Harm Reduction Journal最新文献

Background: Heroin-assisted treatment (HAT) was introduced in Switzerland in 1994 and comprises the prescription of diacetylmorphine (DAM, heroin) for patients with severe opioid use disorder. Provision of Swiss HAT is limited to specialised treatment centres, 22 of which operate today. The aim of this study was to assess the characteristics and clinical procedures of these centres.

Methods: A questionnaire was designed and sent out to all operating Swiss HAT centres.

Results: The response rate was 91% and all questionnaires were filled in by the medical heads of the corresponding centres. All centres employed psychiatrists and prescribed psychiatric medication. Additionally, 85% reported to offer in-house psychotherapeutic treatment and 95% reported to employ social workers. Few treatment barriers to HAT were found, with the mean time from referral to treatment initiation being 10 days. Only one centre reported to employ a waiting list. Off-label prescriptions, including intramuscular and intranasal administrations, were common. All centres offered the concurrent prescription of methadone and slow-release oral morphine. Furthermore, all centres prescribed take-home DAM. However, vast differences among centres regarding DAM dosing and titration were found. No uniformly employed factors for converting DAM to other opioids exist across centres. Overdoses and seizures were reported to be very rare.

Conclusions: Swiss HAT is overall easily accessible, patient-centred and safe for patients and staff. Some procedures are based on local tradition rather than on scientific evidence. Evidence-based treatment recommendations are needed to further improve quality of care.

Background: People who use drugs report hesitance to seek employment because of stigma around drug use, which other forms of stigma may compound. We evaluated risk factors for substance use-related employment stigma among emergency department (ED) patients who use drugs.

Methods: This was a cross-sectional study among ED patients at high risk of opioid overdose in Rhode Island. The outcomes were three self-reported measures of substance use-related employment stigma. Multivariable log-binomial regression was used to estimate the association between participant characteristics and each outcome.

Results: Among 648 participants, 25.8% reported they had been turned down for a job due to current/past drug use, 40.8% disagreed that most employers will hire someone treated for drug use if qualified, and 77.7% agreed that most employers will pass over applicants treated for drug use in favor of others. Females reported they had been turned down for a job due to drug use less often than males (adjusted prevalence ratio [PR] 0.72, 95% confidence interval [CI] 0.53-0.98). Persons with a history of homelessness (aPR 1.82, 95% CI 1.24-2.66) and addiction treatment (aPR 1.95, 95% CI  1.22-3.12) more often reported having ever been turned down for a job due to drug use. Race/ethnicity was not associated with substance use-related employment stigma.

Discussion: Perceived substance use-related employment stigma was common among ED patients who use drugs, and men and those with a history of homelessness or addiction treatment may be particularly affected. Employers can diminish the harms of stigmatization by acknowledging those who struggle with addiction and changing hiring practices to reduce stigma.

Background: Incorporating people who use substances into a community-engaged research process can support the implementation and evaluation of evidence-based harm reduction programs. Attending to their voice ensures those who need these programs will use them. Yet, ongoing co-learning with people who use substances, often the ideal for community engaged research, poses a challenge for recruitment, ongoing participation, and obtaining diverse perspectives. We need novel strategies to support flexibility among populations experiencing legal and social instability so that community engaged work includes more diverse perspectives. In this paper, we describe a novel community engagement approach called Effective Adaptable and Sustainable in Your Community: Operationalizing Program Sustainability (EASY OPS). EASY OPS uses iterative engagement with people with lived/living substance use experience to design and implement harm reduction vending machine and kiosk programs, aiming to increase program use in those who would benefit most.

Main body: The EASY OPS approach addresses two key challenges to access and use of evidence-based harm reduction programs in underrepresented populations: (1) the need for attention to elements of the environment, and (2) ways to navigate challenges to ongoing research collaboration with community members experiencing substance use disorders. EASY OPS uses walking interviews with participants to identify environmental factors contributing to perceived use of services. Iterative engagement with community members-through interviews, surveys, and focus groups-was conducted to inform program development from the community's perspective as feasibility challenges emerged.

Conclusions: This paper describes the novel EASY OPS strategy that facilitates iterative community engagement for harm reduction research and program development to better tailor implementation to the needs of diverse populations with lived/living experience. The potential impact is to reduce disparities by enhancing representative reach and access to substance use service and harm reduction programs.

Background: A polycrisis of rising drug toxicity, pervasive houselessness, pandemic-related disruptions, coloniality and climate disasters is creating and exacerbating health inequities for People Who Use/Have Used Drugs (PWUD). This confluence of intersecting health, socio-political and environmental issues highlights the need for community-driven and adaptive innovation to address inequities in complex systems of care. To inform service innovations in an inner city social service hub in Edmonton, Alberta, we co-created a process that centres PWUD in health service planning and prioritization.

Methods: Using a community-based participatory research methodology informed by complexity theory, we conducted research with PWUD using SenseMaker micro-narratives and optional arts-based asset-mapping. Academic and peer researchers co-developed the study with input from the PWUD community and collected data at social service hubs and on outreach in the community. An iterative four-phase approach to research design, data collection and analysis guided the study: (i) Pre-data collection, (ii) Formal data collection, (iii) Readjusting, and (iv) Accountability.

