Trends in crime and the introduction of a needle exchange program

Comparing harm reduction and overdose response services between community-based and public health department syringe service programmes using a national cross-sectional survey

Background

Syringe services programmes (SSPs) are an evidence-based strategy to reduce infectious diseases and deliver overdose prevention interventions for people who use drugs. They face regulatory, administrative, and funding barriers that limit their implementation in the US, though the federal government recently began providing funding to support these efforts. In this study we aim to understand whether the organisational characteristics of SSPs are associated with the provision of syringe and other overdose response strategies.

Methods

We examine four outcomes using the National Survey of Syringe Services Programs (NSSSP) (N = 472): syringe distribution, naloxone distribution, fentanyl test strip (FTS) availability, and buprenorphine implementation. These outcomes are assessed across three organizational categories of SSPs-those operated by public health departments (DPH), community-based organizations (CBOs) with government funding, and CBOs without government funding-while adjusting for community-level confounders.

Findings

The proportion of SSPs by organizational category was 36% DPH, 42% CBOs with government funding, and 22% CBOs without government funding. Adjusting for community-level differences, we found that CBO SSPs with government funding had significantly higher provision of all four syringe and overdose response services as compared to DPH SSPs and across three of the four services as compared to CBO SSPs without government funding. CBO SSPs without government funding still had significantly higher provision of three of the four services as compared to programmes maintained by the DPH.

Interpretation

CBO SSPs have strong potential to expand overdose response services nationally, particularly if provided with sustained and adequate funding. Communities should aim to provide funding that does not hinder SSP innovation so they can remain flexible in responding to local needs.

Funding

This study was supported by Arnold Ventures (20-05172).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Overdose Prevention Centers, Crime, and Disorder in New York City

Importance

The first government-sanctioned overdose prevention centers (OPCs) in the US opened in New York City (NYC) in November 2021 amid concerns that they may increase crime and disorder, representing a significant political challenge to OPCs.

Objective

To identify whether opening the first 2 government-sanctioned OPCs in the US was associated with changes in crime and disorder.

Design, Setting, and Participants

In this cohort study, difference-in-differences Poisson regression models were used to compare crime, residents' requests for assistance for emergencies and nuisance complaints, and police enforcement in the vicinity of NYC's 2 OPCs with those around 17 other syringe service programs that did not offer overdose prevention services from January 1, 2019, through December 31, 2022.

Main Outcomes and Measures

Changes in the volume of crimes reported by the public or observed by police; arrests for drug possession and weapons; 911 calls and 311 calls regarding crime, public nuisances, and medical events; and summonses issued by police for criminal infractions in both the immediate vicinity of the sites (ie, a hexagonal area spanning about 6 city blocks) and their wider neighborhoods (ie, a tesselated 3-hexagon array spanning about 18 city blocks).

Results

No significant changes were detected in violent crimes or property crimes recorded by police, 911 calls for crime or medical incidents, or 311 calls regarding drug use or unsanitary conditions observed in the vicinity of the OPCs. There was a significant decline in low-level drug enforcement, as reflected by a reduction in arrests for drug possession near the OPCs of 82.7% (95% CI, -89.9% to -70.4%) and a reduction in their broader neighborhoods of 74.5% (95% CI, -87.0% to -50.0%). Significant declines in criminal court summonses issued in the immediate vicinity by 87.9% (95% CI, -91.9% to -81.9%) and in the neighborhoods around the OPCs by 59.7% (95% CI, -73.8% to -38.0%) were observed. Reductions in enforcement were consistent with the city government's support for the 2 OPCs, which may have resulted in a desire not to deter clients from using the sites by fear of arrest for drug possession.

Conclusions and Relevance

In this difference-in-differences cohort study, the first 2 government-sanctioned OPCs in the US were not associated with significant changes in measures of crime or disorder. These observations suggest the expansion of OPCs can be managed without negative crime or disorder outcomes.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic

BACKGROUND

Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises.

OBJECTIVE

This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19.

METHODS

From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing.

RESULTS

One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing.

CONCLUSIONS

Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

A multi-site intervention using influencers to communicate about syringe service programmes

Introduction

In the USA, syringe services programmes (SSPs) provide a range of harm reduction services and have numerous benefits for communities. However, stigma, misconceptions about SSPs and changing policies/legislation remain a challenge to effective implementation. This study reviews the implementation of two digital interventions, Appalachian Influence and Shared Influence, which used social media influencers and digital volunteers to communicate positive information about harm reduction and SSPs.

