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Bardwell G, Ivsins A, Wallace JR, Mansoor M, Kerr T. "The machine doesn't judge": Counternarratives on surveillance among people accessing a safer opioid supply via biometric machines. Soc Sci Med 2024; 345:116683. [PMID: 38364722 DOI: 10.1016/j.socscimed.2024.116683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/16/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs.
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Affiliation(s)
- Geoff Bardwell
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada; British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - James R Wallace
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | - Manal Mansoor
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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2
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Spencer S, Hedden L, Vaughan C, Marshall EG, Lukewich J, Asghari S, Gill P, Buote R, Meredith L, Moritz L, Ryan D, Mathews M. "It was horrible for that community, but not for the way we had imagined": A qualitative study of family physicians' experiences of caring for communities experiencing marginalisation during COVID-19. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100176. [PMID: 36248310 PMCID: PMC9536327 DOI: 10.1016/j.ssmqr.2022.100176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/16/2022] [Accepted: 09/28/2022] [Indexed: 01/12/2023]
Abstract
The COVID-19 response required family physicians (FPs) to adapt their practice to minimise transmission risks. Policy guidance to facilitate enacting public health measures has been generic and difficult to apply, particularly for FPs working with communities that experience marginalisation. Our objective was to explore the experiences of FPs serving communities experiencing marginalisation during COVID-19, and the impact the pandemic and pandemic response have had on physicians' ability to provide care. We conducted semi-structured qualitative interviews with FPs from four Canadian regions, October 2020 through June 2021. We employed maximum variation sampling and continued recruitment until we reached saturation. Interviews explored participants' roles/experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support communities experiencing marginalisation throughout. We used a thematic approach to analyse the data. FPs working with communities experiencing marginalisation expressed the need to continue providing in-person care throughout the pandemic, often requiring them to devise innovative adaptations to their clinical settings and practice. Physicians noted the health implications for their patients, particularly where services were limited or deferred, and that pandemic response policies frequently ignored the unique needs of their patient populations. Pandemic-related precautionary measures that sought to minimise viral transmission and prevent overwhelming acute care settings may have undermined pre-existing services and superseded the ongoing harms that are disproportionately experienced by communities experiencing marginalisation. FPs are well placed to support the development of pandemic response plans that appreciate competing risks amongst their communities and must be included in pandemic planning in the future.
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Affiliation(s)
- Sarah Spencer
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, V5A 1S6, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, V5A 1S6, Canada,Corresponding author. Faculty of Health Sciences, Simon Fraser University, 8888 University Drive Burnaby, BC, V5A 1S6 Canada
| | - Crystal Vaughan
- Faculty of Nursing, Memorial University, 300 Prince Philip Drive, St. John's, Newfoundland and Labrador, A1B 3V6, Canada
| | - Emily Gard Marshall
- Department of Family Medicine Primary Care Research Unit, Dalhousie University, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada
| | - Julia Lukewich
- Faculty of Nursing, Memorial University, 300 Prince Philip Drive, St. John's, Newfoundland and Labrador, A1B 3V6, Canada
| | - Shabnam Asghari
- Family Medicine, Faculty of Medicine, Memorial University, 300 Prince Philip Drive, St. John's, Newfoundland and Labrador, A1B 3V6, Canada
| | - Paul Gill
- Temerty Faculty of Medicine Department of Family & Community Medicine, University of Toronto, 500 University Avenue, M5G 1V7, Toronto, Ontario, Canada,Gateway Centre of Excellence in Rural Health, 74 Kingston Street, Goderich, Ontario, N7A 3K4, Canada
| | - Richard Buote
- Department of Family Medicine Primary Care Research Unit, Dalhousie University, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada
| | - Leslie Meredith
- Schulich School of Medicine & Dentistry Department of Family Medicine, Western University, 1465 Richmond Street, London, Ontario, N6G 2M1, Canada
| | - Lauren Moritz
- Department of Family Medicine Primary Care Research Unit, Dalhousie University, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada
| | - Dana Ryan
- Faculty of Nursing, Memorial University, 300 Prince Philip Drive, St. John's, Newfoundland and Labrador, A1B 3V6, Canada,Schulich School of Medicine & Dentistry Department of Family Medicine, Western University, 1465 Richmond Street, London, Ontario, N6G 2M1, Canada
| | - Maria Mathews
- Schulich School of Medicine & Dentistry Department of Family Medicine, Western University, 1465 Richmond Street, London, Ontario, N6G 2M1, Canada
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Adams JW, Savinkina A, Fox A, Behrends CN, Madushani RWMA, Wang J, Chatterjee A, Walley AY, Barocas JA, Linas BP. Modeling the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine-naloxone treatment at syringe service programs. Addiction 2022; 117:2635-2648. [PMID: 35315148 PMCID: PMC9951221 DOI: 10.1111/add.15883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 03/06/2022] [Indexed: 12/25/2022]
Abstract
AIM To estimate the number of treatment initiations, averted fatal opioid overdoses and the cost-effectiveness associated with offering buprenorphine-naloxone (buprenorphine) treatment on-site within existing syringe service programs (SSPs) in Massachusetts, USA. DESIGN, SETTING AND PARTICIPANTS This was a cohort-based mathematical model and cost-effectiveness analysis. We derived model inputs from state and national surveillance data, clinical trials and observational cohort studies. We compared an intervention scenario where 30% of SSP clients initiated buprenorphine treatment on-site at least once annually to a status quo scenario where no buprenorphine was available on-site among community treatment providers in Massachusetts, 2020-30. In individuals with opioid use disorder (OUD) we assumed that 80% of SSP clients had recently injected drugs and that treatment within SSPs would have similar or improved retention compared with standard-of-care buprenorphine programs, but higher rates of active opioid use while in treatment. MEASUREMENTS Number of treatment initiations (i.e. individuals began treatment on a medication for opioid use disorder or entered medically managed withdrawal), averted fatal opioid overdoses, quality-adjusted life-years (QALYs) and life-time discounted costs from a health sector and a limited societal perspective. FINDINGS The status quo scenario resulted in 23 051 fatal overdoses and 1 511 613 treatment initiations over a 10-year simulation period. An intervention scenario with on-site SSP buprenorphine treatment averted 4797 (-20.8%) fatal opioid overdoses and resulted in 129 359 (+8.6%) additional treatment initiations compared with the status quo. The intervention scenario was the dominating scenario: providing OUD treatment through Massachusetts SSPs cost less (-$3612 per person) with patients accumulating more QALYs (0.2 per person) compared with the status quo scenario. CONCLUSIONS Offering buprenorphine treatment on-site within syringe service programs has the potential to decrease fatal overdoses substantially, improve treatment engagement and save on costs.
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Affiliation(s)
- Joëlla W. Adams
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
- RTI International, Research Triangle, NC, USA
| | - Alexandra Savinkina
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
| | - Aaron Fox
- Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY, USA
| | - Czarina N. Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York City, NY, USA
| | | | - Jianing Wang
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
| | - Avik Chatterjee
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Joshua A. Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Hedden L, McCracken RK, Spencer S, Narayan S, Gooderham E, Bach P, Boyd J, Chakanyuka C, Hayashi K, Klimas J, Law M, McGrail K, Nosyk B, Peterson S, Sutherland C, Ti L, Yung S, Cameron F, Fernandez R, Giesler A, Strydom N. Advancing virtual primary care for people with opioid use disorder (VPC OUD): a mixed-methods study protocol. BMJ Open 2022; 12:e067608. [PMID: 36167365 PMCID: PMC9516147 DOI: 10.1136/bmjopen-2022-067608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The emergence of COVID-19 introduced a dual public health emergency in British Columbia, which was already in the fourth year of its opioid-related overdose crisis. The public health response to COVID-19 must explicitly consider the unique needs of, and impacts on, communities experiencing marginalisation including people with opioid use disorder (PWOUD). The broad move to virtual forms of primary care, for example, may result in changes to healthcare access, delivery of opioid agonist therapies or fluctuations in co-occurring health problems that are prevalent in this population. The goal of this mixed-methods study is to characterise changes to primary care access and patient outcomes following the rapid introduction of virtual care for PWOUD. METHODS AND ANALYSIS We will use a fully integrated mixed-methods design comprised of three components: (a) qualitative interviews with family physicians and PWOUD to document experiences with delivering and accessing virtual visits, respectively; (b) quantitative analysis of linked, population-based administrative data to describe the uptake of virtual care, its impact on access to services and downstream outcomes for PWOUD; and (c) facilitated deliberative dialogues to co-create educational resources for family physicians, PWOUD and policymakers that promote equitable access to high-quality virtual primary care for this population. ETHICS AND DISSEMINATION Approval for this study has been granted by Research Ethics British Columbia. We will convene PWOUD and family physicians for deliberative dialogues to co-create educational materials and policy recommendations based on our findings. We will also disseminate findings via traditional academic outputs such as conferences and peer-reviewed publications.
