The intersectional risk environment of people who use drugs

Prenatal substance use and mental health comorbidities predict continued use

OBJECTIVE

Prenatal substance use is common and can affect maternal and infant health. In addition, prenatal substance use is associated with mental health comorbidities (depression, anxiety, and posttraumatic stress disorder). Unremitting prenatal substance use disorders and mental health comorbidities are associated with poor health outcomes for mothers and exposed infants. The purpose of this study was to examine how any substance use, type of substance use (polysubstance use vs. single substance use), and combinations of mental health comorbidities predict continued use during pregnancy (i.e., use in the 30 days prior to delivery).

METHOD

Health records of patients enrolled in a comprehensive prenatal program for women with substance use disorders were retrospectively analyzed (N = 281). Urine drug screen records were used to determine substance use, and diagnostic codes were used to identify mental health comorbidities.

RESULTS

Thirty-seven percent of the sample (n = 105/281) tested positive for substances at admission and 42% (n = 119/281) demonstrated continued use. 30% of the sample (n = 85/281) had depression, anxiety, and posttraumatic stress disorder, 27% (n = 76/281) had two of the three mental health comorbidities, 26% (n = 73/281) had one of the three comorbidities, and 17% (n = 47/281) did not have a mental health comorbidity. Any substance use at admission or having all three mental health conditions were associated with continued use.

CONCLUSIONS

Substance use at admission and number of mental health conditions were independent predictors of continued use, although substance use was the stronger predictor. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Assessing fentanyl and methamphetamine in air and on surfaces of transit vehicles

Recently, the misuse of fentanyl and methamphetamine has increased in the United States. These drugs can be consumed via smoking a powder, which can subsequently contaminate air and surfaces with drug residue. With limited access to safe consumption sites, this misuse often occurs in public spaces such as public transit, leading to potential secondhand exposures among transit operators and riders. In the Pacific Northwest, transit operators have reported acute health symptoms and safety concerns regarding these drug exposures. Researchers conducted an exposure assessment, sampling air and surfaces for fentanyl and methamphetamine. A total of 78 air samples and 89 surface samples were collected on 11 buses and 19 train cars from four transit agencies in the Pacific Northwest. Fentanyl was detected above the limit of quantification (LOQ) in 25% of air samples (range of concentrations > LOQ: 0.002 to 0.14 µg/m3) and 38% of surface samples (range of concentrations > LOQ: 0.011 to 0.47 ng/cm2), while methamphetamine was detected in 100% of air samples (range: 0.003 to 2.32 µg/m3) and 98% of surface samples (range of concentrations > LOQ: 0.016 to 6.86 ng/cm2) The highest fentanyl air sample (0.14 µg/m3) was collected in the passenger area of a train for 4 hr, and would exceed the ACGIH® 8-hr TWA TLV® of 0.1 µg/m3 if conditions remained the same for the unsampled period. No surface samples exceed the ACGIH fentanyl surface level TLV (10 ng/cm2). The prevalence of fentanyl and methamphetamine on public transit highlights the need to protect transit operators from secondhand exposure and from the stress of witnessing and responding to smoking events. Future work is needed to evaluate the utility of engineering and administrative controls such as ventilation and cleaning upgrades in reducing exposures on transit, as well as the utility of training and increased workplace support for operators in addressing their health and well-being after observing or responding to drug use events.

Reconceptualizing cannabis use risks in the context of health and social inequities: Insights from a qualitative study with young people in Canada

BACKGROUND

Cannabis became legal in Canada in 2018. Since then, calls for research to evaluate the impact of legalization on youth have been at the forefront of public and academic discussions. Research addressing these calls has largely focused on issues of risk and harm, with limited attention to the role of social context in shaping youth cannabis use. This paper presents the findings of a study that centered youth perspectives on cannabis use in the context of health and social inequities.

METHODS

Between 2021 and 2022, we undertook an exploratory and critical qualitative interview study with 56 youth from across Canada who use cannabis and who reported experiences with health or social struggles, broadly self-defined. Our analysis followed a reflexive thematic approach and leveraged theoretical perspectives from critical drug studies to interrogate youths' variegated cannabis use risks and risk environments, whilst facilitating inquiry into their interface with overlapping forms of hardship and inequity.

FINDINGS

We developed three interconnected themes: (i) cannabis use risks as contextually situated; (ii) cannabis use as a practice of care; and (iii) cannabis use as a survival tool in connection with trauma and violence. Findings within and across these themes centre on the nexus of intentionality and agency in youth narratives of using cannabis and situates their cannabis use in connection with, and in response to, intersecting health and social inequities.

CONCLUSION

This study underscores opportunities for a reconsideration or reconceptualization of risks in the context of youth cannabis use, so that approaches to supporting youth who use cannabis are more resonant and credible with those who experience health and social inequities. Findings offer direction for youth cannabis policy and programming, including to decenter individual pathology, support harm reduction goals, and further consider relationships between cannabis use and context, marginalization, and oppression.

Risk Factors for Infective Endocarditis and Serious Injection Related Infections Among People Who Inject Drugs in Los Angeles, CA and Denver, CO

BACKGROUND

Injection drug use-related infective endocarditis (IDU-IE) and bacterial infections have grown in the United States, but little is known about risk factors for these infections in community samples of people who inject drugs (PWID).

METHODS

During 2021-22, PWID were recruited from community settings and surveyed for history of IDU-IE, serious injection related symptoms (SIRI) and untreated infection symptoms in the last 3 months. We used bivariate analysis and multiple logistic regression to examine factors associated with these outcomes.

RESULTS

Among participants (n = 472), 7 % reported ever having IDU-IE, 14 % reported having SIRI symptoms and 20 % reported untreated infection symptoms in the last 3 months. Ever having IDU-IE was associated with HCV (adjusted odds ratio [AOR]=8.37; 95 % confidence interval [CI]=2.46, 28.49), prior MRSA infection (AOR=5.37; 95 % CI=2.44, 11.80), identifying as female and/or gender minority person (AOR=3.14; 95 % CI=1.42, 6.95). SIRI symptoms were associated with greater material hardship (compared to low; AOR=2.47; 95 % CI=1.17, 5.22), fentanyl use (AOR=2.15; 95 % CI=1.01, 4.61), sharing filter/cotton (AOR=1.93; 95 % CI=1.10, 3.39), and licking needle prior to injection (AOR=1.85; 95 % CI=1.02, 3.36). Untreated infection symptoms were associated with poor quality sleep (AOR=2.04; 95 % CI=1.21, 3.43), any mental health diagnoses (AOR=2.01; 95 % CI=3.56), any chronic pain (AOR=1.89; 95 % CI=1.14, 3.11), sharing filters (AOR=1.81; 95 % CI=1.10, 2.98), and prior MRSA infection (AOR=1.75; 95 % CI=1.04, 2.97).

CONCLUSION

Risk factors identified include treatable co-morbidities (i.e., HCV & MRSA history, mental health, pain, opioid use), modifiable health behaviors (i.e., equipment sharing, needle-licking), and addressable structural conditions (material hardship, housing).

Psychosocial Impact of Suspected Xylazine-Associated Skin Wounds Among People Using Fentanyl, Philadelphia, 2022 to 2023

BACKGROUND

The United States opioid crisis has been worsened by the emergence of fentanyl adulterated or associated with the veterinary sedative xylazine. Designated by the White House as an "emerging threat to the US" in 2023, xylazine use is associated with severe skin wounds.

METHODS

This research explored beliefs, concerns, and treatment behaviors for skin wounds among 93 participants recruited outside of a Philadelphia, Pennsylvania harm reduction agency who reported past-6-month history of a skin wound via a cross-sectional survey administered August-September 2022 (group 1; n = 33). Following a December 2022 Philadelphia Department of Public Health Report that indicated xylazine was becoming more prevalent in the Philadelphian drug supply, additional data was collected with new participants from February-March 2023 (group 2; n = 60) using the same survey. Participants were ≥18 years old, reported past-year fentanyl use, and spoke English. Our 17-item tool measured skin wound-related beliefs, concerns, treatment behaviors, and treatment sources. An open-response item explored why participants self-treat skin wounds.