Results: This methodology paper describes how our four-phase framework guided the study and promoted a dynamic and accountable approach to centering PWUD in health system innovation. Over five months, 215 PWUD participants shared narratives and rich insights into their experiences with healthcare access, harm reduction, and community support. Our results emphasise the importance of taking time to orient to each other and the community, even as a diverse team with many preexisting relationships. An iterative data analysis process allowed for adjustments in real-time to guide research focus, ensuring equity-oriented engagement with structurally vulnerable groups. Accountability began with research design, was maintained throughout data collection by creating safety for participants, and then defined the final phase of the research where we created an accessible final report and are now working with the host nonprofit partner and community members on action-oriented responses to the narratives shared.

Conclusions: Meaningful engagement with PWUD in co-creating health system innovation requires relational and adaptive methodologies. The process-focused results of this study demonstrate how community-based participatory research informed by complexity theory can enable accountable healthcare innovation amidst a changing social and political landscape. We conclude with a set of recommendations for co-creation and other peer-centred approaches that prioritize PWUD voices in developing effective health services.

Background: Death by drug toxicity is now the leading cause of death among youth in British Columbia (BC). In January 2023, BC implemented decriminalization for personal possession (2.5 g) of certain substances for individuals 18 and over. This research aimed to gain a deeper understanding of service providers who work with youth (ages 15-24). Specifically, the study aimed to explore: (1) their attitudes and beliefs regarding drug decriminalization, and (2) the knowledge and resources they need to effectively discuss drug decriminalization with their clients.

Methods: Community-based participatory research and interpretive description were used to co-design an interview guide and recruitment strategy with leaders at a BC integrated youth services initiative. Fifteen semi-structured interviews were conducted in the fall of 2023 (pre-period of the decimalization repeal in BC) with service providers and data were coded using reflexive, inductive semantic thematic analysis.

Results: The thematic analysis revealed that while decriminalization was perceived as a "step in the right direction," it remains insufficient to address the needs of youth in BC. Service providers expressed a significant disconnect between the policy and practical support required for youth clients. Despite their strong understanding of youth's needs, providers reported a lack of involvement in the policy development process.

Conclusion: Service providers said that decriminalization is "a step in the right direction, but not enough." Additional youth-centred policies and services are needed to address the drug toxicity crisis in BC, and service providers and people who use drugs need a seat at the table to inform, design, and implement policies that will impact youth who use drugs.

Introduction: People who inject drugs (PWID) contribute significantly to the global HIV burden. Various individual and contextual factors exacerbate the risk of HIV among PWID, this problem is particularly acute in low- and middle-income countries, where resource constraints impede effective prevention and treatment efforts. Although Bangladesh is classified as a low HIV prevalence country, and despite national efforts, including surveillance through the Integrated Biobehavioural Survey (IBBS), gaps in evidence and actionable insights persist. This study aims to analyse the latest IBBS 2020 data to identify risk factors associated with HIV vulnerability among PWID in Bangladesh, informing culturally relevant and targeted harm reduction strategies to mitigate these risks.

Method: This study analysed data from IBBS, which used a two-stage cluster sampling and Time Location Sampling methods to recruit participants. Data were collected across four domains: (1) Sociodemographic characteristics, (2) Drug and Injection-Related Behaviours, (3) Sexual Behaviours, and (4) Co-infections, with blood samples collected for HIV, hepatitis-C, and syphilis serological testing. Sample weights were applied to adjust for the complex survey design. Descriptive statistics summarized participant characteristics and risk behaviours. Two binary logistic regression models were used to identify HIV risk factors: The Fully Adjusted Model, which included all plausible confounders and used the Wald backward elimination method to determine significant predictors, and the Partially Adjusted Model, which controlled for age, gender, and education to explore intermediate factors through adjusting confounding or mediation.

Result: Overall, the prevalence of HIV among PWID was 4.1%. Social exclusion (AOR: 1.71, 95% CI 1.1, 2.7). Hepatitis C infection (AOR: 2.57, 95% CI 1.6, 4.0), drug use of more than 10 years (AOR: 3.74, 95% CI 1.3, 10.8), injecting once or more daily (AOR: 5.23, 95% CI 2.6, 10.7), having multiple injecting partners (AOR: 3.11, 95% CI 1.8, 5.3) sharing injecting accessories (AOR: 2.55, 95% CI 1.5, 4.4) and engaging with a commercial sex partner (AOR: 1.80, 95% CI 1.1, 2.9) emerged as significant predictors of HIV risk among PWID patients.

Conclusion: This study reveals the heightened HIV risk among PWID in Bangladesh, driven by intertwined social, behavioural, biological, and structural factors. It underscores the urgent need for tailored, holistic interventions combining harm reduction, structural reforms, and biomedical strategies to address vulnerabilities, reduce high-risk behaviours, and improve healthcare access for this marginalized group.