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Affiliation(s)
- Lindsay Hedden
- Simon Fraser University Faculty of Health Sciences, Burnaby, British Columbia, Canada
| | - Rita K McCracken
- Department of Family Practice, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sarah Spencer
- Simon Fraser University Faculty of Health Sciences, Burnaby, British Columbia, Canada
| | - Shawna Narayan
- Department of Family Practice, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Ellie Gooderham
- Simon Fraser University Faculty of Health Sciences, Burnaby, British Columbia, Canada
| | - Paxton Bach
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Jade Boyd
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Christina Chakanyuka
- Faculty of Human and Social Development, University of Victoria School of Nursing, Victoria, British Columbia, Canada
| | - Kanna Hayashi
- Simon Fraser University Faculty of Health Sciences, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Jan Klimas
- Department of Family Practice, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Michael Law
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Simon Fraser University Faculty of Health Sciences, Burnaby, British Columbia, Canada
- Centre for Health Evaluation & Outcome Sciences, Vancouver, British Columbia, Canada
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christy Sutherland
- Department of Family Practice, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Lianping Ti
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Seles Yung
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fred Cameron
- SOLID Outreach Society, Victoria, British Columbia, Canada
| | | | - Amanda Giesler
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Nardia Strydom
- Department of Primary Care, Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
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Krawczyk N, Allen ST, Schneider KE, Solomon K, Shah H, Morris M, Harris SJ, Sherman SG, Saloner B. Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs. Harm Reduct J 2022; 19:95. [PMID: 36002850 PMCID: PMC9400571 DOI: 10.1186/s12954-022-00676-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic. Methods We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs. Results We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services. Conclusions In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.
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Affiliation(s)
- Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, USA.
| | - Sean T Allen
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kristin E Schneider
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Keisha Solomon
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hridika Shah
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Miles Morris
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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6
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Weaver VK, Kennedy MC. Response to “Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians” by Harvey et al. Open Forum Infect Dis 2022; 9:ofac145. [PMID: 35663287 PMCID: PMC9154324 DOI: 10.1093/ofid/ofac145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Victoria K Weaver
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver
| | - Mary Clare Kennedy
- British Columbia Centre on Substance Use, Vancouver, Canada
- School of Social Work, University of British Columbia Okanagan, Canada
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Abstract
Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.
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Affiliation(s)
- Carolyn A Chan
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Bethany Canver
- Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Ryan McNeil
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A, New Haven, CT 06510, USA
| | - Kimberly L Sue
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 417A, New Haven, CT 06510, USA.
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8
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Taylor JL, Johnson S, Cruz R, Gray JR, Schiff D, Bagley SM. Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings : Harm Reduction in Outpatient Addiction Treatment. J Gen Intern Med 2021; 36:3810-3819. [PMID: 34159545 PMCID: PMC8218967 DOI: 10.1007/s11606-021-06904-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/30/2021] [Indexed: 01/10/2023]
Abstract
Opioid use disorder (OUD) is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care-based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care-based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families.
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Affiliation(s)
- Jessica L Taylor
- Section of General Internal Medicine, Boston University School of Medicine & Boston Medical Center, Boston, MA, USA.
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA.
| | - Samantha Johnson
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA
| | - Ricardo Cruz
- Section of General Internal Medicine, Boston University School of Medicine & Boston Medical Center, Boston, MA, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Jessica R Gray
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA
| | - Davida Schiff
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA
| | - Sarah M Bagley
- Section of General Internal Medicine, Boston University School of Medicine & Boston Medical Center, Boston, MA, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Division of General Pediatrics, Boston University School of Medicine, Boston, MA, USA
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9
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Bouzanis K, Joshi S, Lokker C, Pavalagantharajah S, Qiu Y, Sidhu H, Mbuagbaw L, Qutob M, Henedi A, Levine MAH, Lennox R, Tarride JE, Kalina D, Alvarez E. Health programmes and services addressing the prevention and management of infectious diseases in people who inject drugs in Canada: a systematic integrative review. BMJ Open 2021; 11:e047511. [PMID: 34556508 PMCID: PMC8461723 DOI: 10.1136/bmjopen-2020-047511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID. DESIGN This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada. RESULTS This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction. CONCLUSIONS These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care. PROSPERO REGISTRATION NUMBER CRD42020142947.
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Affiliation(s)
- Katrina Bouzanis
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Joshi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Cynthia Lokker
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Yun Qiu
- School of Health Sciences, Jiangsu Institute of Commerce, Nanjing, Jiangsu, China
| | - Hargun Sidhu
- Department of Undergraduate Medical Education, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Majdi Qutob
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Alia Henedi
- Faculty of Pharmacy, Eastern Mediterranean University, Famagusta, North Cyprus, Cyprus
| | - Mitchell A H Levine
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robin Lennox
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Dale Kalina
- Department of Infectious Diseases, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Elizabeth Alvarez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
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10
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Raffi ER, Gray J, Conteh N, Kane M, Cohen LS, Schiff DM. Low barrier perinatal psychiatric care for patients with substance use disorder: meeting patients across the perinatal continuum where they are. Int Rev Psychiatry 2021; 33:543-552. [PMID: 34406106 DOI: 10.1080/09540261.2021.1898351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pregnant and postpartum patients with substance use disorders (SUD) often have other co-occurring mental health disorders. Complications of substance use and mental health conditions, such as overdose and suicide, are a significant contributor to maternal morbidity and mortality. For individuals dually diagnosed with SUD and other mental health disorders, the perinatal period can be both a motivating and a vulnerable period for care. Barriers to optimal care include, but are not limited to, lack of screening, lack of referrals for care, a limited number of psychiatric providers available to care for pregnant patients, and stigma around mental health and addiction care in pregnancy. In this review, we discuss approaches to low-barrier perinatal psychiatric care for women with SUD to promote engagement in care. We review (1) appropriate psychiatric assessment and diagnostic work-up; (2) treatment planning incorporating shared-decision making, non-punitive and culturally sensitive patient-centred care, and principles of harm reduction with a focus on psychopharmacology, and (3) the benefits of an integrated and collaborative multidisciplinary care model for this subpopulation of vulnerable patients.
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Affiliation(s)
- Edwin R Raffi
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Gray
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,MassGeneral Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - Nkechi Conteh
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha Kane
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lee S Cohen
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Davida M Schiff
- MassGeneral Hospital for Children, Harvard Medical School, Boston, MA, USA
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11
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Abstract
: Buprenorphine treatment for opioid use disorder is safe and effective, but only a fraction of Americans who need treatment receive it. One reason for this is that many buprenorphine treatment programs have rigid requirements for entry and continuation, limiting the number of people who receive treatment. "Low-threshold treatment" is a term used to describe an alternative approach that attempts to remove as many barriers to treatment as possible. However, few studies have described its essential features. In this article, we define low-threshold treatment and propose the approach be guided by the following principles: same-day treatment entry; harm-reduction approach; flexibility; and wide availability in places where people with opioid use disorder go. We discuss the evidence and rationale for these principles and directions for future research.