RESULTS

Participants averaged 41 years old (SD = 9), slightly more than half were men (n = 54, 58%), 31% (n = 29) were non-White, and most (n = 66, 71%) were unhoused. Overall, 79% of participants self-treated skin wounds. Participants endorsed worry about limb loss (n = 77; 83%), wound shame (n = 76; 82%), and appearance changes (n = 80; 86%). Sixty participants (65%) reported waiting to see wound severity before seeking care. Forty-one participants (44%) delayed wound care because of withdrawal fears.

CONCLUSIONS

People with probable xylazine-associated skin wounds have psychosocial concerns about and self-treat these wounds. Findings may be a harbinger of skin wound harm in other regions of the United States and internationally where xylazine is increasing.

Systematic review of cognitive and behavioral strategies used in effective harm reduction interventions for people who use cocaine

OBJECTIVE

The aim of this systematic review is to identify cognitive and behavioral strategies that have been used in effective harm reduction interventions for people who use cocaine.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the search was performed on February 26, 2023 across databases including PsycInfo, PubMed, Scopus, and Web of Science. Studies were included if they (1) report the use of one cognitive or behavioral strategy, (2) have harm reduction as the objective, (3) involve participants who used cocaine as at least one of their substances, (4) be published within the last 10 years, and (5) have a randomized controlled trial design. The Cochrane RoB 2.0 Tool was used to assess risk of bias. The cognitive and behavioral strategies were extracted and organized based on their frequency of use in the studies and their corresponding outcomes.

RESULTS

The final synthesis included k = 10 studies with N = 3,567 participants. Psychoeducation strategies, influence on social norms, personalized feedback, increased self-efficacy and motivational interviewing were the most frequently used promising strategies across studies.

CONCLUSIONS

This review underscores the significance of incorporating cognitive and behavioral strategies within harm reduction interventions, as they represent a promising domain that could enhance the effectiveness of addressing cocaine use.

"A safe place to use": People who use drugs' perceptions and preferences prior to the implementation of Rhode Island's first overdose prevention center

INTRODUCTION

In July 2021, Rhode Island became the first state in the United States (US) to legalize overdose prevention centers (OPCs). To inform the design and implementation of an OPC in Providence, Rhode Island's capital, we explored perceptions of OPCs and programmatic needs among people who use drugs.

METHODS

The study conducted in-depth qualitative interviews from December 2023 to March 2024 with 25 people who use drugs. Thematic analysis explored OPC implementation considerations, with a focus on perceived social and structural barriers and facilitators for use. The study shared findings iteratively with the future OPC's operating organization.

RESULTS

Overall, participants were aware of plans to open an OPC locally and were largely supportive. Participant narratives underscored social, spatial, and programmatic needs to facilitate OPC accessibility and uptake, including the site's hours of operation, environment, and ancillary services provided. Participants further underscored concerns and considerations that would affect their willingness to use the site, including police presence, preferred substances and use modalities, use routines, and housing status. These considerations and concerns were grounded in participants' own social locations and levels of structural vulnerability.

CONCLUSION

Our findings underscore the need for inclusive services that ensure the OPC's accessibility and uptake as a safer environment for a variety of key populations.

Resident and staff experiences of structural barriers to a housing-based overdose prevention site in Vancouver, Canada: "There is a double standard if you smoke"

OBJECTIVES

Most overdoses in British Columbia (BC), Canada, occur within housing settings. In response, the provincial government is increasingly implementing housing-based overdose prevention sites (HOPS). Within the context of a contaminated drug supply, and changing consumption practices, there is little research examining the effectiveness of HOPS. The aim of this study was to explore qualitatively how residents and staff experience HOPS, focusing on how this intervention fits into the day-to-day operations of a low-barrier housing facility.

METHODS

This study was undertaken at a non-profit housing and emergency shelter facility, with a HOPS in Vancouver, BC. We employed rapid-ethnographic methods including six weeks of non-participant observation (> 200 h), three focus groups, 20 informal interviews with residents, and 10 semi-structured interviews with staff. Data were analyzed through an inductive thematic approach.

RESULTS

Our results suggest that this facility's HOPS is underutilized due to a variety of structural factors, the most prominent of these being the lack of inhalation services. This lack of service provision exacerbates overdose vulnerability and stigma. Continued drug consumption near the building and in non-monitored areas inside the building creates challenges for staff in identifying potential overdoses and exposes residents who do not consume drugs to drug use within the building.

CONCLUSION

Housing provision which provides a safer consumption environment to include those who smoke drugs is urgently needed to support both individuals who smoke and those looking to transition from injecting to smoking.

Mapping the risk environment for peers with lived-living experience working in the alcohol and other drugs sector in Queensland

INTRODUCTION

Peer workers in the Alcohol and Other Drugs (AOD) sector play a vital role in harm reduction for people who use drugs (PWUDs); however, their experiences are often shaped by complex macro- and micro-risk environments. This study explores these environments and their implications for peer workers, particularly concerning stigma, legal barriers, and organisational culture.

METHODS

Semi-structured interviews were conducted with 18 peers with lived-living experience of illicit drug use. Purposive sampling was employed, leveraging established peer networks and community organisations. Interviews (range = 42-90 mins) were conducted via Microsoft Teams, transcribed, and analysed. The iterative coding process involved deductive codes based on predetermined topics and inductive codes derived from identified themes.

RESULTS

Participants identified key systemic challenges, including peer stigma, limited career prospects, and the complexities of navigating legal frameworks that criminalise drug use, thereby undermining the efficacy of peer work. The interplay between regulatory frameworks and societal attitudes creates barriers to employment, which disproportionately affects people with drug-related offenses. The significance of collective connection as a source of safety and support was also highlighted, particularly through peer supervision, which fosters enabling environments that promote wellbeing.

DISCUSSION

Findings highlight the need for advocacy towards legal reform and the creation of inclusive organisational cultures. Recognising and valuing the LLE of peer workers is essential for enhancing harm reduction initiatives and promoting the wellbeing of PWUDs. Addressing these macro- and micro-risk factors, including the importance of peer supervision, can improve peer workers' efficacy in providing meaningful support within their communities.

Characteristics of supervised injection site clients and factors associated with requiring overdose intervention, Montreal, Canada, 2018-2022

BACKGROUND

Supervised injection sites (SIS) offer a hygienic environment in which people can inject drugs under observation; as such, these harm reduction services have been on the forefront of the overdose epidemic. We sought to understand factors predictive of an overdose requiring an emergency response intervention at SIS in Montréal, Canada.

METHODS

We used administrative data from all four Montréal SIS from 1 March 2018 - 31 October 2022 to first calculate the rate of onsite overdose requiring intervention (e.g., naloxone or oxygen administration, nurse or paramedic assessment, etc.) and descriptive statistics. We then used a logistic regression model, with generalized estimating equations to adjust for clients' repeat visits, to test associations between onsite overdose intervention and client gender, age, drug injected (fentanyl vs other opioid vs non-opioid), most frequent injection location, frequency of injecting, duration of injecting, housing stability, attendance at multiple SIS, and time period (before or after 15 March 2020).

RESULTS

During the observation period, Montréal SIS received 122,509 visits from 2,127 unique clients. The rate of overdose requiring intervention was 8.16 (95 % CI 7.66, 8.68) per 1000 visits. While 278 (13 %) of clients experienced an onsite overdose intervention, these clients accounted for 64,267 (52 %) SIS visits. Transgender clients (aOR = 2.28, 95 % CI 1.18, 4.41, compared to men) and clients younger than 25 were at greater risk of experiencing an onsite overdose requiring intervention (e.g., clients 35-44 had an aOR = 0.44, 95 % CI 0.30, 0.64, compared to clients younger than 25). Injecting most often in a public place was associated with greater risk of an onsite overdose requiring intervention (aOR = 3.62, 95 % CI 3.04, 4.30), while reporting unstable housing (aOR = 0.56, 95 % CI 0.47, 0.66) and attending more than one SIS (aOR = 0.13, 95 % CI 0.10, 0.16) predicted lesser risk. Compared to clients who reported injecting daily, greater risk of overdose requiring intervention was observed among those who reported injecting 3-6 days a week (aOR = 1.48, 95 % CI 1.18, 1.85), 1-2 days a week (aOR = 2.43, 95 % CI 1.90, 3.11), and "occasionally" (aOR = 2.60, 95 % CI 2.13, 3.18), but not those who reported not injecting in the past several months (aOR = 0.44, 95 % CI 0.25, 0.79). Compared to clients who had been injecting for five or more years, an injection duration of 1-4 years was associated with reduced risk of an overdose requiring intervention (aOR = 0.79, 95 % CI 0.64, 0.98), while those newer (<1 year) to injecting were at greater risk of such an intervention (aOR = 2.11, 95 % CI 1.50, 2.97). Compared to clients intending to inject fentanyl, we observed a lower risk of an overdose requiring intervention for those injecting other opioids (aOR = 0.22, 95 % CI 0.18, 0.26) or non-opioids (aOR = 0.06, 95 % CI 0.04, 0.08). Injecting after 15 March 2020 was also associated with greater risk (aOR = 1.99, 95 % CI 1.65, 2.41).

