Harm Reduction Journal最新文献

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.

Background: Gambling Disorder (GD) is associated with significant personal and social harms, yet most individuals, especially those with mild to moderate symptoms, do not seek treatment. Online interventions offer an accessible and resource-efficient approach, but their cultural fit and feasibility across contexts remain unclear. This study examined the feasibility, engagement, and perceived cultural compatibility of a brief (1-week) Canadian self-directed gambling intervention among Israeli individuals with mild and moderate GD who were not actively seeking treatment.

Method: A sample of 102 participants (age range 19-74, 83.3% men) were recruited via a social networks campaign; 92 eligible participants were randomly assigned to either an interactive website online gambling intervention or to a static information-based control condition, with each condition including 1 week of participation. GD was assessed using the Problem Gambling Severity Index (PGSI) for screening and the Structured Clinical Interview for DSM-5 (SCID) for diagnostic classification. Participants completed daily self-report measures of interest, enjoyment, perceived benefit, and overall evaluation over seven days. Forty-five participants also participated in focus groups exploring user experience, engagement factors, and cultural relevance.

Results: Quantitative analyses showed that participants with mild GD in the website condition reported increasing levels of interest, perceived benefit, and task evaluation over time (ps < 0.01), while enjoyment remained stable. Participants with moderate GD in the control condition showed decreasing engagement across these variables (ps < 0.001). Thematic analysis revealed that engagement was supported by practical tools, privacy, accessibility, and perceived cultural fit, with participants emphasizing the value of autonomy and confidentiality in addressing gambling behavior.

Conclusions: Findings indicate that a brief self-directed online intervention is feasible and engaging for individuals with mild GD and shows high perceived acceptability and cultural compatibility among Israeli users. These results provide preliminary support for the cross-cultural scalability of evidence-based digital harm reduction tools and identify areas for future localization and long-term evaluation.

Background: Stimulant-affected drivers are overrepresented in global road trauma statistics, however, studies to date have not accurately defined how drug consumption contributes to increased risk of road trauma. This study examined whether attitudes toward drug driving predicts dangerous driving behaviour among people who currently use methamphetamine, and whether this differs to individuals with no history of any drug use.

Method: Three attitude factors (favourable attitudes toward risks, unfavourable attitudes toward sanctions, and favourable peer attitudes) were explored using an adapted version of attitudes towards drug driving scale and dangerous driving was measured using the Dula Dangerous Driving Index.

Results: A multigroup structural equation model indicated that individuals who use methamphetamine report more favourable attitudes toward drug driving compared to those who have never used drugs. Among people who use methamphetamine, a favourable attitude towards drug driving risks predicted higher dangerous driving behaviour scores, while more unfavourable attitudes toward sanctions for drug driving predicted lower scores. Among those with no history of substance use, favourable peer attitudes toward drug driving predicted dangerous driving behaviour.

Conclusions: Attitudes towards drug-driving, and their relationship to dangerous driving behaviour differs between those who use methamphetamine and those who do not have a history of substance usage. Targeted campaigns aimed specifically at reducing methamphetamine-related road trauma should challenge general underlying beliefs and attitudes about drug driving, rather than simply the impact of potential sanctions or influence of peers.

Background: Sex workers who use drugs are disproportionately impacted by the current overdose crisis and face many structural barriers to health and harm reduction services. Delivered in either community (e.g., embedded in supportive housing) or clinic (e.g., hospitals) settings, overdose prevention services are crucial harm reduction interventions. Gaining insight into which services sex workers use, and whether sex worker-specific programs impact this use, is key to identifying targeted prevention strategies and enhancing the continuum of overdose care for this population.

Methods: Data were derived from An Evaluation of Sex workers' Health Access (AESHA), a prospective, community-based cohort of women (trans-inclusive) sex workers in Vancouver, Canada (March 2017-March 2024). We plotted biannual trends in use of overdose prevention services, comparing community-based and clinic-based services (Aim 1), and used generalized linear mixed models to characterize uptake of overdose prevention services, including potential differences between community and clinic-based services (Aim 2). Finally, we evaluated the association between use of sex worker-specific programs and uptake of overdose prevention services, including potential differences between community or clinic-based services over the 7-year study period (Aim 3).

Results: Among 503 sex workers who used drugs, 82.1% (N = 413) used any overdose prevention services over the seven-year study. Uptake of community-based versus clinic-based overdose prevention services was 70.2% (N = 353) and 60.2% (N = 303), respectively. Use of sex worker-specific programs was positively associated with use of overdose prevention services (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI] 1.82-2.62), and this association was strongest for community-based services (AOR 2.66, 95% CI 2.21-3.20) as opposed to clinic-based services (AOR 1.73, 95%CI 1.41-2.13).

Conclusion: Uptake of overdose prevention services among sex workers is relatively high, but faced concerning declines over the study period, highlighting the need for additional interventions to scale-up access. Use of sex worker-specific programs facilitated wider access to overdose prevention services. Findings underscore the importance of expanding sex worker-specific and peer-led programs as part of scaling up overdose prevention efforts.

