An urgent impetus for action: safe inhalation interventions to reduce COVID-19 transmission and fatality risk among people who smoke crack cocaine in the United Kingdom

Distributing aluminium foil as harm reduction strategy among people who use drugs in prison

OBJECTIVES

Drug use via inhalation substantially reduces the risk of overdose and blood borne infections when compared to parenteral consumption. In order to promote a change in consumption habits and provide a safe framework for inhalation consumption, the distribution of foil was introduced into the Catalan prison, Brians 1. The aim of this study was to know the perceptions of the people who participated in this program.

MATERIAL AND METHOD

An exploratory qualitative study was carried out through semi-structured interviews with 18 users (11 men and 7 women, one of them transgender) aged between 23 and 55 years. The data was analyzed using thematic analysis methodology.

RESULTS

Users highlighted the fewer negative consequences arising from inhalation drug use with a foil kit, compared to other means available in prison. The kit was used for heroin consumption, as well as in the manufacture of hashish and crack pipes. Among users who normally injected, there was increased awareness of alternative means and a higher probability of drug use via the pulmonary route. All users reported having received health education and subsequent monitoring by the particular team in charge.

DISCUSSION

Foil distribution is a practical and effective harm reduction strategy in prisons. Going forward, it is necessary to extend this program to other prisons and diversify the kits so they can more broadly address inhalation drug use.

Improving measures of context in process evaluations: development and use of the Context Tracker tool

BACKGROUND

Process evaluations are increasingly integrated into randomised controlled trials (RCTs) of complex interventions to document their delivery and interactions with local systems and dynamics, helping understand observed health outcomes. Yet process evaluations often struggle to assess relevant contextual determinants, leaving much of the important role of "context" in shaping an intervention's mechanisms opaque in many studies. A lack of easily adapted data collection methods to help define and operationalise indicators of context likely contributes to this.

METHODS

We present a method to help structure measures of context in process evaluations and describe its use in two very different settings. The "Context Tracker" is an innovative tool for use within trials and quasi-experiments to more systematically capture and understand key dimensions of context. It was developed in Zimbabwe as part of a cluster randomised controlled trial and then adapted for a quasi-experimental evaluation in the UK. Both studies provided harm reduction and health services for marginalised and hard-to-reach populations.

RESULTS

We developed the Context Tracker to be both standardised (i.e. formatted and applied in the same way across study sites) and flexible enough to allow unique features to be explored in greater detail. Drawing on the Context and Implementation of Complex Interventions (CICI) and Risk Environments frameworks, we mapped 5 domains across micro, meso and macro levels in a simple table and used existing evidence and experience to predict factors likely to affect delivery of and participation in intervention components. We tracked these over time across study sites using routine programme statistics, observation and qualitative methods. The Context Tracker enables identification and comparison of facilitators and barriers to implementation, variations in engagement with interventions, and how mechanisms of action are (or are not) triggered in different settings.

CONCLUSIONS

The Context Tracker is one example of how evidence-based contextual determinants can be used to guide data collection and analysis within process evaluations. It is relevant in low- and high-income settings and applicable to both qualitative and quantitative analyses. While perhaps most useful to process evaluations of complex interventions targeting marginalised communities, the broader approach would benefit a more general research audience.

Patterns of drug use among people who inject drugs: A global systematic review and meta-analysis

BACKGROUND

A better understanding of global patterns of drug use among people who inject drugs can inform interventions to reduce harms related to different use profiles. This review aimed to comprehensively present the geographical variation in drug consumption patterns among this population.

METHODS

Systematic searches of peer reviewed (PsycINFO, Medline, Embase) and grey literature published from 2008-2022 were conducted. Data on recent (past year) and lifetime drug use among people who inject drugs were included. Data were extracted on use of heroin, amphetamines, cocaine, benzodiazepines, cannabis, alcohol, and tobacco; where possible, estimates were disaggregated by route of administration (injecting, non-injecting, smoking). National estimates were generated and, where possible, regional, and global estimates were derived through meta-analysis.

RESULTS

Of 40,427 studies screened, 394 were included from 81 countries. Globally, an estimated 78.1 % (95 %CI:70.2-84.2) and 71.8 % (65.7-77.2) of people who inject drugs had recently used (via any route) and injected heroin, while an estimated 52.8 % (47.0-59.0) and 19.8 % (13.8-26.5) had recently used and injected amphetamines, respectively. Over 90 % reported recent tobacco use (93.5 % [90.8-95.3]) and recent alcohol use was 59.1 % (52.6-65.6). In Australasia recent heroin use was lowest (49.4 % [46.8-52.1]) while recent amphetamine injecting (64.0 % [60.8-67.1]) and recent use of cannabis (72.3 % [69.9-74.6]) were higher than in all other regions. Recent heroin use (86.1 % [78.3-91.4]) and non-injecting amphetamine use (43.3 % [38.4-48.3]) were highest in East and Southeast Asia. Recent amphetamine use (75.8 % [72.7-78.8]) and injecting heroin use (84.8 % (81.4-87.8) were highest in North America while non-injecting heroin use was highest in Western Europe (45.0 % [41.3-48.7]).