Globally, punitive drug control upholds racist and colonial structures. Marginalised and racialised communities, including Indigenous peoples, are disproportionately targeted and affected by punitive drug policy in law enforcement, judicial and carceral systems, and policy implementation. Power imbalances also exist at the international level, with high income countries exerting influence over drug policy in low- and middle-income countries. This paper examines that influence through financial and material aid, technical assistance, capacity building, education and awareness campaigns and the interaction between the vested interests of the private sector and the State, specifically via the Prison Industrial Complex and land and resource grabbing in conflict and post-conflict contexts. The global war on drugs entrenches power imbalances and reproduces mechanisms of racial control and subordination. To begin to decolonise drug policy, the financial and material basis of these mechanisms must be illuminated and dismantled and this paper offers recommendations on how to move forward (Dangerous Drugs Ordinance, 1923; Carrier et al., 2020).

With the overdose crisis continuing to pose significant challenges in North America, harm reduction strategies are critical for public health systems to reduce mortality and morbidity. Despite the considerable strides in harm reduction research, high-quality evidence for decision-making is limited. This is compounded by a variation in reported outcomes, drug supply, administration changes, and policy and social impacts, which further challenge researchers and practitioners in their efforts to implement effective, nimble harm reduction interventions. Adoption of common data elements (CDEs) and common outcome measures (COMs) helps researchers standardize and enhance data collection and outcome reporting, ultimately improving the comparability and generalizability of research findings. To accelerate the pace and use of CDEs, members of the NIDA HEAL Research on Interventions for Stability and Engagement (RISE) engaged in prospective semantic harmonization and consensus on CDEs and COMs using a rigorous pragmatic Delphi community informed approach. This process resulted in a set of CDEs and COMs that standardized data collection and reporting across 10 harm reduction research projects. This paper describes this process and presents the derived CDEs and COMs, along with key considerations, challenges encountered, and lessons learned.

Background: Canada's historical reliance on criminal justice approaches to drug policy has intensified structural and social stigma, and high-risk behaviours among people who use drugs. In response to pressure from local advocates, British Columbia implemented a pilot decriminalization policy in January 2023, permitting adults to possess up to 2.5 g of specified unregulated substances, cumulatively. While not designed to address the toxic drug supply directly, it aimed to reduce stigma and encourage engagement with health and harm reduction services. In May 2024, however, drug possession in public spaces was recriminalized, raising concerns about a return to punitive environments. To date, little is known about how these policy shifts have been experienced by people who use drugs themselves. We conducted a qualitative study exploring the impacts of British Columbia's decriminalization policy and its subsequent recriminalization amendment on the drug use behaviours of people who use drugs across the province.

Methods: A cross-sectional qualitative study with 75 people who use drugs across British Columbia, including a socio-demographic survey, and semi-structured interviews. Interviews were transcribed verbatim and analyzed using thematic analysis. The codebook was applied across all transcripts using a comparative approach to identify recurring patterns, divergent experiences, and key themes related to drug use behaviours.

Results: Participants reported little to no change in their drug use patterns following either decriminalization or recriminalization, as drug use was primarily driven by dependence, routine, and structural factors. Nonetheless, many described a psychological benefit under decriminalization, including reduced shame, internalized stigma, and fear of criminalization. These gains were largely reversed following the recriminalization amendment, which pushed drug use back into hidden, high-risk environments. Participants also noted destabilizing shifts in the drug supply, including increased potency and a rise in less experienced dealers, linked to the 2.5 g threshold.

Conclusion: Decriminalization did not significantly alter drug use behaviours but offered notable psychological relief for participants. The subsequent recriminalization amendment then reversed these perceived gains, illustrating how this abrupt policy change led to unintended consequences, undermining the original goals of the decriminalization policy. These findings highlight the need for sustained and structurally supported effective policy approaches that center the lived realities of people who use drugs.

Background: As the first EU country to enact laws regulating the non-medical use of cannabis and with established legislation for the cultivation and production of cannabis for medical purposes and scientific research, Malta is at the forefront of cannabis regulation and research initiatives. Despite this context, healthcare professionals' attitudes, beliefs, and knowledge regarding medicinal cannabis remain variable. We assess these constructs and examine perceived barriers to clinical integration.

Methods: A cross-sectional survey was distributed to doctors and pharmacists across Malta (n = 198). Data analysis included independent samples t-tests, Pearson correlation analyses, and hierarchical regression to examine demographic influences, professional comparisons, and predictors of prescription attitudes.

Results: Most professionals acknowledged medicinal cannabis's therapeutic benefits but exhibited notable hesitancy in clinical practice, largely due to insufficient formal guidelines and inadequate education. No significant gender differences were observed, and only a weak correlation emerged between age and attitudes among male doctors. The strongest predictor of willingness to prescribe medicinal cannabis was doctors' attitudes, outweighing formal education or knowledge.

Conclusions: Despite broad acknowledgment of potential therapeutic benefits, Maltese healthcare professionals remain cautious due to insufficient training and unclear guidelines. Enhancing evidence-based education and providing clear prescribing frameworks may significantly boost clinicians' confidence and willingness to integrate medicinal cannabis into clinical practice.