International Journal of Drug Policy最新文献

High dose and long-acting opioid overdose reversal drugs can precipitate withdrawal in people who are opioid dependent. Products recently brought to market for community use in the United States (US) have drawn international concern because of their increased risk of withdrawal. At the March 18–19, 2024, Compassionate Overdose Response Summit & Naloxone Dosing Meeting, a panel of harm reduction experts issued the following call to action: 1) people who use drugs should be directly involved in decisions regarding the research, development, selection, and distribution of opioid overdose reversal products; 2) regulatory agencies and pharmaceutical manufacturers should carefully consider and communicate the risk and duration of withdrawal associated with higher dose and longer-acting opioid antagonists; 3) take-home naloxone kits should include at least two doses of an intramuscular (IM) product containing 0.4 mg or an intranasal (IN) product containing ≤4 mg; 4) At this time, high dose and long-acting opioid antagonists have no use in acute opioid overdose response; and, 5) overdose response educational materials, instructions on overdose response, and training should emphasize the restoration of breathing, avoiding withdrawal, and compassionate post-overdose support and care. High dose and long-acting opioid overdose reversal drugs were approved without testing for withdrawal and are often aggressively marketed despite decades of evidence from naloxone distribution programs worldwide that the ideal dose of naloxone is one that restores breathing without inducing withdrawal. Government agencies should direct resources to harm reduction programs to make standard dose take-home naloxone products widely available among people who use drugs. Lay bystanders, people who use drugs, their families, and professional first responders can learn and apply a compassionate approach to opioid overdose response.

Background

In the United States, community overdose education and naloxone distribution (OEND) programs have demonstrated efficacy in reducing opioid-related mortality. OEND programs have expanded across San Diego County, California, but differential naloxone accessibility among people who use drugs (PWUD) has not been assessed. We examined factors that shape individual naloxone accessibility in San Diego.

Methods

We employed a convergent parallel mixed methods design using surveys (n = 194) and qualitative interviews (n = 20). Ordinal logistic regression examined factors associated with individual naloxone accessibility (i.e., the frequency with which participants could access naloxone within five minutes, categorized as never, sometimes, or always). Qualitative interviews explored participant perceptions of naloxone accessibility and whether and how they maintained naloxone. We organized multilevel findings into a modified social-ecological model.

Results

In quantitative and qualitative samples, participants were majority male (72 % and 70 % respectively), non-White race/ethnicity (55 % and 75 %), with an average age around 42 years. In the quantitative sample, 24 % never had personally accessible naloxone, 52 % sometimes did, and 24 % always did. Factors independently associated with individual naloxone accessibility were female gender (Adjusted Odds Ratio [AdjOR]: 2.51, 95 % Confidence Interval [CI]: 1.31–4.85), monthly income <$500 (AdjOR: 0.42, 95 %CI:0.19, 0.90), witnessing an overdose (AdjOR: 3.51, 95 %CI:1.67–7.55), and knowing where to get free naloxone (AdjOR: 3.44, 95 %CI: 1.79–6.75). Qualitative data suggested that naloxone was generally easy to acquire in San Diego due to community harm reduction outreach and mutual aid among peers, albeit community barriers including distance to harm reduction providers and frequent relocation/displacement for those experiencing homelessness. Individual attitudes toward overdose risk, naloxone, and community responsibility contributed to varied individual naloxone accessibility.

Conclusions

This study highlights multilevel factors influencing individual naloxone accessibility among people who use drugs in San Diego, emphasizing the importance of harm reduction outreach and peer-to-peer support. We identified opportunities for interventions that address both individual attitudes and community-level barriers to improve naloxone accessibility.

Background

Drug use was criminalized in Sweden in 1988 with aim of reducing the number of consumers and drug-related risks and harms. Imprisonment was introduced into the penalty scale in 1993 to improve the legislation's effectiveness. The criminalization has never been evaluated.

Method

Goal-attainment evaluation based on a range of indicators from surveys, case-finding estimates, healthcare and cause-of-death data, and crime statistics. Comparative drug policy analysis is conducted with other Nordic countries.

Results

The criminalization is not followed by a reduced or more expensive drug supply, reduced consumption levels, problematic drug use or healthcare needs, or to fewer drug-related deaths. Most of the indicators instead show the opposite. Control costs are high, and trends are no better than those of other Nordic countries, despite Sweden's more repressive drug policy.

Conclusion

Criminalization emerges as an ineffective, expensive and harmful means of dealing with the drugs problem.

Background

Examining take-home naloxone (THN) uptake using a ‘cascade of care’ framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs.

Methods

People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression.

Results

Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91–3.42) and ≥daily injecting (1.32; 1.01–1.73) were associated with awareness. OAT (1.79; 1.38–2.33), past-year opioid overdose (1.68; 1.18–2.42) and older age (1.02; 1.00–1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31–0.58) and acquisition (0.59; 0.44–0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24–0.88).

Conclusion

Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids.

Objectives

Many people who use drugs in the United States and Canada continue to access the contaminated unregulated drug supply, resulting in the ever-escalating overdose epidemic. In Canada, even in areas where healthcare providers are authorized to prescribe alternatives to the unregulated supply (e.g., prescribed safer supply), availability and accessibility are low. We sought to characterize the needs of people who use unregulated opioids in Vancouver, Canada by asking them whether access to any pharmaceutical opioids would reduce their use of unregulated opioids, and if so, which pharmaceutical opioids they preferred.

