Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: Results from a community-based behavioral intervention trial

Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.

Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities

BACKGROUND

Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities.

METHODS

PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals.

RESULTS

Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23).

CONCLUSIONS

The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

What features of drug treatment programs help, or not, with access? a qualitative study of the perspectives of family members and community-based organization staff in Atlantic Canada

BACKGROUND

Withdrawal management and opioid agonist treatment (OAT) programs help to reduce some of the harms experienced by people who use substances (PWUS). There is literature on how features of drug treatment programs (e.g., policies and practices) are helpful, or not helpful, to PWUS when seeking access to, or in, treatment. There is, however, relatively little literature based on the perspectives of family members/family of choice of PWUS and community-based organization staff within the context of Atlantic Canada. This paper explored the perspectives of these two groups on what was helpful, or not, about drug treatment programs in Atlantic Canada in terms of supporting access to, and retention in, treatment.

METHODS

One-on-one qualitative telephone interviews were conducted in 2020 with the two groups. Interviews focused on government-funded withdrawal management and OAT programs. Data were coded using a qualitative data management program (ATLAS.ti) and analyzed inductively for key themes/subthemes using grounded theory techniques.

RESULTS

Fifteen family members/family of choice and 16 community-based organization staff members participated (n = 31). Participants spoke about features of drug treatment programs in various places, and noted features that were perceived as helpful (e.g., quick access), as well as not helpful (e.g., wait times, programs located far from where PWUS live). Some participants provided their perceptions of how PWUS felt when seeking or accessing treatment. A number of participants reported taking various actions to help support access to treatment, including providing transportation to programs. A few participants also provided suggestions for change to help support access and retention such as better alignment of mental health and addiction systems.

CONCLUSIONS

Participants highlighted several helpful and not helpful features of drug treatment programs in terms of supporting treatment access and retention. Previous studies with PWUS and in other places have reported similar features, some of which (e.g., wait times) have been reported for many years. Changes are needed to reduce barriers to access and retention including the changes recommended by study participants. It is critical that the voices of key groups, (including PWUS) are heard to ensure treatment programs in all places support access and retention.

Were Needles Everywhere?: Differing Views on Syringe Waste and Disposal Associated With Needs-Based Syringe Services Programs Among Community Partners and Persons Who Inject Drugs

BACKGROUND

Community concerns surrounding syringe waste are a common barrier to syringe services program (SSP) implementation. In Kanawha County, West Virginia, community opposition to SSPs resulted in the closure of needs-based SSPs prior to and during an HIV outbreak among persons who inject drugs (PWID). This qualitative analysis examines views of PWID and community partners on syringe waste and disposal associated with needs-based SSPs.

METHODS

Qualitative interviews with 26 PWID and 45 community partners (medical and social service providers, law enforcement personnel, policymakers, and religious leaders) were conducted. Interviews were recorded, transcribed, and coded. Code summaries described participants' views on syringe waste and disposal and needs-based SSPs.

RESULTS

Community partners and PWID who favored needs-based SSPs reported that needs-based SSPs had not affected or reduced syringe waste. Conversely, community partners who favored one-to-one exchange models and/or barcoded syringes described needs-based SSPs increasing syringe waste. Community partners often cited pervasive community beliefs that SSPs increased syringe waste, risk of needlesticks, drug use, and crime. Community partners were unsure how to address syringe waste concerns and emphasized that contradictory views on syringe waste posed barriers to discussing and implementing SSPs.

CONCLUSIONS

Participants' views on whether syringe waste was associated with needs-based SSPs often aligned with their support or opposition for needs-based SSPs. These differing views resulted in challenges finding common ground to discuss SSP operations amid an HIV outbreak among PWID. SSPs might consider addressing syringe waste concerns by expanding syringe disposal efforts and implementing community engagement and stigma reduction activities.

Harm reduction workforce, behavioral health, and service delivery in the USA: a cross-sectional study

BACKGROUND

Despite recent financial and policy support for harm reduction in the USA, information on the types of workers within organizations who design, implement, and actualize harm reduction services remains nascent. Little is known about how variability in the harm reduction workforce impacts referrals and linkages to other community supports. This exploratory mixed-methods study asked: (1) Who constitutes the harm reduction workforce? (2) Who provides behavioral health services within harm reduction organizations? (3) Are referral services offered and by whom? (4) Do referrals differ by type of harm reduction worker?

METHODS

Purposive sampling techniques were used to distribute an electronic survey to U.S.-based harm reduction organizations. Descriptive statistics were conducted. Multivariate binary logistic regression models examined the associations (a) between the odds of the referral processes at harm reduction organizations and (b) between the provision of behavioral health services and distinct types of organizational staff. Qualitative data were analyzed using a hybrid approach of inductive and thematic analysis.

RESULTS

Data from 41 states and Washington, D.C. were collected (N = 168; 48% response rate). Four primary types of workers were identified: community health/peer specialists (87%); medical/nursing staff (55%); behavioral health (49%); and others (34%). About 43% of organizations had a formal referral process; among these, only 32% had follow-up protocols. Qualitative findings highlighted the broad spectrum of behavioral health services offered and a broad behavioral health workforce heavily reliant on peers. Unadjusted results from multivariate models found that harm reduction organizations were more than 5 times more likely (95% CI [1.91, 13.38]) to have a formal referral process and 6 times more likely (95% CI [1.74, 21.52]) to have follow-up processes when behavioral health services were offered. Organizations were more than two times more likely (95% CI [1.09, 4.46]) to have a formal referral process and 2.36 (95% CI [1.11, 5.0]) times more likely to have follow-up processes for referrals when behavioral health providers were included.

CONCLUSIONS

The composition of the harm reduction workforce is occupationally diverse. Understanding the types of services offered, as well as the workforce who provides those services, offers valuable insights into staffing and service delivery needs of frontline organizations working to reduce morbidity and mortality among those who use substances. Workforce considerations within U.S.-based harm reduction organizations are increasingly important as harm reduction services continue to expand.

A Qualitative Analysis of Barriers to Accessing HIV Prevention Services During an HIV Outbreak among Persons who Inject Drugs in West Virginia

In response to an increase in HIV diagnoses among persons who inject drugs (PWID) in Kanawha County, West Virginia, West Virginia Bureau for Public Health and CDC conducted a qualitative assessment in Kanawha County to inform HIV outbreak response activities. Interviews with 26 PWID and 45 community partners were completed. Transcribed interviews were analyzed to identify barriers to accessing HIV prevention services among PWID using the risk environment framework. Participants identified numerous political, physical, social, and economic community-level barriers that influenced access to HIV prevention services among PWID. Political factors included low community support for syringe services programs (SSPs); physical factors included low SSP coverage, low coverage of HIV testing outreach events, low HIV preexposure prophylaxis availability, and homelessness; social factors included stigma and discrimination; economic factors included community beliefs that SSPs negatively affect economic investments and limited resources for HIV screening in clinical settings. Individual-level barriers included co-occurring acute medical conditions and mental illness. Community-level interventions, such as low-barrier one-stop shop models, are needed to increase access to sterile syringes through comprehensive harm reduction services.