CONCLUSION

Across four Montréal SIS, site visits with an overdose requiring intervention were associated with transgender identity, younger age, stable housing, intending to inject fentanyl, injecting less frequently than daily, injecting for either more than five years or less than a year, single site attendance, and injecting most often in a public place. Montréal SIS serve a diverse clientele who inject drugs, with differing risks of onsite overdose.

Attitudes Toward Injection Practices Among People Who Inject Drugs Utilizing Medical Services: Opportunities for Harm Reduction Counseling in Health Care Settings

Hospitals are an important setting to provide harm reduction services to people who inject drugs (PWID). This study aimed to characterize PWID's injection practices, the perceived risk and benefits of those practices, and the immediate IDU risk environment among individuals seeking medical care. Surveys were administered to 120 PWID seeking medical services at an urban hospital. Poisson regression was used to examine the effect of perceived risk or importance of injection practices on the rate of engaging in those practices. The mean participant reported "often" reusing syringes and "occasionally" cleaning their hands or skin prior to injection. 78% of participants reported that syringes were extremely risky to share, which was associated with lower likelihood of sharing them (ARR: 0.59; 95% CI: 0.36-0.95). 38% of participants reported it was extremely important to use a new syringe for each injection, and these participants were more likely to report never reusing syringes >5 times (ARR: 1.62, 95% CI: 1.11-2.35). Other factors that may influence injection practices-including fear of arrest, withdrawal, lack of access to supplies, and injecting outdoors-were common among participants. In conclusion, practices that place PWID at risk of injury and infection are common, and risk-benefit perception is associated with some, but not all, injection practices. Injecting in challenging environments and conditions is common. Therefore, harm reduction counseling in medical settings must be accompanied by other strategies to reduce risk, including facilitating access to supplies. Ultimately, structural interventions, such as affordable housing, are needed to address the risk environment.

Likelihood of using a harm reduction vending machine among rural people who inject drugs in Appalachian Kentucky

BACKGROUND

Harm reduction vending machines (HRVMs) that dispense safe injection equipment and other supplies have operated globally for more than 30 years, yet few operate in the U.S., particularly in the rural epicenters of drug-related harms. This study explores likelihood of using HRVMs and correlates thereto among people who inject drugs in rural Appalachian Kentucky.

METHODS

Respondent-driven sampling and outreach were used to recruit participants who were age 18 or older, resided in an Appalachian Kentucky county, and had used opioids and/or injected drugs to get high in the past 30 days. Interviewer-administered questionnaires elicited data on behavioral and demographic characteristics and likelihood of using HRVMs. Analyses were restricted to participants who injected in the past 6 months (n = 259). Generalized estimating equations were used to estimate adjusted prevalence ratios (APRs) for correlates to likelihood of using HRVMs, controlling for lifetime use of brick-and-mortar syringe service programs.

RESULTS

Overall, 57 % reported being likely to use HRVMs. Participants who lacked consistent access to transportation, engaged in receptive and distributive syringe sharing, experienced more lifetime overdoses, and had unsuccessfully attempted to access medications for opioid use disorder (MOUD) reported being more likely to use HRVMs. Heroin and prescription opioid use were negatively associated with likelihood of HRVM use, as was experience of shame around drug use.

CONCLUSIONS

Most people who inject drugs in this rural Appalachian sample were likely to use HRVMs, with interest being highest among those at highest risk for injection-related infections and overdose and who had faced difficulty accessing MOUD.

"Basically every safety protocol we have in place to protect against overdose, parents can't access": Mothers who use unregulated drugs' experiences of dual public health emergencies

BACKGROUND

A growing body of research details the impacts of COVID-19 pandemic-related public health directives and service disruptions on people who use unregulated drugs, however, there is limited research on the gendered impacts, particularly among mothers.

METHODS

To explore experiences navigating the COVID-19 pandemic during a toxic drug crisis, phone-based semi-structured interviews were conducted from May 2020-Sept. 2021 with 45 women who use unregulated drugs in British Columbia. Iterative-based thematic analysis informed by intersectional theory identified unaccounted for impacts on parents.

FINDINGS

Respondents' experiences of the COVID-19 pandemic involved contending with an increasingly toxic drug supply alongside reduced resources, including service reductions and closures and reduced access to harm reduction supplies in a context already marked by women's marginalization within treatment and policy. Mothers described pandemic-related increased custody and care barriers and burdens, resulting in inability to prioritize self-care. Decisions to prioritize associated risks of either COVID-19 or drug toxicity, given conflicting public health guidelines, were experienced as high stakes for mothers, due to their unique vulnerability to institutional scrutiny. Pandemic-informed overdose risk mitigations, such as access to legal pharmaceutical-grade alternatives to the toxic drug supply, also involved additional risks for mothers (e.g., heightened monitoring; child apprehension), thus, some respondents, responsibilized for their health and childcare, resourcefully relied upon informal, social networks to help mitigate potential harms.

CONCLUSION

While mothers and their experiences are heterogeneous, gendered distinctions impact provision and experience of health care, harm reduction and social supports. Mothers who use drugs must navigate health and care responsibilities, exacerbated by pandemic-related health barriers, while simultaneously inhabiting an unremitting state of fear of punitive measures or postapprehension despair. The continued social exclusion of mothers who use drugs, propelled by moralizing discourses framing them as deviant and consequentially undeserving, can have devastating health impacts (on individuals and communities) yet remain underaddressed.

Characterising people who inject drugs, and association with HIV infection: A situation analysis in Kampala City, Uganda

Uganda implements interventions for injection drug use, but significant barriers hinder efforts to effectively reach and support persons who inject drugs (PWID). We describe characteristics of PWID, and associated risk behaviour, to inform the designing of programmes that are tailored to clients' needs and preferences. A cross-sectional survey (August 23rd to December 5th, 2023) in Kampala interviewed 354 PWID (≥18-years) at selected venues(bars,lodges, street corners and ghetto). Peer eductors and counsellors administered a structured questionnaire covering socio-demographics, drug use, sexual risk, and medical history. HIV serostatus was determined by self-report or testing for consenting participants without history of recent testing Binary logistic regression was used to establish the relationship between HIV infection and risky drug- and sexual behaviour of PWID. Participants were predominantly Ugandan (95.2%), male (73.2%), unmarried (55.9%), unemployed (81.8%), with higher levels of education and varying ages. Mental disorders were prevalent, with 48.7% reporting at least one underlying condition, including depression (30.8%) and anxiety (9.6%). Physical health issues included fever (32.9%), cough (32.5%), malaria (22%), and sexually transmitted infections (15%). Over 82.6% were introduced to drugs by close acquaintances. HIV prevalence among participants was 3.7%, higher in females (8.4%) and non-Ugandans (16.7%). Being female and experiencing difficulty accessing sterile injection materials were associated with HIV-positive status. Our study provides valuable insight into the socio-demographic, mental, physical health, and HIV risk behaviour of PWID in Kampala, Uganda. The findings indicate significant vulnerabilities to injecting drug use, mental disorders, and high-risk behaviors that predispose this population to HIV infection. Despite a low HIV prevalence in this population compared to previous estimates, the interplay between drug use, risky injecting practices, and sexual behaviour suggests an urgent need for targeted interventions to address these intertwined challenges.