Methods

The intervention was designed to deliver accurate and supportive messaging in locally relevant and meaningful ways. Messaging was informed by interviews with subject matter experts and community organisations, and was integrated into prompts used by local influencers (paid individuals with more than 1,000 followers) and digital volunteers (unpaid individuals with no following requirement, who joined the project independently).

Results

In the first 6 months of implementation, Appalachian Influence and Shared Influence engaged a total of 9,014 individuals, 236 of whom were paid influencers and 8,778 of whom were digital volunteers. Paid influencer posts achieved a total of 868,943 impressions, 42,432 engagements and 1,567 comments. Comments on paid influencer posts were overwhelmingly positive, with 87.4% positive and 0.8% negative. Interviews showed the importance of understanding local realities, leading with compassion and emphasising the 'human' aspects of dependency and addiction in messaging.

Conclusion

This study shows the potential to implement an influencer-led social media intervention to reach people with authentic and compassionate messaging about harm reduction and SSPs. Future research should examine intervention effectiveness and how this approach can be applied to other stigmatised topics.

Law enforcement and syringe services program implementation in rural counties in Kentucky: a qualitative exploration

BACKGROUND

Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality.

OBJECTIVE

This study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties.

METHODS

From August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement.

RESULTS

Participants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries.

CONCLUSIONS

The results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity.

Do naloxone access laws affect perceived risk of heroin use? Evidence from national US data

BACKGROUND AND AIMS

Whether expanded access to naloxone reduces perceptions of risk about opioid use has been subject to debate. Our aim was to assess how implementation of naloxone access laws shapes perceived risk of heroin use.

DESIGN

Using data from the restricted-access National Survey on Drug Use and Health, Prescription Drug Abuse Policy System and the US Census, we applied two-way fixed-effects models to determine whether naloxone access laws decreased perceived risk of any heroin use or regular heroin use. We used Bayes factors (BFs) to confirm evidence for null findings.

SETTING

United States.

PARTICIPANTS

A total of 884 800 respondents aged 12 and older from 2004 to 2016.

MEASUREMENTS

A binary indicator of whether a state implemented naloxone access laws was regressed on respondent-perceived risk of (1) any heroin use and (2) regular heroin use. Ratings of perceived risk were assessed on a scale of 1 (none) to 4 (great risk).

FINDINGS

In all instances, the BFs support evidence for the null hypothesis. Across models with three distinct specifications of naloxone access laws, we found no evidence of decreased risk perceptions, as confirmed by BFs ranging from 0.009 to 0.057. Across models of specific vulnerable subgroups, such as people who use opioids (BFs = 0.039-0.225) or young people (BFs = 0.009-0.158), we found no evidence of decreased risk perceptions. Across diverse subpopulations by gender (BFs = 0.011-0.083), socio-economic status (BFs = 0.015-0.168) or race/ethnicity (BFs = 0.016-0.094), we found no evidence of decreased risk perceptions.

CONCLUSIONS

There appears to be no empirical evidence that implementation of naloxone access laws has adversely affected perceptions of risk of heroin in the broader US population or within vulnerable subgroups or diverse subpopulations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION/CONCLUSION

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

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

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

Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data

PURPOSE

To evaluate whether Kentucky counties that established a new syringe services program realized a significant decline in the incidence rate of a set of infectious disease diagnoses commonly transmitted via injection drug use.

METHODS

Longitudinal count models of within-county rates of newly diagnosed infections among populations at risk were estimated using Medicaid claims/encounters data. Generalized estimating equation models were used to report incident rate ratios of 6 diagnoses: (1) HIV; (2) hepatitis C; (3) hepatitis B; (4) osteomyelitis; (5) endocarditis; and (6) skin/soft tissue infection. To investigate whether a delay in effect was present, separate models were fit to estimate the effects of establishing a syringe services program: at its opening date, and again at 1, 3, and 6 months postopening date.

FINDINGS

Taken together, the aggregated within-county incidence rate of these 6 diagnoses was significantly lower following the implementation of a syringe services program (P < .05). Our models estimated that counties which opted to open a syringe services program realized an approximate month-over-month decline in new diagnoses of 0.5% among the population at risk.

CONCLUSIONS

These results lend further support to previous conclusions made in the public health literature regarding the efficacy of syringe services programs. Specifically, declines in incidence rates were observable beginning at 1 month post syringe services program opening. These results are particularly notable due to the typical setting in which these syringe services programs operated-rural communities of fewer than 40,000 residents.

