Harm Reduction Journal最新文献

Background: People who inject drugs (PWID) face premature mortality, particularly from opioid overdose. In Sweden, harm reduction has expanded, including increased access to opioid agonist therapy (OAT) and the 2018 introduction of Take-Home Naloxone (THN). This study aimed to examine trends in all-cause and cause-specific mortality and to estimate predictors of all-cause and opioid overdose mortality among PWID in Stockholm.

Methods: We conducted a retrospective cohort study from April 2013 to March 2023. Data from the national Cause of Death Register were linked to Stockholm Needle and Syringe Program (NSP) records. Causes of death were categorised as opioid overdoses, external causes, internal/natural causes, or other/unknown. Crude mortality rates and age- and sex-standardised mortality ratios were calculated. Time-dependent Cox regression models estimated risk of all-cause death, and Fine and Gray subdistribution hazard models estimated opioid overdose mortality, accounting for competing risks. Person-time began at first NSP visit and ended at death, study end or censoring (> 365 days without a visit).

Results: Among 4192 participants, 685 (16%) died. The crude mortality rate declined from 36.75 to 27.04 deaths per 1,000 person-years and the standardised mortality ratio from 17.24 to 10.94. In multivariable models, reporting opioids as the latest injected drug was the strongest driver for both all-cause and opioid mortality. Other significant predictors included infrequent injecting and current contact with social services, psychiatry or addiction care, while OAT participation was associated with a lower risk. Male sex and age over 56 at enrolment were associated with a higher risk of all-cause mortality. Opioid overdose was the most common cause of death (53%). However, the opioid overdose mortality rate declined from 29.40 to 5.88 deaths per 1,000 person-years over the study period, coinciding with the 2018 introduction of THN and declining reported opioid injecting drug use among NSP clients.

Conclusions: All-cause mortality among PWID in Stockholm declined over the study period, alongside significant reductions in opioid overdose deaths, during a period of broadened harm reduction and reduced reporting of opioid injecting drug use. Our findings support continued scale-up of OAT and THN and consideration of supervised consumption sites to further reduce preventable deaths.

Background: The veterinary sedative xylazine is increasingly found in illicit fentanyl and has been associated with numerous health harms. Xylazine test strips (XTS) are an emerging technology that can theoretically assist consumers in avoiding xylazine, but they require real-world validation. We leverage community-based drug checking program data to compare real-world XTS performance to 'gold standard' methods.

Methods: Samples were initially assessed by dissolving 1 mg of drug product in 1 mL water and dipping an XTS ("first generation" Wisebatch™) in the sample. Subsequently, confirmatory testing was performed by sending samples to the National Institute of Standards and Technology for qualitative analysis using direct analysis in real-time mass spectrometry (DART-MS). A subset was analyzed quantitatively with liquid chromatography gas spectrometry (LC-MS) to quantify xylazine, fentanyl, and other compounds.

Results: A total of n = 1570 drug samples were analyzed between June 2023 and May 2025, and a total of n = 801 XTS were used. N = 715 comparisons between xylazine test strips and mass spectrometry results could be made, including n = 333 among samples that tested positive for fentanyl. Of these, n = 63 samples were confirmed to contain xylazine by mass spectrometry, of which the majority contained low concentrations (average concentration 2.3%; 78% of samples contained less than < 1% xylazine by weight). Of the 63, n = 34 were correctly identified as positive by XTS, yielding sensitivity of 54.0 %. Of n =  270 xylazine negative samples, n = 235 were correctly categorized (specificity = 87.0%). Most false positives occurred with lidocaine present.

Conclusions: In our sample, with a large percentage of low concentration xylazine samples, "first generation" Wisebatch XTS had a relatively low sensitivity, but higher specificity. This highlights the value of confirmatory testing and the complicated and often confusing nature of point-of-care test strips for novel substance detection. Lot testing and validation studies are needed to improve quality control in this area.