CONCLUSION

There is considerable variation in types of drugs and routes of administration used among people who inject drugs. This variation needs to be considered in national and global treatment and harm reduction interventions to target the specific behaviours and harms associated with these regional profiles of use.

Changes in injecting versus smoking heroin, fentanyl, and methamphetamine among people who inject drugs in San Diego, California, 2020-2023

BACKGROUND

Amidst an increasingly toxic drug supply in North America, people who inject drugs may be transitioning to smoking them. We aimed to assess changes in injecting and smoking opioids and methamphetamine among a cohort of people who inject drugs from San Diego, California.

METHODS

Over five six-month periods spanning October 2020-April 2023, we assessed prevalence of injecting and smoking opioids or methamphetamine and whether participants used these drugs more frequently by smoking than injecting. Multivariable Poisson regression via generalized estimating equations was used to examine time trends.

RESULTS

Of 362 participants, median age was 40 years; a minority were female (29%), Hispanic/Latinx/Mexican (45%), and housed (33%). Among this cohort, of whom 100% injected (and 84% injected and smoked) in period one (October 2020-April 2021), by period five (November 2022-April 2023), 34% only smoked, 59% injected and smoked, and 7% only injected. By period five, the adjusted relative risk (aRR) of injecting opioids was 0.41 (95% Confidence Interval [CI]: 0.33, 0.51) and the aRR for injecting methamphetamine was 0.50 (95% CI: 0.39, 0.63) compared to period one. Risks for smoking fentanyl rose significantly during period three (aRR=1.44, 95% CI: 1.06, 1.94), four (aRR=1.65, 95% CI: 1.24, 2.20) and five (aRR=1.90, 95% CI: 1.43, 2.53) compared to period one. Risks for smoking heroin and methamphetamine more frequently than injecting these drugs increased across all periods.

CONCLUSIONS

Opioid and methamphetamine injection declined precipitously, with notable increases in smoking these drugs. Research is needed to understand the health consequences of these trends.

Associations of U.S. state-level COVID-19 policies intensity with cannabis sharing behaviors in 2020

BACKGROUND

Cannabis use before the COVID-19 pandemic for many involved sharing prepared cannabis for inhalation, practices that were less prevalent during the pandemic. State-level COVID-19 containment policies may have influenced this decrease. This study examined the extent to which the intensity of state-level COVID-19 policies were associated with individual-level cannabis sharing. Findings have the potential to guide harm reduction policies for future respiratory pandemics and seasonal respiratory virus waves.

METHODS

This study used cross-sectional individual-level data from the COVID-19 Cannabis Study, an anonymous U.S.-based web survey on cannabis use disseminated during the early phase of the pandemic (Full sample N = 1,883). We combined individual-level data with state-level policy data from Kaiser Family Foundation's State COVID-19 Data and Policy Actions for three time-points from June to August 2020 that overlapped with the survey period. Cannabis sharing was dichotomized as any versus no sharing. We adapted a previously published coding framework to score the intensity of COVID-19 policies implemented in each U.S. state and averaged the policy score across the time period. We then used Poisson regression models to quantify the associations of the average state-level COVID-19 policy score with cannabis sharing during the pandemic.

RESULTS

Participants (n = 925) reporting using inhalation as a mode for cannabis use were included in this analysis. Most respondents were male (64.1%), non-Hispanic White (54.3%), with a mean age of 33.7 years (SD 8.8). A large proportion (74.9%) reported sharing cannabis during the pandemic. Those who shared cannabis more commonly lived in states with a lower average policy score (16.7, IQR 12.3-21.5) compared to those who did not share (18.6, IQR 15.3-25.3). In adjusted models, the prevalence ratio of any cannabis sharing per every 5-unit increase in the average COVID-19 policy score was 0.97 (95% CI 0.93, 1.01).

CONCLUSIONS

Fewer individuals shared cannabis in states with more intense COVID-19 containment policies compared to those in states with less intense policies. Individuals who use cannabis may be willing to make changes to their behavior and may further benefit from specific and directed public health messaging to avoid sharing during respiratory infection outbreaks.

Safe inhalation pipe provision (SIPP): protocol for a mixed-method evaluation of an intervention to improve health outcomes and service engagement among people who use crack cocaine in England

BACKGROUND

Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact.

METHODS

The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms.

ANTICIPATED IMPACT

SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally.

CONCLUSION

People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform.

TRIAL REGISTRATION

ISRCTN12541454  https://doi.org/10.1186/ISRCTN12541454.

Recent increases in crack injection and associated risk factors among people who inject psychoactive drugs in England and Wales

BACKGROUND

Crack use is higher in the United Kingdom (UK) than other European countries. Crack is a stimulant with a short half-life, requiring frequent injection to maintain its euphoric effects, thus increasing the risk of blood borne viruses (BBVs) and skin and soft tissue infections (SSTIs). We assessed trends in the prevalence of current crack injection among people who inject drugs (PWID) and investigated harms and other factors associated with its use.