Disease Conditions and Health Information Needs Among People Who Inject Drugs: Engendering Research to Policy and Interventions Initiatives

BACKGROUND

Injecting drug use is a global public health challenge with multifaceted consequences, not only for people who inject drugs (PWIDs) but also for society at large. Their vulnerability necessitates a deeper exploration of their health information needs, aiming to leverage evidence-based research to shape effective interventions for their well-being.

METHOD

This study employed a qualitative method to gain insights into disease conditions and health information needs of PWIDs. Through purposive and snowball sampling, 71 in-depth interviews were conducted and thematically analyzed.

RESULTS

This study included 43 males and 28 females, predominantly aged 26-35 (59.2%), who had low socioeconomic status. The most reported disease conditions varied and included malaria, infections, and diabetes. Findings revealed a complex understanding of their disease conditions and management practices. Participants emphasized a critical need for access to reliable and comprehensive health information, while also highlighting the significant barriers they face in obtaining this information. Additionally, their preference for receiving health information in video formats, written articles, and through outreach programs underscored their desire for knowledge to make informed decisions. As co-creators and stakeholders in their health, participants expressed a clear demand for sustainable and free healthcare, mosquito nets, and regular outreach programs.

CONCLUSIONS

While drug use presents a significant public health issue, effective interventions for PWIDs require a multifaceted approach that begins with understanding their perspectives and actively involving them as co-creators of their health solutions. Abandoning this population contradicts the Sustainable Development Goals' mandate to ensure no one is left behind. Thus, all stakeholders must prioritize inclusive and participatory approaches to address the complex health information needs of PWIDs.

Spatial Patterns of Delivery Hospitalizations with Opioid Use Disorder in Pennsylvania

BACKGROUND

Opioid use disorder (OUD) in pregnancy has substantially increased throughout the drug overdose crisis, but little is known about how local community environments are associated with OUD in pregnancy. This study investigates spatial patterns and residential ZIP code-level factors associated with delivery hospitalizations with OUD in Pennsylvania and compares these patterns to those for all delivery hospitalizations and all OUD-related hospitalizations.

METHODS

ZIP code-level inpatient hospitalizations based on patients' residential ZIP codes in Pennsylvania were examined from 2016 to 2019. Using Bayesian hierarchical space-time conditional autoregressive models, we assessed the contributions of residential ZIP code-level factors to OUD delivery hospitalizations and compared these associations to those from models of all delivery hospitalizations and all OUD-related hospitalizations.

RESULTS

Significant spatial autocorrelation was identified for all three types of hospitalizations. Higher unemployment, greater population density, higher overall hospitalization rate, and presence of an OUD treatment facility were associated with greater OUD delivery hospitalizations in residential ZIP codes, while higher median household income and a greater proportion of the population who were non-Hispanic Black and Hispanic were associated with lower OUD delivery hospitalizations. Findings were similar to those for all OUD-related hospitalizations. The effect of ZIP code-level unemployment rate differed between all delivery hospitalizations and those with OUD, with a positive association with OUD deliveries and a negative association with all deliveries.

CONCLUSIONS

Areas with worse economic conditions and greater population density are associated with OUD at delivery, similar to all OUD-related hospitalizations. Community OUD programs may consider simultaneously targeting OUD concerns in pregnancy.

Material hardship, forced displacement, and negative health outcomes among unhoused people who use drugs in Los Angeles, California and Denver, Colorado: a latent class analysis

BACKGROUND

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

METHODS

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

RESULTS

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

CONCLUSIONS

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Rapid Assessment Amid an Injection Drug Use-Driven HIV Outbreak in Massachusetts' Merrimack Valley: Highlights from a Case Study

Illicitly manufactured fentanyl within the drug supply has substantially increased opioid-related overdose deaths and driven infectious disease outbreaks among people who use drugs (PWUD). Local jurisdictions often lack the data and tools necessary to detect and translate such moments into actionable and effective responses. Informed by a risk environment framework, this case study adopted a mixed-methods design spanning two rapid assessment studies with PWUD in Lowell (n = 90) and Lawrence (n = 40), Massachusetts, during an HIV outbreak (2017, Study 1) and following the outbreak (2019, Study 2). Survey responses (n = 130) were summarized by computing descriptive statistics, ethnographic field notes were reviewed, and qualitative interviews (n = 34) were thematically analyzed to contextualize quantitative findings. Study 1 participants reported constrained syringe access, high injecting frequency, syringe reuse, and unsafe syringe disposal practices, and uncovered entrenched social and structural factors exacerbating existing substance use and HIV risks: housing instability, limited harm reduction supplies and services (e.g., MOUD access), and tensions between law enforcement and PWUD. Following the outbreak and substantial local investments in harm reduction and treatment infrastructures, Study 2 participants indicated lower injection risk reporting fewer syringe reuse episodes, improved syringe disposal practices, high frequency of naloxone administration at recent overdoses, frequent testing for HIV and HCV, and greater engagement with syringe services programs. A rapid assessment approach to fentanyl's emergence and a concomitant HIV outbreak provided time-sensitive, critical insights and identified needed and local response strategies. However, unless social and structural risk factors are also addressed, community vulnerability to future HIV outbreaks remains.

HIV and Hepatitis C Among People Who Inject Drugs in Memphis, Tennessee: an Intersectional Risk Environment Analysis of the Social Determinants of Health

BACKGROUND

The Southern US is confronting bourgeoning HIV and hepatitis C virus (HCV) epidemics among people who inject drugs (PWID), yet little is known about shared and unique risk factors across the region. We applied an intersectional risk environment framework to understand infectious disease outcomes for sub-groups of PWID that experience multiple axes of social marginalization related to racial and ethnic identity and social and economic vulnerability.

METHODS

HIV and HCV prevalence was estimated from the first iteration of the CDC's National HIV Behavioral Surveillance respondent driven sample of PWID in Shelby County, Tennessee in 2018. We ran adjusted multinomial models to test main and interaction effects of race/ethnicity and structural factors on the prevalence of a three-level outcome: HIV-only, HCV-only, and no infection.

RESULTS

A total of 564 PWID participated, 558 (99%) completed HIV testing, and 540 (96%) HCV testing. Thirty (5%) were HIV-positive, 224 (40%) HCV-positive, and less than 1% were co-infected. Descriptive differences by race/ethnicity and levels of structural vulnerability for HIV and HCV subpopulations were present; however, there was no evidence for statistical interaction. In the final main effects model, HIV status was positively associated with non-Hispanic Black identity (aRR 4.95, 95% CI 1.19, 20.6), whereas HCV status was associated with non-white identity (aRR 0.11 95% CI 0.07, 0.18). Factors associated with HCV infection were higher scores of structural vulnerability (aRR 2.19 95% CI 1.10, 4.35), and criminal legal involvement (aOR 1.99 95% CI 1.18, 3.37).

CONCLUSION

This is the first study to implement local population-based survey data to evaluate distinctive intersections of ethnic/racial and social factors associated with HIV and HCV status among PWID in the Memphis region. Findings come at an opportune time as harm reduction programs are in development in the South and shed light to the need for socially equitable race conscious resource investment.

Overdose risk environment for people who use drugs in New Jersey: Imagining possible points of intervention for harm reduction practitioners

Background

The Risk Environment Framework is widely utilized theoretical framework for understanding the landscape of harm for people who use drugs (PWUD). This study sought to understand factors contributing to risk of overdose for PWUD in New Jersey. Understanding these factors can lead to improved policy interventions, programmatic targets, and a shared understanding that overdose risk is impacted by larger societal forces influencing PWUD.

Methods

Using a community based participatory design model, this study conducted 30 semi-structured, in-depth interviews with PWUD and naloxone distributors in New Brunswick and Newark, New Jersey from February to November of 2022. Thematic analysis was performed using a collaborative analytical approach.

Results

Risk factors for overdose fell into all four categories of Rhodes's Risk Environment Framework - physical, social, economic, and policy. Many factors overlapped in multiple categories, and most factors had elements existing at both the macro and micro levels.