A Mixed Methods Analysis of Southern HIV Service Organizations' Implementation of Harm Reduction to Address the HIV and Opioid Syndemic

Southern HIV Service Organizations (SHSOs) are promising sites for the adoption and implementation of harm reduction as a means for addressing the HIV and opioid syndemic. However, little research to date has examined exactly how harm reduction is operationalized within and among SHSOs. Using program evaluation data (i.e., organizational assessment data and semi-structured qualitative group interview data with SHSO staff), this study aimed to characterize organizational implementation of harm reduction among SHSOs that sought harm reduction capacity-building assistance (i.e., training, coaching, funding) from the SUSTAIN Center. Authors utilized a convergent mixed methods design in which quantitative and qualitative approaches were employed in parallel to gain simultaneous insights into how harm reduction was operationalized in SHSOs and how the local context influenced implementation. Means and proportions of each organizational assessment domain were compared. Thematic analysis of group interview transcripts examined SHSO staff perceptions of harm reduction implementation in their respective communities. Quantitative results revealed that SHSOs most commonly operationalize harm reduction in the Outreach, Advocacy, and Principles domains but struggle to do so in terms of Services and Organizational Infrastructure. Qualitative results revealed that various factors in SHSOs' local context, such as the community's lack of knowledge and understanding of harm reduction, limited harm reduction services, and a challenging socio-political context, influence SHSOs implementation of harm reduction. Taken together, analyses reveal that (1) SHSOs expend significant effort conducting outreach activities because Southern communities are generally unaware of harm reduction, (2) SHSOs continually advocate for harm reduction in the midst of a challenging socio-political context, and (3) SHSOs offer fewer harm reduction services and integrate harm reduction into their organizational infrastructure to a lesser extent due to external, contextual factors. The combination of organizational-level data and SHSO staff insights provided by this mixed methods study have implications for policy advocacy, funding initiatives, and capacity-building efforts.

Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial

Background

Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD.

Methods

The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support.

Results

The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed.

Conclusions

This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes.

Trial Registration

The study is registered at ClinicalTrials.gov (NCT04991974).

Abolition and harm reduction in the struggle for "Care, Not Cages"

Care that is organized around the principles of harm reduction and the movement for police and prison abolition has the potential to uproot and transform structural causes of harm and violence, in the interconnected crises of drug-related harm, policing, and punishment. The United States' crisis of overdose and drug-related harm and its system of policing and punishment are historically and empirically linked phenomena. The abandonment of people whose use of drugs leads to their premature death, in the form of an overdose, is directly and indirectly connected to wider systems of criminalization and incarceration that also produce premature suffering and death. Organizations advocating for harm reduction for people who use drugs (PWUD) and organizations seeking the abolition of police and prisons have developed in parallel albeit with different genealogies. We examine the historical origins, principles, and practical applications of the two movements to identify points of overlap and lessons to be learned for the public health goals of addressing and preventing premature suffering and death in the United States. A case study of Los Angeles (LA) County, where elected officials have promised a new paradigm of care, not punishment, frames our analysis. We show how the principles and strategies of harm reduction and abolition are both necessary to practically realizing a paradigm of care, not punishment, and achieving system transformation.

Availability of telehealth-based services at syringe services programs under the COVID-19 Public Health Emergency

INTRODUCTION

The expanded capacity of syringe services programs (SSPs) in the USA to integrate telehealth services was largely related to flexibility of buprenorphine prescription in response to the COVID-19 pandemic. SSPs demonstrated the potential of using telehealth to reach participants with both medical and non-medical services. The present study examines the implementation of medical and non-medical telehealth-based health services in 2020 at SSPs in the USA and organizational characteristics associated with adopting specific telehealth services.

METHODS

We administered a cross-sectional survey among all known SSPs operating in the USA as of 2021. The two primary study outcomes were (1) implementation of medical telehealth and (2) implementation of non-medical telehealth in 2020. Medical services included HIV counseling/care, hepatitis C virus (HCV) counseling/care, and buprenorphine. Non-medical services included wellbeing/check-ins, overdose prevention training, health navigation, harm reduction and psychological counseling. Bivariate and multivariable mixed effects logistic regression models were used to directly estimate the odds ratio associated with organizational characteristics on the implementation of telehealth-based health services.

RESULTS

Thirty percent of programs (n = 290) reported implementing telehealth-based health services. In multivariable logistic regression models, community-based organization SSPs had higher odds of implementing medical (aOR = 4.69, 95% CI [1.96, 11.19]) and non-medical (aOR = 2.18, 95% CI [1.10, 4.31]) health services compared to public health department SSPs. SSPs that received governmental funding had higher odds of implementing medical services via telehealth (aOR = 2.45, 95% CI [1.35, 4.47]) compared to programs without governmental funding.

CONCLUSION

Community-based organization SSPs and those with government funding had the highest odds of telehealth implementation in response to the COVID-19 Public Health Emergency. Federal, state, and local governments must increase funding for low-barrier venues like SSPs to support telehealth implementation to serve the needs of people who use drugs.

Connect To Care (C2C): protocol for two-site randomized controlled pilot trial to improve outcomes for patients with hazardous drinking and PTSD and/or depression symptoms

BACKGROUND

In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options.

METHODS/DESIGN

Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective.

DISCUSSION

Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05023317.

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

"We want everything in a one-stop shop": acceptability and feasibility of PrEP and buprenorphine implementation with mobile syringe services for Black people who inject drugs

INTRODUCTION

A recent surge in HIV outbreaks, driven by the opioid and stimulant use crises, has destabilized our progress toward targets set forth by Ending the HIV Epidemic: A Plan for America for the high-priority community of people who inject drugs (PWID), particularly Black PWID.

METHODS

In order to ascertain the acceptability and feasibility of using a mobile syringe services program (SSP) for comprehensive HIV prevention via PrEP and medications for opioid use disorder (MOUD), our mixed methods approach included a quantitative assessment and semi-structured qualitative interviews with Black PWID (n = 30) in Miami-Dade County who were actively engaged in mobile syringe services.

RESULTS

Participants felt that delivery of MOUD and PrEP at a mobile SSP would be both feasible and acceptable, helping to address transportation, cost, and stigma barriers common within traditional healthcare settings. Participants preferred staff who are compassionate and nonjudgmental and have lived experience.

CONCLUSIONS

A mobile harm reduction setting could be an effective venue for delivering comprehensive HIV prevention services to Black PWID, a community that experiences significant barriers to care via marginalization and racism in a fragmented healthcare system.

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Only a small minority of people with substance use disorders (SUDs) receive treatment. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD - especially drug use disorders - as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.

Implementation and first-year operating costs of an academic medical center-based syringe services program

BACKGROUND

Syringe services programs (SSPs) remain highly effective, cost-saving interventions for the prevention of blood-borne infections among people who inject drugs. However, there have been restrictions regarding financial resources allocated to these programs, particularly in the US South. This study aimed to provide cost data regarding the implementation and first-year operations of an academic-based SSP utilizing fixed and mobile strategies, including the integration of onsite wound care.