METHODS

We used data from the annual Unlinked Anonymous Monitoring Survey of PWID, which recruits people who have ever injected psychoactive drugs through specialist services. Participants provide a biological sample and self-complete a questionnaire. We included participants from England and Wales who had injected in the past month. We examined trends in crack injection over time (2011-2021) and factors associated with crack injection using multivariable logistic regression (2019-2021).

RESULTS

The proportion of people self-reporting crack injection in the past month almost doubled between 2011-2020/21, from 34 % (416/1237) to 57 % (483/850). Crack injection was more frequently reported by males than females (adjusted odds ratio 1.46, 95 % confidence interval: 1.15-1.87) and injected alongside heroin (6.67, 4.06-10.97) more frequently than alone. Crack injection was independently associated with injecting equipment sharing (1.64, 1.30-2.07), groin injection (2.03, 1.60-2.56) in the past month, overdosing in the past year (1.90, 1.42-2.53), homelessness in the past year (1.42, 1.14-1.77) and ever having hepatitis C infection (1.64, 1.31-2.06).

CONCLUSION

Crack injection has increased significantly over the past decade in England and Wales. People injecting crack are more likely to engage in behaviours that increase the risk of BBV and SSTI acquisition, such as needle/syringe sharing, groin injection and polydrug use. Harm reduction and drug treatment services should adapt to support the needs of this growing population of people injecting stimulants.

The utilization and delivery of safer smoking practices and services: a narrative synthesis of the literature

BACKGROUND

Providing sterile drug smoking materials to people who use drugs can prevent the acquisition of infectious diseases and reduce overdose risk. However, there is a lack of understanding of how these practices are being implemented and received by people who use drugs globally.

METHODS

A systematic review of safer smoking practices was conducted by searching PubMed, PsycInfo, Embase for relevant peer-reviewed, English-language publications from inception or the availability of online manuscripts through December 2022.

RESULTS

Overall, 32 peer-reviewed papers from six countries were included. 30 studies exclusively included people who use drugs as participants (n = 11 people who use drugs; generally, n = 17 people who smoke drugs, n = 2 people who inject drugs). One study included program staff serving people who use drugs, and one study included staff and people who use drugs. Sharing smoking equipment (e.g., pipes) was reported in 25 studies. People who use drugs in several studies reported that pipe sharing occurred for multiple reasons, including wanting to accumulate crack resin and protect themselves from social harms, such as police harassment. Across studies, smoking drugs, as opposed to injecting drugs, were described as a crucial method to reduce the risk of overdose, disease acquisition, and societal harms such as police violence. Ten studies found that when people who use drugs were provided with safer smoking materials, they engaged in fewer risky drug use behaviors (e.g., pipe sharing, using broken pipes) and showed improved health outcomes. However, participants across 11 studies reported barriers to accessing safer smoking services. Solutions to overcoming safer smoking access barriers were described in 17 studies and included utilizing peer workers and providing safer smoking materials to those who asked.

CONCLUSION

This global review found that safer smoking practices are essential forms of harm reduction. International policies must be amended to help increase access to these essential tools. Additional research is also needed to evaluate the efficacy of and access to safer smoking services, particularly in the U.S. and other similar countries, where such practices are being implemented but have not been empirically studied in the literature.

Associations of U.S. state-level COVID-19 policies intensity with cannabis sharing behaviors in 2020

Background

Cannabis use before the COVID-19 pandemic for many involved sharing prepared cannabis for inhalation, practices that were less prevalent during the pandemic. State-level COVID-19 containment policies may have influenced this decrease. This study examined the extent to which the intensity of state-level COVID-19 policies were associated with individual-level cannabis sharing. Findings have the potential to guide harm reduction policies for future respiratory pandemics and seasonal respiratory virus waves.

Methods

This study used cross-sectional individual-level data from the COVID-19 Cannabis Study, an anonymous U.S.-based web survey on cannabis use disseminated during the early phase of the pandemic (Full sample N = 1,883). We combined individual-level data with state-level policy data from Kaiser Family Foundation's State COVID-19 Data and Policy Actions for three time-points from June to August 2020 that overlapped with the survey period. Cannabis sharing was dichotomized as any versus no sharing. We adapted a previously published coding framework to score the intensity of COVID-19 policies implemented in each U.S. state and averaged the policy score across the time period. We then used logistic regression models to quantify the associations of the average state-level COVID-19 policy score with cannabis sharing during the pandemic.

Results

Participants (n = 975) reporting using inhalation as a mode for cannabis use were included in this analysis. Most respondents were male (64.1%), non-Hispanic White (54.3%), with a mean age of 33.7 years (SD 8.8). A large proportion (75.1%) reported sharing cannabis during the pandemic. Those who shared cannabis more commonly lived in states with a lower average policy score (15.3, IQR 11.3-19.0) compared to those who did not share (16.3, IQR 13.7-22.7). In adjusted models, the odds of any cannabis sharing per every 5-unit increase in the average COVID-19 policy score were 0.78 (95% CI 0.58, 1.04).