Conclusions

Interventions supporting PWUD should see overdose risk as an environmental, structural consideration, and be constructed to address comprehensive risks, rather than directing themselves exclusively at the individual level. Factors contributing to risk at the macro level included systemic and institutional concerns and stigma toward PWUD. At the micro level, mental health, substance use behaviors, treatment and recovery, and trauma were cited as potential risk factors.

HIV Prevention in Syringe Service Programs Since the Start of COVID-19: Where Do We Go From Here?

PURPOSE

This narrative review addresses post-2020, specific, complex challenges for use of and adherence to pre-exposure prophylaxis (PrEP) for HIV prevention among out-of-treatment people who use drugs (PWUD) at syringe services programs (SSPs).

RECENT FINDINGS

The COVID-19 pandemic and its associated changes to the provision of healthcare have significantly impacted HIV prevention, especially for PWUD. Through a synthesis of literature and clinical experience, we (1) characterize the operational changes imposed by the pandemic on SSPs that shaped the current HIV prevention landscape; (2) describe three levels of current challenges for PWUD, including consumer attitudes, non-medical and medical provider attitudes, and structural and scalability barriers; (3) characterize current models for PrEP in SSPs; and (4) offer practical recommendations for HIV prevention in harm reduction programs. PrEP is a highly effective prevention tool if taken as prescribed. It has been enthusiastically promoted by members of the research, public health and provider communities. Despite its efficacy, PWUD struggle to engage with the PrEP care continuum. We highlight opportunities to advance HIV prevention for PWUD by enhancing tailored, whole-person approaches that may set aside PrEP in favor of other risk reduction routes. For most PWUD who receive services at SSPs, PrEP is a single tool and not realistic until other social and structural determinants of health are addressed.

The hidden epidemic of occult hepatitis B and C among injection drug users (IDUs): A call for action

Objective

This study aims to determine the prevalence of Occult Hepatitis B and C Infections among Egyptian injection drug users (IDUs) and identify key risk factors contributing to their occurrence within this high-risk group.

Methods

In this cross-sectional study, 200 Egyptian IDUs were assessed. Participants were negative for Hepatitis B surface antigen and hepatitis C virus (HCV) RNA, with anti-HCV positive patients who achieved sustained virologic response after treatment included. Quantitative polymerase chain reaction (PCR) was used to detect HCV RNA in plasma and peripheral blood mononuclear cells, while HBV DNA was identified via nested PCR. Comparisons were made between Occult Hepatitis B infection (OBI) positive and OBI negative subgroups, as well as between other comprehensive income (OCI) positive and OCI negative subgroups. A significance level of 0.05 was set, with P-values below this indicating statistical significance. Statistical comparisons between OBI and OCI-positive and negative groups were performed using the Mann-Whitney U test and Chi-square test.

Results

OBI was found in 32% of IDUs, while OCI was detected in 42% of IDUs, and was present in 53.6% of seropositive individuals. All OBI patients showed a significant increase in all liver function tests, while OCI patients had significant elevations in alanine transaminase and aspartate transaminase values. HIV coinfection was identified in 39.1% and 26.1% of OBI and OCI cases respectively. OBI and OCI coinfection were detected in 31 patients.

Conclusion

Hidden infections such as OBI and OCI remain an overlooked public health issue in Egypt's IDU population. These findings highlight the need for targeted strategies to address these reservoirs of infection and could inform similar approaches in countries with comparable HBV/HCV epidemiology.

Material Hardship, Forced Displacement, and Negative Health Outcomes Among Unhoused People Who Use Drugs in Los Angeles, California and Denver, Colorado: A Latent Class Analysis

Background

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

Methods

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

Results

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

Conclusions

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Exploring drug consumption rooms as 'inclusion health interventions': policy implications for Europe

People who use drugs are among the most socially excluded groups in Europe. Qualitative research on Drug Consumption Rooms (DCRs) has reported various benefits to clients, including increased feelings of well-being, safety and connection, however, few studies have explored in-depth client narratives of belonging and social inclusion. In this article, we explore this literature and describe the ways in which DCRs foster social inclusion and feelings of belonging amongst their clients. With a view towards the future of DCR implementation in Europe, this argument positions DCRs as effective 'inclusion health interventions'. The shift in analysis from DCRs as a purely harm reduction or overdose prevention and response intervention to one of 'inclusion health' could work towards a wider recognition of their effectiveness in addressing broader health and social inequities. At a policy level, this shift could result in increased political support for DCRs as recognized interventions, which through their design, effectively promote social inclusion.

Structural Influences on Methamphetamine Use Among Black Sexual Minority Men (HISTORY Study): Protocol for a Longitudinal Cohort Study

BACKGROUND

Sexual minority men are disproportionately affected by methamphetamine use, with recent studies suggesting an increase in use specifically among Black sexual minority men. Black sexual minority men face unique structural barriers to achieving optimal health. Given its harmful effects, and in light of existing health disparities, an increase in methamphetamine use among Black sexual minority men poses a significant public health concern.

OBJECTIVE

The Health Impacts and Struggles to Overcome the Racial Discrimination of Yesterday (HISTORY) study is investigating the potential impacts of exposure to the census tract-level structural racism and discrimination (SRD) on methamphetamine use among Black sexual minority men in Atlanta, Georgia, and will identify intervention targets to improve prevention and treatment of methamphetamine use in this population.

METHODS

This study uses a mixed methods and multilevel design over a 5-year period and incorporates participatory approaches. Individual-level quantitative data will be collected from a community-based cohort of Black sexual minority men (N=300) via periodic assessment surveys, ecological momentary assessments, and medical record abstractions. Census tract-level measures of SRD will be constructed using publicly available administrative data. Qualitative data collection will include longitudinal, repeated in-depth interviews with a subset (n=40) of study participants. Finally, using a participatory group model-building process, we will build on our qualitative and quantitative data to generate causal maps of SRD and methamphetamine use among Black sexual minority men, which in turn will be translated into actionable recommendations for structural intervention.

RESULTS

Enrollment in the HISTORY study commenced in March 2023 and is anticipated to be completed by November 2024.

CONCLUSIONS

The HISTORY study will serve as a crucial background upon which future structural interventions can be built, to mitigate the effects of methamphetamine use and SRD among Black sexual minority men.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63761.

A place of encounter: Health and social care workers' perspectives on public gathering spaces for people using drugs

Background: The use of drugs is an escalating concern, with significant implications for the health and daily functionality for individuals. It has proven challenging to provide accessible health and social services. In the context of addressing substance use issues in urban areas, public gathering places for individuals who use drugs play a multifaceted role, serving as sites of belonging, support and potential illicit activity. This qualitative study explores the experiences of healthcare and social workers regarding a public gathering place, referred to as "the Bench", in a medium-sized Norwegian city. Methods: A qualitative research design consisting of semi-structured focus group interviews and individual interviews with 13 participants representing various support agencies. Results: The analysis resulted in four thematic areas: (1) belonging and a gateway to support and services; (2) balancing user autonomy at the Bench and systems support; (3) the role of a centralised location; and (4) the preventive role of support workers at the Bench. Conclusion: While the Bench fosters a sense of community and provides access to vital services, concerns about illicit activities persist due to its visibility. Nevertheless, its central location facilitates outreach efforts and ensures easy access to support services. The study underscores the preventive role of healthcare and social workers in stabilising the environment and mitigating conflicts. Furthermore, it highlights the importance of central locations for public gathering places, emphasising the proximity to low-threshold services. The Bench represents a crucial venue for establishing relationships and providing assistance to individuals who use drugs, contributing to harm reduction efforts in the community.

An evolutionary concept analysis: stigma among women living with hepatitis C

BACKGROUND

Stigma is a complex social phenomenon that leads to marginalization and influences the course of illness. In the context of hepatitis C virus (HCV), stigma is a well-documented barrier to accessing care, treatment, and cure. In recent years, HCV rates among women have increased, resulting in an urgent need to address stigma and its harmful effects. The purpose of this concept analysis was to investigate stigma in the context of women living with HCV using Rodgers' evolutionary method.

