Harm Reduction Journal最新文献

Background: Xylazine is an increasingly common adulterant in the North American unregulated drug supply that is associated with adverse health outcomes (e.g., skin infections, overdose). However, there are significant knowledge gaps regarding how xylazine was initially identified and how syringe services program (SSP) staff and clients (people who use drugs) responded to its emergence.

Methods: From June-July 2023, we conducted qualitative interviews with medical (e.g., clinicians) and frontline SSP staff (e.g., outreach workers) and adult clients with a history of injection drug use at a Miami-based SSP. Inductive memos identified emergent codes; thematic analysis involving team consensus established final themes.

Results: From interviews with SSP staff (n = 8) and clients (n = 17), xylazine emergence was identified at different times, in various ways. Initially, during summer 2022, clients identified a "tranquilizer-like substance" that worsened sedation and withdrawal and caused wounds. SSP medical staff later identified this adulterant as xylazine by treating new medical cases and through diverse information-sharing networks that included professional societies and news sources; however, frontline SSP staff and clients needed additional educational resources about xylazine and its side effects. With limited guidance on how to reduce harm from xylazine, SSP clients altered their drug consumption routes, reduced drug use, and relied on peers' experiences with the drug supply to protect themselves. Some individuals also reported preferring xylazine-adulterated opioids and increasing their drug use, including the use of stimulants to avoid over sedation.

Conclusions: Xylazine's emergence characterizes the current era of unprecedented shifts in the unregulated drug supply. We found that xylazine spurred important behavioral changes among people who use drugs (e.g., transitioning from injecting to smoking). Incorporating these experiences into early drug warning surveillance systems and scaling up drug-checking services and safer smoking supply distribution could help mitigate significant health harms caused by xylazine and other emergent adulterants.

This commentary outlines the development of an Inclusion Collaborative in a large health district in Sydney, New South Wales Australia. The Collaborative grew out of ongoing efforts to reduce stigma associated with blood borne viruses while recognising that there are many health conditions and situations where people feel judged when attending services for health care. The formation of the Collaborative drew in health workers in other sectors to create a critical mass of voices calling for stigma reduction, move beyond siloed responses to stigma and to reframe conversations about stigma to a more positive description of "inclusion". The involvement of consumer representatives (paid for their time) was a key principle of the Collaborative. The members of the Collaborative identified the common experience of their clients being 'othered' by the mainstream services and that services can be unwelcoming or not supportive of difference, and therefore create a significant barrier to accessing healthcare. The group considered ways to highlight these issues among colleagues from mainstream services and community members who were not 'othered'. The Collaborative designed and carried out a range of activities including a Festival of Inclusion, a series of seeding grants for staff and consumer-focused initiatives, promotion of diversity days and an audit of compliance with strategic priorities. The Inclusion Collaborative is an example of a structured approach for efforts to reducing stigma that draws on the ambitions of many parts of a large, complex public health service to deliver better outcomes for its staff and consumers.

Background: 2-Benzylbenzimidazole 'nitazene' opioids pose a growing threat to public health. Nitazene analogues are increasingly found mixed with or (mis)sold as heroin and in falsified (non-)opioid medications, posing a great risk of intoxication in users (un)knowingly exposed to these potent opioids. Lateral flow immunoassay nitazene test strips (NTS; BTNX Rapid Response™) became commercially available in Q1 2024, with the aim to enable rapid detection of nitazene analogues in drug samples. As only limited independent data is available on the performance of these strips, this lab-based study aimed at evaluating their potential for drug checking applications.

Methods: Following dilution of drug standards in water, the NTS readouts were analyzed independently by two individuals and by ImageJ. The limit of detection for isotonitazene was determined using two manufacturing lots of NTS. Cross-reactivity with 32 other nitazene analogues was evaluated. Six sourced drug samples were tested to explore the ability of NTS to detect the presence of a nitazene analogue in authentic samples.