Conclusions

Fewer individuals shared cannabis in states with more intense COVID-19 containment policies compared to those in states with less intense policies. Individuals who use cannabis may be willing to make changes to their behavior and may further benefit from specific and directed public health messaging to avoid sharing during respiratory infection outbreaks.

High levels of interest in access to free safer smoking equipment to reduce injection frequency among people who inject drugs in Seattle, Washington

Background

Drug use route transition interventions promote safer consumption by facilitating a switch from injection to safer routes such as smoking or oral consumption.

Methods

We performed a descriptive analysis using data from questions about "free, clean equipment for smoking" heroin, methamphetamine and/or crack from the Seattle 2018 National HIV Behavioral Surveillance survey of people who inject drugs (N = 555). We estimated the proportion of respondents with access to free safer smoking equipment, and among these participants, the proportion who reported that this access reduced their injection frequency. Among respondents without access to free safer smoking equipment, we described the proportion who were interested in getting access, and whether they thought this access would reduce their injection frequency.

Results

Among participants who reported prior year heroin (n = 495), methamphetamine (n = 372), or crack (n = 88) injection, 11%, 11% and 12% reported access to free safer smoking equipment, respectively. Of those with access, the proportion that reported that access reduced their injection frequency ranged from 12% to 44%. Among participants without access, 28% who used heroin, 45% who used methamphetamine, and 49% who used crack were interested in access. Of interested participants, a majority reported that they thought this access would reduce their frequency of injection.

Conclusions

Access to free safer smoking equipment was limited. Many participants were interested in getting free safer smoking equipment and reported that this access may reduce their injection frequency. Safer smoking equipment is a harm reduction strategy that should be available to reduce risks from opioid and stimulant injection.

Not all screens are created equal: examination of surface features and other physical properties of commonly used screen materials for smoking drugs

BACKGROUND

Brass screens are considered an essential part of the safer drug smoking/inhalation supplies and are widely distributed by harm reduction programs in Canada. However, the use of commercially available steel wools as screens for smoking crack cocaine remains a common practice among people who smoke drugs in Canada. Use of these steel wool materials is associated with different adverse effects on health. This study aims to determine what changes folding and heating have on several filter materials, including brass screens and commercially available steel wool products, and examine the implications of these changes on health of people who smoke drugs.

METHODS

This study investigated the microscopic differences, studied by optical and scanning electron microscopy, between four screen and four steel wool filter materials used in a simulated drug consumption process. New materials were manipulated, compacted into its own Pyrex® straight stem using a push stick and then heated with a butane lighter simulating a common method in preparing drugs for consumption. The materials were studied in the as-received (new), as-pressed (compressed and inserted into the stem tube but without heating) and as-heated (compressed and inserted into the stem tube and heated with a butane lighter) conditions.

RESULTS

The steel wool materials with the smallest wire thicknesses were found to be the easiest to prepare for pipe use, but degrade significantly during shaping and heating, making them wholly unsuitable as a safe filter material. In contrast the brass and stainless steel screen materials remain mostly unchanged by the simulated drug consumption process. After the stainless steel pellet screen, the Brass Impact 2.0 screen material had the best characteristics of the materials tested due to its mesh wire diameter, pitch, alloy choice and its pre-strained state.

CONCLUSION

Commonly used steel wool alternatives degrade during the handling and stem insertion, and heating the screens in the stem. Debris is generated by wool deformation on insertion and after heating that easily separates from the screen and can be inhaled during drug consumption. The brass and stainless steel screen materials are safer to use as they remain mostly stable during the simulated drug consumption process.

Individuals Reporting Past 3-month Smoked Stimulant Use Are Placed at Risk for Infection and Injury Amid COVID-19

OBJECTIVES

Smoking stimulants, such as methamphetamine and "crack" cocaine, can spread infections, including hepatitis C and COVID-19, and lead to injuries, particularly when individuals share or use makeshift pipes. The purpose of the study was to assess the practices of people who inhale ("smoke") stimulants to guide future clinical harm reduction efforts.

METHODS

Anonymous surveys were administered to participants reporting inhalation of crack cocaine and/or methamphetamine in the past 3 months. Participants were eligible if they sought services from an outreach team staffed by a municipal syringe service program (SSP) or if they were patients at a low-threshold substance use disorder treatment program, the Massachusetts General Hospital Bridge Clinic.

RESULTS

The survey was administered to 68 total participants, 30% of whom were recruited in the Massachusetts General Hospital Bridge Clinic and 70% through SSP outreach. Unsafe smoking practices were reported by 93% of participants. Among the 46% of participants surveyed who both smoked and injected stimulants, 61% of those participants stated that they injected instead of smoked stimulants because of lack of access to pipes. Amid COVID-19, 35% of participants adopted safer smoking practices. Most participants reported that they would be more likely to attend an SSP or health center if pipes were provided.