METHODS

PubMed, CINAHL, Scopus, Medline, PsycINFO, and Nursing and Allied Health were used to identify articles describing HCV stigma among women. Articles from peer-reviewed journals and geographic locations, published between 2002-2023, were included in the analysis. As specified in Rodgers' evolutionary method, articles were analyzed with a focus on the concept's context, surrogate and related terms, antecedents, attributes, examples, and consequences.

RESULTS

Following screening, 33 articles were selected for inclusion in the analysis. Discrimination and marginalization were identified as surrogate and related terms to stigma; and antecedents of stigma were identified as limited knowledge, fear of diagnosis, and disclosure. Prevalent attributes of stigma in the literature were described as feelings of decreased self-worth, negative stereotyping, and fear of transmission. Importantly, HCV stigma among women is unique in comparison to other forms of infectious disease-related stigma, primarily due its impact on women's identity as mothers and caregivers. Stigmatization of women living with HCV resulted in negative consequences to personal relationships and healthcare access due to decreased health-seeking behaviours. Although access to HCV treatment has changed considerably over time, a temporal analysis could not be completed due to the limited number of articles.

CONCLUSIONS

Stigma in the context of women living with HCV has its own unique antecedents, attributes, and consequences. This enhanced understanding of stigma among women living with HCV has the potential to inform improved and more effective approaches to care, which will be required to reach HCV elimination. Furthermore, this analysis identifies stigma layering and stigma in the direct-acting antiviral  treatment era as areas for more in-depth future inquiry.

Social determinants of injection drug use-associated bacterial infections and treatment outcomes: systematic review and meta-analysis

Background

Individual injecting practices (e.g., intramuscular injecting, lack of skin cleaning) are known risk factors for injection drug use-associated bacterial and fungal infections; however, social contexts shape individual behaviours and health outcomes. We sought to synthesize studies assessing potential social determinants of injecting-related infections and treatment outcomes.

Methods

We searched five databases for studies published between 1 January 2000 and 18 February 18 2021 (PROSPERO CRD42021231411). We included studies of association (aetiology), assessing social determinants, substance use, and health services exposures influencing development of injecting-related infections and treatment outcomes. We pooled effect estimates via random effects meta-analyses.

Results

We screened 4,841 abstracts and included 107 studies. Several factors were associated with incident or prevalent injecting-related infections: woman/female gender/sex (adjusted odds ratio [aOR] 1.57, 95% confidence interval [CI] 1.36-1.83; n=20 studies), homelessness (aOR 1.29, 95%CI 1.16-1.45; n=13 studies), cocaine use (aOR 1.31, 95%CI 1.02-1.69; n=10 studies), amphetamine use (aOR 1.74, 95%CI 1.39-2.23; n=2 studies), public injecting (aOR 1.40, 95%CI 1.05-1.88; n=2 studies), requiring injecting assistance (aOR 1.78, 95%CI 1.40-2.27; n=8 studies), and use of opioid agonist treatment (aOR 0.92, 95%CI 0.89-0.95; n=9 studies). Studies assessing outcomes during treatment (e.g., premature hospital discharge) or afterward (e.g., rehospitalization; all-cause mortality) typically had smaller sample sizes and imprecise effect estimates.

Conclusions

Injecting-related infections and treatment outcomes may be shaped by multiple social contextual factors. Approaches to prevention and treatment should look beyond individual injecting practices towards addressing the social and material conditions within which people live, acquire and consume drugs, and access health care.

Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model

ISSUES

To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors.

APPROACH

Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors.

KEY FINDINGS

Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder.

IMPLICATIONS

There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement.

CONCLUSION

There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.

Characterising People who inject drugs, and association with HIV infection: A Situation Analysis in Kampala city, Uganda

Background

Uganda has implemented targeted interventions to address the rising burden of injection drug use, yet barriers persist in reaching persons who inject drugs (PWID). This study describes the characteristics of people who inject drugs, physical and mental health states, and associated risk behaviors, to inform the designing of programs that are tailored to client's needs and preferences.

Methods

A cross-sectional survey was conducted between August and December 2023 at selected hotspots in Kampala, interviewing 499 PWID aged ≥18 years. Data was collected using a semi-structured questionnaire administered by peer educators and Uganda Harm Reduction Network (UHRN) counselors. Measurements included socio-demographics, injecting drug use and sexual risk behaviors, and medical history. HIV serostatus was dtermined by self-report and testing for participants who had no recent history of testing and consented to be tested. Binary logistic regression was used to establish the relationship between HIV infection and risky drug- and sexual behaviors of PWID.

Results

Participants were predominantly Ugandan (95.2%), male (73.2%), unmarried (55.9%), unemployed (81.8%), with higher levels of education and varying ages. Mental disorders were prevalent, with 48.7% reporting at least one underlying condition, including depression (30.8%) and anxiety (9.6%). Physical health issues were also noted, with reported cases of fever (32.9%), cough (32.5%), malaria (22%) and sexually transmitted infections (STIs) (15%).Regarding drug use patterns, the majority (82.6%) were introduced to drugs by close acquaintances, with 70.9% categorized as people who inject drugs. HIV prevalence among injecting drug users was 3.7%, with higher rates among females (8.4%) and non-Ugandans (16.7%). Being female and experiencing difficulty accessing sterile injection materials were associated with HIV-positive status, highlighting the complex interplay between socio-demographic factors, risk behaviors, and HIV infection among individuals with injecting drug use Disorder in Uganda.

Conclusion

Our study provides a comprehensive insight into the socio-demographic, mental, physical health, and HIV risk behavoir of PWID in Kampala, Uganda. The findings indicate significant vulnerabilities to injecting drug use, mental disorders, and high-risk behaviors that predispose this population to HIV infection. Despite a low HIV prevalence compared to previous estimates, the interplay between drug use, risky injecting practices, and sexual behaviors suggests an urgent need for targeted interventions to address these intertwined challenges.

Using drugs alone in single room occupancy housing: Understanding environmental drivers of overdose risk

BACKGROUND

Across North America most overdose deaths occur in housing, largely due to individuals using drugs alone. In cities, fatalities are disproportionately concentrated in low-income housing, including single room occupancy (SRO) housing. While research has highlighted how SROs operate as risk environments for various poor outcomes, there has been little attention to specific drug use practices (i.e., using alone) associated with overdose vulnerability in these spaces. This study explores how environmental contexts of SROs shape overdose risks, with specific attention to practices of using drugs alone.

METHODS

In-depth semi-structured interviews were conducted with 30 people who use drugs (PWUD) living in Vancouver SROs. Interviews covered topics such as social-structural environments of housing, drug use practices, and housing-based harm reduction. Thematic analysis drew on the intersectional risk environment framework.

RESULTS

Narratives positioned SROs as extensions of public space, with similar expectations of risks and behaviours as in public spaces. For some participants, using alone in their room was characterized as a practice in claiming privacy within the context of a public existence. Participants highlighted how certain features of SRO's social-structural environments were routinely leveraged against them (e.g., security cameras, staff surveillance), suggesting using alone as a tactic to minimize risks of hyper-surveillance and punitive policies. Further, participants discussed using alone as "safer," describing how this practice mitigated place-based risks of social-structural harms (e.g., violence, criminalization) in ways that eclipsed overdose risk.

CONCLUSION

Using drugs alone may be understood as a spatial negotiation of vulnerability to diverse harms produced by environmental contexts of SROs. Interventions accounting for broader contextual factors (e.g., improvements housing quality/quantity, providing a safer supply of drugs) that render using alone as instrumental to survival, and that reduce the implicit threat of punishment from intensive surveillance and control practices are critical to reduce vulnerability to overdose and other harms.

Public stigma against fentanyl overdose decedents in the United States: A conjoint vignette experiment

The United States is facing a drug overdose crisis, and stigma against people who use drugs is a major roadblock to implementing solutions. Despite the public health importance of understanding and mitigating substance use stigma, prior research has focused mainly on perceptions of individuals with substance use disorders and a limited set of demographic traits. This leaves critical gaps in our understanding of stigma against fentanyl overdose decedents, who represent a much broader group, including people who use substances recreationally. This study develops a more robust understanding of these attitudes through an experimental vignette survey fielded to a national sample of American adults (n = 1432). Respondents were shown two fictional fentanyl overdose obituaries where a complex suite of decedent characteristics-including demographic traits and contexts of substance use-were randomly varied in a conjoint design. Respondents then endorsed one of the two decedents for each of several attitudinal outcomes, including blameworthiness and support for various interventions, and justified their choices in an open-ended format. Results indicate that the public assesses victims of fentanyl overdose meritocratically, making judgments based on personal history and life experience rather than traditional race, class, and gender status beliefs. While certainly a signal of progress on some fronts, this meritocratic lens conflicts with the public health model of addressing the overdose crisis and exposes the alarming persistence of explicit stigma against people who use drugs.

Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites

BACKGROUND

Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD.

METHODS

This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework.

RESULTS

The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]).

CONCLUSION

As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

'Change creates change' - older female sex workers' experiences through the early COVID-19 pandemic

COVID-19 and associated policy responses created unique social, economic and health risks for sex workers. Through semi-structured interviews we explored pre- and early COVID-19 experiences and work practices of ten cisgender female sex workers 50 years of age and older in Queensland, Australia, analysing the findings using a risk environment framework. Throughout early 2020, participants navigated a complex risk environment, managing economic needs, health and safety, occupational stigma and policing. Australia's policy responses altered the risks and opportunities available to participants. Half the participants continued sex work and half stopped sex work with some accessing economic support and withdrawing superannuation savings. Those who continued sex work drew on life and work experience to reassess changing health, stigma, and policing risks, and adapted their work strategies by increasing client screening and modifying services. Participants relied on information from peer networks and organisations to guide work practices but remained wary of contact tracing, police and the media. Decriminalisation of sex work and the strengthening of sex worker organisation and government partnerships are important in embedding equity in responses to ongoing and new public health threats.

Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia

INTRODUCTION

Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia.

METHODS AND ANALYSIS

KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness.

ETHICS AND DISSEMINATION

The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings.

TRIAL REGISTRATION NUMBER

NCT05657106.

Association between willingness to use an overdose prevention center and probation or parole status among people who use drugs in Rhode Island

BACKGROUND

Overdose prevention centers (OPCs) are being implemented in the United States as a strategy to reduce drug-related mortality and morbidity. Previous studies have suggested that people who use drugs (PWUD) with a history of criminal legal system (CLS) involvement (e.g. current probation/parole) are at greater risk of overdose but may also encounter significant barriers to OPC use. The objective of this study was to explore the association between willingness to use an OPC and probation/parole status in a sample of PWUD in Rhode Island.

METHODS

This study utilized data from the Rhode Island Prescription and Illicit Drug Study, which enrolled adult PWUD from August 2020 to February 2023. We used Pearson's chi-square and Wilcoxon rank-sum tests to assess bivariate associations between willingness to use an OPC and probation/parole status (current/previous/never), as well as other sociodemographic and behavioral characteristics. In multivariable Poisson analyses, we examined the association between willingness to use an OPC and probation/parole status, adjusting for key sociodemographic and behavioral characteristics.

RESULTS

Among 482 study participants, 67% were male, 56% identified as white, 20% identified as Hispanic/Latine, and the median age was 43 (IQR 35-53). Nearly a quarter (24%) had never been on probation/parole, 44% were not currently on probation/parole but had a lifetime history of probation and parole, and 32% were currently on probation/parole. Most participants (71%) reported willingness to use an OPC, and in both bivariate and multivariable analyses, willingness to use an OPC did not vary by probation/parole status. Crack cocaine use and lifetime non-fatal overdose were associated with greater willingness to use an OPC (all p < 0.05).

CONCLUSIONS

These data demonstrate high willingness to use OPC among PWUD in Rhode Island regardless of CLS-involvement. As OPCs begin to be implemented in Rhode Island, it will be imperative to engage people with CLS-involvement and to ensure access to the OPC and protection against re-incarceration due to potential barriers, such as police surveillance of OPCs.

Factors Associated With Indirect Exposure to and Knowledge of Fentanyl Among Youth

PURPOSE

Using data from an online assessment of youth in the United States, this study examined factors associated with youth's indirect exposure to fentanyl; factors related to youth's level of knowledge of fentanyl; and sources of substance use information obtained by youth.

METHODS

This is a secondary analysis of data from a cross-sectional online assessment of youth ages 13 to 18 in the United States in 2022. Participants self-reported on substance use knowledge and concerns, indirect exposure to substance use, access to substance use information and resources, the extent to which youth discussed drug use harms with someone, and COVID-related stress.

RESULTS

Analyses revealed that most youth did not have knowledge of fentanyl even though they reported indirect likely exposure to fentanyl. Youth concerned about alcohol or drug use in their own life were less likely to have knowledge of fentanyl and more likely to know someone who, if using drugs, would likely be exposed to fentanyl. A significant risk factor of indirect likely exposure to fentanyl was COVID-related stress. Prevalent sources of information included the internet, social media, friends or peers, and school classes.

DISCUSSION

While youth may have close proximity to fentanyl exposure and a degree of understanding of fentanyl, there is a general lack of knowledge of the substance, a critical gap that future substance use prevention initiatives could fill.

Estimation of place-based vulnerability scores for HIV viral non-suppression: an application leveraging data from a cohort of people with histories of using drugs

The relationships between place (e.g., neighborhood) and HIV are commonly investigated. As measurements of place are multivariate, most studies apply some dimension reduction, resulting in one variable (or a small number of variables), which is then used to characterize place. Typical dimension reduction methods seek to capture the most variance of the raw items, resulting in a type of summary variable we call "disadvantage score". We propose to add a different type of summary variable, the "vulnerability score," to the toolbox of the researchers doing place and HIV research. The vulnerability score measures how place, as known through the raw measurements, is predictive of an outcome. It captures variation in place characteristics that matters most for the particular outcome. We demonstrate the estimation and utility of place-based vulnerability scores for HIV viral non-suppression, using data with complicated clustering from a cohort of people with histories of injecting drugs.

Depoliticization of Violence: Critical Limits of Risk Environment Frameworks in Drug Use Research

The risk environment framework (REF) is a widely-accepted tool in policy research related to drug use. Its prevalence warrants a critical exploration of its strengths and weaknesses. This critical appraisal is a comprehensive analysis of the REF by definition and through relevant examples of its use within the context of public health evaluations, social science research, and epidemiological strategies in substance use-related policy. We examine the tensions inherent to a risk environment analysis, centering on its deficit-based lens of behavior, risk, and harm. This narrative review argues for shifts in frameworks within drug policy research away from individual- and community-level blame.

"It would really support the wider harm reduction agenda across the board": A qualitative study of the potential impacts of drug checking service delivery in Scotland

Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures.

A Social History of Opioids' Crimedical Cycle

Historically, public and political discourse around people who nonmedically use opioids has largely been rendered via a deficits-oriented lens, presenting this population as weak, disinterested, and deviant, and thus undesirable and ill-positioned for wellness and communal integration. These narratives, and subsequent policies used to engage people who use opioids, are intermittently formed and disrupted by geopolitical changes, as public and institutional attitudes, often driven by racial and class-related considerations, shift. As part of what we term the crimedical cycle, a population's health behaviors fluctuate between periods of medicalization and criminalization. Strengths-based theory, an offshoot of "positive psychology" that helps contextualize this cycle, emphasizes the value of recognizing and affirming the inherent and learned skills that individuals possess and can leverage toward self-actualization. A strengths-based orientation and approach to clinical praxis is particularly critical in improving the health and well-being of populations, such as those who use opioids, that are highly criminalized and disenfranchised through social and public policy. However, strengths-based theory is underdeveloped in addiction medicine, despite it having deep roots in the treatment field. This ongoing omission engenders narratives around opioid use that congeal to propel the stigmatization, over-policing, economic marginalization, and poor health of those who use opioids. This article discusses the historical trajectory of views and attitudes on opioid use and presents models that advance strengths-based approaches to engaging this population.