Results: The limits of detection for isotonitazene were 2000 or 3000 ng/mL, depending on the lot. Twenty-four of the 33 tested nitazene analogues cross-reacted with the NTS at concentrations ≤ 9000 ng/mL. Structural analysis indicated that either substitution or removal of the 5-nitro group, or lengthening the linker between the two aromatic rings, generally hampered detection. All six authentic drug samples consistently tested positive, with no observed false negatives.

Conclusions: This study provides a better understanding of the potential of NTS for drug checking purposes. Our findings indicate that NTS can theoretically alert to the presence of most nitazene analogues that have emerged on recreational drug markets. However, 'desnitazenes' (lacking the 5-nitro group) may yield false negative results due to low cross-reactivity. Although factors like specificity, lot-to-lot variability, nitazene analogue content in drug samples, solubility, and different testing conditions should be considered, our study results indicate that, at least under the conditions evaluated here (using reference standards and sourced powders), NTS are capable of detecting the presence of a wide range of nitazene analogues. Hence, NTS may alert users of the presence of nitazene analogues in drug samples.

Background: Syringe services programs (SSPs) provide harm reduction supplies and services to people who use drugs and are often required by funders or partners to collect data from program participants. SSPs can use these data during monitoring and evaluation (M&E) to inform programmatic decision making, however little is known about facilitators and barriers to collecting and using data at SSPs.

Methods: Using the Consolidated Framework for Implementation Research (CFIR), we conducted 12 key informant interviews with SSP staff to describe the overall landscape of data systems at SSPs, understand facilitators and barriers to data collection and use at SSPs, and generate recommendations for best practices for data collection at SSPs. We used 30 CFIR constructs to develop individual interview guides, guide data analysis, and interpret study findings.

Results: Four main themes emerged from our analysis: SSP M&E systems are primarily designed to be responsive to perceived SSP client needs and preferences; SSP staffing capacity influences the likelihood of modifying M&E systems; external funding frequently forces changes to M&E systems; and strong M&E systems are often a necessary precursor for accessing funding.

Conclusions: Our findings highlight that SSPs are not resistant to data collection and M&E, but face substantial barriers to implementation, including lack of funding and disjointed data reporting requirements. There is a need to expand M&E-focused funding opportunities, harmonize quantitative indicators collected across funders, and minimize data collection to essential data points for SSPs.

Background: Direct acting antivirals (DAAs) as a curative treatment of hepatitis C have been available for several years and have replaced interferon-containing therapies. However, treatment rates of people who inject drugs (PWID) are declining in Germany, putting the elimination of hepatitis C by 2030 at risk. This study aimed at elucidating the knowledge of, and attitude towards, hepatitis C treatment in a clinical sample of PWID.

Methods: Participants were recruited between February 2019 and October 2020 at two opioid agonist therapy (OAT) clinics and two in-patient drug detoxification wards. Based on the European Addiction Severity Index (Europ-ASI), a standardized interview focusing on: sociodemographic data, drug history, risky behavior, infection with hepatitis C virus (HCV) and HIV, and previous experience with HCV treatment was carried out. In addition, participants filled in a questionnaire evaluating 13 statements relating to HCV treatment (right/wrong) and 15 statements on their personal 'pros and cons' views to start such a treatment assessed with the means of a 6-point Likert scale.

Results: A total of 153 patients (average age 45 years, male 78%; 106 (69.3%) currently in opioid maintenance treatment, 47 (30.7%) currently admitted to an inpatient detoxification) with an opioid use disorder were investigated. All of them reported having injected drugs at least once in their lives; 97 participants (63.3%) stated that they had been previously diagnosed with HCV infection. Among them, 27/97 patients (27.8%) reported a previous treatment with interferon; 27/97 (27.8%) with DAAs; and 32/97 (33.0%) reported a currently active hepatitis C. Most patients knew about the availability and efficacy of DAAs. However, DAAs' low rate of side effects, their short treatment duration, and their replacement of interferon, were not correctly evaluated by up to 50.3% of patients. 25-40% of 32 patients with currently active hepatitis C prioritized handling of social and other medical issues, e.g., reduction of heroin use, over treatment of hepatitis C.