METHODS

We conducted a micro-costing study that retrospectively collected detailed resource utilization and unit cost data for both the fixed and mobile SSP strategies, including onsite wound care, from both healthcare and societal perspectives. A three-step approach was used to identify, measure, and value intervention costs, and cost components were categorized into implementation, variable program, and time-dependent costs. Sensitivity analysis was performed to examine the impact of SSP operational changes (i.e., needs-based distribution and opt-out HIV/HCV testing) on the cost-per-participant. Cost data we presented as overall cost and cost-per-participant adjusted to 2017 US dollars.

RESULTS

A total of 452 and 129 participants enrolled in fixed and mobile SSP services, respectively. The total cost associated with implementation and first year operations for the fixed site was $407,217.22 or $729.72 per participant and $311,625.52 or $2415.70 per participant for the mobile unit. The largest cost component for both modalities was time-dependent costs (personnel and overhead), while intervention materials (syringes, injection equipment, naloxone) were less than 15% of the total program cost.

DISCUSSION/CONCLUSION

Implementation and operation of new SSP models continue to be low cost compared to treatment for the multitude of harms PWID face without access to evidence-based prevention. Future cost-effectiveness and cost-benefit analyses integrating a comprehensive SSP model within an academic institution, including onsite wound care and other medical services, will provide a more comprehensive understanding of this model, and state-level policy action must be taken to lift the prohibition of state and local funds for the implementation, sustainability, and maintenance of these programs in Florida.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Acceptability of an mHealth App That Provides Harm Reduction Services Among People Who Inject Drugs: Survey Study

Background

Harm reduction services reduce the negative consequences of drug injection and are often embedded within syringe service programs (SSPs). However, people who inject drugs (PWID) suboptimally engage with such services because of stigma, fear, transportation restrictions, and limited hours of operation. Mobile health (mHealth) apps may provide an opportunity to overcome these barriers and extend the reach of SSPs beyond that of the traditional brick-and-mortar models.

Objective

This study aims to assess the prevalence of smartphone ownership, the level of comfort in providing the personal information required to use mHealth apps, and interest in using an mHealth app to access harm reduction services among PWID to guide the development of an app.

Methods

We administered a survey to 115 PWID who were enrolled via respondent-driven sampling from July 2018 to July 2019. We examined the extent to which PWID had access to smartphones; were comfortable in providing personal information such as name, email, and address; and expressed interest in various app-based services. We measured participant characteristics (demographics, health status, and behaviors) and used binary logistic and Poisson regressions to identify independent correlates of mHealth-related variables. The primary regression outcomes included summary scores for access, comfort, and interest. The secondary outcomes included binary survey responses for individual comfort or interest components.

Results

Most participants were White (74/105, 70.5%), male (78/115, 67.8%), and middle-aged (mean=41.7 years), and 67.9% (74/109) owned a smartphone. Participants reported high levels of comfort in providing personal information to use an mHealth app, including name (96/109, 88.1%), phone number (92/109, 84.4%), email (85/109, 77.9%), physical address (85/109, 77.9%), and linkage to medical records (72/109, 66.1%). Participants also reported strong interest in app-based services, including medication or sterile syringe delivery (100/110, 90.9%), lab or appointment scheduling (90/110, 81.8%), medication reminders (77/110, 70%), educational material (65/110, 59.1%), and group communication forums (64/110, 58.2%). Most participants were comfortable with the idea of home delivery of syringes (93/109, 85.3%). Homeless participants had lower access to smartphones (adjusted odds ratio [AOR] 0.15, 95% CI 0.05-0.46; P=.001), but no other participant characteristics were associated with primary outcomes. Among secondary outcomes, recent SSP use was positively associated with comfort with the home delivery of syringes (AOR 3.29, 95% CI 1.04-10.3 P=.04), and being older than 50 years was associated with an increased interest in educational materials (AOR 4.64, 95% CI 1.31-16.5; P=.02) and group communication forums (AOR 3.69, 95% CI 1.10-12.4; P=.04).

Conclusions

Our findings suggest that aside from those experiencing homelessness or unstable housing, PWID broadly have access to smartphones, are comfortable with sharing personal information, and express interest in a wide array of services within an app. Given the suboptimal access to and use of SSPs among PWID, an mHealth app has a high potential to address the harm reduction needs of this vulnerable population.

Voluntary Pregnancy Screening at Syringe Exchanges: A Feasibility Study

The purpose of this study was to explore the feasibility of offering voluntary pregnancy screening at syringe exchange programs using the National Implementation Research Network Hexagon Discussion and Analysis Tool. We conducted a survey among female syringe exchange clients that assessed perceived needs, values, and behavioral intentions for parenting and entering treatment if they received a positive pregnancy screen and surveys among staff and core volunteers to assess organizational fit, capacity, and needed supports. Participants and staff reported that pregnancy screening was needed at syringe exchange and that capacity needs to be expanded to provide services. Pregnancy screening at syringe exchanges holds the potential to lead to early detection of pregnancy. Early detection of pregnancy among women who inject drugs may result in improved prenatal care, including substance use treatment and treatment of infectious diseases, for women who would otherwise be unlikely to receive prenatal care.

A call for training graduate medical students on harm reduction for people who inject drugs

There is a lack of standardized education on topic of harm reduction for graduate medical students. In order to fill this curricular gap, we delivered a two-hour pilot training introducing local community harm reduction organizations and harm reduction ideology and strategies for people who inject drugs to graduate medical students at Boston University. We used pre-post survey design to evaluate attendee demographic characteristics and training efficacy. We matched 29 attendees responses, 69% were first and second year medical students, and found that our training positively reinforced comfort and knowledge surrounding harm reduction ideology, safer injection techniques, and naloxone administration. Delivering trainings covering harm reduction early in graduate medical schools may be beneficial in giving students initial exposure to practical risk mitigation tools they can utilize later in their clinical careers.

Syringe service program-based telemedicine linkage to opioid use disorder treatment: protocol for the STAMINA randomized control trial

Background

A key strategy for mitigating the current opioid epidemic is expanded access to medications for treating opioid use disorder (MOUD). However, interventions developed to expand MOUD access have limited ability to engage opioid users at higher levels of overdose risk, such as those who inject opioids. This paper describes the study protocol for testing STAMINA (Syringe Service Telemedicine Access for Medication-assisted Intervention through NAvigation), an intervention that engages high-risk opioid users at community-based syringe service programs (SSP) and quickly links them to MOUD using a telemedicine platform.