Community-level determinants of stakeholder perceptions of community stigma toward people with opioid use disorders, harm reduction services and treatment in the HEALing Communities Study

BACKGROUND

Community stigma toward people with opioid use disorder (OUD) can impede access to harm reduction services and treatment with medications for opioid use disorder (MOUD). Such community OUD stigma is partially rooted in community-level social and economic conditions, yet there remains a paucity of large-scale quantitative data examining community-level factors associated with OUD stigma. We examined whether rurality, social inequity, and racialized segregation across communities from four states in the HEALing Communities Study (HCS) were associated with 1) greater perceived community stigma toward people treated for OUD, 2) greater perceived intervention stigma toward MOUD, and 3) greater perceived intervention stigma toward naloxone by community stakeholders in the HCS.

METHODS

From November 2019-January 2020, a cross-sectional survey about community OUD stigma was administered to 801 members of opioid overdose prevention coalitions across 66 communities in four states prior to the start of HCS intervention activities. Bivariate analyses assessed pairwise associations between community rural/urban status and each of the three stigma variables, using linear mixed effect modeling to account for response clustering within communities, state, and respondent sociodemographic characteristics. We conducted similar bivariate analyses to assess pairwise associations between racialized segregation and social inequity.

RESULTS

On average, the perceived community OUD stigma scale score of stakeholders from rural communities was 4% higher (β=1.57, SE=0.7, p≤0.05), stigma toward MOUD was 6% higher (β=0.28, SE=0.1, p≤0.05), and stigma toward naloxone was 10% higher (β=0.46, SE=0.1, p≤0.01) than among stakeholders from urban communities. No significant differences in the three stigma variables were found among communities based on racialized segregation or social inequity.

CONCLUSION

Perceived community stigma toward people treated for OUD, MOUD, and naloxone was higher among stakeholders in rural communities than in urban communities. Findings suggest that interventions and policies to reduce community-level stigma, particularly in rural areas, are warranted.

Effect of incarceration and opioid agonist treatment transitions on risk of hospitalisation with injection drug use-associated bacterial infections: A self-controlled case series in New South Wales, Australia

BACKGROUND

Transitional times in opioid use, such as release from prison and discontinuation of opioid agonist treatment (OAT), are associated with health harms due to changing drug consumption practices and limited access to health and social supports. Using a self-controlled (within-person) study design, we aimed to understand if these transitions increase risks of injection drug use-associated bacterial infections.

METHODS

We performed a self-controlled case series among a cohort of people with opioid use disorder (who had all previously accessed OAT) in New South Wales, Australia, 2001-2018. The outcome was hospitalisation with injecting-related bacterial infections. We divided participants' observed days into time windows related to incarceration and OAT receipt. We compared hospitalization rates during focal (exposure) windows and referent (control) windows (i.e., 5-52 weeks continuously not incarcerated or continuously receiving OAT). We estimated adjusted incidence rate ratios (aIRR) using conditional logistic regression, adjusted for time-varying confounders.

RESULTS

There were 7590 participants who experienced hospitalisation with injecting-related bacterial infections (35% female; median age 38 years; 78% hospitalised with skin and soft-tissue infections). Risk for injecting-related bacterial infections was elevated for two weeks following release from prison (aIRR 1.45; 95%CI 1.22-1.72). Risk was increased during two weeks before (aIRR 1.89; 95%CI 1.59-2.25) and after (aIRR 1.91; 95%CI 1.54-2.36) discontinuation of OAT, and during two weeks before (aIRR 3.63; 95%CI 3.13-4.22) and after (aIRR 2.52; 95%CI 2.09-3.04) OAT initiation.

CONCLUSION

Risk of injecting-related bacterial infections varies greatly within-individuals over time. Risk is raised immediately after prison release, and around initiation and discontinuation of OAT. Social contextual factors likely contribute to excess risks at transitions in incarceration and OAT exposure.

Social-spatial network structures among young urban and suburban persons who inject drugs in a large metropolitan area

BACKGROUND

Recent studies underscore the significance of adopting a syndemics approach to study opioid misuse, overdose, hepatitis C (HCV) and HIV infections, within the broader context of social and environmental contexts in already marginalized communities. Social interactions and spatial contexts are crucial structural factors that remain relatively underexplored. This study examines the intersections of social interactions and spatial contexts around injection drug use. More specifically, we investigate the experiences of different residential groups among young (aged 18-30) people who inject drugs (PWID) regarding their social interactions, travel behaviors, and locations connected to their risk behaviors. By doing so, we aim to achieve a more comprehensive understanding of the multidimensional risk environment, thereby facilitating the development of informed policies.

METHODS

We collected and examined data regarding young PWID's egocentric injection network and geographic activity spaces (i.e., where they reside, inject drugs, purchase drugs, and meet sex partners). Participants were stratified based on the location of all place(s) of residence in the past year i.e., urban, suburban, and transient (both urban and suburban) to i) elucidate geospatial concentration of risk activities within multidimensional risk environments based on kernel density estimates; and ii) examine spatialized social networks for each residential group.

RESULTS

Participants were mostly non-Hispanic white (59%); 42% were urban residents, 28% suburban, and 30% transient. We identified a spatial area with concentrated risky activities for each residential group on the West side of Chicago in Illinois where a large outdoor drug market area is located. The urban group (80%) reported a smaller concentrated area (14 census tracts) compared to the transient (93%) and suburban (91%) with 30 and 51 tracts, respectively. Compared to other areas in Chicago, the identified area had significantly higher neighborhood disadvantages. Significant differences were observed in social network structures and travel behaviors: suburban participants had the most homogenous network in terms of age and residence, transient participants had the largest network (degree) and more non-redundant connections, while the urban group had the shortest travel distance for all types of risk activities.

CONCLUSION

Distinct residential groups exhibit varying patterns of network interaction, travel behaviors, and geographical contexts related to their risk behaviors. Nonetheless, these groups share common concentrated risk activity spaces in a large outdoor urban drug market area, underscoring the significance of accounting for risk spaces and social networks in addressing syndemics within PWID populations.

Demographic patterns and disparities in new HIV diagnoses attributed to injection drug use in the United States

People who inject drugs (PWID) exhibit disproportionate HIV burdens in the United States. We characterized longitudinal patterns and demographic disparities in new HIV diagnoses attributed to injection drug use (IDU) in 2008-2020. Although new IDU-attributed HIV diagnoses fell by 53.9%, new HIV diagnoses remained disproportionately elevated in female (100.9/100 000), Black (258.8/100 000), and Hispanic (131.0/100 000) PWID. Despite considerable declines in new HIV diagnoses, disparities by race/ethnicity and sex persist among US PWID.

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.

Using ADAPT-ITT framework to tailor evidence-based interventions for addressing methamphetamine use among methadone patients in Vietnam

INTRODUCTION

Methamphetamine use threatens positive treatment outcomes in substance use and HIV, for people with opioid use disorders (POUD) in many countries. This paper describes the adaptation of four evidence-based interventions (EBI) (motivational interviewing, contingency management, Matrix group model and SMS text messaging) for treating methamphetamine use among POUD receiving methadone maintenance therapy in Vietnam.

METHODS

Following the ADAPT-ITT (Assessment-Decision-Administration-Production-Topical experts-Training-Testing) framework, we conducted 16 focus group discussions with POUD (n = 25) and providers (n = 22) at four methadone clinics in two largest cities (Hanoi in the North, Ho Chi Minh City in the South) to assess patterns of methamphetamine use and to get feedback on proposed EBIs. The proposed EBIs were properly adapted and used to train providers in two of the four methadone clinics. The revised EBIs were tested over 12 weeks among 42 POUD on methadone who use methamphetamine. Post-intervention feedback served to fine-tune the revised EBIs.

RESULTS

Insights about patterns of methamphetamine use suggested that EBIs should focus on different triggers to methamphetamine use among POUD receiving methadone treatment in the two cities. All EBIs should emphasise family-related topics to build a strong motivation for treatment. Participants suggested when, where and how each EBI should be delivered. Most participants were satisfied with the adapted EBIs. Limited human resources at methadone clinics might hinder implementation of the adapted EBIs.

DISCUSSION AND CONCLUSIONS

We successfully completed the adaptation of EBIs for POUD who use methamphetamine on methadone in Vietnam. The pilot testing of the adapted EBIs demonstrated feasibility and acceptability.

TRIAL REGISTRATION

NCT04706624. Registered 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.