Harm Reduction Journal最新文献

Background: Lack of access to sterile supplies among people who use drugs contributes to increased rates of infectious disease transmission, including human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections. People residing in California, United States Veterans, and those who have experienced homelessness are disproportionately impacted. Syringe services programs (SSPs) are vital to reducing these harms, but access may be limited by hours of operation, geographic barriers, need for in-person interaction, and stigma. Harm reduction vending machines (HRVMs) which often dispense sterile syringes and condoms are an evidence-based strategy to increase access; however, no studies have evaluated implementation or impacts among these populations. This cross-sectional, mixed-methods study aims to evaluate the first HRVM program designed for Veterans in California who experienced homelessness and reside in supportive housing buildings.

Methods: We will recruit 40 Veteran residents and 20 staff (Veterans Affairs [VA] and housing staff) at six housing buildings with a co-located HRVM. Participants will provide informed consent, complete a standardized electronic questionnaire, semi-structured qualitative interview, and be compensated via Visa gift cards ($90 for Veterans; $60 for staff). Interview transcripts will be analyzed thematically using inductive coding. Program-level data will be collected from enrollment logs, facility records, and HRVM software to evaluate reach, effectiveness, adoption, implementation, and maintenance (RE-AIM).

Discussion: Findings will provide essential evidence on how HRVMs may reduce longstanding access barriers and expand delivery of life-saving harm reduction supplies to underserved Veterans. This study is the first to evaluate HRVMs in Veterans supportive housing and among this population disproportionately affected by substance use, stigma, and homelessness. Results may inform the expansion of community-based and VA SSPs nationwide. Study strengths include a theory-informed design, real-world implementation data, and attention to user and staff experiences. Limitations include reliance on self-report data, lack of a control group, and limited generalizability beyond Veterans. Future research may examine long-term health outcomes, cost-effectiveness, and feasibility of HRVMs scaled up in diverse settings. Findings from this study may guide policymakers and public health practitioners in integrating HRVMs into broader harm reduction strategies to prevent overdose, infections, and other adverse outcomes.

Background: Opioid Use Disorder (OUD), a chronic condition with significant health and social consequences, has been intensified by synthetic opioids such as fentanyl. Although medications for OUD (MOUD) reduce mortality and improve treatment retention, many individuals continue to engage in non-prescribed opioid use while in treatment. Harm reduction services (HRSs), including syringe exchange sites, supervised injection facilities, or sites that distribute fentanyl test strips or naloxone, seek to mitigate the risks associated with substance use. This study explores engagement with harm reduction services and opioid use practices among adults receiving MOUD in Philadelphia and compares these patterns between methadone and buprenorphine recipients.

Methods: We conducted a cross-sectional survey of 116 adults receiving buprenorphine or methadone for moderate-to-severe OUD at three Philadelphia treatment sites between November 2023 and October 2024. Participants completed a RedCAP-based questionnaire assessing recent opioid use, HRS utilization and attitudes, and substance use practices. Group differences were examined using t-tests, chi-square, and Kruskal-Wallis tests.

Results: Overall, 37% of participants reported non-prescribed opioid use in the past 6 months, most commonly via injection. Sterile injection practices varied considerably. 61% of all participants had utilized harm reduction services at least once; however, regular use was uncommon, with only 29% reporting use in the past week. HRS utilization was significantly associated with fentanyl test strip use (p = 0.002) but not with consistent sterile injection practices (p = 0.20). Compared with methadone recipients, buprenorphine recipients were more likely to report HRS utilization, feel welcomed at these sites, recommend them to others, and perceive a positive community impact (all p < 0.05). There was no observed difference in non-prescribed opioid use in the last six months between buprenorphine or methadone recipients.

Conclusions: Despite ongoing MOUD treatment, many patients reported continued, non-prescribed opioid use and infrequent engagement with HRS. More favorable attitudes and higher HRS utilization among buprenorphine recipients suggest that MOUD setting and structure may influence harm reduction engagement. These findings add quantitative evidence describing HRS use among MOUD populations and suggests that tailoring harm-reduction supports to these contextual factors may be an important consideration for MOUD programs.