CONCLUSIONS

Inhalational practices that place participants at risk of injury and illness are common. Providing safer smoking equipment may promote health and engage individuals in care.

"That Line Just Kept Moving": Motivations and Experiences of People Who Use Methamphetamine

INTRODUCTION

Methamphetamine use is on the rise with increasing emergency department (ED) visits, behavioral health crises, and deaths associated with use and overdose. Emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and violence against staff, but little is known about the patient's perspective. In this study our objective was to identify the motivations for initiation and continued methamphetamine use among people who use methamphetamine and their experiences in the ED to guide future ED-based approaches.

METHODS

This was a qualitative study of adults residing in the state of Washington in 2020, who used methamphetamine in the prior 30 days, met criteria for moderate- to high-risk use, reported recently receiving care in the ED, and had phone access. Twenty individuals were recruited to complete a brief survey and semi-structured interview, which was recorded and transcribed prior to being coded. Modified grounded theory guided the analysis, and the interview guide and codebook were iteratively refined. Three investigators coded the interviews until consensus was reached. Data was collected until thematic saturation.

RESULTS

Participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. Many initially used methamphetamine to enhance social interactions, combat boredom, and escape difficult circumstances by numbing the senses. However, continued use regularly led to isolation, ED visits for the medical and psychological sequelae of methamphetamine use, and engagement in increasingly risky behaviors. Because of their overwhelmingly frustrating experiences in the past, interviewees anticipated difficult interactions with healthcare clinicians, leading to combativeness in the ED, avoidance of the ED at all costs, and downstream medical complications. Participants desired a non-judgmental conversation and linkage to outpatient social resources and addiction treatment.

CONCLUSION

Methamphetamine use can lead patients to seek care in the ED, where they often feel stigmatized and are provided little assistance. Emergency clinicians should acknowledge addiction as a chronic condition, address acute medical and psychiatric symptoms adequately, and provide positive connections to addiction and medical resources. Future work should incorporate the perspectives of people who use methamphetamine into ED-based programs and interventions.

Puff, Puff, Don't Pass: harm reduction for cannabis use during a viral respiratory pandemic

BACKGROUND

Prior to the COVID-19 pandemic, cannabis use social practices often involved sharing prepared cannabis (joints/blunts/cigarettes) and cannabis-related paraphernalia. Previous studies have demonstrated that sharing paraphernalia for cannabis, tobacco, and crack cocaine is a risk factor for respiratory viral and bacterial infections. Although COVID-19 is a respiratory viral infection that spreads through droplets and airborne transmission, it is unclear if many individuals adopted harm reduction practices around sharing cannabis. This study: quantifies the prevalence of sharing prepared non-medical cannabis and cannabis-related paraphernalia reported before and during the pandemic; assesses changes in sharing of non-medical cannabis from before to during the pandemic; assess the association between frequency of non-medical cannabis use and sharing of cannabis during the pandemic; and describes how respondents obtained their cannabis and the reasons for changing their cannabis use during the pandemic to explain differences in sharing patterns.

METHODS

This cross-sectional study used data collected from an anonymous, US-based web survey on cannabis-related behaviors from August to September 2020 (n = 1833). Participants were included if they reported using a mode of inhalation for non-medical cannabis consumption. We calculated proportional changes in sharing cannabis before/during the COVID-19 pandemic. Associations between frequency of cannabis use and cannabis sharing during the COVID-19 pandemic were assessed using logistic regression analysis.

RESULTS

Overall, 1,112 participants reported non-medical cannabis use; 925 (83.2%) reported a mode of cannabis inhalation. More respondents reported no sharing during (24.9%) than before the pandemic (12.4%; p < 0.01); less respondents shared most of the time (19.5% before; 11.2% during; p < 0.01) and always during the pandemic (5.2% before; 3.1% during; p < 0.01). After adjusting for covariates, the odds of any sharing during the pandemic for those who reported ≥ weekly cannabis use was 0.53 (95% CI 0.38, 0.75) compared to those who reported ≤ monthly.

CONCLUSIONS

Sharing of prepared cannabis and cannabis-related paraphernalia decreased during the COVID-19 pandemic compared to before the pandemic. This finding suggests potential risk mitigation strategies taken by participants for COVID-19 prevention either directly through behavior change or indirectly through adherence to COVID-19 prevention recommendations. Harm reduction messaging around sharing of cannabis during surges of COVID-19 or other respiratory infections may provide benefit in reducing infection among those who use cannabis, especially as cannabis use in the USA continues to increase.

Analysis of the UK Government's 10-Year Drugs Strategy-a resource for practitioners and policymakers

In 2021, during a drug-related death crisis in the UK, the Government published its ten-year drugs strategy. This article, written in collaboration with the Faculty of Public Health and the Association of Directors of Public Health, assesses whether this Strategy is evidence-based and consistent with international calls to promote public health approaches to drugs, which put 'people, health and human rights at the centre'. Elements of the Strategy are welcome, including the promise of significant funding for drug treatment services, the effects of which will depend on how it is utilized by services and local commissioners and whether it is sustained. However, unevidenced and harmful measures to deter drug use by means of punishment continue to be promoted, which will have deleterious impacts on people who use drugs. An effective public health approach to drugs should tackle population-level risk factors, which may predispose to harmful patterns of drug use, including adverse childhood experiences and socioeconomic deprivation, and institute evidence-based measures to mitigate drug-related harm. This would likely be more effective, and just, than the continuation of policies rooted in enforcement. A more dramatic re-orientation of UK drug policy than that offered by the Strategy is overdue.