Infective Endocarditis Among Persons Aged 18-64 Years Living with Human Immunodeficiency Virus, Hepatitis C Infection, or Opioid Use Disorder, United States, 2007-2017

BACKGROUND

Infective endocarditis (IE) is a life-threatening bacterial infection of the heart valves, most often diagnosed in older persons and persons with prior cardiac surgery. It is also associated with injection drug use, a behavior that has increased in recent years along with the US opioid crisis.

METHODS

We conducted a retrospective cohort analysis of commercial and Medicaid health insurance databases to estimate incident cases of IE in the United States in 2017, stratified by persons living with human immunodeficiency virus (HIV), hepatitis C virus (HCV), and opioid use disorder (OUD). We also estimated annual percentage changes (EAPCs) in IE from 2007-2017 among persons with commercial insurance.

RESULTS

The weighted incidence rate of IE was 13.8 cases per 100 000 persons among persons with commercial insurance, and 78.7 among those with Medicaid. The incidence rate of IE among commercially insured persons increased slightly from 2007-2017 (EAPC, 1.0%). It decreased among commercially insured persons living with HIV, from 148.0 in 2007 to 112.1 in 2017 (EAPC, -4.3%), and increased among those with HCV infection, from 172.4 in 2007 to 238.6 in 2017 (EAPC, 3.2%). Among persons aged 18-29 years with HCV infection, IE increased from 322.3 in 2007 to 1007.1 in 2017 (EAPC, 16.3%), and among those with OUD it increased from 156.4 in 2007 to 642.9 in 2017 (EAPC, 14.8%).

CONCLUSIONS

The incidence rate of IE increased markedly among young persons with HCV infections or OUD. This increase appears to parallel the ongoing national opioid crisis. Harm reduction with syringe services programs, medications for opioid use disorder, and safe injection practices can prevent the spread of HIV, HCV, and IE.

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia

BACKGROUND

Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations.

OBJECTIVES

We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP.

METHODS

PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP.

RESULTS

Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979).

CONCLUSION

PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Preventing HIV outbreaks among people who inject drugs in the United States: plus ça change, plus ça même chose

: This editorial review covers current trends in the epidemiology of HIV among people who inject drugs (PWID) in the United States, including four recent HIV outbreaks. We discuss gaps in the prevention and treatment cascades for HIV and medications for opioid disorder and propose lessons learned to prevent future HIV outbreaks. Over the last decade, North America has been in the throes of a major opioid epidemic, due in part to over-prescribing of prescription opiates, followed by increasing availability of cheap heroin, synthetic opioids (e.g. fentanyl), and stimulants (e.g. methamphetamine). Historically, HIV infection among PWID in the US had predominantly affected communities who were older, urban and Black. More recently, the majority of these infections are among younger, rural or suburban and Caucasian PWID. All four HIV outbreaks were characterized by a high proportion of women who inject drugs and underlying socioeconomic drivers such as homelessness and poverty. We contend that the US response to the HIV epidemic among PWID has been fractured. A crucial lesson is that when evidence-based responses to HIV prevention are undermined or abandoned because of moral objections, untold humanitarian and financial costs on public health will ensue. Restructuring a path forward requires that evidence-based interventions be integrated and brought to scale while simultaneously addressing underlying structural drivers of HIV and related syndemics. Failing to do so will mean that HIV outbreaks among PWID and the communities they live in will continue to occur in a tragic and relentless cycle.

State Laws Governing Syringe Services Programs and Participant Syringe Possession, 2014-2019

OBJECTIVE

Law is an important factor in the diffusion of syringe services programs (SSPs). This study measures the current status of, and 5-year change in, state laws governing SSP operations and possession of syringes by participants.

METHODS

Legal researchers developed a cross-sectional data set measuring key features of state laws and regulations governing the possession and distribution of syringes across the 50 US states and the District of Columbia in effect on August 1, 2019. We compared these data with previously collected data on laws as of August 1, 2014.

RESULTS

Thirty-nine states (including the District of Columbia) had laws in effect on August 1, 2019, that removed legal impediments to, explicitly authorized, and/or regulated SSPs. Thirty-three states had 1 or more laws consistent with legal possession of syringes by SSP participants under at least some circumstances. Changes from 2014 to 2019 included an increase of 14 states explicitly authorizing SSPs by law and an increase of 12 states with at least 1 provision reducing legal barriers to SSPs. Since 2014, the number of states explicitly authorizing SSPs nearly doubled, and the new states included many rural, southern, or midwestern states that had been identified as having poor access to SSPs, as well as states at high risk for HIV and hepatitis C virus outbreaks. Substantial legal barriers to SSP operation and participant syringe possession remained in >20% of US states.