Methods

This randomized control trial will be conducted at three SSP sites in Chicago. All participants will complete an initial assessment with a provider from a Federally Qualified Health Center who can prescribe or refer MOUD services as appropriate. The control arm will receive standard referral to treatment and the intervention arm will receive immediate telemedicine linkage to the provider and (depending on the type of MOUD prescribed) provided transportation to pick up their induction prescription (for buprenorphine or naltrexone) or attend their intake appointment (for methadone). We aim to recruit a total of 273 participants over two years to provide enough power to detect a difference in our primary outcome of MOUD treatment linkage. Secondary outcomes include treatment engagement, treatment retention, and non-MOUD opioid use. Data will be collected using structured interviews and saliva drug tests delivered at baseline, three months, and six months. Fixed and mixed effects generalized linear regression analyses and survival analysis will be conducted to compare the probabilities of a successful treatment linkage between the two arms, days retained in treatment, and post-baseline opioid and other drug use.

Discussion

If successful, STAMINA’s telemedicine approach will significantly reduce the amount of time between SSP clients’ initial indication of interest in the medication and treatment initiation. Facilitating this process will likely lead to stronger additional treatment- and recovery-oriented outcomes. This study is also timely given the need for more rigorous testing of telemedicine interventions in light of temporary regulatory changes that have occurred during the COVID-19 pandemic.

Trial registration

ClinicalTrials.gov (Clinical Trials ID: NCT04575324 and Protocol Number: 1138–0420). Registered 29 September 2020. The study protocol is also registered on the Open Science Framework (DOI 10.17605/OSF.IO/4853 M).

Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida

INTRODUCTION

Syringe services programs (SSPs) are evidence-based HIV prevention programs for people who inject drugs. However, not all SSPs operate evidence-based syringe distribution models, such as needs-based distribution. This study aims to provide preliminary evidence from the IDEA SSP on changes in injection risk behaviors over time, and to examine factors, including syringe coverage, associated with injection risk behavior trajectories over time under a one-for-one syringe distribution model.

METHODS

We used a prospective observational study design to generate a cohort of SSP clients who completed three behavioral assessments at SSP service visits between December 2016 and January 2020 (N = 115). The study used generalized estimating equations (GEE) to examine the relationship between covariate measures and the primary outcomes. The primary outcomes were 1) sharing of any injection equipment (e.g. syringes, needles, cookers, cottons) in the previous 30 days (yes/no) and 2) reusing of needles/syringes in the previous 30 days (yes/no).

RESULTS

Men were more likely to report reusing syringes (aRR = 1.15, 95% CI: 1.01-1.37) and those who reported injecting in public were less likely to report reusing syringes (aRR = 0.90, 95% CI: 0.82-0.99). HCV-positive clients had a 62% reduction in sharing injection equipment and those who reported public injection had a 62% increase in sharing injection equipment over time. Most importantly, increasing syringe coverage was associated with a decrease in both sharing injection equipment (aRR = 0.42, 95% CI: 0.25-0.72) and reusing syringes (aRR = 0.79, 95% CI: 0.66-0.95).

CONCLUSION

This study provides preliminary evidence of reductions in injection-related risk behaviors from the IDEA SSP and highlights potential high priority groups, such as people experiencing homelessness, that may need additional intervention. In addition, improving syringe coverage among SSP clients may be an important factor in reducing behaviors that place individuals at risk for contracting HIV and HCV.

Warm Handoffs for Improving Client Receipt of Services: A Systematic Review

INTRODUCTION

Warm handoffs intend to improve receipt of services by clients who receive referrals to services that are stigmatized or not easily accessible. Such strategies are characterized as the handoff or transfer of an individual between two service providers through a face-to-face, phone, or technology-assisted interaction. This approach may be useful for maternal and child health home visitors who provide direct services and facilitate connections to community resources for client families. However, little is known about the effectiveness of warm handoffs.

METHODS

A systematic review of the literature on warm handoffs was conducted with studies identified in four databases. Full text was reviewed for studies for which abstracts met inclusion criteria or for which abstracts were not available. Evidence tables summarizing study characteristics, outcome measures and data sources, intervention descriptions, intervention components, and study results were constructed.

RESULTS

Of the 42,816 unique articles identified, 32,163 titles/abstracts were screened, 227 qualified for full text review, and five comprised the study sample. Three studies examined referrals from substance use treatment centers to self-help groups, one from federally qualified health centers to community mental health clinics, and one from a mobile needle exchange program to substance use treatment/intake. Three studies showed increases in receipt of services by clients following referral between the warm handoff intervention and control group.

DISCUSSION

Current evidence regarding the effectiveness of warm handoffs is limited. An examination of the effectiveness of warm handoffs in the context of home visits is needed to assess whether they facilitate client referrals.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Implementation of strength-based case management for opioid-dependent patients presenting in medical emergency departments: rationale and study design of a randomized trial

BACKGROUND

As the USA grapples with an opioid epidemic, medical emergency departments (EDs) have become a critical setting for intervening with opioid-dependent patients. Brief interventions designed to bridge the gap from acute ED care to longer-term treatment have shown limited efficacy for this population. Strength-based case management (SBCM) has shown strong effects on treatment linkage among patients with substance use disorders in other healthcare settings. This study aimed to investigate whether SBCM is an effective model for linking opioid-dependent ED patients with addiction treatment and pharmacotherapy. Here, we describe the implementation and challenges of adapting SBCM for the ED (SBCM-ED). Study rationale, design, and baseline characteristics are also described.

METHODS

This study compared the effects of SBCM-ED to screening, assessment, and referral alone (SAR) on treatment linkage, substance use, and functioning. We recruited participants from a public hospital in NYC. Working alliance between case managers and participants and the feasibility of SBCM implementation were evaluated. Baseline data from the randomized sample were analyzed for group equivalency. Outcomes analyses are forthcoming.

RESULTS

Three hundred adult participants meeting DSM-IV criteria for opioid dependence were randomly assigned to either SBCM, in which they received a maximum of six case management sessions within 90 days of enrollment, or SAR, in which they received a comprehensive referral list and pamphlet outlining drug use consequences. No significant differences were found between groups at baseline on demographic or substance use characteristics. All SAR participants and 92.6% of SBCM-ED participants initiated their assigned intervention. Over half of SBCM-ED first sessions occurred in the ED on the day of enrollment. Case managers developed a strong working alliance with SBCM-ED participants after just one session.

CONCLUSION

Interventions that exceed SBIRT were accepted by an opioid-dependent patient population seen in an urban medical ED. At the time of study funding, this trial was one of the first to focus specifically on this population in this challenging setting. The successful implementation of SBCM demonstrates its adaptability to the ED and may serve as a potential model for EDs seeking to adopt an intervention that overcomes the barrier between the ED encounter and more intensive treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02586896 . Registered on 27 October 2015.

Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami, FL

Background

Blood-borne viral infections, such as HIV and hepatitis C (HCV), are common infections among people who inject drugs (PWID). This study aims to determine the prevalence of HIV and HCV infection among PWID accessing the first legal syringe services program (SSP) in the state of Florida, along with examining baseline correlates of HIV and HCV infection.

Methods

Baseline behavioral enrollment assessments of 837 participants accessing an SSP for the first time were analyzed. Patients self-reporting or testing HIV or HCV positive at the enrollment visit were included. Socio-demographic, drug use, and injection-related risk behaviors in the last 30 days were compared across groups defined by all combinations of HIV and HCV serostatus.