Background: The COVID-19 pandemic presented significant new needs and challenges for people experiencing homelessness (PEH) and people with substance use disorders (SUDs). In response, program leaders modified existing programs and developed new ones to meet these needs during a unique policy and public health environment. This study aimed to examine how these innovations unfolded and what lessons can be learned from their implementation.

Methods: We performed in-depth, semi-structured qualitative interviews with key informants (n = 37 informants) from programs serving PEH and addressing substance use created or adapted during the COVID-19 pandemic in the United States (U.S.) and Canada. Informants spanned a wide range of backgrounds, program types, and geographic locations. We completed rapid sequence qualitative analysis using templated summaries for each interview, which we compiled into a summary matrix. We reviewed the summary matrix to identify key topics and develop a code list that was applied to transcripts using line-by-line coding. Results from rapid analysis and line-by-line coding were discussed iteratively to develop and refine key themes.

Results: Key informants described innovations including SUD treatment and harm reduction interventions via telemedicine, hotel shelters, and street outreach. Interviews revealed four overarching themes related to innovation implementation: (1) Removal of usual bureaucratic barriers and easing of regulations facilitated action, (2) Individuals stepped up and said, "We're gonna do it," (3) Stigma and mixed attitudes about harm reduction impacted the implementation of pandemic innovations, and (4) Innovations in shelter and SUD care delivery for PEH during the COVID-19 pandemic resulted in durable lessons and new program models.

Conclusions: A combination of individual action and systemic changes produced new innovations to address the intersecting issues of homelessness and substance use during the COVID-19 pandemic. Lessons from these innovations can inform sustained improvements in SUD care for PEH.

Background: In April 2022, a new Drug Consumption Room (DCR) opened in Athens' city centre. To date, no qualitative research has evaluated the operational strengths and weaknesses of the site from the viewpoint of people who use drugs locally, including those who use the DCR and those who use in street-based settings who do not access the DCR.

Methods: Rapid-ethnographic fieldwork was conducted over a seven-week period. This comprised an initial five-week period of non-participant observation (≈ 200 h) followed by a community consultation regarding the research design and question protocols. Qualitative data were then collected through five focus groups with 24 regular DCR clients and 25 street-based interviews with non-DCR clients who consume drugs in street-based settings.

Results: Regular DCR clients reported increased physical, structural, and emotional safety and increased connection with auxiliary health and social services and staff and peers. Those who did not use the facility could see potential benefits but noted several operational and contextual barriers including anticipated stigma within the service and contextual and operational barriers.

Conclusion: Addressing DCR barriers could increase service access, reduce the presence and visibility of street-based drug use, and improve public health outcomes for people who use drugs in Athens. Indeed, some of these barriers have been addressed since the research was conducted (e.g. by expanding operating hours, increasing the number of staff with lived experience, offering on-site drug checking), illustrating the value of evaluating DCRs and subsequently adapting design and delivery based on the perspectives of actual and potential clients.

Background: There are increasing accounts of benzodiazepine adulteration and contamination in the unregulated drug supply in Canada and internationally. In some Canadian settings, drug checking services (DCS) are available for people to identify the constituents of their drugs. This study examines the relationship between suspected, unintentional benzodiazepine consumption and DCS utilization frequency, and whether gender modifies this relationship. We hypothesized that suspected unintentional benzodiazepine consumption would predict frequent DCS utilization, particularly for women, who may be at heightened risk for pertinent harms related to benzodiazepine use.

Methods: Data were drawn from a cross-sectional study (2021-2023) evaluating DCS that used spectroscopy and immunoassay strips in British Columbia, Canada. Multivariable ordinal logistic regression was used to examine the relationship between suspected unintentional benzodiazepine consumption and DCS utilization frequency, categorized as: once, > once and < once/month, once/month, > once/month and < three times/month, weekly, and > weekly. Potential confounders included age, population centre size, and frequent unregulated opioid use (≥ weekly). In planned exploratory analyses, gender was included as a possible effect modifier.

Results: Of 220 participants, 73 (33.2%) were women and 143 (65.0%) believed they had unintentionally consumed benzodiazepines in the previous six months. Bivariable ordinal regression showed a significant relationship between suspected unintentional benzodiazepine consumption and DCS utilization frequency (odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.22-3.69). However, after adjusting for confounders, particularly frequent unregulated opioid use, this association was no longer statistically significant (adjusted OR: 1.49; 95%CI: 0.75-2.99). We also failed to find that gender modified the relationship between suspected unintentional benzodiazepine consumption and DCS utilization.

Conclusions: Findings suggest that frequent unregulated opioid use may best explain the frequency of DCS utilization. Although gender did not significantly modify the association between suspected unintentional benzodiazepine consumption and frequency of DCS utilization, continued research should explore the role and context of gender in this relationship.