CONCLUSION

Legal barriers to effective operation of SSPs have declined but continue to hinder the prevention and reduction of drug-related harm.

Syringe services programs and real-world research: An overview for pharmacists

OBJECTIVE

To review key arguments supporting and criticizing syringe services programs (SSPs).

DATA SOURCES

Peer-reviewed literature and publicly available documents.

SUMMARY

Pharmacy organizations-including the American Pharmacists Association and the American Society of Health-System Pharmacists-have stated that pharmacists should support programs that supply sterile injection materials to persons who use injection drugs. SSPs may include needle exchanges or other programs that meet these aims. Pharmacists should know that observational public health research demonstrates that SSPs can lower the transmission of blood-borne illnesses, improve linkage to care for substance use disorders, reduce health care expenditures, and reduce drug overdoses. Concerns about SSPs and increases in syringe litter or crime have not been borne out by research. Despite these findings and the positions of professional organizations, contemporary research suggests that pharmacists may be reluctant to support SSPs and other programs that would increase supply of sterile injection supplies to their communities.

CONCLUSION

The review of evidence in this commentary should help pharmacists better understand the evidence in favor of SSPs, the potential criticisms of SSPs, and the reasons that their profession is moving to support these programs.

Confronting the opioid epidemic: public opinion toward the expansion of treatment services in Virginia

BACKGROUND

Public opinion polls have consistently shown Americans prefer treatment over arrest policies for opioid users. As the opioid epidemic remains a major health problem in the United States, it is important to determine the type of treatment policies the public would support. Theoretically, government should take into consideration the opinion of its constituents when deciding how to act. As such, the 2018 Virginia Commonwealth Public Policy Poll determined levels of support for the expansion of community-based treatment in one's community.

RESULTS

Overall, the results showed 80% of Virginians (n = 788) supported the expansion of community-based treatment centers in their neighborhood, 69% supported the use of housing in their community, while less than half supported the provision of clean needles to IV drug users so they do not use dirty needles that could spread infection. Multivariate analyses revealed education, sex, and political party affiliation are significant factors in predicting support for the expansion of services.

CONCLUSIONS

Given the lack of progress made by the government in reducing the supply and demand of drugs over the course of the war on drugs, it is time to move away from punitive policies to responsible and pragmatic approaches that include the expansion of community-based treatment.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The value of harm reduction for injection drug use: A clinical and public health ethics analysis

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

[Harm reduction interventions in drug users: current situation and recommendations]

Harm reduction encompasses interventions, programmes and policies that seek to reduce the negative consequences of the consumption of both legal and illegal drugs on the individual and public health. Harm reduction looks to mitigate the harm suffered by drug users through drug use monitoring and prevention, and promotes initiatives that respect and protect the human rights of this population. The harm reduction policies that have proven effective and efficient are: opioid substitution maintenance therapy (methadone); needle and syringe exchange programmes; supervised drug consumption rooms; and overdose prevention through peer-based naloxone distribution. In order to be effective, these policies must have comprehensive coverage and be implemented in areas where the target population is prevalent. Resident-based opposition to the implementation of these policies is known as the NIMBY (Not In My Back Yard) phenomenon, which is characterised by being against the implementation of new measures in a particular place, but does not question their usefulness. Given that any NIMBY phenomenon is a complex social, cultural and political phenomenon, it is important to conduct a thorough analysis of the situation prior to implementing any of these measures. Harm reduction policies must be extended to other substances such as alcohol and tobacco, as well as to other conditions beyond infectious/contagious diseases and overdose.

The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect

INTRODUCTION AND AIMS

Needle and syringe automatic dispensing machines (ADM) aim to increase needle/syringe distribution to people who inject drugs. ADM implementation has been met with community concern about potential perceived increases in crime and drug use and that they will attract non-resident drug users-the 'honey-pot effect'. In April 2013, an ADM commenced operation in inner-city Sydney. We assessed the impact of the ADM on crime and examined its use by non-resident drug users (the honey-pot effect).

DESIGN AND METHODS

Fixed-site needle and syringe program (n = 207) and ADM clients (n = 55) were surveyed to determine whether they lived within 1 km of the ADM. Police-recorded offences between January 2012 and March 2014 across six crime categories for the local and surrounding areas were assessed for trend to measure impact on crime.

RESULTS

The majority (78%) of needle and syringe program clients reported residing within 1 km of the service. Most (95%) ADM users were fixed-site service clients. The 2 year trend for crime categories remained stable or decreased, except for fraud, which increased significantly (P < 0.05).