A qualitative study exploring the impact of the COVID-19 pandemic on People Who Inject Drugs (PWID) and drug service provision in the UK: PWID and service provider perspectives

BACKGROUND

People Who Inject Drugs (PWID) are subject to distinct socio-structural inequalities that can expose them to high risks of COVID-19 transmission and related health and social complications. In response to COVID-19 mitigation strategies, these vulnerabilities are being experienced in the context of adapted drug treatment service provision, including reduced in-person support and increased regulatory flexibility in opioid substitution therapy (OST) guidelines. This study aimed to explore the longer-term impact of the pandemic on the health and wellbeing of PWID in the UK, including provider and client experiences of treatment changes.

METHODS

Interviews were conducted with 19 PWID and 17 drug treatment providers between May and September 2021, recruited from drug and homelessness charities providing treatment services and healthcare in the UK. Data were analysed using reflexive thematic analysis.

RESULTS

Most participants expressed ongoing fears of COVID-19 transmission, although socio-structural inequalities limited the contexts in which physical distancing could be practised. In addition, virus mitigation strategies altered the risk environment for PWID, resulting in ongoing physical (e.g. changing drug use patterns, including transitions to crack cocaine, benzodiazepine and pregabalin use) and socio-economic harms (e.g. limited opportunities for sex work engagement and income generation). Finally, whilst clients reported some favourable experiences from service adaptations prompted by COVID-19, including increased regulatory flexibility in OST guidelines, there was continued scepticism and caution among providers toward sustaining any treatment changes beyond the pandemic period.

CONCLUSIONS

Whilst our findings emphasize the importance of accessible harm reduction measures attending to changing indices of drug-related harm during this period, there is a need for additional structural supports to ensure pre-existing disparities and harms impacting PWID are not exacerbated further by the conditions of the pandemic. In addition, any sustained policy and service delivery adaptations prompted by COVID-19 will require further attention if they are to be acceptable to both service users and providers.

Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence

BACKGROUND

People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England.

METHODS

We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research.

RESULTS

Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with 'drugs used in substance dependence' collectively categorised as posing low risk if delayed and moderate risk if omitted.

CONCLUSIONS

Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the 'low-risk' categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.

Is Methadone Safe for Patients With Opioid Use Disorder and Coronavirus Disease 2019 Infection?

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has led to not only increase in substance misuse, substance use disorder, and risk of overdose but also lack of access to treatment services. Due to lack of knowledge of the course and impact of COVID-19 and outcomes of it's interactions with existing treatments, the Substance Misuse Service Team initiated a safety improvement project to review the safety of opioid substitution treatment, particularly the safety of methadone. This preliminary retrospective cross-sectional audit of safety improvement intiative underscores the importance of providing treatment services to those with opioid use disorders and that methadone is safe among this population with a high burden of comorbidity, most of which leads to negative outcomes from COVID-19. The outcomes show that patients who have COVID-19 should continue with opioid substitution treatment with methadone. Although treatment with methadone is safe, symptomatic patients should be monitored. In addition, patients who take methadone at home should be educated on the risk of overdose due to, and adverse outcomes from, COVID-19 infection. Patients should monitor themselves using pulse oximeter for any signs of hypoxia.

Harm reduction must be recognised an essential public health intervention during crises

The COVID-19 had a substantial impact on the provision of harm reduction services for people who use drugs globally. These front-line public health interventions serve a population that due to stigma, discrimination and criminalisation, faces barriers to accessing health and social services and are particularly vulnerable to public health crises. Despite this, the pandemic has seen many harm reduction services close, reduce operations or have their funding reduced. Simultaneously, around the world, harm reduction services have been forced to adapt, and in doing so have demonstrated resilience, flexibility and innovation. Governments must recognise the unique abilities of harm reduction services, particularly those led by the community, and identify them as essential health services that must be protected and strengthened in times of crisis.

Transition from injecting opioids to smoking fentanyl in San Francisco, California

BACKGROUND

The introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco.

METHODS

We used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018-2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids.

RESULTS

The median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID's motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma.

CONCLUSION

Between 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.

Injecting drug use, the skin and vasculature

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

"You know, we can change the services to suit the circumstances of what is happening in the world": a rapid case study of the COVID-19 response across city centre homelessness and health services in Edinburgh, Scotland

BACKGROUND

The COVID-19 pandemic has necessitated unprecedented changes in the way that health, social, and housing services are delivered to individuals experiencing homelessness and problem substance use. Protecting those at high risk of infection/transmission, whilst addressing the multiple health and social needs of this group, is of utmost importance. This study aimed to document the impact of the COVID-19 pandemic on individuals who were experiencing homelessness in one city centre in Scotland, and how services adapted in response.