Drug-checking services (DCS) provide people who use drugs (PWUD) with crucial information concerning the substances they may consume. The intent of DCS is to reduce harms potentially associated with those substances, by providing evidence-based information about the contents of said substances and possibly influencing PWUD consumption-related behaviors. This pilot project reports on a network of 10 dedicated Raman spectroscopy drug-checking devices, located at various organizations throughout the province of Ontario, Canada. The spectrometers were specifically developed for drug-checking analysis and use machine learning (ML) enabled software to provide participants with automated, real-time results. The same software was also used to collect participants' demographic data and self-reported consumption-related behavior changes. In this work, we report on the results provided by this network over a 14-months period from July 2023 to August 2024 on 7752 samples provided by 5083 participants. On select samples, high-performance liquid chromatography-mass spectrometry (HPLC-MS) measurements were also collected to probe the accuracy of the results and quantify variations between the two techniques. Voluntary feedback was also collected from a limited number of participants concerning the potential impact the drug-checking process may have on their consumption-related behaviors.

Background: Chemsex, a form of sexualized drug use, is a growing public health concern among men who have sex with men (MSM) in Malaysia. It is associated with an increased likelihood of HIV transmission and other adverse health outcomes, such as overdose. Although harm-reduction services are proven to be efficacious in mitigating these outcomes, they often remain inaccessible because of stigma, criminalization, and limited availability of the service. This study examines the barriers MSM face in such services and explores how a mobile smartphone app with tailored features could help overcome these barriers.

Methods: From February to August 2022, six virtual focus groups were conducted with 22 MSM participants who had engaged in chemsex in the past six months. Participants were recruited through geosocial networking (GSN) applications and Facebook advertisements. The focus group sessions were recorded, transcribed, translated into English, and analyzed using thematic analysis.

Results: Participants described multiple barriers to practicing chemsex harm reduction, including limited knowledge of safer drug use, peer pressure, fear of legal consequences, and stigma from healthcare providers. They emphasized the need for a mobile app that provides reliable educational resources, peer support groups, discreet ordering of harm-reduction supplies (e.g., condoms, lubricants, sterile injection equipment), and access to emergency assistance during adverse events. Privacy protection and a simple, familiar user interface were identified as essential for building trust and encouraging sustained use of the mobile app and uptake of harm reduction services among MSM.

Conclusions: This study underscores the persistent structural and social barriers to harm reduction among MSM who engage in chemsex in Malaysia. A mobile app tailored to their lived experiences and privacy needs may offer a confidential pathway to harm-reduction information, community support, and linkage to services that MSM trust.

Introduction: In response to the overdose epidemic, novel strategies including Overdose Response Hotlines and Applications (ORHAs) have been introduced to help mitigate the crisis. These technologies enable individuals with a phone to access harm reduction support via smartphones and applications. Such supports include overdose monitoring, access to social services, mental health referrals, and more. This study analyzed data from the Canadian National Questionnaire on Overdose Monitoring (CNQOM), a large bilingual national survey, to evaluate the perspectives of people who use unregulated substances currently (PWUS-C), people who used unregulated substances previously (PWUS-P), and addiction service provider (ASP) on the importance of specific ORHA features.

Methods: One component of the CNQOM pertained to the importance of specific ORHA service elements. Examined categories included accessibility and technological features, overdose response functionality, data privacy and philosophies of care, additional support services, and substance usage. Each group responded to 33 questions on a 5-point Likert scale, and the data was analyzed using descriptive statistics involving percentages and ordinal logistical regression analysis.

Results: The study involved 971 participants: 840 PWUS-C, 298 PWUS-P, and 169 ASP. The majority of respondents from the key groups considered all ORHA elements important. Generally, the groups ranked the elements in a similar order of importance, with only minor variations. The highest-ranked elements in each element category with regards to importance were: 24/7 availability (84% of PWUS-C, 88% of PWUS-P, and 90% of ASP), the ability of EMS to resuscitate individuals during an overdose (81% of PWUS-C, 83% of PWUS-P, 85% ASP), non-judgmental support (87% of PWUS-C, 87% of PWUS-P, and 91% of ASP), access to mental health support (82% of PWUS-C, 84% of PWUS-P, and 90% of ASP), and feeling safer when using substances (80% of PWUS-C, 81% of PWUS-P, and 88% of ASP).

Conclusion: This paper highlights the importance multiple groups place on various elements of ORHAs, reflecting critical elements that should be considered when standardizing these virtual harm reduction technologies. The results of this study provide insight into opportunities to enhance virtual platforms, making them more responsive, accessible, and trusted as harm reduction resources.