DISCUSSION AND CONCLUSION

Automatic dispensing machine users were largely clients of the existing fixed-site service and lived locally. There was no apparent concurrent increase in crime or a honey-pot effect. It is important that services continue to be aware of community concerns and respond to them appropriately.[Day CA, White B, Haber PS. The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect. Drug Alcohol Rev 2016;35:637-643].

Barriers and Potential Improvements for Needle and Syringe Exchange Programs (NSPs) in China: A Qualitative Study from Perspectives of Both Health and Public Security Sectors

This study explores the acceptability, the barriers to the implementation of needle and syringe exchange programs (NSPs) and the potential improvement strategies in China from the perspectives of governmental health and public security officials. Purposive sampling was used for recruitment of participants who had been involved in NSPs implementation. Semi-Structured individual interviews were conducted in Mandarin to address three aspects of NSPs: (1) participants’ attitudes towards NSPs, (2) participants’ opinions on the effectiveness and barriers of NSPs, and (3) suggestions for improving the program. Content analysis was used to analyse the translated interview data. A total of 68 participants from 12 Hunan counties were interviewed (34 from each of the Bureau of Health and the Narcotic Division). Both groups recognised the importance and effectiveness of NSPs in HIV prevention, but public security officials regarded NSPs as a temporary intervention in place of punitive measures. Most health officials (32/34) regarded the main barriers to its implementation as administrative and structural, whereas participants from Narcotics Division (n=24) questioned the legitimacy of NSPs and concerned about the poor management of drug users’ risk behaviours. Close cooperation between the health and public security sectors, engagement of the drug user community and an enabling policy environment were reportedly to be critical for potential improvements of NSPs in China. Misconceptions about NSPs encourage drug users’ addictive behaviour, and an unclear leadership and insufficient support de-motivate the participants from the Bureau of Health and the Narcotics Division to actively support the program implementation.

Drug-related deaths and the sales of needles through pharmacies

BACKGROUND

Providing needles to people who inject drugs is a well-proven public health response to the transmission of HIV and other blood borne viruses. Despite over a quarter of a century of research, new concerns about potential unintended negative consequences of needle distribution continue to emerge. Specifically, a claim was recently made that the introduction of pharmacy sales of needles was followed by an increase in overdoses in pharmacy parking lots. If true, this would have serious implications for the design of needle access programs, particularly those involving pharmacy sales of needles.

METHODS

We examine spatial relationships between drug-related deaths and pharmacies in Los Angeles County (population 9.8 million) before and after the 2007 enactment of a California law allowing pharmacy sales of needles without a prescription. Seven thousand and forty-nine drugs related deaths occurred in Los Angeles county from 2000 to 2009 inclusive. Four thousand two hundred and seventy-five of these deaths could be geocoded, and were found to be clustered at the census tract level.

RESULTS

We used three methods to examine spatial relationships between overdose death locations and pharmacy locations for two years on either side of the enactment of the pharmacy sales law, and found no statistically significant changes. Among the 711 geocodable deaths occurring in the two years following the change in law, no death was found to occur within 50m of a pharmacy which sold needles.

CONCLUSION

These results are consistent with prior studies which suggest pharmacy sales of needles improve access to needles without causing increased harms to the surrounding community.

Impact of supervised injection facilities on community HIV levels: a public health perspective

The health and social consequences of intravenous drug use pose major challenges to cities across North America. Preventable drug-related harms including accidental overdose, serious bacterial infections, injuries of violence and more recently, the emergence of HIV and hepatitis C, have major impacts on community health. Among the various interventions designed to reduce the harms associated with injection drug use, the establishment of a supervised injection facility is perhaps the most controversial. This review will focus on the potential impact of supervised injection facilities on HIV transmission in conjunction with current HIV prevention initiatives. This will include a review of the health and social consequences associated with illicit drugs use, the limitations of drug enforcement, and the potential impact of supervised injection facilities on reducing the harms associated with injection drug use.

Is crime associated with over-the-counter pharmacy syringe sales? Findings from Los Angeles, California

BACKGROUND

More than 50,000 new HIV infections occur annually in the United States. Injection drug users represent twelve percent of incident HIV infections each year. Pharmacy sales of over-the-counter (OTC) syringes have helped prevent HIV transmission among injection drug users in many states throughout the United States. However, concerns exist among some law enforcement officials, policymakers, pharmacists, and community members about potential links between OTC syringe sales and crime.