Bivariate and multivariable logistic regression models were used to assess correlates of baseline HCV and HIV infection independently.

Results

Overall prevalence for HCV and HIV infection were 44.4% and 10.2%, respectively. After adjusting for confounders, the most significant correlates of baseline HCV infection were age (aOR = 1.01), lower education level (aOR = 1.13), currently homeless (aOR = 1.16), injecting more than seven times a day (aOR = 1.14), reusing syringes (aOR = 1.18), and sharing injection equipment (aOR = 1.13). The most significant predictors of baseline HIV infection were age (aOR = 1.01), non-Hispanic Black race (aOR = 1.28), Hispanic ethnicity (aOR = 1.12), gay or bisexual orientation (aOR = 1.22), and methamphetamine injection (aOR = 1.22). In addition, heroin injection (aOR = 0.92) was significantly associated with a lower odds of HIV infection.

Discussion/conclusion

Baseline behavioral predictors differed between HIV infection and HCV infection among participants accessing syringe services. Understanding the risk factors associated with each infection should be considered when developing additional harm reduction interventions tailored for diverse PWID populations served at SSPs.

When is an abscess more than an abscess? Syringe services programs and the harm reduction safety-net: a case report

Background

Syringe services programs (SSPs) are able to offer wrap-around services for people who inject drugs (PWID) and improve health outcomes.

Case presentation

A 47-year-old man screened positive for a skin and soft tissue infection (SSTI) at an SSP and was referred to a weekly on-site student-run wound care clinic. He was evaluated by first- and third-year medical students, and volunteer attending physicians determined that the infection was too severe to be managed on site. Students escorted the patient to the emergency department, where he was diagnosed with a methicillin-resistant Staphylococcus aureus arm abscess as well as acute HIV infection.

Conclusion

Student-run wound care clinics at SSPs, in conjunction with ongoing harm reduction measures, screenings, and treatment services, provide a safety-net of care for PWID and help mitigate the harms of injection drug use.

Navigation Services to Avoid Rehospitalization among Medical/Surgical Patients with Comorbid Substance Use Disorder: Rationale and Design of a Randomized Controlled Trial

Substance use disorders (SUDs) are associated with significant morbidity and mortality and contribute to inefficient use of healthcare services. Hospitalized medical/surgical patients with comorbid SUD are at elevated risk of hospital readmission and poor outcomes. Thus, effective interventions are needed to help such patients during hospitalization and post-discharge. This article reports the rationale, methodological design, and progress to date on a randomized trial comparing the effectiveness of Navigation Services to Avoid Rehospitalization (NavSTAR) vs Treatmentas-Usual (TAU) for hospital medical/surgical patients with comorbid SUD (N = 400). Applying Andersen’s theoretical model of health service utilization, NavSTAR employed Patient Navigation and motivational interventions to promote entry into SUD treatment, facilitate adherence to recommendations for medical follow-up and self-care, address basic needs, and prevent the recurrent use of hospital services. As part of the NavSTAR service model, Patient Navigators embedded within the SUD consultation service at a large urban hospital delivered patient-centered, proactive navigation and motivational services initiated during the hospital stay and continued for up to 3 months post-discharge. Participants randomized to TAU received usual care from the hospital and the SUD consultation service, which included referral to SUD treatment but no continued contact post-hospital discharge. Hospital service utilization will be determined via review of electronic health records and the regional Health Information Exchange. Participants were assessed at baseline and again at 3-, 6-, and 12-month follow-up on various measures of healthcare utilization, substance use, and functioning. The primary outcome of interest is time-to-rehospitalization through 12 months. In addition, a range of secondary outcomes spanning the medical and SUD service areas will be assessed. The study will include a health economic evaluation of NavSTAR. If NavSTAR proves to be effective and cost-effective in this high-risk patient group, it would have important implications for addressing the needs of hospital patients with comorbid SUD, designing hospital discharge planning services, informing cost containment initiatives, and improving public health.

Gaps in the Substance Use Disorder Treatment Referral Process: Provider Perceptions

OBJECTIVES

The demand for substance use disorder treatment is increasing, fueled by the opioid epidemic and the Affordable Care Act mandate to treat substance use disorders. The increased demand for treatment, however, is not being met by a corresponding increase in access to or availability of treatment. This report focuses specifically on the treatment referral process, which we have identified as 1 of the key barriers to timely and effective treatment. Difficulties in referral to substance use disorder treatment are examined through the lens of providers who make referrals (ie, referral source) and individuals who work in substance use disorder facilities (ie, referral recipient).

METHODS

Administrative officials, emergency department physicians, addiction physicians, government officials, providers, insurance officials, and mental health advocates (n = 59) were interviewed on the referral process protocol, challenges for providers and others making referrals, and issues with substance use treatment facility intake procedures.

RESULTS

Several main themes were identified as barriers in the process: difficulties in determining patient eligibility, lack of transparency regarding treatment capacity, referral source knowledge/understanding of options, and issues with communication between referral source and recipient. We then proposed several solutions to address specific barriers.

CONCLUSIONS

Current gaps in the referral process cause delays to care. Improving systems would involve addressing these themes and expanding the use of appropriate treatments for the many patients in need.

Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky

PURPOSE

Kentucky experiences a disproportionate burden of substance use disorder (SUD), particularly in rural areas of the state. Multiple factors increase vulnerability to SUD and limit access to services in rural communities. However, the recent implementation and expansion of syringe service programs (SSPs) in rural Kentucky may provide a leverage point to reach at-risk people who inject drugs (PWID).

METHODS

Data were collected as part of an ongoing NIDA-funded study designed to examine uptake of SSPs among PWID in Appalachian Kentucky. Using Respondent Driven Sampling (RDS), the study enrolled a sample of 186 PWID SSP attenders across 3 rural Appalachian Kentucky counties and conducted face-to-face interviews regarding health behaviors, injecting practices, SSP utilization, and treatment services. Using logistic regression analyses, we examined consistent SSP use, as well as importance and confidence to reduce substance use as predictors of current treatment participation.

FINDINGS

For the prior 6 months, 44.6% of the sample reported consistent SSP use. Consistent use of SSPs was associated with treatment participation in the unadjusted logistic regression models. Significant predictors of treatment participation in the adjusted model included high confidence to reduce substance use, and not reporting primary methamphetamine injection.

CONCLUSIONS

Rurally located SSPs may play an important role in supporting confidence and motivation to change substance use behaviors among PWID impacted by SUD. SSPs may be critical venues for integration and expansion of prevention, health promotion, and treatment linkage services for this underserved population.

Syringe Decriminalization Advocacy in Red States: Lessons from the North Carolina Harm Reduction Coalition

PURPOSE OF REVIEW

Syringe access programs (SAPs) are cornerstone harm reduction interventions for combatting the national opioid epidemic. The goal of this paper is to describe effective advocacy strategies for enacting syringe decriminalization legislation to foster the expansion of SAPs in high-need areas amidst political opposition.