Background: Prescribed safer supply consists of the provision of pharmaceutical alternatives to people who use drugs to reduce reliance on the highly toxic unregulated supply and mitigate risk of overdose. Prescribed safer supply programs (SSP) have recently been scaled-up in some Canadian jurisdictions, including Ontario, showing demonstratable individual and population level benefits. Differences between prior experiences of opioid agonist therapy (OAT) among clients enrolled in the SSP are not well described, including how safer supply programs differ from existing approaches to OAT provision.

Methods: Drawing on qualitative interviews (n=22) with participants of a safer supply program in Kitchener-Waterloo, a mid-sized southwestern Ontario city, we use thematic analysis to examine contrasting experiences of safer supply and OAT among SSP clients.

Results: There were several key differences identified between OAT and safer supply program models on key programmatic elements, particularly the medical management of withdrawal, tolerance, and medication side effects. Additionally, differences in the program model and philosophy of care impacted therapeutic rapport and provided greater autonomy for SSP clients. The greater autonomy for clients within SSP aligned strongly with client goals and helped maximize program retention, which is key to the public health goal of reducing overdose related mortality.

Conclusion: The findings underscore the benefits of - and urgent need for - collaborative decision-making and comprehensive models of care for substance use, including individualized dosing in both OAT and safer supply programs to improve their public health impact. Participants' experiences provide a window into reorienting to substance use care that offers potential solutions to longstanding challenges within existing OAT models that undermine retention and therapeutic benefit.

Chemsex is defined as the use of psychoactive substances - most commonly methamphetamine, synthetic cathinones, and Gamma-hydroxybutyrate/Gamma butyrolactone (GHB/GBL) - to enhance sexual activity primarily among gay, bisexual, and other men who have sex with men (GBM). It is associated with higher rates of sexually transmitted infections, HIV, and mental health conditions. However, despite substantial public health concerns regarding rising overdose deaths, the relationship between chemsex and overdose remains poorly studied. In this perspective, we synthesize the current evidence, identify critical knowledge gaps regarding the association between chemsex and overdose risk among GBM, and outline harm reduction and behavioral interventions. Assessing chemsex-related overdose deaths among GBM is challenging due to the limited documentation of sexual practices and sexual orientation in medical or legal records. Stigma further reduces disclosure, and chemsex involvement is rarely identifiable posthumously. Chemsex frequency and perceptions of harm also obscure problematic use. Effective pharmacologic treatments for stimulant dependence remain limited. In contrast, contingency management (CM) has been proven effective in reducing stimulant use, yet remains underutilized. Integrated harm reduction approaches are essential to mitigate the potential risks of chemsex. Key interventions include HIV testing, needle exchange, sexual health screenings, psychosocial interventions, and vaccinations. There is an urgent need for targeted research, improved data collection, and tailored harm reduction strategies to better understand and reduce overdose risk within chemsex contexts. Addressing these gaps is essential for reducing preventable deaths and improving health outcomes in this population.

Background: Alcohol Use Disorder (AUD) is a leading contributor to global morbidity and mortality, disproportionately affecting people experiencing homelessness. Managed Alcohol Programs (MAPs) represent a harm reduction-based strategy for individuals with severe AUD and homelessness, providing controlled amounts of alcohol alongside comprehensive health and social supports. While evidence of MAP benefits continues to grow, important questions remain about how best to integrate social and medical care, and how to tailor services to align with participants' goals, values, and broader social and structural contexts.

Main body: This commentary explores the operational strategies and clinical practices of the Ottawa Inner City Health (OICH) MAP, which has been running since 2001. We describe how the program is embedded within supportive housing and leverages an interdisciplinary team-including peer workers and an Indigenous healer-to deliver person-centered care. Key components include structured alcohol delivery tailored to individual needs, meal provision, social supports including life skills training, medication administration and comprehensive physical and mental health services. Clinical care is tailored to participants' day-to-day circumstances, challenges, and goals in managing their AUD, with particular attention to hygiene and nutrition, proactive screening for health decline, and timely management of common health complications. The program operates through strong partnerships with community organizations, pharmacies and subspecialists, to enable integrated, coordinated care. Collaborative and trauma-informed approaches reduce reliance on emergency care and foster a sense of dignity, stability, and community.

