International Journal of Drug Policy最新文献

The overdose epidemic in the United States is evolving, with a rise in stimulant (cocaine and/or methamphetamine)-only and opioid and stimulant-involved overdose deaths for reasons that remain unclear. We conducted interviews and group model building workshops in Massachusetts and South Dakota. Building on these data and extant research, we identified six dynamic hypotheses, explaining changes in stimulant-involved overdose trends, visualized using causal loop diagrams. For stimulant- and opioid-involved overdose deaths, three dynamic hypotheses emerged: (1) accidental exposure to fentanyl from stimulants; (2) primary stimulant users increasingly using opioids, often with resignation; (3) primary opioid (especially fentanyl) users increasingly using stimulants to balance the sedating effect of fentanyl. For stimulant-only overdose deaths, three additional dynamic hypotheses emerged: (1) disbelief that death could occur from stimulants alone, and doubt in testing capabilities to detect fentanyl; (2) the stimulant supply has changed, leading to higher unpredictability and thus higher overdose risk; and (3) long-term stimulant use contributing to deteriorating health and increasing overdose risk. These hypotheses likely each explain a portion of the recent trends in stimulant-involved overdoses. However, confusion and uncertainty around the drug supply emerged as a central theme, underscoring the chaotic and unpredictable nature of the stimulant market. Our findings indicate the need for research to develop targeted public health interventions, including analyzing the extent of the effect of contamination on overdoses, reducing confusion about the stimulant supply, and examining historical stimulant use trends.

Background: Hepatitis B virus (HBV) and hepatitis C virus (HCV) are estimated to be of the most prevalent infectious diseases in correctional settings worldwide. However, viral hepatitis services have not been routinely integrated into South African correctional facilities. We aimed to assess prevalence of HBV infection and HCV infection among people accessing HIV services and assess the feasibility of viral hepatitis service integration in a South African correctional centre.

Methods: Voluntarily participating people in a correctional services facility were offered free hepatitis B surface antigen (HBsAg) and anti-HCV point-of-care testing in addition to routine HIV testing and treatment services on a first-come, first-served basis during June 2021-March 2022. Off-site laboratory testing (HBV and HCV molecular testing and non-invasive liver fibrosis staging) and screening for hepatocellular carcinoma informed further management. A general practitioner at the facility managed participants, with virtual support from hepatologists. Data on age and history of injecting was collected and point-of-care and laboratory results were recorded. Data were analysed using descriptive statistics.

Results: The median age of the 765 people who participated was 32.5 years (IQR 27.5 - 38.2), with 2.2% (17/765) reporting having ever injected a drug. The sample prevalence was 3.9% (30/765) for HBV infection, 0.5% (3/665) for HCV infection, and 1.2% (9/765) for HIV-HBV coinfection. Thirty people had reactive HBsAg point-of-care tests. Among those with reactive HBsAg point-of-care tests 90.0% (27/30) received work-up, among whom 48.1% (13/27) were monitored, 44.4% (12/27) were placed on treatment and two people were released before a management plan could be finalised. Of those treated 33.3% (4/12) started tenofovir/emtricitabine and 66.7% (8/12) antiretroviral therapy. Of the eligible participants, 27.3% (201/735) received at least one hepatitis B vaccine dose and 26.9% (54/201) received three doses. All three participants who had confirmed HCV infection were started on direct-acting antivirals. Of the two completing treatment one achieved sustained virological response at 12 weeks (SVR12), one person was released before SVR12 was done. One person was lost to follow-up. No clinical adverse events were reported.

Conclusion: There was a notable viral hepatitis burden among people in this correctional centre and integration of viral hepatitis services into the existing HIV services was acceptable and feasible. Further efforts to sustain and expand access to viral hepatitis services in South African correctional centres could catalyse national viral hepatitis elimination efforts.

Background: Identifying the most effective state laws and provisions to reduce opioid overdose deaths remains critical.