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12
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Socías ME, Choi J, Lake S, Wood E, Valleriani J, Hayashi K, Kerr T, Milloy MJ. Cannabis use is associated with reduced risk of exposure to fentanyl among people on opioid agonist therapy during a community-wide overdose crisis. Drug Alcohol Depend 2021; 219:108420. [PMID: 33342591 PMCID: PMC8006801 DOI: 10.1016/j.drugalcdep.2020.108420] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/14/2020] [Accepted: 10/31/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The ongoing opioid overdose crisis is driven largely by exposure to illicitly-manufactured fentanyl. Preliminary observational and experimental research suggests that cannabis could potentially play a role in reducing use of prescription opioids among individuals with chronic pain. However, there is limited data on the effects of cannabis on illicit opioid consumption, particularly fentanyl, especially among individuals on opioid agonist therapy (OAT). We sought to assess the longitudinal association between cannabis use and exposure to fentanyl among people on OAT. METHODS Data were drawn from two community-recruited prospective cohorts of people who use drugs in Vancouver, Canada. We used generalized linear mixed-effects modeling, adjusted by relevant confounders, to investigate the relationship between cannabis use and recent fentanyl exposure (both assessed by urine drug testing) among participants on OAT between 2016 and 2018. RESULTS Among the 819 participants on OAT who contributed 1989 observations over the study period, fentanyl exposure was common. At the baseline interview, fentanyl was detected in a majority of participants (431, 53 %), with lower prevalence among individuals with urine drug tests positive for tetrahydrocannabinol (47 vs. 56 %, p = 0.028). Over all study interviews, cannabis use was independently associated with reduced likelihood of being recently exposed to fentanyl (Adjusted Prevalence Ratio = 0.91, 95 % Confidence Interval: 0.83 - 0.99). CONCLUSIONS Participants on OAT using cannabis had significantly lower risk of being exposed to fentanyl. Our findings reinforce the need for experimental trials to investigate the potential benefits and risks of controlled cannabinoid administration for people on OAT.
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Affiliation(s)
- M Eugenia Socías
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - JinCheol Choi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Stephanie Lake
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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13
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McNeil R, Puri N, Boyd J, Mayer S, Hayashi K, Small W. Understanding concurrent stimulant use among people on methadone: A qualitative study. Drug Alcohol Rev 2020; 39:209-215. [PMID: 32202009 DOI: 10.1111/dar.13049] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION AND AIMS Opioid-related overdoses are an epidemic in North America, prompting a greater use of medications for opioid use disorder, such as methadone. Although many people work toward overall drug abstinence while on methadone, a sub-population of people with and without histories of polysubstance use engage in stimulant use while on methadone treatment. This study explores motivations for concurrent stimulant and methadone use in a street-involved drug-using population. DESIGN AND METHODS Semi-structured qualitative interviews were conducted with 39 people on methadone in Vancouver, Canada. Participants were recruited from among the participants in two community-based prospective cohort studies consisting of HIV-positive and HIV-negative people who use drugs. Interview transcripts were analysed using an inductive and iterative approach. RESULTS Our analysis identified three primary themes. First, participants articulated how stimulants were used to counter the sedating effects of methadone and enable them to engage in daily and survival activities (e.g. income generation). Second, participants described increased stimulant use to compensate for reduced stimulant intoxication while taking methadone. Finally, participants described the desire to achieve intoxication on stimulants once stable on methadone, as their substance use treatment goals did not involve drug abstinence. DISCUSSION AND CONCLUSION Among a street-involved drug-using population in which people do not have abstinence-based treatment goals, there are several functional reasons to use stimulants concurrently while on methadone. A deeper and more nuanced understanding of substance use motivators may contribute to further research and inform policy and guideline changes that support low threshold and harm reduction-focused methadone treatment programs and other interventions to reduce drug-related harms.
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Affiliation(s)
- Ryan McNeil
- Program in Addiction Medicine, Yale School of Medicine, New Haven, USA.,General Internal Medicine, Yale School of Medicine, New Haven, USA.,British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - Nitsaha Puri
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Samara Mayer
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Will Small
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
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14
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Butt ZA, Wong S, Rossi C, Binka M, Wong J, Yu A, Darvishian M, Alvarez M, Chapinal N, Mckee G, Gilbert M, Tyndall MW, Krajden M, Janjua NZ. Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes. Open Forum Infect Dis 2020; 7:ofaa347. [PMID: 32964065 PMCID: PMC7489531 DOI: 10.1093/ofid/ofaa347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023] Open
Abstract
Background Hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections are associated with significant mortality globally and in North America. However, data on impact of concurrent multiple infections on mortality risk are limited. We evaluated the effect of HCV, HBV, and HIV infections and coinfections and associated factors on all-cause mortality in British Columbia (BC), Canada. Methods The BC Hepatitis Testers Cohort includes ~1.7 million individuals tested for HCV or HIV, or reported as a case of HCV, HIV, or HBV from 1990 to 2015, linked to administrative databases. We followed people with HCV, HBV, or HIV monoinfection, coinfections, and triple infections from their negative status to date of death or December 31, 2016. Extended Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with all-cause mortality. Results Of 658 704 individuals tested for HCV, HBV, and HIV, there were 33 804 (5.13%) deaths. In multivariable Cox regression analysis, individuals with HCV/HBV/HIV (HR, 8.9; 95% CI, 8.2–9.7) infections had the highest risk of mortality followed by HCV/HIV (HR, 4.8; 95% CI, 4.4–5.1), HBV/HIV (HR, 4.1; 95% CI, 3.5–4.8), HCV/HBV (HR, 3.9; 95% CI, 3.7–4.2), HCV (HR, 2.6; 95% CI, 2.6–2.7), HBV (HR, 2.2; 95% CI, 2.0–2.3), and HIV (HR, 1.6; 95% CI, 1.5–1.7). Additional factors associated with mortality included injection drug use, problematic alcohol use, material deprivation, diabetes, chronic kidney disease, heart failure, and hypertension. Conclusions Concurrent multiple infections are associated with high mortality risk. Substance use, comorbidities, and material disadvantage were significantly associated with mortality independent of coinfection. Preventive interventions, including harm reduction combined with coinfection treatments, can significantly reduce mortality.
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Affiliation(s)
- Zahid A Butt
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Carmine Rossi
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amanda Yu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Maria Alvarez
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Geoff Mckee
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mark Gilbert
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark W Tyndall
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,BCCDC Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Sevigny EL, Meylakhs P, Feizollahi MJ, Amini MR. Development of a global index measuring national policy commitments to HIV prevention and treatment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 84:102877. [PMID: 32717705 DOI: 10.1016/j.drugpo.2020.102877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND People who inject drugs (PWID) around the world are disproportionately affected by the HIV epidemic. National policy responses to the epidemic heavily influence risk factors for HIV acquisition among this key group. Prior efforts to monitor national policy responses to HIV/AIDS among PWID were limited both in scope and coverage. In this paper we develop and validate the HIV-PWID Policy Index (HPPI) to benchmark and monitor national commitments to HIV prevention and treatment among PWID. METHODS Composite indicator was constructed employing fuzzy multilayer data envelopment analysis (FMLDEA). Model inputs based on data from 105 countries included 27 variables measured across six conceptual domains, including needle and syringe programs, opioid substitution treatment, testing and counseling, information and education, monitoring and evaluation, and legal and policy climate. RESULTS According to the HPPI, which ranges from 0 to 1, the top performing countries in policy commitments to HIV prevention and treatment among PWID were Spain (0.988), Switzerland (0.982), Luxembourg (0.970), Moldova (0.970), and Kyrgyzstan (0.945), whereas the poorest performing included Nicaragua (0.094), Japan, (0.094), Cape Verde (0.097), Syria (0.174), and Benin (0.185). Regionally, commitment to HIV services targeting PWID was highest among European countries (0.81) and lowest among African countries (0.50), with Oceania (0.76), Asia (0.66), and the Americas (0.56) in the mid-range. Subregional differences were even more prominent, with West and Central European nations (0.84) and Central American nations (0.22) earning the highest and lowest HPPI scores, respectively. CONCLUSIONS The HPPI documented substantial national and regional variation in policy responses to the HIV epidemic among PWID. Our analysis also revealed that many countries have limited HIV/AIDS data collection and monitoring capabilities. Continued enhancement and standardization of global HIV/AIDS monitoring efforts are therefore vital to articulated national and international benchmarking and performance assessment goals.