METHODS

We used a geographic information system and novel spatial and longitudinal analyses to determine whether implementation of pharmacy-based OTC syringe sales were associated with reported crime between January 2006 and December 2008 in Los Angeles Police Department Reporting Districts. We assessed reported crime pre- and post-OTC syringe sales initiation as well as longitudinal associations between crime and OTC syringe-selling pharmacies.

RESULTS

By December 2008, 9.3% (94/1010) of Los Angeles Police Department Reporting Districts had at least one OTC syringe-selling pharmacy. Overall reported crime counts and reported crime rates decreased between 2006 and 2008 in all 1010 Reporting Districts. Using generalized estimating equations and adjusting for potential confounders, reported crime rates were negatively associated with OTC syringe sales (adjusted rate ratio: 0.89; 95% confidence interval: 0.81, 0.99).

CONCLUSION

Our findings demonstrate that OTC pharmacy syringe sales were not associated with increases in reported crime in local communities in Los Angeles during 2006-2008.

Spatial Epidemiology of HIV among Injection Drug Users in Tijuana, Mexico

The northwest border city of Tijuana is Mexico's fifth largest and is experiencing burgeoning drug use and human immunodeficiency virus (HIV) epidemics. Since local geography influences disease risk, we explored the spatial distribution of HIV among injection drug users (IDUs). From 2006-2007, 1056 IDUs were recruited using respondent-driven sampling, and then followed for eighteen months. Participants underwent semi-annual surveys, mapping, and testing for HIV, tuberculosis, and syphilis. Using Average Nearest Neighbor and Getis-Ord Gi* statistics, locations where participants lived, worked, bought and injected drugs were compared with HIV status and environmental and behavioral factors. Median age was thirty-seven years; 85 percent were male. Females had higher HIV prevalence than males (10.2 percent vs. 3.4 percent; p=0.001). HIV cases at baseline (n=47) most strongly clustered by drug injection sites (Z-Score -6.173; p < 0.001), with a 16 km² hotspot near the Mexico/U.S. border, encompassing the red-light district. Spatial correlates of HIV included syphilis infection, female gender, younger age, increased hours on the street per day, and higher number of injection partners. Almost all HIV seroconverters injected within a 2.5 block radius of each other immediately prior to seroconversion. Only history of syphilis infection and female gender were strongly associated with HIV in the area where incident cases injected. Directional trends suggested a largely static epidemic until July-December 2008, when HIV spread to the southeast, possibly related to intensified violence and policing that spiked in the latter half of 2008. While clustering allows for targeting interventions, the dynamic nature of epidemics suggests the importance of mobile treatment and harm reduction programs.

Spatial access to sterile syringes and the odds of injecting with an unsterile syringe among injectors: a longitudinal multilevel study

Despite the 2010 repeal of the ban on spending federal monies to fund syringe exchange programs (SEPs) in the U.S.A., these interventions--and specifically SEP site locations--remain controversial. To further inform discussions about the location of SEP sites, this longitudinal multilevel study investigates the relationship between spatial access to sterile syringes distributed by SEPs in New York City (NYC) United Hospital Fund (UHF) districts and injecting with an unsterile syringe among injectors over time (1995-2006). Annual measures of spatial access to syringes in each UHF district (N = 42) were created using data on SEP site locations and site-specific syringe distribution data. Individual-level data on unsterile injecting among injectors (N = 4,067) living in these districts, and on individual-level covariates, were drawn from the Risk Factors study, an ongoing cross-sectional study of NYC drug users. We used multilevel models to explore the relationship of district-level access to syringes to the odds of injecting with an unsterile syringe in >75% of injection events in the past 6 months, and to test whether this relationship varied by district-level arrest rates (per 1,000 residents) for drug and drug paraphernalia possession. The relationship between district-level access to syringes and the odds of injecting with an unsterile syringe depended on district-level arrest rates. In districts with low baseline arrest rates, better syringe access was associated with a decline in the odds of frequently injecting with an unsterile syringe (AOR, 0.95). In districts with no baseline syringe access, higher arrest rates were associated with increased odds of frequently injecting with an unsterile syringe (AOR, 1.02) When both interventions were present, arrest rates eroded the protective effects of spatial access to syringes. Spatial access to syringes in small geographic areas appears to reduce the odds of injecting with an unsterile syringe among local injectors, and arrest rates elevate these odds. Policies and practices that curtail syringe flow in geographic areas (e.g., restrictions on SEP locations or syringe distribution) or that make it difficult for injectors to use the sterile syringes they have acquired may damage local injectors' efforts to reduce HIV transmission and other injection-related harms.