RECENT FINDINGS

Decades or research shows that SAPs prevent the transmission of HIV among people who inject drugs (PWID) and are a cost-effective tool for linking PWID to medical care, health education, and social services. In the USA, state laws criminalizing distribution and possession of syringes impede the expansion of SAPs into areas where they are sorely needed. In 2016, North Carolina became the first state to legalize SAPs with a Republican super majority. This paper distills strategies for community organizations seeking to advance syringe decriminalization legislation in politically conservative states with histories of prioritizing punitive sanctions over public health responses to drug use.

Factors associated with tobacco, alcohol, and other drug use among youth living in West Central Mexico

AIM

To determine the prevalence of drug and substance abuse among high school students in Jalisco and its association with the severity of health, behavior and psychosocial problems in order to provide evidence for possible prevention and treatment needs.

METHODS

A multi-stage random sample of Jalisco high school students was given a paper-and-pencil survey based upon an adapted version of the drug use screening inventory (DUSI) (n = 24699; n = 2832). The DUSI showed adequate psychometric characteristics in this population. The statistical analyses accommodated the complex survey design with attention to unequal probability of selection and clustering of participants within schools and regions.

RESULTS

An estimated 44% of the students had smoked tobacco, one in five students was a current smoker, and one in four students used to smoke but had not smoked for one year or more. By contrast, 6.8% of the students reported having used marijuana, cocaine, or both. Behavioral problems, deviant peer affiliation, and troubled families were independently associated with drug use. One in two students who used tobacco or alcohol had used these drugs in the past year (46% and 54%, respectively), and one in four students who used marijuana or cocaine in their lifetime had used those drugs in the past year (28% in both cases).

CONCLUSION

The rates of cocaine use as well as the proportion of current users were higher than expected among high school students and indicate changing patterns of drug use in Mexico. These results corroborate that the general trend of drug use by youth in Mexico is increasing. Results from this study help us better understand the needs of at-risk youth and the need for new treatment and prevention strategies.

Scoping out the literature on mobile needle and syringe programs-review of service delivery and client characteristics, operation, utilization, referrals, and impact

BACKGROUND

Needle and syringe program (NSP) service delivery models encompass fixed sites, mobile services, vending machines, pharmacies, peer NSPs, street outreach, and inter-organizational agreements to add NSP services to other programs. For programs seeking to implement or improve mobile services, access to a synthesis of the evidence related to mobile services is beneficial, but lacking.

METHODS

We used a scoping study method to search MEDLINE, PSYCHInfo, Embase, Scopus, and Sociological for relevant literature. We identified 39 relevant manuscripts published between 1975 and November 2017 after removing duplicates and non-relevant manuscripts from the 1313 identified by the search.

RESULTS

Charting of the data showed that these publications reported findings related to the service delivery model characteristics, client characteristics, service utilization, specialized interventions offered on mobile NSPs, linking clients to other services, and impact on injection risk behaviors. Mobile NSPs are implemented in high-, medium-, and low-income countries; provide equipment distribution and many other harm reduction services; face limitations to service complement, confidentiality, and duration of interactions imposed by physical space; adapt to changes in locations and types of drug use; attract people who engage in high-risk/intensity injection behavior and who are often not reached by other service models; and may lead to reduced injection-related risks.

DISCUSSION

It is not clear from the literature reviewed, what are, or if there are, a "core and essential" complement of services that mobile NSPs should offer. Decisions about service complement for mobile NSPs need to be made in relation to the context and also other available services. Reports of client visits to mobile NSP provide a picture of the volume and frequency of utilization but are difficult to compare given varied measures and reference periods.

CONCLUSION

Mobile NSPs have an important role to play in improving HIV and HCV prevention efforts across the world. However, more work is needed to create clearer assessment metrics and to improve access to NSP services across the world.

Transmission dynamics for Methicilin-resistant Staphalococous areus with injection drug user

Background

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial pathogen resistance to antibiotics including methicillin. The resistance first emerged in 1960 in a healthcare setting only after two years of using methicillin as a viable treatment for methicillin-susceptible Staphylococcus aureus. MRSA leads to infections in different parts of the body including the skin, bloodstream, lungs, or the urinary tract.

Methods

A deterministic model for methicillin-resistant Staphylococcus aureus (MRSA) with injection drug users is designed. The model incorporates transmission of MRSA among non-injection drug users and injection drug users (IDUs) who are both low-and high-risk users. A reduced MRSA transmission model with only non-IDUs is fitted to a 2008-2013 MRSA data from the Agency for Healthcare and Research and Quality (AHRQ). The parameter estimates obtained are projected onto the parameters for the low-and high-risk IDUs subgroups using risk factors obtained by constructing a risk assessment ethogram. Sensitivity analysis is carried out to determine parameters with the greatest impact on the reproduction number using the reduced non-IDUs model. Change in risk associated behaviors was studied using the full MRSA transmission model via the increase in risky behaviors and enrollment into rehabilitation programs or clean needle exchange programs. Three control effectiveness levels determined from the sensitivity analysis were used to study control of disease translation within the subgroups.

Results

The sensitivity analysis indicates that the transmission probability and recovery rates within the subgroup have the highest impact on the reproduction number of the reduced non-IDU model. Change in risk associated behaviors from non-IDUs to low-and high-risk IDUs lead to more MRSA cases among the subgroups. However, when more IDUs enroll into rehabilitation programs or clean needle exchange programs, there was a reduction in the number of MRSA cases in the community. Furthermore, MRSA burden within the subgroups can effectively be curtailed in the community by implementing moderate- and high-effectiveness control strategies.

Conclusions

MRSA burden can be curtailed among and within non-injection drug users and both low-and high-risk injection drug users by encouraging positive change in behaviors and by moderate- and high-effectiveness control strategies that effectively targets the transmission probability and recovery rates within the subgroups in the community.

A Strengths-Based Case Management Intervention to Reduce HIV Viral Load Among People Who Use Drugs

Engaging highly marginalized HIV positive people in sustained medical care is vital for optimized health and prevention efforts. Prior studies have found that strengths-based case management helps link people who use drugs to HIV care. We conducted a pilot to assess whether a strengths-based case management intervention may help people who use injection drugs (PWID) or smoke crack cocaine (PWSC) achieve undetectable HIV viral load. PWID and PWSC were recruited in Oakland, California using targeted sampling methods and referral from jails and were tested for HIV. HIV positive participants not receiving HIV care (n = 19) were enrolled in a pilot strengths-based case management intervention and HIV positive participants already in HIV care (n = 29) were followed as comparison participants. The intervention was conducted by a social worker and an HIV physician. Special attention was given to coordinating care as participants cycled through jail and community settings. Surveys and HIV viral load tests were conducted quarterly for up to 11 visits. HIV viral load became undetectable for significantly more participants in the intervention than in the comparison group by their last follow-up (intervention participants: 32% at baseline and 74% at last follow-up; comparison participants: 45% at baseline and 34% at last follow-up; p = 0.008). In repeated measures analysis, PBO intervention participants had higher odds of achieving undetectable viral load over time than comparison participants (p = 0.033). Strengths-based case management may help this highly vulnerable group achieve undetectable HIV viral load over time.