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Affiliation(s)
- Eric L Sevigny
- Department of Criminal Justice and Criminology, Georgia State University, Atlanta, GA, USA.
| | - Peter Meylakhs
- Laboratory for Comparative Social Research, National Research University Higher School of Economics, St. Petersburg, Russian Federation
| | | | - Mohamad Reza Amini
- Systems Management, Management and Economic Department, Tarbiat Modares University, Tehran, Iran
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16
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Frank D. Methadone maintenance treatment is swapping one drug for another, and that's why it works: Towards a treatment-based critique of the war on drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102844. [PMID: 32653670 DOI: 10.1016/j.drugpo.2020.102844] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 06/16/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
The claim that methadone maintenance treatment (MMT) is 'just swapping one drug for another' has typically been used to de-legitimize the treatment and attack those who use it. However, this commentary re-positions that argument as a way of bringing analytic focus to the role of structural forces, like criminalization and the war on drugs, in the treatment decisions of people who use illegal drugs. Specifically, I use my experience as a qualitative sociologist who studies MMT as well as my own experience on MMT to demonstrate how criminalization functions as source of harm in the lives of people who use illegal drugs, that drives them towards the legal, and thus comparatively safer, style of substance use made available by MMT. Moreover, I argue that the dominance of individually-focused theories based on addiction and recovery to understand MMT is related to its punitive organizational structure and lack of popularity among people who use illegal opioids. Ultimately, I argue for a paradigm shift, both in policy and scholarship, that acknowledges the pragmatic value of MMT within the structural context of criminalization.
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Affiliation(s)
- David Frank
- New York University, Behavioral Science Training in Drug Abuse Research program, United States.
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17
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Ivsins A, Boyd J, Beletsky L, McNeil R. Tackling the overdose crisis: The role of safe supply. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 80:102769. [PMID: 32446183 PMCID: PMC7252037 DOI: 10.1016/j.drugpo.2020.102769] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022]
Abstract
North America is experiencing an unprecedented overdose crisis driven by the proliferation of fentanyl and its analogues in the illicit drug supply. In 2018 there were 67,367 drug overdose deaths in the United States, and since 2016, there have been more than 14,700 overdose deaths in Canada, with most related to fentanyl. Despite concerted efforts and some positive progress, current public health, substance use treatment, and harm reduction interventions (such as widespread naloxone distribution and implementation of supervised consumption sites) have not been able to rapidly decrease overdose fatalities. In view of the persistent gaps in services and the limitations of available options, immediate scale-up of low-barrier opioid distribution programs are urgently needed. This includes "off-label" prescription of pharmaceutical grade opioids (e.g., hydromorphone) to disrupt the toxic drug supply and make safer opioids widely available to people at high risk of fatal overdose.
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Affiliation(s)
- Andrew Ivsins
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada; British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, BC, V6Z 2A9, Canada.
| | - Jade Boyd
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada; British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, BC, V6Z 2A9, Canada
| | - Leo Beletsky
- Health in Justice Action Lab, Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States; UC San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Ryan McNeil
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada; British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, BC, V6Z 2A9, Canada; General Internal Medicine, Yale School of Medicine, 367 Cedar St, New Haven, CA 06510, United States; Program in Addiction Medicine, Yale School of Medicine, 367 Cedar St, New Haven, CA 06510, United States
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18
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Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting. AIDS Behav 2019; 23:3267-3276. [PMID: 30924066 DOI: 10.1007/s10461-019-02472-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.
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19
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Weicker SA, Hayashi K, Grant C, Milloy MJ, Wood E, Kerr T. Willingness to take buprenorphine/naloxone among people who use opioids in Vancouver, Canada. Drug Alcohol Depend 2019; 205:107672. [PMID: 31706251 PMCID: PMC6894418 DOI: 10.1016/j.drugalcdep.2019.107672] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Opioid agonist therapy is the cornerstone of treatment of opioid use disorder. In Canada, buprenorphine/naloxone has recently been adopted as the first line agonist therapy given its comparable effectiveness to methadone and superior safety profile. This study examines factors associated with willingness to take buprenorphine/naloxone among opioid users. METHODS Data were derived from two prospective cohorts of high-risk individuals who use drugs in Vancouver, Canada. Multivariable logistic regression analyses were used to determine factors associated with willingness to use buprenorphine/naloxone among people who use opioids and were not currently accessing this treatment option. Participants who were unwilling to use buprenorphine/naloxone were invited to provide reason(s) and their responses were examined in a sub-analysis. RESULTS Between December 2014 and May 2018, 1103 participants were interviewed. Overall, 194 (17.6%) respondents indicated that they would be willing to take buprenorphine/naloxone. Variables independently associated with willingness were previous buprenorphine/naloxone treatment (adjusted odds ratio [AOR] = 2.04), having ever used methadone treatment (AOR = 1.87), and age (AOR = 0.98, per year older) (all p < 0.05). Satisfaction with current agonist therapy (25.4%), not knowing what buprenorphine/naloxone is (25.1%), and wanting more information about buprenorphine/naloxone (15.1%) were the most commonly cited reasons for unwillingness. A low rate of willingness to use buprenorphine/naloxone (15.1%) was also observed among the sub-set of participants not using methadone. CONCLUSIONS While an overall low level of willingness to take buprenorphine/naloxone was observed, this appeared to be largely driven by satisfaction with other agonists and a low prevalence of community knowledge about buprenorphine/naloxone.
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Affiliation(s)
- Sarah A Weicker
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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20
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Fan X, Zhang X, Xu H, Yang F, Lau JT, Hao C, Li J, Zhao Y, Hao Y, Gu J. Effectiveness of a Psycho-Social Intervention Aimed at Reducing Attrition at Methadone Maintenance Treatment Clinics: A Propensity Score Matching Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224337. [PMID: 31703302 PMCID: PMC6888175 DOI: 10.3390/ijerph16224337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 12/16/2022]
Abstract
Methadone maintenance treatment (MMT) is an important approach to address opioid dependence. However, MMT clinics usually report high attrition rates. Our previous randomized controlled trial demonstrated additional psycho-social services delivered by social workers could reduce attrition rates compared to MMT alone. This study aimed to evaluate the effectiveness of psycho-social service in a real-world context. A quasi-experimental design and propensity score matching was adopted. 359 clients were recruited from five MMT clinics in Guangzhou from July 2013 to April 2015. One 20-minute counseling session was offered to the control group after enrolment. The intervention group received six sessions of psycho-social services. The baseline characteristics were unbalanced between two arms in the original sample. After propensity score matching, 248 participants remained in the analysis. At month six, the intervention group had a lower attrition rate [intervention (39.5%) versus control (52.4%), P = 0.041], higher monthly income [monthly income of 1000 CNY or higher: intervention (55.9%) versus control (39.0%), P = 0.028)], higher detoxification intention score [full intention score: intervention (51.6%) versus control (32.5%), P = 0.012)], higher family support in MMT participation [intervention (77.9%) versus control (61.4%), P = 0.049)]. This study demonstrated that psycho-social services delivered by social workers can reduce MMT clients’ attrition and improve their well-being in real-world settings.
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Affiliation(s)
- Xiaoyan Fan
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
| | - Xiao Zhang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Huifang Xu
- Guangzhou Centre for Disease Prevention and Control, Guangzhou 510080, Guangdong, China; (H.X.); (Y.Z.)
| | - Fan Yang
- Institute for Global Health and Infectious Diseases, University of North Carolina, Project-China, Guangzhou 510080, Guangdong, China;
| | - Joseph T.F. Lau
- Centre for Medical Anthropology and Behavioural Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China;
- Centre for Health Behaviours Research, School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Chun Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Jinghua Li
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Yuteng Zhao
- Guangzhou Centre for Disease Prevention and Control, Guangzhou 510080, Guangdong, China; (H.X.); (Y.Z.)
| | - Yuantao Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Jing Gu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
- Correspondence: ; Tel.: +86-136-6001-7090
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Murphy A, Barbaro J, Martínez-Aguado P, Chilunda V, Jaureguiberry-Bravo M, Berman JW. The Effects of Opioids on HIV Neuropathogenesis. Front Immunol 2019; 10:2445. [PMID: 31681322 PMCID: PMC6813247 DOI: 10.3389/fimmu.2019.02445] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/01/2019] [Indexed: 12/13/2022] Open
Abstract
HIV associated neurocognitive disorders (HAND) are a group of neurological deficits that affect approximately half of people living with HIV (PLWH) despite effective antiretroviral therapy (ART). There are currently no reliable molecular biomarkers or treatments for HAND. Given the national opioid epidemic, as well as illegal and prescription use of opioid drugs among PLWH, it is critical to characterize the molecular interactions between HIV and opioids in cells of the CNS. It is also important to study the role of opioid substitution therapies in the context of HIV and CNS damage in vitro and in vivo. A major mechanism contributing to HIV neuropathogenesis is chronic, low-level inflammation in the CNS. HIV enters the brain within 4–8 days after peripheral infection and establishes CNS reservoirs, even in the context of ART, that are difficult to identify and eliminate. Infected cells, including monocytes, macrophages, and microglia, produce chemokines, cytokines, neurotoxic mediators, and viral proteins that contribute to chronic inflammation and ongoing neuronal damage. Opioids have been shown to impact these immune cells through a variety of molecular mechanisms, including opioid receptor binding and cross desensitization with chemokine receptors. The effects of opioid use on cognitive outcomes in individuals with HAND in clinical studies is variable, and thus multiple biological mechanisms are likely to contribute to the complex relationship between opioids and HIV in the CNS. In this review, we will examine what is known about both HIV and opioid mediated neuropathogenesis, and discuss key molecular processes that may be impacted by HIV and opioids in the context of neuroinflammation and CNS damage. We will also assess what is known about the effects of ART on these processes, and highlight areas of study that should be addressed in the context of ART.