Conclusion: MAPs have evolved from experimental interventions into internationally recognized harm reduction models. The OICH MAP demonstrates how the integration of housing, healthcare, and social supports can address the complex needs of individuals experiencing homelessness and severe AUD. However, challenges remain in scaling these models, refining screening protocols, and developing evidence-based policy frameworks. This commentary offers practical insights to inform the effective operation of MAPs and calls for continued research and dialogue to ensure they remain adaptable, sustainable, and aligned with the realities of the populations they serve.

Background: Harms associated with gamma-hydroxybutyrate (GHB) use have increased recently in Australia. However, research predominantly focuses on the experience of GHB use among LGBTQ + populations. Non-prescribed GHB use has not been well described in heterosexual populations. Research to examine the experience of heterosexual people, including motivations for use, experiences of harms, and utilisation of harm reduction practices, can inform public health messaging.

Methods: We recruited 26 participants at least 18 years of age, reporting three or more occasions of GHB use in the past 12 months, via a national social media campaign and snowball methods. Semi-structured interviews were conducted via video conference, and analysed using a thematic framework analysis.

Results: Nineteen women (73%) and seven men (27%), mean age 29 years (standard deviation 7 years) completed interviews. Participants described three distinct patterns of occasional, regular, or daily GHB use. Across these patterns, four key themes emerged: (1) Escapism: participants used GHB to manage mental health symptoms, counteract stimulant effects of methamphetamine, enhance self-confidence, and facilitate sex. Women described using GHB to alleviate body consciousness/dysmorphia. (2) Diverse understandings and experiences of overdose: participants described a spectrum from mild to life-threatening toxicity. Notably, dosing GHB to achieve unconsciousness (intentional overdose) was a theme that dovetailed with boundary play in our sample. Misconceptions included using stimulants to counter GHB toxicity. Fear of police involvement delayed or prevented help seeking. (3) Stigma: Participants reported stigma from peers who use and do not use drugs. (4) Gendered harm reduction practices: A set of practices centred on women protecting women from harms associated with GHB use emerged, with narrations of heightened vigilance and protective behaviours to reduce risks of sexual violence.

Conclusion: In our heterosexual sample of people who use GHB in Australia, we identified novel aspects of GHB use characterised by escapism, intentional risk-taking, and gendered harm reduction strategies, while stigma featured alongside GHB use. Findings highlight gaps in public health education, particularly regarding intentional dosing towards unconsciousness, misconceptions about overdose management, and barriers to help seeking. Targeted, context-specific harm reduction and mental health interventions responsive to these experiences are required.

Background: The rate of hepatitis C virus (HCV) treatment initiation and cure is suboptimal among people experiencing homelessness. A recent randomized controlled trial conducted by our study team compared peer-assisted telemedicine for HCV (TeleHCV) to peer-assisted referral to local providers (enhanced usual care [EUC]) in a rural population in Oregon. We hypothesized that the TeleHCV treatment model is more effective than EUC among those with unstable housing.

Methods: In this secondary analysis of the Oregon TeleHCV randomized controlled trial in adults with HCV and injection drug use (n = 203), we explored the role of unstable housing as an effect modifier of the TeleHCV intervention using a Poisson regression analysis. Randomized arm, frequency of peer contacts, and medication lockers were exposures of interest. HCV cure, defined as undetectable HCV RNA 12 weeks after treatment initiation, is the primary outcome.

Results: Overall, attaining HCV cure was less likely for those with unstable housing (RR = 0.68, 0.49-0.96, p = 0.026). However, unstably housed participants assigned to the TeleHCV arm were more than 6 times more likely to achieve HCV cure compared to unstably housed EUC participants (RR = 6.47, 3.12-13.43, p < 0.001) with a statistically significant interaction between treatment assignment and housing status (p = 0.022). The impact of TeleHCV on HCV cure was also identified among stably housed participants, but with a smaller effect size (RR = 2.15, 1.19-3.89, p = 0.012). Among participants with unstable housing, greater peer engagement was associated with an increased likelihood of both treatment initiation (RR = 1.24, p < 0.001) and HCV cure (RR 1.26; p < 0.001).

Conclusions: The peer-assisted TeleHCV intervention was substantially more effective for achieving HCV cure among participants with unstable housing at baseline compared to those unstably housed who received EUC. The treatment model should be broadly disseminated to target populations with HCV and high rates of homelessness to achieve HCV elimination goals.

Clinical trials registration: NCT04798521.