Needle exchange and the HIV epidemic in Vancouver: lessons learned from 15 years of research

During the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injection drug users (IDU) and many questioned how this could occur in the presence of a high volume needle exchange program (NEP). Specific concerns were fuelled by early research demonstrating that frequent needle exchange program attendees were more likely to be HIV positive than those who attended the NEP less frequently. Since then, some have misinterpreted this finding as evidence that NEPs are ineffective or potentially harmful. In light of continuing questions about the Vancouver HIV epidemic, we review 15 years of peer-reviewed research on Vancouver's NEP to describe what has been learned through this work. Our review demonstrates that: (1) NEP attendance is not causally associated with HIV infection, (2) frequent attendees of Vancouver's NEP have higher risk profiles which explain their increased risk of HIV seroconversion, and (3) a number of policy concerns, as well as the high prevalence of cocaine injecting contributed to the failure of the NEP to prevent the outbreak. Additionally, we highlight several improvements to Vancouver's NEP that contributed to declines in syringe sharing and HIV incidence. Vancouver's experience provides a number of important lessons regarding NEP. Keys to success include refocusing the NEP away from an emphasis on public order objectives by separating distribution and collection functions, removing syringe distribution limits and decentralizing and diversifying NEP services. Additionally, our review highlights the importance of context when implementing NEPs, as well as ongoing evaluation to identify factors that constrain or improve access to sterile syringes.

Intraurban mobility and its potential impact on the spread of blood-borne infections among drug injectors in Tijuana, Mexico

We explored intraurban mobility of Tijuana, Mexico, injection drug users (IDUs). In 2005, 222 IDUs underwent behavioral surveys and infectious disease testing. Participants resided in 58 neighborhoods, but regularly injected in 30. From logistic regression, "mobile" IDUs (injecting ≥3 km from their residence) were more likely to cross the Mexico/U.S. border, share needles, and get arrested for carrying syringes-but less likely to identify hepatitis as an injection risk. Mobile participants lived in neighborhoods with less drug activity, treatment centers, or migrants, but higher marriage and home ownership rates. Mobile IDUs should be targeted for outreach and further investigation. The study's limitations are noted.

Comparison of injection drug users accessing syringes from pharmacies, syringe exchange programs, and other syringe sources to inform targeted HIV prevention and intervention strategies

OBJECTIVE

To describe injection drug users (IDUs) who access syringes through different outlets to help inform the prevention needs of IDUs who underuse safe syringe sources in New York City (NYC), where syringe availability is high compared with other U.S. cities.

DESIGN

Cross sectional.

SETTING

NYC, 2005-2007.

PARTICIPANTS

285 IDUs.

INTERVENTION

Participants were recruited using random street-intercept sampling in 36 socioeconomically disadvantaged neighborhoods.

MAIN OUTCOME MEASURES

IDUs using syringe exchange programs (SEPs), pharmacies, or other outlets as a primary syringe source were compared based on sociodemographic characteristics, injection practices, and medical service use.

RESULTS

Chi-square tests and polytomous logistic regression were used to compare IDUs with different self-reported primary syringe sources used in the 6 months preceding study entry. Compared with IDUs using other syringe sources, those primarily using SEPs were less likely to be black (adjusted odds ratio 0.26 [95% CI 0.11-0.57]), more likely to inject daily (3.32 [1.58-6.98]), and more likely to inject with a new syringe (2.68 [1.30-5.54]). Compared with IDUs using other syringe sources, those primarily using pharmacies were less likely to be black (0.39 [0.17-0.90]).

CONCLUSION

These data suggest that pharmacies and SEPs may be reaching different populations of IDUs and highlight a subpopulation of highly marginalized IDUs (i.e., black race, infrequent injectors) who are underusing safe syringe sources in NYC. Targeted interventions are needed to reduce racial disparities and increase use of safe syringe outlets.

Organizational issues in the implementation of a hospital-based syringe exchange program

Little published information exists to guide health care institutions in establishing syringe exchange program (SEP) services. To address this gap, this article discusses organizational issues encountered in the implementation of a hospital-based SEP in San Francisco, California (USA). Investigators collaborated with a community organization in implementing a county hospital-based SEP. SEP services integrated into a public hospital presented unique challenges directly related to their status as a health care institution. In the course of introducing SEP services into a hospital setting as part of a clinical trial, various ethical, legal, and logistical issues were raised. Based on these experiences, this paper provides guidance on how to integrate an SEP into a traditional health care institution.