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Affiliation(s)
- Aniella Murphy
- Laboratory of Dr. Joan W. Berman, Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - John Barbaro
- Laboratory of Dr. Joan W. Berman, Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Pablo Martínez-Aguado
- Laboratory of Dr. Joan W. Berman, Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Vanessa Chilunda
- Laboratory of Dr. Joan W. Berman, Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Matias Jaureguiberry-Bravo
- Laboratory of Dr. Joan W. Berman, Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Joan W Berman
- Laboratory of Dr. Joan W. Berman, Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, United States.,Laboratory of Dr. Joan W. Berman, Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, United States
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22
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Mohd Salleh NA, Fairbairn N, Nolan S, Barrios R, Shoveller J, Richardson L, Milloy MJ. Dispensation of antiretroviral therapy and methadone maintenance therapy at the same facility in a low-barrier setting linked to optimal adherence to HIV treatment. HIV Med 2019; 20:606-614. [PMID: 31359615 DOI: 10.1111/hiv.12777] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We sought to examine the association between dispensation of methadone maintenance therapy (MMT) and antiretroviral therapy (ART) at the same facility, across multiple low-barrier dispensing outlets, and achieving optimal adherence to ART among people who use illicit drugs (PWUD). METHODS We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) study, a long-running study of a community-recruited cohort of HIV-positive PWUD, linked to comprehensive HIV clinical records in Vancouver, Canada, a setting of no-cost, universal access to HIV care. The longitudinal relationship between MMT-ART dispensation at the same facility and the odds of ≥ 95% ART adherence was analysed using multivariable generalized linear mixed-effects modelling. We conducted a further analysis using a marginal structural mode with inverse probability of treatment weights as a sensitivity analysis. RESULTS This study included data on 1690 interviews of 345 ART- and MMT-exposed participants carried out between June 2012 and December 2017. In the final multivariable model, MMT-ART dispensation, compared with nondispensation at the same facility, was associated with greater odds of achieving ≥ 95% adherence [adjusted odds ratio (AOR) 1.56; 95% confidence interval (CI) 1.26-1.96]. A marginal structural model estimated a 1.48 (95% CI 1.15-1.80) greater odds of ≥ 95% adherence among participants who reported MMT-ART dispensation at the same facility compared with those who did not. CONCLUSIONS The odds of achieving optimal adherence to ART were 56% higher during periods in which MMT and ART medications were dispensed at the same facility, in a low-barrier setting. Our findings highlight the need to consider a simpler integrated approach with medication dispensation at the same facility in low-threshold settings.
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Affiliation(s)
- N A Mohd Salleh
- Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, BC, Canada.,BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - N Fairbairn
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - S Nolan
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - R Barrios
- BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada.,Vancouver Coastal Health, Vancouver, BC, Canada
| | - J Shoveller
- BC Centre on Substance Use, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - L Richardson
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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23
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Workplace violence among female sex workers who use drugs in Vancouver, Canada: does client-targeted policing increase safety? J Public Health Policy 2018; 39:86-99. [PMID: 29109517 DOI: 10.1057/s41271-017-0098-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Workplace violence, by clients or predators, poses serious negative health consequences for sex workers. In 2013, the Vancouver (British Columbia), Canada Police Department changed their guidelines with the goal of increasing safety for sex workers by focusing law enforcement on clients and third parties, but not sex workers. We sought to examine the trends and correlates of workplace violence among female sex workers (FSW) before and after the guideline change, using data collected from prospective cohorts of persons who use illicit drugs in Vancouver, Canada. Among 259 FSW, 21.0% reported workplace violence at least once during the study period between 2008 and 2014. There was no statistically significant change in rates of workplace violence after the guideline change. In our multivariable analysis, daily heroin use was independently associated with workplace violence. The 2013 policing guideline change did not appear to have resulted in decreased reports of workplace violence. Increased access to opioid agonist therapies may reduce workplace violence among drug-using FSW.
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24
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Butt ZA, Shrestha N, Gesink D, Murti M, Buxton JA, Gilbert M, Balshaw RF, Wong S, Kuo M, Wong J, Yu A, Alvarez M, Samji H, Roth D, Consolacion T, Hull MW, Ogilvie G, Tyndall MW, Krajden M, Janjua NZ. Effect of opioid-substitution therapy and mental health counseling on HIV risk among hepatitis C-infected individuals. Clin Epidemiol 2018; 10:1127-1145. [PMID: 30214316 PMCID: PMC6124790 DOI: 10.2147/clep.s173449] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Understanding differences in HIV incidence among people living with hepatitis C virus (HCV) can help inform strategies to prevent HIV infection. We estimated the time to HIV diagnosis among HCV-positive individuals and evaluated factors that could affect HIV-infection risk in this population. Patients and methods The British Columbia Hepatitis Testers Cohort includes all BC residents (~1.5 million: about a third of all residents) tested for HCV and HIV from 1990 to 2013 and is linked to administrative health care and mortality data. All HCV-positive and HIV-negative individuals were followed to measure time to HIV acquisition (positive test) and identify factors associated with HIV acquisition. Adjusted HRs (aHRs) were estimated using Cox proportional-hazard regression. Results Of 36,077 HCV-positive individuals, 2,169 (6%) acquired HIV over 266,883 years of follow-up (overall incidence of 8.1 per 1,000 person years). Overall median (IQR) time to HIV infection was 3.87 (6.06) years. In Cox regression, injection-drug use (aHR 1.47, 95% CI 1.33–1.63), HBV infection (aHR 1.34, 95% CI 1.16–1.55), and being a man who has sex with men (aHR 2.78, 95% CI 2.14–3.61) were associated with higher risk of HIV infection. Opioid-substitution therapy (OST) (aHR 0.59, 95% CI 0.52–0.67) and mental health counseling (aHR 0.48, 95% CI 0.43–0.53) were associated with lower risk of HIV infection. Conclusion Injection-drug use, HBV coinfection, and being a man who has sex with men were associated with increased HIV risk and engagement in OST and mental health counseling were associated with reduced HIV risk among HCV-positive individuals. Improving access to OST and mental health services could prevent transmission of HIV and other blood-borne infections, especially in settings where access is limited.