METHODS

Semi-structured interviews were conducted with individuals with lived/living experience of homelessness (n = 10), staff within onethird sector service (n = 5), and external professionals (n = 5), during April-August 2020, using a rapid case study design. These were audio-recorded, fully transcribed, and analysed using Framework. Analysis was informed by inclusion health and equity-orientated approaches to meeting the needs of people with multiple and complex needs, and emerging literature on providing harm reduction in the context of COVID-19.

RESULTS

Those with lived/living experience of homelessness and problem substance use faced a range of additional challenges during the pandemic. Mental health and use of substances were affected, influenced by social isolation and access to services. A range of supports were provided which flexed over the lockdown period, including housing, health and social care, substance use treatment, and harm reduction. As well as documenting the additional risks encountered, findings describe COVID-19 as a 'path-breaking' event that created opportunities to get evidence into action, increase partnership working and communication, to proactively address risks.

CONCLUSIONS

This rapid case study has described the significant impact of the COVID-19 pandemic on a group of people experiencing homelessness and problem substance use within one city centre in Scotland and provides a unique lens on service/professional responses. It concludes with lessons that can inform the international and ongoing response to this pandemic. It is vital to recognise the vision and leadership that has adapted organisational responses in order to reduce harms. We must learn from such successes that were motivated both by compassion and care for those vulnerable to harms and the desire to provide high-quality, evidence-based, harm reduction services.

Clinical vulnerability for severity and mortality by COVID-19 among users of alcohol and other substances

The COVID-19 pandemic is a public health emergency. Individuals with substance use disorder have a higher risk of infection and may suffer from more severe forms of the disease. Our goal is to investigate the prevalence of risk factors for COVID-19 severity in individuals with different substance use and explore whether specific types of substance are potentially associated with more clinical risk factors which could increase morbimortality in this population. The sample included 821 men hospitalized at an inpatient Addiction unit (305 alcohol users, 233 cocaine/crack users, and 283 multiusers). Data were collected using the Addiction Severity Index version 6. The most prevalent risk factors for COVID-19 severity observed in our sample were: smoking (82.5%), arterial hypertension (26.6%), respiratory problems (23.4%), and history of homelessness (25.1%). Arterial hypertension and cirrhosis occurred more frequently among alcohol users. Multiusers lived in the streets longer and had a higher prevalence of HIV than alcohol users. Overall, 28% of the sample had three or more risk factors. The frequency of risk factors was high and this scenario suggests that these individuals could be more susceptible to worse COVID-19 prognosis. Therefore, prevention strategies directed at specific characteristics of substance users merit attention during the pandemic.

Addictions in the COVID-19 era: Current evidence, future perspectives a comprehensive review

BACKGROUND

In the context of the COVID-19 worldwide pandemic, an up-to-date review of current challenges in addictions is necessary. While large scale disasters may have an impact on substance use and addictions, the use of some substances is also likely to modify the risk of COVID-19 infection or course. Many countries have imposed lockdowns. Whether this quarantine or the end of lockdown measures will have an impact on substance use is discussed. The aim of this review is to gather knowledge for clinicians and to guide public health policies during/after lockdown.

METHODS

PubMed was reviewed in August 6th (2020), to determine the current evidences and observations concerning the addictions and SARS-CoV2. We used all the names of the severe acute respiratory syndrome of coronavirus 2 (SARS-CoV2 previously 2019 nCoV), the name of the coronavirus disease 2019 (COVID-19), and common substances of abuse. For the physiopathological parts, searches were conducted using key words such as "infection" or "pneumonia". For the lockdown effects, key words such as "quarantine", "disaster" or "outbreak" were used.

RESULTS

Overall, pathophysiological data showed an increased risk of infections for individuals with Substance Use Disorders (SUD) and a possible protective role of nicotine. During lockdown, there is a substantial risk of increasing SUDs. Individuals with opioid use disorder are particularly at risk of relapse or of involuntary withdrawal. After lockdown, increase of use may be observed as far as years after. Individuals with addictions are at higher risk of multimorbidity and mortality during COVID outbreak.

CONCLUSION

This review describes useful strategies in clinical practice, including a systematic assessment of addiction comorbidity during this almost worldwide lockdown/pandemic. This review also highlights important areas for future research.