Methods: Using expert ratings of opioid laws, we developed annual state scores for three domains: opioid prescribing restrictions, harm reduction, and Medicaid treatment coverage. We modeled associations of state opioid policy domain scores with opioid-involved overdose death counts in 3133 counties, and among racial/ethnic subgroups in 1485 counties (2013-2020). We modeled a second set of domain scores based solely on experts' highest 20 ranked provisions to compare with the all-provisions model.

Results: From 2013 to 2020, moving from non- to full enactment of harm reduction domain laws (i.e., 0 to 1 in domain score) was associated with reduced county-level relative risk (RR) of opioid overdose death in the subsequent year (adjusted RR = 0.84, 95 % credible interval (CrI): 0.77, 0.92). Moving from non- to full enactment of opioid prescribing restrictions and Medicaid treatment coverage domains was associated with higher overdose in 2013-2016 (aRR 1.69 (1.35, 2.11) and aRR 1.20 (1.11, 1.29) respectively); both shifted to the null in 2017-2020. Effect sizes and direction were similar across racial/ethnic groups. Results for experts' highest 20 ranked provisions did not differ from the all-provision model.

Conclusions: More robust state harm reduction policy scores were associated with reduced overdose risk, adjusting for other policy domains. Harmful associations with opioid prescribing restrictions in 2013-2016 may reflect early unintended consequences of these laws. Medicaid coverage domain findings did not align with experts' perceptions, though data limitations precluded inclusion of several highly ranked Medicaid policies.

Sexualised drug use (SDU) is a highly prevalent phenomenon of increasing public health significance in communities of men who have sex with men (MSM). This prospectively registered PRISMA-ScR-adherent systematic scoping review examines the current state of knowledge surrounding violence amongst MSM in the context of SDU. A broad search was conducted across four databases, with no restrictions. Studies citing or cited by all database-identified records retained for full-text review were retrieved and screened. Three journals were hand-searched across the past five years, and three searches were conducted on Google Scholar. In addition, 13 key opinion leaders were contacted via email to request any additional published or unpublished data. The twenty-eight studies included in the final synthesis reported mostly qualitative data from geographically diverse non-representative samples, predominantly relating to sexual violence with other typologies seldom investigated or reported. Although quantitative data were limited, sexual violence appeared common in this context and was directly associated with impaired mental health and suicidality. Some participants reported first- or second-hand accounts of non-consensual administration of incapacitating doses of GHB/GBL to men who were subsequently raped. This was frequently perpetrated by men whose age, status, or financial privilege afforded them power over their victims. While reports from some participants suggested context-specific blurring of the lines of consent, a few quotes demonstrated a dearth of knowledge surrounding the centrality of consent in lawful sex. Given the historical denigration of MSM, any efforts to further investigate or address this issue must be community-led.

Background: In October 2018, Canada legalized recreational cannabis, with Ontario distributing retailer licenses through a lottery system in 2019. This study investigates the impact of recreational cannabis retailer allocation on emergency department (ED) visits related to cannabis, alcohol, and opioids.

Method: A longitudinal study of 278 communities in Ontario (proxied by Forward Sortation Areas, FSAs) was conducted using health administrative data from ICES for all Ontario residents covered by public health insurance. The cohort included 11,156,100 adults aged 18 and above, monitored quarterly from January 2016 to March 2023. The allocation of cannabis retailers through a randomized lottery system provided a natural experiment. Staggered difference-in-differences proposed by Callaway and Sant'Anna (CSDID) models, weighted by the inverse probability of retailer allocation, were used to estimate the impact of cannabis store openings on ED visits, comparing FSAs with and without retailers.

Results: No significant effects were found in cannabis-, alcohol-, or opioid-related ED visits following the allocation of cannabis retailers. Sensitivity analyses, including alternate diagnostic codes, co-use of cannabis and other substances, and cannabis use without other substances, corroborated our main findings. The null results may be due to online cannabis sales preceding retail store openings, geographic distribution minimizing access disparities, and potential spillover effects.

Conclusion: The allocation of recreational cannabis retailer licenses did not significantly impact acute care use. Continuous monitoring, comprehensive sales tracking, and integrated substance use prevention strategies are recommended for future policy considerations.