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Affiliation(s)
- Zahid A Butt
- School of Population and Public Health, University of British Columbia, Vancouver, BC,
| | - Nabin Shrestha
- School of Population and Public Health, University of British Columbia, Vancouver, BC,
| | - Dionne Gesink
- Dalla Lana School of Public Health, University of Toronto
| | - Michelle Murti
- Dalla Lana School of Public Health, University of Toronto.,Public Health Ontario, Toronto, ON
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, .,Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Mark Gilbert
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Robert F Balshaw
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Stanley Wong
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Margot Kuo
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Jason Wong
- School of Population and Public Health, University of British Columbia, Vancouver, BC, .,Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Amanda Yu
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Maria Alvarez
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Hasina Samji
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | - David Roth
- Clinical Prevention Services, British Columbia Centre for Disease Control
| | | | - Mark W Hull
- Division of AIDS, Faculty of Medicine, University of British Columbia.,AIDS Research Program, British Columbia Centre for Excellence in HIV/AIDS
| | - Gina Ogilvie
- School of Population and Public Health, University of British Columbia, Vancouver, BC, .,Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Mark W Tyndall
- School of Population and Public Health, University of British Columbia, Vancouver, BC, .,Clinical Prevention Services, British Columbia Centre for Disease Control
| | - Mel Krajden
- School of Population and Public Health, University of British Columbia, Vancouver, BC, .,Clinical Prevention Services, British Columbia Centre for Disease Control.,BCCDC Public Health Laboratory, Vancouver, BC, Canada
| | - Naveed Z Janjua
- School of Population and Public Health, University of British Columbia, Vancouver, BC, .,Clinical Prevention Services, British Columbia Centre for Disease Control
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25
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High HIV seroconversion rate in hepatitis C virus-infected drug users followed in a harm reduction unit: a lost opportunity for preexposure prophylaxis. AIDS 2018; 32:1157-1163. [PMID: 29561294 DOI: 10.1097/qad.0000000000001806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Current harm reduction strategies will probably remain insufficient to eliminate HIV transmission among drug users. We aimed to estimate the HIV seroconversion rate among drug users followed at a harm reduction unit (HRU) to evaluate the potential use of preexposure prophylaxis as a prevention tool. DESIGN AND METHODS A cohort of drug users has been followed at an HRU in Madrid between 2013 and 2016. Individuals who were HIV negative at baseline and who had at least one retest for HIV infection were eligible. Kaplan-Meier methods were employed to estimate the incidence density. RESULTS A total of 954 drug users had at least an HIV test. At baseline, 260 were HIV negative and had at least one follow-up HIV test. After 330.89 person-years of risk for HIV infection, 10 (3.8%) seroconverted. Overall incidence density of HIV seroconversion was 3.02 [95% confidence interval (CI); 1.4-5.5] per 100 person-years, with differences according to hepatitis C virus (HCV) serostatus: 1.17 (95% CI; 0.1-4.2) per 100 person-years in negative HCV individuals and 4.98 (95% CI; 2.1-9.8) per 100 person-years in positive HCV individuals. In the multivariable analysis, infection with HCV remained independently associated with time to HIV seroconversion (adjusted hazard ratio = 6.43; 95% CI; 1.1-36.5, P = 0.035). CONCLUSION Despite efforts in HIV prevention in a HRU, a high incidence of HIV was found among active drug users. Positive HCV status is a strong predictor of HIV seroconversion. In this context, preexposure prophylaxis implementation should be considered as an additional tool for HIV prevention in this population.
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26
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Fraser H, Mukandavire C, Martin NK, Hickman M, Cohen MS, Miller WC, Vickerman P. HIV treatment as prevention among people who inject drugs - a re-evaluation of the evidence. Int J Epidemiol 2018; 46:466-478. [PMID: 27524816 DOI: 10.1093/ije/dyw180] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 01/01/2023] Open
Abstract
Background Population-level associations between community measures of HIV viral load and HIV incidence have been interpreted as evidence for HIV anti-retroviral treatment (ART) as prevention among people who inject drugs (PWID). However, investigation of concurrent HCV and HIV incidence trends allows examination of alternative explanations for the fall in HIV incidence. We estimate the contribution of ART and reductions in injecting risk for reducing HIV incidence in Vancouver between 1996 and 2007. Methods A deterministic model of HIV and HCV transmission among PWID was calibrated to the baseline (1996) HIV and HCV epidemic among PWID in Vancouver. While incorporating parameter uncertainty, the model projected what levels of ART protection and decreases in injecting risk could reproduce the observed reduction in HIV and HCV incidence for 1996-2007, and so what impact would have been achieved with just ART or just reductions in injecting risk. Results Model predictions suggest the estimated reduction (84%) in HCV incidence for 1996-2007 required a 59% (2.5-97.5 percentile range 49-76%) reduction in injecting risk, which accounted for nine-tenths of the observed decrease in HIV incidence; the remainder was achieved with a moderate ART efficacy for reducing sexual HIV infectivity (70%, 51-89%) and an uncertain ART efficacy for reducing injection-related HIV infectivity (44%, 0-96%). Despite this uncertainty, projections suggest that the decrease in injecting risk reduced HIV incidence by 76% (63-85%) and ART further reduced HIV incidence by 8% (2-19%), or on its own by 3% (-34-37%). Conclusions Observed declines in HIV incidence in Vancouver between 1996 and 2007 should be seen as a success for intensive harm reduction, whereas ART probably played a small role.
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Affiliation(s)
- Hannah Fraser
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Natasha K Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Global Public Health, University of California San Diego, CA, USA and
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Myron S Cohen
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - William C Miller
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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27
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Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addict Sci Clin Pract 2018; 13:3. [PMID: 29409539 PMCID: PMC5812056 DOI: 10.1186/s13722-017-0104-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/12/2017] [Indexed: 01/23/2023] Open
Abstract
Objectives A growing body of evidence supports the effectiveness of injectable diacetylmorphine (i.e., heroin) for individuals with treatment-refractory opioid use disorder. Despite this evidence, and the increasing toll of opioid-associated morbidity and mortality, it remains controversial in some settings. To investigate the possible contribution of heroin-assisted treatment (HAT) to HIV treatment-related outcomes, we sought to estimate the proportion and characteristics of HIV-positive people who inject opioids that might be eligible for HAT in Vancouver, Canada. Methods We used data from a prospective cohort of people living with HIV who use illicit drugs in Vancouver, Canada. Using generalized estimating equations (GEE), we assessed the longitudinal relationships between eligibility for HAT, using criteria from previous clinical trials and guidelines, with behavioural, social, and clinical characteristics. Results Between 2005 and 2014, 478 participants were included in these analyses, contributing 1927 person-years of observation. Of those, 94 (19.7%) met eligibility for HAT at least once during the study period. In a multivariable GEE model, after adjusting for clinical characteristics, being eligible for HAT was positively associated with homelessness, female gender, high-intensity illicit drug use, drug dealing and higher CD4 count. Conclusions In our study of HIV-positive people with a history of injection drug use, approximately 20% of participants were eligible for HAT at ≥ 1 follow-up period. Eligibility was linked to risk factors for sub-optimal HIV/AIDS treatment outcomes, such as homelessness and involvement in the local illicit drug trade, suggesting that scaling-up access to HAT might contribute to achieving optimal HIV treatment in this setting.
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Tavitian-Exley I, Maheu-Giroux M, Platt L, Heimer R, Uusküla A, Levina O, Vickerman P, Boily MC. Differences in risk behaviours and HIV status between primary amphetamines and opioid injectors in Estonia and Russia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 53:96-105. [PMID: 29306786 DOI: 10.1016/j.drugpo.2017.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE People who inject drugs (PWID) account for over half of new HIV infections in Eastern Europe and central Asia, where opioids continue to be the dominant illicit drugs injected. Stimulants including amphetamines (ATS) have been associated with HIV infection risk in several settings. We sought to examine whether primary ATS injection was associated with greater HIV risk, compared to opioid injection in two European locales with significant HIV epidemics. METHODS PWID in Kohtla-Järve and St. Petersburg were recruited using respondent-driven sampling in 2012-2013. Survey data on demographic characteristics, service use, injecting and sexual risk behaviours and HIV-status (and HCV in Kohtla-Järve) were compared between primary opioid and ATS injectors using logistic regression models. RESULTS Of 591 injectors recruited in Kohtla-Järve and 811 in St. Petersburg, 195 (33%) and 27 (4%) primarily injected ATS in each city. In both cities, ATS injectors were younger than opioid injectors, initiated injection later, injected less frequently and were more likely to have been paid for sex. In both cities, PWID had high levels of multiple sex partners. In Kohtla-Järve, ATS-injectors had lower odds of back-loading and greater odds of polydrug use than opioid-injectors. In St. Petersburg, where over half of PWID reported unsafe sharing practices, ATS-injectors were less likely to report these practices. ATS-injection was negatively associated with being HIV positive in Kohtla-Järve (aOR = 0.6; 95%CI: 0.5-0.8) and St. Petersburg (aOR = 0.3; 95%CI: 0.1-0.7). ATS-injection was negatively associated with HCV-reactivity in Kohtla-Järve (aOR = 0.5; 95%CI: 0.3-0.6). CONCLUSIONS In both locations, primary ATS injection was associated with lower injecting risk behaviours, lower odds of HIV and being paid for sex compared to opioid injection. Interventions targeting the characteristics and needs of ATS injectors are needed to increase contact with services and reduce sexual and injecting risk. Harm reduction services, including sexual risk reduction, need to be expanded for all PWID in St. Petersburg.