Medetomidine has recently emerged in the illicit drug supply in the United States, and lateral flow immunoassay test strips are an inexpensive and easy-to-use field screening option for detecting this highly potent sedative. However, the drug is chiral, and the response of test strips to the different enantiomers has not been reported. This study evaluated the chiral sensitivity of 7 lots of medetomidine test strips produced by two manufacturers. Test strips were assessed using solutions of dexmedetomidine, levomedetomidine, and racemic medetomidine at varying concentrations, water types, and temperature conditions. Specificity was evaluated by testing structurally related compounds and other interferences. Multiple lots of medetomidine strips responded only to dexmedetomidine. These strips detect racemic medetomidine but give a negative result for pure levomedetomidine. Other lots of medetomidine strips required both dexmedetomidine and levomedetomidine to be present to give a positive result-either pure dexmedetomidine or pure levomedetomidine gave negative results. All strips performed best in 18 MΩ water. at temperatures of 25 °C or below. Xylazine did not cross-react. The veterinary sedative detomidine HCl caused false positives on all the strips at concentrations down to 0.07 mg/mL, and levamisole gave faint test lines (which can be misread as false positives) for almost all the strips at 2 mg/mL. Organizations selecting test strips for public health applications should select strips that can detect both dexmedetomidine and racemic versions of this sedative.

Background United States drug policy is primarily based on the Controlled Substances Act of 1970 and largely contradicts scientific evidence about how to mitigate drugs' harms. Expert consensus on drug harms could inform policy that improves the health of people who use drugs while reducing negative societal impacts of drug use. Therefore, this study adapted and extended the relevant 2010 United Kingdom multi-criteria decision analysis, rating drug harms by criteria comprising health and social impacts to people who use drugs and their families, communities, and society.Methods Seventeen experts on drug use in the US, including three with lived experience of drug use and recovery, assessed 19 drugs across 18 criteria. Drugs were scored from 0 to 100 points on each criterion. Then, criteria were weighted to represent the experts' view of their relative importance, and each drug was assigned an overall harm score. We also created a numerical rating to represent Controlled Substances Act-defined harm.Results Fentanyl (scoring 90), methamphetamine (84), crack (83), and heroin (82) were the most harmful drugs. Cannabis (32) ranked in the middle, and mushrooms (3) were the least harmful. Drug-specific mortality and economic cost were the largest overall contributors to harm, while environmental damage was the smallest. The correlation between Controlled Substances Act-defined harm and experts' harm ratings was - 0.26.Conclusions These findings add to the growing international literature highlighting how drug policy contradicts expert assessments of drug harms across nations. To reduce these harms, public health strategies informed by evidence and expert input should be prioritized over punitive approaches.

Background: Most individuals self-excluding from gambling have lost control over their gambling behavior. Commercial solicitations are prohibited during the self-exclusion period, but resume immediately afterwards. The self-exclusion system appears insufficient, particularly for short self-exclusions and among the heaviest gamblers. We assessed the impact of extending suspension of commercial solicitations on gambling intensity.

Methods: In this parallel randomized study, we included 2548 French online gamblers who self-excluded for up to 3 months from May-November 2022. They were assigned 1:1 to optimized self-exclusion with extended commercial solicitations ban for 9 months or standard procedure. The primary outcome was the change in total loss over the past 4 weeks at Month 9. We also assessed total deposit, total stakes, compulsivity, number and duration of gaming sessions and subsequent self-exclusions at 6, 9, 12 and 18 months.

Results: Participants were randomized to the optimized group (n = 1265) or standard group (n = 1283). The results didn't show a significant difference in the reduction in total losses. The optimized group showed significantly reduced 4-week total deposits versus standard group at 6 months (455.68 euros vs. 319.65 euros, p = 0.017), 9 months (451.92 euros vs. 343.21 euros, p = 0.040), and 12 months (484.27 euros vs. 370.02 euros, p = 0.025). Significance was lost at 18 months (492.61 euros vs. 404.73 euros, p = 0.087).

Conclusions: An extended 9-month ban on direct commercial solicitations after self-exclusion significantly reduces gambling deposits during, and 3 months after, the ban. This supports the effectiveness of improving self-exclusion procedure. Future research should explore longer bans and indirect commercial solicitations.

Trial registration: NCT05413564.

Background: In Georgia, MMT has evolved since 2005 from donor-funded pilot projects to a fully government-funded national program. We aimed to describe long-term patterns of engagement, retention and exit rates in the context of policy changes (removing financial barriers in 2017 and introducing take-home doses in 2020), by retrospectively analyzing nationwide data. We also aimed to analyze the association between the retention and factor variables (age, average daily methadone doses and location of MMT).