Background: Multiple studies have documented stigma towards people who use drugs, but a less well studied aspect of stigmatisation is the phenomenon known as "not in my backyard," The aim of this study was to analyse the relationship between living near a drug treatment centre and the degree of perceived public stigma, as well as to identify differences among sociodemographic profiles.

Methods: Based on the Barcelona Health Survey (N=3270), public stigma was defined as scores at or above the 66th percentile of an index of 2 questions on the general population's perceptions of people who use drugs as failures and as dangerous (Cronbach's alpha = 0.84). Survey participants were categorised into 3 areas based on their proximity to a drug treatment centre: in a buffer within 150 metres, between 150 and 300-metres, and the rest of the city. Logistic regression models were used to evaluate the association between perceived public stigma and spatial proximity to a drug treatment centre, as well as variations among sociodemographic profiles.

Results: Living within 150 metres of a drug treatment centre increased the probability of perceived public stigma (odds ratio=1.85 95%CI 1.12-3.07). At the city level, higher public stigma was associated with the older population, those with a lower educational level, and those born in a low-income country. However, the increase in public stigma within the 150-metre buffer was driven by groups that showed low levels of stigma at the city level.

Conclusion: Public stigma in the city is high and increases with proximity to a drug treatment centre, especially among groups that exhibit low levels of stigma at the city level. Identifying social groups showing high levels of "not in my back yard"-related stigma may help to redesign harm reduction interventions focusing on specific groups.

Healthcare avoidance or delays for wounds and related skin- and soft-tissue infections are often attributed to negative interactions with medical providers. An infrastructural violence framework posits that healthcare infrastructure serves as a material channel for structural violence, maintaining inequities in healthcare experiences and outcomes. Infrastructural violence ensues when infrastructure is designed for some members or groups within a society while perpetuating violence among others. This study draws on the concept to understand how healthcare infrastructure creates and perpetuates inequities within the healthcare system for people who inject drugs for their wound care-related needs. Between January and September 2023, semi-structured interviews were conducted with 12 medical providers in Maryland. An abductive thematic analysis approach was followed. Healthcare infrastructure mediated the relationship between structural factors, such as policies on prescribing privileges of medications for opioid use disorder and subsequent individual health experiences. Medical providers also described how their access to training, protocols, and other resources was insufficient to meet the needs of people who inject drugs presenting to healthcare settings for wound care. A new conceptual grounding provides recommendations on extending beyond medical provider behavior change interventions in healthcare settings to create supportive infrastructure, which includes readily available and accessible policies, protocols, and resources to care for this patient population.

Though the United Nations deals with its Sustainable Development Goals (SDGs) in blocs of 15 years at a time, "sustainable" indicates a longer-term focus, aiming at steady human progress, including in public health and welfare. But the alcohol history in many countries shows "long waves" of consumption, repetitively rising, then falling, then rising again. Underlying this dynamic are competing interests pushing in opposite directions. One set of interests, both private and governmental, seeks profits from an attractive and habit-forming product, with relative costs that have fallen with industrialisation and commercialisation. Opposed are the interests of those harmed by the effects of alcohol, and the interests of public health and welfare. With alcohol, there is also a less obvious set of interests favouring drinking: alcohol is an instrument of conviviality and collectivity, as expressed in rituals like reciprocal drink-buying and toast-offering. The long waves result from the competition of these interests. Alcohol becomes more available by industrialisation or other factors, and alcohol consumption and harms from drinking rise. Reaction to this from public health and welfare interests results in measures driving consumption levels back down. Then to a new generation the restrictions seem unnecessary; they are removed; and consumption rises again. Long waves with different periodicity are exemplified in 3 different patterns of national history: in countries with strong temperance movement histories, in Russia, and in France. The long waves raise an issue which challenges the steady-progress assumption of the SDGs: are moves to lower alcohol consumption sustainable? More complex thinking and policymaking may be required to deal with alcohol policies in the frame of the Sustainable Development Goals.