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Affiliation(s)
- Isabel Tavitian-Exley
- Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom.
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Lucy Platt
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Robert Heimer
- Epidemiology of Microbial Diseases, School of Public Health, Yale University, United States
| | - Anneli Uusküla
- Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Olga Levina
- NGO Stellit, St Petersburg, Russian Federation
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom.
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29
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Parpouchi M, Moniruzzaman A, Rezansoff SN, Russolillo A, Somers JM. Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness. Addict Behav Rep 2017; 6:106-111. [PMID: 29450244 PMCID: PMC5800549 DOI: 10.1016/j.abrep.2017.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/22/2017] [Accepted: 09/22/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada. MATERIAL AND METHODS Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics. RESULTS Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051). CONCLUSIONS The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.
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Affiliation(s)
- Milad Parpouchi
- Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300 — 8888 University Dr., Burnaby, British Columbia V5A 1S6, Canada
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30
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Socías ME, Wood E, McNeil R, Kerr T, Dong H, Shoveller J, Montaner J, Milloy MJ. Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV-related outcomes: An interrupted time series analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 45:1-8. [PMID: 28454044 PMCID: PMC5820001 DOI: 10.1016/j.drugpo.2017.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/17/2017] [Accepted: 03/22/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND In February 2014, several regulatory reforms were introduced to the methadone maintenance treatment (MMT) program in British Columbia, Canada, including a switch to a ten-times more concentrated methadone formulation and restrictions in pharmacy delivery services. We evaluated possible unintended effects of these changes on illicit drug use patterns and HIV treatment outcomes among HIV-positive opioid users. METHODS Data was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive people who use illicit drugs in Vancouver, Canada. Interrupted Time Series Analyses were used to evaluate impacts of the policy change on monthly rates of MMT enrolment, illicit heroin injection, antiretroviral therapy (ART) adherence, and HIV viral suppression among HIV-positive opioid users between November 2012 and May 2015. RESULTS A total of 331 HIV-positive opioid users were included. The MMT policy change led to a significant immediate 11.5% increase in heroin injection, and 15.9% drop in optimal ART adherence. A gradual increase in the prevalence of MMT enrolment after the policy change was also documented (0.9% per month). No changes in viral suppression rates were observed. CONCLUSION We observed immediate increases in illicit heroin injection and decreases in ART adherence in the wake of regulatory changes to the local MMT program. These findings underscore the need to consider potential unintended effects of altering health programmes for vulnerable populations, the need to develop appropriate mitigation strategies, as well as to involve all relevant stakeholders in the planning and implementations of new policies.
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Affiliation(s)
- M Eugenia Socías
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Jean Shoveller
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Jiang R, Lee I, Lee TA, Pickard AS. The societal cost of heroin use disorder in the United States. PLoS One 2017; 12:e0177323. [PMID: 28557994 PMCID: PMC5448739 DOI: 10.1371/journal.pone.0177323] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/25/2017] [Indexed: 02/07/2023] Open
Abstract
Objective Heroin use in the United States has reached epidemic proportions. The objective of this paper is to estimate the annual societal cost of heroin use disorder in the United States in 2015 US dollars. Methods An analytic model was created that included incarceration and crime; treatment for heroin use disorder; chronic infectious diseases (HIV, Hepatitis B, Hepatitis C, and Tuberculosis) and their treatments; treatment of neonatal abstinence syndrome; lost productivity; and death by heroin overdose. Results Using literature-based estimates to populate the model, the cost of heroin use disorder was estimated to be $51.2 billion in 2015 US dollars ($50,799 per heroin user). One-way sensitivity analyses showed that overall cost estimates were sensitive to the number of heroin users, cost of HCV treatment, and cost of incarcerating heroin users. Conclusion The annual cost of heroin use disorder to society in the United States emphasizes the need for sustained investment in healthcare and non-healthcare related strategies that reduce the likelihood of abuse and provide care and support for users to overcome the disorder.
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Affiliation(s)
- Ruixuan Jiang
- Center for Pharmacoepidemiology and Pharmacoeconomics Research and Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, College of Pharmacy, Chicago, IL, United States of America
| | - Inyoung Lee
- Center for Pharmacoepidemiology and Pharmacoeconomics Research and Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, College of Pharmacy, Chicago, IL, United States of America
| | - Todd A. Lee
- Center for Pharmacoepidemiology and Pharmacoeconomics Research and Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, College of Pharmacy, Chicago, IL, United States of America
| | - A. Simon Pickard
- Center for Pharmacoepidemiology and Pharmacoeconomics Research and Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, College of Pharmacy, Chicago, IL, United States of America
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
- * E-mail:
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Stopka TJ, Donahue A, Hutcheson M, Green TC. Nonprescription naloxone and syringe sales in the midst of opioid overdose and hepatitis C virus epidemics: Massachusetts, 2015. J Am Pharm Assoc (2003) 2017; 57:S34-S44. [PMID: 28189540 DOI: 10.1016/j.japh.2016.12.077] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the prevalence of nonprescription naloxone and sterile syringe sales, factors associated with nonprescription sales, geospatial access to nonprescription naloxone and syringe-selling pharmacies, and targets for potential interventions. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS Massachusetts has experienced steep increases in reported opioid overdoses and hepatitis C virus cases in the past decade. Pharmacists have the potential to play a substantial role in increasing access to nonprescription naloxone and sterile syringes, which can reverse opioid overdoses and decrease hepatitis C virus transmission, respectively. We completed brief telephone surveys with 809 of 1042 retail pharmacies across Massachusetts (response rate = 77.6%) during 2015 to assess experience with nonprescription sales of naloxone and sterile syringes. OUTCOME MEASURES Our primary outcomes were the stocking and selling of naloxone in the pharmacy (yes or no) for nonprescription sales and nonprescription syringe sales (yes or no). We conducted multivariable regression analyses and created maps using a geographic information system to identify factors associated with nonprescription sales of naloxone and sterile syringes, and to improve our understanding of geospatial access to pharmacy-based naloxone and syringe sales. RESULTS More than 97% of pharmacies reported selling sterile syringes without requiring a prescription, and 45% of pharmacies reported stocking and selling naloxone. Factors associated with nonprescription sales included hours of operation, experience with and interest in harm reduction activities, and presence in an opioid overdose hotspot. Geographic access to nonprescription sale of sterile syringes is widespread, whereas geospatial access to naloxone is limited. Training to understand the benefits, applications, and distribution needs of naloxone is of interest to surveyed pharmacists. CONCLUSION Access to sterile syringes through nonprescription sales is strong across Massachusetts, and although more than 350 pharmacies (45%) reported stocking and selling naloxone to prevent opioid overdose deaths, there is much room for improvement in access and training among pharmacy staff members.
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Prangnell A, Dong H, Daly P, Milloy MJ, Kerr T, Hayashi K. Declining rates of health problems associated with crack smoking during the expansion of crack pipe distribution in Vancouver, Canada. BMC Public Health 2017; 17:163. [PMID: 28158995 PMCID: PMC5292004 DOI: 10.1186/s12889-017-4099-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/01/2017] [Indexed: 11/23/2022] Open
Abstract
Background Crack cocaine smoking is associated with an array of negative health consequences, including cuts and burns from unsafe pipes, and infectious diseases such as HIV. Despite the well-established and researched harm reduction programs for injection drug users, little is known regarding the potential for harm reduction programs targeting crack smoking to reduce health problems from crack smoking. In the wake of recent crack pipe distribution services expansion, we utilized data from long running cohort studies to estimate the impact of crack pipe distribution services on the rates of health problems associated with crack smoking in Vancouver, Canada. Methods Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2005 and November 2014. We employed multivariable generalized estimating equations to examine the relationship between crack pipe acquisition sources and self-reported health problems associated with crack smoking (e.g., cut fingers/sores, coughing blood) among people reported smoking crack. Results Among 1718 eligible participants, proportions of those obtaining crack pipes only through health service points have significantly increased from 7.2% in 2005 to 62.3% in 2014 (p < 0.001), while the rates of reporting health problems associated with crack smoking have significantly declined (p < 0.001). In multivariable analysis, compared to those obtaining pipes only through other sources (e.g., on the street, self-made), those acquiring pipes through health service points only were significantly less likely to report health problems from smoking crack (adjusted odds ratio: 0.82; 95% confidence interval: 0.73–0.93). Conclusions These findings suggest that the expansion of crack pipe distribution services has likely served to reduce health problems from smoking crack in this setting. They provide evidence supporting crack pipe distribution programs as a harm reduction service for crack smokers.