Syringe-Exchange Programs and HIV Prevention

Injection drug users and their sexual partners and children represent an increasing proportion of Americans living with HIV or AIDS. Syringe-exchange programs (SEPs), which are based on the theory of harm reduction, are effective in preventing the transmission of HIV and other pathogens through injection drug use. Most programs also serve as gateways to other vital medical services. Yet SEPs remain controversial. This article describes the controversy, considers the evidence, and discusses the nursing implications.

Effects of an intensive street-level police intervention on syringe exchange program use in Philadelphia, PA

Repeated measurements and mixed-effects models were used to analyze the effects of an intensive long-term street-level police intervention on syringe exchange program use. Utilization data for 9 months before and after the beginning of the intervention were analyzed. Use fell across all categories and time periods studied, with significant declines in use among total participants, male participants, and Black participants. Declines in use among Black and male participants were much more pronounced than decreases among White and female participants.

Evaluation of Needle Exchange Programs

Needle exchange programs exist in every major population area in the United States and in many other countries. Some operate legally under emergency health decrees issued by local departments of health, with the stated intention of risk reduction through the removal of used injection equipment from use by injection drug users. It is theorized that this results in a reduced transmission of human immunodeficiency virus, hepatitis, and, possibly, other blood-borne diseases. Needle exchange programs also offer access to drug treatment programs for the participants. It is a difficult but necessary task to evaluate these programs. This article examines examples of evaluations attempted in the past and discusses the challenges of such evaluations. Experimental evaluations, economic program analysis, legal aspects, and risk-benefit assessment along with ethical aspects are considered. An outline of program evaluation is proposed. Needle exchange programs offer an opportunity to encourage risk reduction and to offer counseling and access to health care for individuals at high risk. It is essential that such programs demonstrate their effectiveness. Assumptions of efficacy are insufficient for health care in the twenty-first century.

Readiness for cessation of drug use among recent attenders and nonattenders of a needle exchange program

Needle exchange programs (NEPs) represent a bridge to drug abuse treatment. NEP attenders tend to have more severe drug problems, however, and may be less ready to reduce their drug use than other drug users. This study investigated the relationship between NEP attendance and readiness for cessation of drug use. Since the period from 1988 through 1989, a community-based sample of injection drug users (IDUs) in Baltimore has undergone semiannual interview-administered questionnaires and HIV testing. A total of 288 IDUs completed a questionnaire on readiness for cessation of drug use. Readiness for drug use cessation was assessed from a 28-item validated scale of problem drug use and intention to quit, based on the "stages of change" model. Logistic regression was used to determine factors associated with readiness for cessation of drug use, including sociodemographics, drug use behaviors, and NEP attendance. Thirty percent of respondents attended the NEP in the past month. Stage of change in readiness for cessation of drug use did not differ between NEP attenders and nonattenders (OR = 0.9; 95% CI: 0.5-1.6). Similar proportions of persons recently attending and not attending the NEP were classified as ready to stop drug use (about 30%). In multivariate analysis, readiness for cessation of drug use was associated with speedball injection and previous enrollment in drug treatment but not with NEP attendance. NEP attenders, although exhibiting characteristics consistent with more severe drug dependence, were as motivated for cessation of drug use as were nonattenders. These findings suggest that formal collaboration between NEPs and drug treatment programs could increase the proportion of IDUs in treatment.

Needle exchange programs and experience of violence in an inner city neighborhood

OBJECTIVE

To assess the association between proximity to a needle exchange program (NEP) and experience of violence in an inner city neighborhood.

METHODS

A cross-sectional survey of residents of Harlem, New York City provided data for this study. We used geocoding to obtain the distance between respondents and the nearest NEP. Respondents reported violence they were aware of or had personally experienced in their neighborhood. Multiple logistic regression analyses assessed the relation between violence and distance from the nearest NEP.

RESULTS

Among 220 respondents, 50.1% were African American, 39.0% were Latino, 44.7% were male, and the mean age was 44.5 years. In separate age-, race-, sex-, and income-adjusted logistic regression models, there was no significant association between (1) reporting a fight and distance from the nearest NEP (odds ratio [OR] = 1.05, p =.89); (2) robbery in the neighborhood in the previous 6 months and distance from the nearest NEP (OR = 1.13, p =.71); (3) ever having experienced violence and distance from the nearest NEP (OR = 0.72, p =.52); or (4) ever having been robbed by drug users and distance from the nearest NEP (OR = 1.05, p =.91).

CONCLUSIONS

There was no consistent association between living close to NEPs and violence reported by residents of Harlem in this study. This study suggests that NEPs do not adversely affect rates of violence in their vicinity.