'Resurgent', 'twin' or 'silent' epidemic? A select data overview and observations on increasing psycho-stimulant use and harms in North America

In the early 2000s, increasing prevalence of psycho-stimulant (e.g., crack/cocaine, methamphetamine) use and related harms, including severe adverse health outcomes, was observed among - mostly marginalized - populations of persons using illicit drugs in North America, underscoring an urgent need for interventions options towards improved prevention and treatment. By about 2010, however, the 'opioid crisis', featuring unprecedented use and public health burden, had accelerated into full force in North America, largely muting attention to the psycho-stimulant issue until recently. Recent surveillance data on drug use and related mortality/morbidity from the present decade has documented a marked resurgence of psycho-stimulant use and harms especially in at-risk populations, commonly in direct combination with opioids, across North America, resulting in a 'twin epidemic' comprised of opioids and psycho-stimulants We briefly review select epidemiological data indicators for these developments from the United States and Canada; in the latter jurisdiction, related evidence has been less prevalent and systematic but corroborating the same trends. Evidently, the (widely ongoing) focus on the 'opioid epidemic' as a 'mono-type' drug problem has become an anachronism that requires urgent and appropriate correction. We then briefly consider existing, evidence-based options for - prevention and treatment - interventions targeting psycho-stimulant use and harms, which are substantially more limited and/or less efficacious than those available for problematic opioid use, while presenting major gaps and challenges. The observed resurgence of psycho-stimulants may, indirectly, relate to recent efforts towards curtailing (medical) opioid availability, thereby accelerating demand and supply for both illicit opioids and psycho-stimulants. The presently unfolding 'twin epidemic' of opioids and psycho-stimulants, combined with limited intervention resources, presents an acute challenge for public health and may crucially undermine actively extensive efforts to reduce opioid-related health harms in North America.

An ethical analysis of UK drug policy as an example of a criminal justice approach to drugs: a commentary on the short film Putting UK Drug Policy into Focus

Background

Drug-related deaths in the UK are at the highest level on record—the war on drugs has failed. A short film has been produced intended for public and professional audiences featuring academics, representatives of advocacy organisations, police and policymakers outlining the problems with, and highlighting alternative approaches to, UK drug policy. A range of ethical arguments are alluded to, which are distilled here in greater depth for interested viewers and a wider professional and academic readership.

Main body

The war on drugs is seemingly driven by the idea that the consumption of illegal drugs is immoral. However, the meaning ascribed to ‘drug’ in the illicit sense encompasses a vast range of substances with different properties that have as much in common with legal drugs as they do with each other. The only property that distinguishes illegal from legal drugs is their legal status, which rather than being based on an assessment of how dangerous they are has been defined by centuries of socio-political idiosyncrasies. The consequences of criminalising people who use drugs often outweigh the risks they face from drug use, and there is not convincing evidence that this prevents wider drug use or drug-related harm. Additionally, punishing someone as a means, to the end of deterring others from drug use, is ethically problematic. Although criminalising the production of harmful drugs may seem more ethically tenable, it has not reduced the supply of drugs and it precludes effective regulation of the market. Other potential policy approaches are highlighted, which would be ethically preferable to existing punitive policy.

Conclusion

It is not possible to eliminate all drug use and associated harms. The current approach is not only ineffective in preventing drug-related harm but itself directly and indirectly causes incalculable harm to those who use drugs and to wider society. For policymakers to gain the mandate to rationalise drug policy, or to be held accountable if they do not, wider engagement with the electorate is required. It is hoped that this film will encourage at least a few to give pause and reflect on how drug policy might be improved.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

To what extent do supervised drug consumption services incorporate non-injection routes of administration? A systematic scoping review documenting existing facilities

BACKGROUND

Most of the existing research on supervised consumption services (SCS) is focused on injection drug use. Less is known about the applicability of SCS for people who consume drugs orally, intranasally, or through inhalation. This is problematic because people who use drugs through modes other than injection are also at risk of overdose death and other harm, and experience barriers accessing health and social services. We aimed to describe existing SCS models that accommodate these alternate routes of drug consumption, and synthesize available information on characteristics of program participants.

METHODS

We conducted a systematic scoping review of 9 peer-reviewed and 13 grey literature databases on SCS that incorporate non-injection routes of consumption. We screened 22,882 titles, and excluded 22,843 (99.8%) articles. We ultimately included 39 (0.2%) full-text articles; 28 (72%) of these articles explicitly identified SCS that permit alternate routes of consumption and 21 (54%) discussed characteristics of participants who consume drugs through non-injection routes. Data on study characteristics, terms and definitions, and site and program participant characteristics were extracted and double-coded. Extracted data were analyzed using descriptive statistics and narrative synthesis.

RESULTS

Included articles describe 48 SCS that permit non-injection routes of consumption, most of which were located in Germany. The majority of these SCS were legally sanctioned and had models of care that were largely comparable to supervised injection services. Notable differences included physical infrastructure such as ventilated rooms or outdoor areas to accommodate inhalation, and shorter time limits on non-injection drug consumption episodes. Program participants engaging in non-injection forms of consumption were typically men over the age of 30 and structurally vulnerable (e.g., experiencing homelessness or unstable housing).

CONCLUSIONS

Extant academic and grey literature indicates that site characteristics and demographics of program participants of SCS that permit non-injection routes of consumption largely reflect those of supervised injection services. Further research on the range of existing SCS that incorporate non-injection routes of consumption is needed to ensure high quality service provision, and improved health outcomes for people who consume drugs via oral, intranasal, and inhalation routes.