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Affiliation(s)
- Amy Prangnell
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,School of Population and Public Health, University of British Columbia, 206 E Mall, Vancouver, BC, V6T 1Z9, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,School of Population and Public Health, University of British Columbia, 206 E Mall, Vancouver, BC, V6T 1Z9, Canada
| | - Patricia Daly
- Vancouver Coastal Health, #800-601 West Broadway, Vancouver, BC, V5Z 4C2, Canada
| | - M J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Urban Health Research Initiative, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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Methadone maintenance therapy and viral suppression among HIV-infected opioid users: The impacts of crack and injection cocaine use. Drug Alcohol Depend 2016; 168:211-218. [PMID: 27701042 PMCID: PMC5257247 DOI: 10.1016/j.drugalcdep.2016.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Methadone maintenance therapy (MMT) is associated with improved HIV treatment outcomes among people who use drugs (PWUD). The extent to which these benefits are sustained in the context of ongoing cocaine use is unclear. We assessed differential impacts of MMT on HIV viral load (VL) suppression in relation to discrete patterns of cocaine use. METHODS Data was drawn from ACCESS, a prospective cohort of HIV-positive PWUD in Vancouver, Canada. Generalized linear mixed-effects were used to model the independent effect of MMT on VL suppression across strata of frequency of cocaine injection and crack smoking (≥daily versus <daily), after adjustment for confounders. RESULTS The analysis included 397 HIV-positive opioid users who completed ≥1 study interview between 2005 and 2014. At baseline, 304 (77%) reported participation in MMT, 37 (9%) ≥daily cocaine injection, and 158 (40%) ≥daily crack smoking. In adjusted analyses, MMT remained independently associated with increased odds of VL suppression in both strata of crack smokers (AOR=3.11, 95% CI: 1.86-5.21 and AOR=1.48, 95%CI: 1.04-2.09, for ≥daily and <daily smokers, respectively), and among <daily cocaine injectors (AOR=1.88, 95%CI 1.38-2.56), but not among ≥daily cocaine injectors (AOR=1.37, 95%CI 0.53-3.49). Longer retention on MMT was positively associated with VL suppression in all strata of cocaine injection and crack smoke. CONCLUSIONS Exposure to MMT was associated with increased odds of VL suppression among HIV- positive opioid users regardless of crack use. However, this beneficial effect of MMT was lost among frequent cocaine injectors with shorter retention on MMT.
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Montain J, Ti L, Hayashi K, Nguyen P, Wood E, Kerr T. Impact of length of injecting career on HIV incidence among people who inject drugs. Addict Behav 2016; 58:90-4. [PMID: 26921723 DOI: 10.1016/j.addbeh.2016.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 11/30/2015] [Accepted: 02/14/2016] [Indexed: 02/01/2023]
Abstract
We examined the relationship between duration of injecting career and HIV seroconversion among people who inject drugs (PWID) in Vancouver, Canada. Data were derived from HIV-negative PWID enrolled in a prospective cohort study. We employed Kaplan-Meier methods and Cox regression to investigate the effect of length of time since injection drug use initiation on time to HIV seroconversion. In multivariable Cox analysis, duration of injecting career was negatively associated with time to HIV seroconversion (adjusted hazard ratio=0.82; 95% confidence interval [CI]: 0.69-0.97). Our findings highlight the need for interventions that target individuals who participate in high-risk drug use behaviors.
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Des Jarlais DC, Kerr T, Carrieri P, Feelemyer J, Arasteh K. HIV infection among persons who inject drugs: ending old epidemics and addressing new outbreaks. AIDS 2016; 30:815-26. [PMID: 26836787 PMCID: PMC4785082 DOI: 10.1097/qad.0000000000001039] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIDS among persons who inject drugs, first identified in December 1981, has become a global epidemic. Injecting drug use has been reported in 148 countries and HIV infection has been seen among persons who inject drugs in 61 countries. Many locations have experienced outbreaks of HIV infection among persons who inject drugs, under specific conditions that promote very rapid spread of the virus. In response to these HIV outbreaks, specific interventions for persons who inject drugs include needle/syringe exchange programs, medicated-assisted treatment (with methadone or buprenorphine) and antiretroviral therapy. Through a 'combined prevention' approach, these interventions significantly reduced new HIV infections among persons who inject drugs in several locations including New York City, Vancouver and France. The efforts effectively ended the HIV epidemic among persons who inject drugs in those locations. This review examines possible processes through which combined prevention programs may lead to ending HIV epidemics. However, notable outbreaks of HIV among persons who inject drugs have recently occurred in several countries, including in Athens, Greece; Tel-Aviv, Israel; Dublin, Ireland; as well as in Scott County, Indiana, USA. This review also considers different factors that may have led to these outbreaks. We conclude with addressing the remaining challenges for reducing HIV infection among persons who inject drugs.
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Affiliation(s)
- Don C Des Jarlais
- aBaron Edmond de Rothschild Chemical Dependency Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, USA bUrban Health Research Initiative British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada cINSERM, U912 (SESSTIM), Marseille, France
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Nosyk B, Krebs E, Min JE, Ahamad K, Buxton J, Goldsmith C, Hull M, Joe R, Krajden M, Lima VD, Olding M, Wood E, Montaner JSG. The 'Expanded HIV care in opioid substitution treatment' (EHOST) cluster-randomized, stepped-wedge trial: A study protocol. Contemp Clin Trials 2015; 45:201-209. [PMID: 26342295 DOI: 10.1016/j.cct.2015.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/28/2015] [Accepted: 08/30/2015] [Indexed: 11/18/2022]
Abstract
The public health response to HIV/AIDS has turned its focus onto optimizing health care system delivery to maximize case identification, access and sustained engagement in antiretroviral treatment (ART). Opioid Agonist Treatment (OAT) provides a critical opportunity for HIV testing and linkage to ART. The EHOST study is a cluster-randomized, stepped-wedge trial to evaluate a prescriber-focused intervention to increase HIV testing rates, and optimize ART engagement and retention outcomes among individuals engaged in OAT. The study will encompass all drug treatment clinics currently admitting patients for the treatment of opioid use disorder across the province of British Columbia, encompassing an estimated 90% of the OAT caseload. The trial will be executed over a 24-month period, with groups of clinics receiving the intervention in 6-month intervals. Evaluation of the proposed intervention's effectiveness will focus on three primary outcomes: (i) the HIV testing rate among those not known to be HIV positive; (ii) the rate of ART initiation among those not on ART; and (iii) the rate of ART continuation among those on ART. A difference-in-differences analytical framework will be applied to estimate the intervention's effect. This approach will assess site-specific changes in primary outcomes across clusters while adjusting for potential residual heterogeneity in patient case mix, volume, and quality of care across clinics. Statistical analysis of outcomes will be conducted entirely with linked population-level administrative health datasets. Facilitated by established collaborations between key stakeholders across the province, the EHOST intervention promises to optimize HIV testing and care within a marginalized and hard-to-reach population.
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Affiliation(s)
- B Nosyk
- BC Centre for Excellence in HIV/AIDS, Canada; Faculty of Health Sciences, Simon Fraser University, Canada.
| | - E Krebs
- BC Centre for Excellence in HIV/AIDS, Canada
| | - J E Min
- BC Centre for Excellence in HIV/AIDS, Canada
| | - K Ahamad
- BC Centre for Excellence in HIV/AIDS, Canada
| | - J Buxton
- BC Centre for Disease Control and Prevention, Canada; School of Population and Public Health, University of British Columbia, Canada
| | - C Goldsmith
- Faculty of Health Sciences, Simon Fraser University, Canada
| | - M Hull
- BC Centre for Excellence in HIV/AIDS, Canada; Vancouver Coastal Health Authority, Canada
| | - R Joe
- Vancouver Coastal Health Authority, Canada
| | - M Krajden
- BC Centre for Disease Control and Prevention, Canada
| | - V D Lima
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
| | - M Olding
- BC Centre for Excellence in HIV/AIDS, Canada
| | - E Wood
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
| | - J S G Montaner
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
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Affiliation(s)
- Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China.
| | - Roger Detels
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA
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