Harm reduction principles for healthcare settings

BACKGROUND

Harm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely. The vast majority of the harm reduction literature focuses on the harms of drug use and on specific harm reduction strategies, such as syringe exchange, rather than on the harm reduction philosophy as a whole. Given that a harm reduction approach can address other risk behaviors that often occur alongside drug use and that harm reduction principles have been applied to harms such as sex work, eating disorders, and tobacco use, a natural evolution of the harm reduction philosophy is to extend it to other health risk behaviors and to a broader healthcare audience.

METHODS

Building on the extant literature, we used data from in-depth qualitative interviews with 23 patients and 17 staff members from an HIV clinic in the USA to describe harm reduction principles for use in healthcare settings.

RESULTS

We defined six principles of harm reduction and generalized them for use in healthcare settings with patients beyond those who use illicit substances. The principles include humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. For each of these principles, we present a definition, a description of how healthcare providers can deliver interventions informed by the principle, and examples of how each principle may be applied in the healthcare setting.

CONCLUSION

This paper is one of the firsts to provide a comprehensive set of principles for universal harm reduction as a conceptual approach for healthcare provision. Applying harm reduction principles in healthcare settings may improve clinical care outcomes given that the quality of the provider-patient relationship is known to impact health outcomes and treatment adherence. Harm reduction can be a universal precaution applied to all individuals regardless of their disclosure of negative health behaviors, given that health behaviors are not binary or linear but operate along a continuum based on a variety of individual and social determinants.

Barriers and facilitators of the HIV care continuum in Southern New England for people with drug or alcohol use and living with HIV/AIDS: perspectives of HIV surveillance experts and service providers

BACKGROUND

Contemporary studies about HIV care continuum (HCC) outcomes within substance using populations primarily focus on individual risk factors rather than provider- or systems-level influences. Over 25% of people living with HIV (PLWH) have substance use disorders that can alter their path through the HCC. As part of a study of HCC outcomes in nine small cities in Southern New England (population 100,000-200,000 and relatively high HIV prevalence particularly among substance users), this qualitative analysis sought to understand public health staff and HIV service providers' perspectives on how substance use may influence HCC outcomes.

METHODS

Interviews with 49 participants, collected between November 2015 and June 2016, were analyzed thematically using a modified social ecological model as the conceptual framework and codes for substance use, HCC barriers and facilitators, successes and failures of initiatives targeting the HCC, and criminal justice issues.

RESULTS

Eight themes were identified concerning the impact of substance use on HCC outcomes. At the individual level, these included coping and satisfying basic needs and could influence all HCC steps (i.e., testing, treatment linkage, adherence, and retention, and viral load suppression). The interpersonal level themes included stigma issues and providers' cultural competence and treatment attitudes and primarily influenced treatment linkage, retention, and viral load suppression. These same HCC steps were influenced at the health care systems level by organizations' physical environment and resources as well as intra-/inter-agency communication. Testing and retention were the most likely steps to affect at the policy/society level, and the themes included opposition within an organization or community, and activities with unintended consequences.

CONCLUSIONS

The most substantial HCC challenges for PLWH with substance use problems included linking and retaining in treatment those with multiple co-morbidities and meeting their basic living needs. Recommendations to improve HCC outcomes for PLWH with substance use problems include increasing easy access to effective drug and mental health treatment, expanding case management and peer navigation services, training staff about harm reduction, de-stigmatizing, and culturally competent approaches to interacting with patients, and increasing information-sharing and service coordination among service providers and the social service and criminal justice systems.

Still "at risk": An examination of how street-involved young people understand, experience, and engage with "harm reduction" in Vancouver's inner city

BACKGROUND

Vancouver is an international leader in implementing interventions to reduce harms related to drug use. However, street-involved young people who use drugs continue to be vulnerable to overdose death, hepatitis C (HCV) infection, and high rates of syringe sharing. To better understand this in the context of the intensive public health response, we examined how young people, who are involved in the 'street drug scene', understood, experienced and engaged with harm reduction.

METHODS

Twelve semi-structured interviews were conducted in 2013 with 13 young people (ages 17-28) recruited from the At-Risk Youth Study, a prospective cohort of street-involved and drug-using young people. These interviews were embedded within a larger, eight-year program of ethnographic research and explored participants' understandings of harm reduction, their use of specific services, and their ideas about improving their day-to-day lives. Interviews were transcribed verbatim and a thematic analysis was performed.

RESULTS

Young peoples' ideas about harm reduction were diverse and expansive. They articulated the limitations of existing programs, indicating that while they are positioned to reduce the risk of HIV and HCV transmission, they offer little meaningful support to improve young peoples' broader life chances. Young people described strategies to mitigate risk and harm in their own lives, including transitioning to drugs deemed less harmful and attempting to gain access to drug treatment. Finally, young people indicated that spatial considerations (e.g., distance from Vancouver's Downtown Eastside) strongly determined access to services.

CONCLUSIONS

In Vancouver, a large, well established harm reduction infrastructure seeks to reduce HIV and HCV transmission among street-involved young people. However, young peoples' multiple understandings, experiences and engagements with harm reduction in this setting illustrate the limitations of the existing infrastructure in improving their broader life chances.

Update on Barriers to Pharmacotherapy for Opioid Use Disorders

PURPOSE OF REVIEW

The recent heroin and prescription opioid misuse epidemic has led to a sharp increase in the number of opioid overdose deaths in the USA. Notwithstanding the availability of three FDA-approved medications (methadone, buprenorphine, and naltrexone) to treat opioid use disorder, these medications are underutilized. This paper provides an update from the recent peer-reviewed literature on barriers to the use of these medications.

FINDINGS

These barriers are interrelated and can be categorized as financial, regulatory, geographic, attitudinal, and logistic. While financial barriers are common to all three medications, other barriers are medication-specific. The adverse impact of the current opioid epidemic on public health can be reduced by increasing access to effective pharmacotherapy for opioid use disorder.

Effects of naloxone distribution alone or in combination with addiction treatment with or without pre-exposure prophylaxis for HIV prevention in people who inject drugs: a cost-effectiveness modelling study

BACKGROUND

In the USA, an epidemic of opioid overdose deaths is occurring, many of which are from heroin. Combining naloxone distribution with linkage to addiction treatment or pre-exposure prophylaxis (PrEP) for HIV prevention through syringe service programmes has the potential to save lives and be cost-effective. We estimated the outcomes and cost-effectiveness of five alternative strategies: no additional intervention, naloxone distribution, naloxone distribution plus linkage to addiction treatment, naloxone distribution plus PrEP, and naloxone distribution plus linkage to addiction treatment and PrEP.