Conclusions: Although current levels of risky behavior have reportedly been reduced by active PWID over the past few years, educational and motivational interventions to increase hepatitis C treatment uptake should address the gaps in patients' knowledge.

Background: Overdose prevention sites (OPS) are a harm reduction strategy that offer people who use drugs a variety of resources including but not limited to sterile supplies, linkage to healthcare resources, and intervention if an overdose occurs. OPS operate in over 120 countries and evidence has demonstrated they are an effective harm reduction strategy. Despite their success elsewhere, OPS remain federally illegal in the United States and thus there is limited research on their implementation and outcomes in the United States. This study aimed to identify Colorado healthcare providers' knowledge and attitudes about OPS and determine if there is a correlation between healthcare providers with more knowledge about OPS having a more positive attitude about OPS.

Methods: An electronic survey was distributed to healthcare providers in Colorado. Responses were collected in early 2022 and recorded on a 5-point Likert scale. Mean scores between 1 and 5 were calculated for each participant and analysis of variance methods were used to determine correlating demographic factors. A p value of ≤ 0.05 was used to determine statistical significance of all findings.

Results: This study included 698 participants. A Pearson correlation analysis revealed a strong positive relationship (r = 0.76, p < 0.0001) between provider knowledge and attitudes about OPS. Emergency medicine providers scored the highest in mean knowledge and attitude scores in comparison to all other specialties. Respondents affiliated with a harm reduction center exhibited the highest mean knowledge and attitude scores. Mean knowledge and attitude scores generally rose with respondents' increasing encounters with people who inject drugs in a typical workday, except when reaching nine or more encounters, where a sharp decline occurred.

Conclusions: Our study highlights the importance of education, exposure to harm reduction strategies, and inter-specialty collaboration in shaping healthcare providers' knowledge and attitudes about OPS. The positive correlation between providers' knowledge and attitudes about OPS suggests that educating healthcare providers on harm reduction strategies, specifically OPS, may lead to reduced stigmatization of OPS among healthcare professionals.

Aim: Illicitly manufactured fentanyl and its analogs are the primary drivers of opioid overdose deaths in the United States (U.S.). People who use drugs may be exposed to fentanyl or its analogs intentionally or unintentionally. This study sought to identify strategies used by rural people who use drugs to reduce harms associated with unintentional fentanyl exposure.

Methods: This analysis focused on 349 semi-structured qualitative interviews across 10 states and 58 rural counties in the U.S conducted between 2018 and 2020. Interview guides were collaboratively standardized across sites and included questions about drug use history (including drugs currently used, frequency of use, mode of administration) and questions specific to fentanyl. Deductive coding was used to code all data, then inductive coding of overdose and fentanyl codes was conducted by an interdisciplinary writing team.

Results: Participants described being concerned that fentanyl had saturated the drug market, in both stimulant and opioid supplies. Participants utilized strategies including: (1) avoiding drugs that were perceived to contain fentanyl, (2) buying drugs from trusted sources, (3) using fentanyl test strips, 4) using small doses and non-injection routes, (5) using with other people, (6) tasting, smelling, and looking at drugs before use, and (7) carrying and using naloxone. Most people who used drugs used a combination of these strategies as there was an overwhelming fear of fatal overdose.

Conclusion: People who use drugs living in rural areas of the U.S. are aware that fentanyl is in their drug supply and use several strategies to prevent associated harms, including fatal overdose. Increasing access to harm reduction tools (e.g., fentanyl test strips, naloxone) and services (e.g., community drug checking, syringe services programs, overdose prevention centers) should be prioritized to address the polysubstance-involved overdose crisis. These efforts should target persons who use opioids and other drugs that may contain fentanyl.