Methods: We used routine data obtained from the Center for Mental Health and Prevention of Addiction as of February 9, 2025. Each patient can have multiple treatment episodes. Retention days were assessed at the episode level, whereas "total engagement duration" reflected the total time a patient spent in treatment across all episodes. Exit rates for first treatment episodes were calculated for one, three, and five-year follow-ups, standardized per 100 person-years. Cox regression was used to examine associations between retention duration and factor variables.

Results: The final dataset consisted of 59828 treatment episodes representing 30747 patients, enrolled in the program from August 6, 2008, to December 31, 2024. Age ranged from 21 to 85 years with median of 40 [IQR 34-47] years. The mean years of total engagement gradually declined across annual cohorts from 6.6 to 0,3 from 2008 to 2024. Peaks in retention occurred: in 2017 and in 2020. Each additional year of age reduced the risk of dropout by 26-28%, while higher doses were associated with 48% lower risk. One year exit rates calculated per 100 person-years showed higher variability across the annual cohorts from 40 (95%CI 33-47) in 2008 to 186 (95%CI 168-197) in 2015, compared to three- (40(95%CI 37-47) in 2008 to 120 (95%CI (113-128) in 2015), and five-year follow-ups (40 (95%CI 33-44) in 2008 to 102 (95%CI(95-106) in 2015).

Conclusions: Findings highlight the potential role of adequate dosing, sustained accessibility, and patient-centered approaches. Descriptive results suggest that removing financial barriers and introducing take-home doses may improve retention. For a comprehensive assessment of program effectiveness, total engagement duration and long-term exit rates should also be considered.

Background: Transitions in how people use drugs have long influenced drug use research and the policy landscape. In unregulated drug markets, route of administration (ROA) transitions from injecting opioids to non-injecting modes of use, sometimes called reverse transitions, are rare but have been documented historically, driven by local characteristics including social networks and drug market factors. National and local data find ROA transitions are on the rise in the US. We investigated patterns of ROA transitions, including personal and market-based motivations and perceived effects and health benefits.

Methods: We examined trends in San Francisco's drug market, including changes in substance use administration patterns and the forces motivating people who use drugs to adopt alternate or multimodal dosing strategies. We conducted 32 semi-structured qualitative interviews in 2022 using rapid assessment ethnography and observation to triangulate findings on ROA patterns and techniques among people using opioids.

Results: We observed fluctuations in the relative availability of heroin and fentanyl which contributed to subsequent changes in ROA. Like other US locations, participants initiated fentanyl use as heroin availability diminished. Able to achieve comparable effects from fentanyl smoking relative to injection most participants indicated they had transitioned within the past several years, driven by venous access, overdose concerns and market characteristics. Transitions were graduated along a spectrum of stability, from frequent multimodal use to transitions in accord with recent patterns, notably featuring total cessation of injection. Others found combining smoking and injecting allowed greater flexibility, with smoking favored when in public, for convenience, considering sensitivity to non-injecting peers, or when seeking a milder experience enabling productivity or vigilance. Injecting was chosen for its faster effect, to avoid sharing drugs/equipment with others and especially for polysubstance combinations. A small subset of participants indicated that smoking was not a durable transition for them, necessitating a return to injection.

Conclusions: The stability of ROA transitions and their health impacts remain in flux amidst widespread uptake of smoking fentanyl. Smoking supply provision and harm reduction organizations are facing notable headwinds but continue to be essential for providing people control over their health and embodied and social experiences.

Background: People who use drugs possess valuable expertise, knowledge, needs, and preferences as part of their lived experience, which should be incorporated into overdose-focused public health programs and policies.

Methods: We formed a community advisory board composed of 16 clients from four syringe services programs (SSPs) in Wisconsin for an overdose prevention research study to inform project priorities. Over 6 meetings spanning 10 months, the board engaged in a root cause analysis facilitated by SSP staff and University researchers using a semi-structured assessment technique from the Community Anti-Drug Coalitions of America. The board then identified solutions to each root cause and rated solutions on two dimensions: impact and effort required to implement. Similar solutions were combined by averaging effort and impact scores respectively. After the activity concluded, we gathered members' perceptions of the activity using a brief, open-ended questionnaire.

