spaces (AOR, 1.90 [1.33–2.72]; p<0.001), and arrest for carrying syringes (AOR, 3.17 [1.95–5.17]; p<0.001).

Conclusions

Despite the availability of harm reduction services, the seroprevalence of HCV in young PWID in New York City remained high and constant during 2005–2012. Age and several injection behaviors conferred independent risk. Individuals were somewhat aware of their own risk. Public and outdoor injection and arrest for possession of a syringe are risk factors for HCV that can be modified through structural interventions.