Background: Fentanyl and fentanyl analogues have disrupted the illicit drug supply through contamination of other substances (i.e., methamphetamine and cocaine) and replacement of heroin in illicit markets. Increasingly, they are contributing to opioid-overdose related deaths. The rapid and growing presence of fentanyl has led to gaps in research on the impact of this illicit market change on people who use drugs (PWUD). We sought to examine how the changing opioid market and growing fentanyl availability influences the role and use of medication for opioid use disorder (MOUD).

Methods: Semi-structured qualitative interviews were conducted with a community recruited sample of PWUD (N = 22) in Los Angeles, California between September 2021 and April 2022. Interviews examined opioid use history, current opioid use behaviors and consumption patterns, and MOUD experiences and perceptions. Thematic analysis was used to systematically code and analyze textual interview data.

Results: The following themes related to fentanyl use and MOUD emerged: (1) Use of deviated MOUD to address fentanyl contamination, (2) Changing perception of the effectiveness of MOUD on fentanyl, and (3) Regulatory limitations of MOUD for fentanyl use disorder.

Conclusions: PWUD described several repertoires for adjusting to changes in the illicit market of opioids. Clinicians treating PWUD should ask about recent fentanyl use prior to starting MOUD to account for increased tolerance to opioids. Harm reduction strategies such as naloxone kits, safe supply, and supervised consumption facilities can all prevent overdose deaths due to fentanyl.

Introduction: Since the beginning of the COVID-19 pandemic, COVID-19 risk mitigation measures have expanded to include increased rules and surveillance in supportive housing. Yet, in the context of the dual public health emergencies of COVID-19 and the unregulated drug toxicity crisis, we have not evaluated the unintended health and social consequences of such measures, especially on criminalized women. In order to address this dearth of evidence, our aim was to assess the association between increased housing rules and surveillance during COVID-19 and (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal among women sex workers who use drugs in Vancouver, BC.

Methods: This study is nested within An Evaluation of Sex Workers Health Access (AESHA), a community-based prospective cohort of women sex workers in Metro Vancouver (2010-present). Using cross-sectional data collected during the first year of COVID-19 (April 2020-2021), we developed separate multivariable logistic regression confounder models to examine the independent associations between experiencing increased housing rules and surveillance during COVID-19 on (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal in the last 6 months.

Results: Amongst 166 participants, 10.8% reported experiencing a recent non-fatal overdose and 31.3% recently administered naloxone for overdose reversal. 56.6% reported experiencing increased rules and surveillance within their housing during COVID-19. The prevalence of non-fatal overdose and administering naloxone was significantly elevated among those exposed to increased housing rules and surveillance during COVID-19 versus those who were unexposed (83.3% vs. 52.1%; 75.0% vs. 48.2%, respectively). In separate multivariate confounder models, exposure to increased housing rules and surveillance during COVID-19 was independently associated with increased odds of administering naloxone [AOR: 3.66, CI: 1.63-8.21], and marginally associated with non-fatal overdose [AOR: 3.49, CI: 0.92-13.27].

Conclusion: Efforts to prioritize the right to safe, adequate and affordable housing must avoid reinforcing an overly coercive reliance on surveillance measures which, while often well-intended, can negatively shape residents' well-being. Furthermore, public health responses to pandemics must include criminalized populations so that measures do not exacerbate overdose risk. Implementation of a regulated drug supply is recommended, alongside housing policies that promote residents' rights, safety, and health.

The opioid epidemic has taken the lives of thousands of people across North America and Europe. Moreover, lack of housing, inflation, and a rapidly changing economy have affected millions of people, and many have become homeless. Many governments, researchers, health agencies, and not-for-profits have offered innovative ways to tackle this crisis, including many harm-reduction technologies that rely on Internet. In the age of the first artificial intelligence (AI) revolution, where reliance and accessibility to Internet have become a necessity for finding jobs, housing, affordable food, social services, social connection, and staying alive, the creation of free Wi-Fi zones around inner city neighborhood by towns and municipalities is not only a cost-effective way to reduce death, social costs, but a human rights issue during the initial stage of first A.I. revolution.