Results: Members identified nine root causes of overdose that spanned individual (e.g., solitary drug use), structural (e.g., inaccessible or suboptimal substance use treatment programs), and policy (e.g., criminalization of drug use) drivers of overdose occurrence and fatality risk. Substance use stigma was a cross-cutting, fundamental driver of all root causes. The board proposed 28 solutions responsive to these root causes, including changing policies, implementing whole-person focused harm reduction and treatment programs, and incorporating people with lived/living experience of drug use into the design and implementation of public health programs. Members felt the activity was meaningful and effectively facilitated, but highlighted that several solutions were unable to be acted upon in the context of the research study.

Conclusion: This work reinforces a need for multi-dimensional, comprehensive interventions, programs, and policies to address the overdose crisis. Collectively, new and continued overdose prevention programming should broaden access to and use of harm reduction tools (e.g., naloxone, drug checking) and substance use and mental health treatments as well as reform policies that negatively impact the health of people who use drugs. Our findings underscore the need to incorporate the expertise of directly impacted populations into future research and program planning focused on overdose prevention by partnering with people who use drugs.

Background: Although medical cannabis has been legally available by prescription in the Netherlands for more than two decades, few individuals use it. Instead, most people who use cannabis for therapeutic purposes continue to obtain it through unregulated, illicit sources. This study examined barriers to accessing prescribed cannabis from the perspectives of people using non-prescribed cannabis for medicinal purposes in the Netherlands.

Methods: Semi-structured qualitative interviews were conducted with thirty-three participants who used non-prescribed cannabis to manage somatic or psychiatric symptoms. Data collection and analysis were guided by Levesque and colleagues' patient-centred access to care framework, which encompasses five dimensions of accessibility: affordability, availability, approachability, appropriateness, and acceptability. The framework provides a multidimensional view of access within healthcare systems. A deductive coding approach and thematic analysis were applied. Reporting followed the COREQ guidelines.

Results: Participants reported barriers across all five dimensions of the access to care framework. Key challenges included the perceived high cost of prescribed cannabis, the limited availability of prescribing physicians, restrictive medical guidelines, and a lack of accurate and accessible information. Additional barriers were the perceived poor fit between services and patient needs, particularly in terms of cannabis product variety and effectiveness, as well as persistent stigma surrounding cannabis use. While most participants expressed a preference for prescribed cannabis in principle-valuing its safety, quality, and legitimacy-these perceived barriers prevented or dissuaded them from access through the formal healthcare system.

Conclusions: Despite its longstanding legal status, access to prescribed cannabis in the Netherlands remains constrained by significant structural, informational, and sociocultural barriers. Addressing these barriers requires coordinated policy reforms and healthcare responses to ensure equitable, patient-centred access to prescribed cannabis and reduce reliance on unregulated sources.

Background: Mothers and pregnant women who use opioids are particularly vulnerable. Mothers often fear surveillance, stigma, and loss of custody of their children when seeking treatment. Although opioid agonist therapy (OAT) has been shown to be effective, access varies regionally, and not all mothers can cease using opioids. This study compares outcomes of mothers who use opioids in the UK with universal healthcare and OAT access, and mothers in the U.S. with restricted healthcare and OAT access, focusing on their interactions with services.

Methods: This is a secondary data analysis of two studies on mothers who use opioids. Data were collected from nine mothers in Scotland (UK) and 20 mothers in New Jersey (US) through ethnographic, longitudinal studies spanning one year. The UK study used a "Learning Alliance" engagement approach, a patient/public engagement model that involves stakeholders in developing objectives and the dissemination of findings. The US study engaged "community-based consultants," who are paid individuals with lived experience from the study field communities to assist researchers in recruitment and ethnographic fieldwork. Ethical approval was received from review boards. Data were anonymized before analysis, and people with lived experience provided feedback on findings. Grounded theory methods were used for analysis.

Results: Findings reveal both convergent and divergent experiences. Mothers in Scotland had more access to healthcare and social housing but faced increased surveillance, while New Jersey mothers often experienced housing insecurity and difficulty obtaining healthcare. Shared challenges included trust issues, stigmatization, inconsistent practitioner engagement, responsibilization, and unclear expectations from child protection services. While Scottish mothers had better access to OAT, both groups faced child custody loss due to unregulated drug use. Mothers in both studies were struggling to meet reunification requirements of abstinence (with or without OAT) within the required time frame.

Conclusions: Differing governance structures create persistent challenges across national boundaries. While health practitioners generally support harm reduction strategies, it does not go beyond OAT for mothers. Our findings indicate the need for radical harm reduction approaches with social justice for mothers who use drugs, including safer parental drug use strategies.