METHODS

We developed a decision analytical Markov model to simulate opioid overdose, HIV incidence, overdose-related deaths, and HIV-related deaths in people who inject drugs in Connecticut, USA. Model input parameters were derived from published sources. We compared each strategy with no intervention, as well as simultaneously considering all strategies. Sensitivity analysis was done for all variables. Linkage to addiction treatment was referral to an opioid treatment programme for methadone. Endpoints were survival, life expectancy, quality-adjusted life-years (QALYs), number and percentage of overdose deaths averted, number of HIV-related deaths averted, total costs (in 2015 US$) associated with each strategy, and incremental cost per QALY gained.

FINDINGS

In the base-case analysis, compared with no additional intervention, the naloxone distribution strategy yielded an incremental cost-effectiveness ratio (ICER) of $323 per QALY, and naloxone distribution plus linkage to addiction treatment was cost saving compared with no additional intervention (greater effectiveness and less expensive). The most efficient strategies (ie, those conferring the greatest health benefit for a particular budget) were naloxone distribution combined with linkage to addiction treatment (cost saving), and naloxone distribution combined with PrEP and linkage to addiction treatment (ICER $95 337 per QALY) at a willingness-to-pay threshold of $100 000. In probabilistic sensitivity analysis, the combination of naloxone distribution, PrEP, and linkage to addiction treatment was the optimal strategy in 37% of iterations and the combination of naloxone distribution and linkage to addiction treatment was the optimal strategy in 34% of iterations.

INTERPRETATION

Naloxone distribution through syringe service programmes is cost-effective compared with syringe distribution alone, but when combined with linkage to addiction treatment is cost saving compared with no additional services. A strategy that combines naloxone distribution, PrEP, and linkage to addiction treatment results in greater health benefits in people who inject drugs and is also cost-effective.

FUNDING

State of Connecticut Department of Public Health and the National Institute of Mental Health.

Effect of Case Management Interventions for Patients with Substance Use Disorders: A Systematic Review

BACKGROUND

Substance use disorder (SUD) is an important health problem that requires a complex range of care because of the chronic nature of the disorder and the multiple psychosocial problems involved. Current outpatient programs often have difficulties in delivering and coordinating ongoing care and access to different health-care providers. Various case management (CM) models have been developed, first for patients in other psychiatric domains and then for patients with SUD, in order to improve treatment outcomes.

AIM

This paper aims to assess the effectiveness of CM for patients with SUD.

METHODS

We performed a systematic review of CM interventions for patients with SUD by analyzing randomized controlled studies published on the subject between 1996 and 2016 found on the electronic database PubMed.

RESULTS AND CONCLUSION

Fourteen studies were included in the analysis. Differences between studies in outcome measures, populations included, and intervention characteristics made it difficult to compare results. Most of these studies reported improvement in some of the chosen outcomes. Treatment adherence mostly improved, but substance use was reported to decrease in only a third of the studies. Overall functioning improved in about half of the studies. The heterogeneity of the results might be linked to these differences between studies. Further research is needed in the field.

Determinants of willingness to enroll in opioid agonist treatment among opioid dependent people who inject drugs in Ukraine

BACKGROUND

Coverage with opioid agonist treatments (OAT) that include methadone and buprenorphine is low (N=8400, 2.7%) for the 310,000 people who inject drugs (PWID) in Ukraine. In the context of widespread negative attitudes toward OAT in the region, patient-level interventions targeting the barriers and willingness to initiate OAT are urgently needed.

METHODS

A sample of 1179 PWID with opioid use disorder not currently on OAT from five regions in Ukraine was assessed using multivariable logistic regression for independent factors related to willingness to initiate OAT, stratified by their past OAT experience.

RESULTS

Overall, 421 (36%) PWID were willing to initiate OAT. Significant adjusted odds ratios (aOR) for covariates associated with the willingness to initiate OAT common for both groups included: higher injection frequency (previously on OAT: aOR=2.7; never on OAT: aOR=1.8), social and family support (previously on OAT: aOR=2.0; never on OAT: aOR=2.0), and positive attitude towards OAT (previously on OAT: aOR=1.3; never on OAT: aOR=1.4). Among participants previously on OAT, significant correlates also included: HIV-negative status (aOR=2.6) and depression (aOR=2.7). Among participants never on OAT, however, living in Kyiv (aOR=4.8) or Lviv (aOR=2.7), previous imprisonment (aOR=1.5), registration at a Narcology service (aOR=1.5) and recent overdose (aOR=2.6) were significantly correlated with willingness to initiate OAT.

CONCLUSIONS

These findings emphasize the need for developing interventions aimed to eliminate existing negative preconceptions regarding OAT among PWID with opioid use disorder in Ukraine, which should be tailored to meet the needs of specific characteristics of PWID in geographically distinct setting based upon injection frequency, prior incarceration, and psychiatric and HIV status.

Malmö Treatment Referral and Intervention Study (MATRIS)—effective referral from syringe exchange to treatment for heroin dependence: a pilot randomized controlled trial

AIMS

Syringe exchange has been suggested as a potential conduit to treatment for drug dependence, but this has never been documented in Europe. The primary aim was to compare the effectiveness of strength-based case management intervention (CMI) against referral only to facilitate treatment attendance in a syringe exchange programme. We also assessed the effectiveness of a syringe exchange programme for referral of heroin-dependent patients to evidence-based treatment with methadone or buprenorphine (buprenorphine-naloxone).

DESIGN

Single-site, two-group randomized controlled trial.

SETTING

The syringe exchange programme in Malmö, Sweden and an out-patient clinic (research treatment facility) for maintenance treatment, situated outside the hospital area and run by Malmö Addiction Centre.

PARTICIPANTS

Heroin-dependent patients willing to participate (n = 75) were referred to maintenance treatment and randomized to either a strength-based case management intervention aiming to facilitate referral (n = 36) or to referral-only (n = 39).

INTERVENTION

The intervention group received an appointment for maintenance treatment and a CMI adjusted to individual patient needs. The CMI was semi-structured, assessing the patients' strengths and needs and identifying what practical help they might need to get to the appointment for maintenance treatment. The control group received an appointment for maintenance treatment.

MEASURES

The primary outcome was treatment entry.

FINDINGS

Among patients who turned up for recruitment interview and randomization, the percentage of patients who started treatment was 95% in the intervention group and 94% in the control group. Treatment entry was unrelated to intervention status [unadjusted odds ratio (OR) = 0.92 (0.12–6.89), P = 1.00 and adjusted OR = 0.96 (0.12–7.83)].

CONCLUSIONS

A randomized controlled trial in a syringe exchange programme showed no evidence that a strength-based case management intervention improved attendance for treatment over referral alone. Attendance rates were high in both groups.

Commentary on Enns et al. (2016): Supervised injection facilities as a cost-effective intervention

The authors build upon evidence for expanded access to supervised injection facilities (SIFs) based on a growing body of cost-effectiveness literature that evaluates estimable costs and costs avoided from infectious diseases. Future directions for economic evaluations of SIFs should seek to examine broader SIF benefits and costs that encompass increased access to addiction treatment and other key health and social outcomes.