Methods

We analyzed data from participants who self-reported using unregulated opioids in three Vancouver-based prospective cohort studies between 2021 and 2022. We employed multivariable logistic regression to identify factors associated with reporting a preferred pharmaceutical opioid to reduce unregulated opioid use.

Results

Of 681 eligible participants, 504 (74.0 %) identified a preferred pharmaceutical opioid to reduce unregulated opioid use. The most commonly reported preferred opioids included: diacetylmorphine (42.9 %), fentanyl patches (11.1 %), and fentanyl powder (10.5 %). Overall, 5.6 % of participants who identified diacetylmorphine, 12.5 % of participants who identified fentanyl patches, and no participants who identified fentanyl powder as their preferred opioids reported receiving prescriptions of them. In multivariable analysis, exposure to benzodiazepines through unregulated drug use (adjusted odds ratio [AOR] = 2.57; 95 % confidence interval [CI] = 1.69–3.90), and receipt of prescribed safer supply of opioids without opioid agonist therapy (OAT; AOR = 2.66; 95 % CI = 1.12–6.36) within the past six months were significantly associated with reporting a preferred pharmaceutical opioid.

Conclusion

Three-quarters of participants reported that receiving prescribed pharmaceutical opioids of their preference could reduce their use of unregulated opioids; however, the proportions of those actually being prescribed their preferred opioids were very low. Further, these participants were also more likely to report exposure to benzodiazepine-adulterated drugs. Our findings provide important implications for future safer supply programs.

Despite the surge of interest in psychedelic research in the past decade, largely due to the promise of psychedelics for improving mental health outcomes, there has been comparatively little discussion about the social and environmental consequences of psychedelic drug use. While there is growing evidence to suggest psychedelics could foster a greater connection to the natural world and improve social relationships, such positive repercussions are far from guaranteed. In this commentary, we focus on LSD, psilocybin and especially MDMA, and outline three insights we came to see as crucial to creating beneficial outcomes: 1) the importance of setting and rituals, 2) the establishment of boundaries, and 3) understanding the long-term commitment required. These insights are grounded in the history of psychedelics, which is intimately intertwined with ritualised use, yet the process of commercialisation of these substances threatens to strip away important contextual factors. Creating boundaries around when, how and with whom psychedelics are used have been found to protect recreational users from harm and could also be instrumental in steering commercial interests to align with socio-environmental goals. Finally, far from being a ‘quick fix’ for social or environmental problems, the use of psychedelics requires sustained engagement to integrate the insights obtained. Whereas we remain optimistic about the transformative potential of psychedelics for social relationships and the environment, we also emphasise the need for a more cautious, considered approach if we are to harness the benefits and minimise the challenges of psychedelic drug use.

Many nations and communities have reinvigorated discussions around universal basic income (UBI) as a means to address growing inequity. Research to date suggests that such systems can have profound positive public health and social impacts. Substance use, however, has not been explored as an area that may be impacted by UBI. This essay explores the current UBI literature and suggests how such a program could impact substance use health concerns within the Canadian context. Specifically, a UBI program in Canada could significantly reduce the negative health concerns of substance use and reduce the nation's current expenditures on healthcare interventions. Canada and other nations should consider UBI as a means to address substance use concerns and future research should include reviewing substance use data as part of any basic income intervention.

Introduction

Rates of fatal overdose continue to rise in the United States, and most people with opioid use disorder (OUD) are not engaged in evidence-based treatment with medications. In Philadelphia, a city with one of the highest fatal overdose rates in the country, many residents face significant care access barriers. The COVID-19 pandemic – which destabilized the street drug supply and forced many clinics to limit services – worsened this crisis, but also led to regulatory changes that allowed for buprenorphine induction and maintenance visits via telehealth in the U.S. To increase access to buprenorphine across the Philadelphia area and reach individuals who struggle to access care, Penn Medicine developed the CareConnect Warmline in October 2021. CareConnect is embedded in an existing virtual urgent care practice. Staffed by advanced practice providers and substance use navigators (SUNs), CareConnect provides same-day buprenorphine bridge (i.e., short-term) prescriptions and linkage to longitudinal OUD care.

Objective

To examine barriers and facilitators to implementing CareConnect from the perspective of key stakeholders, including CareConnect leadership, clinicians, and staff, and attitudes and beliefs about providing care for patients with OUD via this model.

Methods

In this qualitative descriptive study, we interviewed 14 participants and used thematic analysis to analyze the data. The sample included CareConnect prescribing clinicians, SUNs, and administrative staff.

Results

Our analysis yielded four themes: 1/ CareConnect is a unique program that fills an important care gap; 2/ Benefits of leveraging existing infrastructure; 3/ Importance of an interdisciplinary team; and 4/ Necessity of relationships with outside stakeholders. Prescribing clinicians and administrative staff – most of whom had little experience with OUD care before CareConnect – stressed how embedding the model within an existing virtual clinic and involving experienced SUNs increased their comfort prescribing buprenorphine. However, all participants highlighted how the program's effectiveness is contingent upon buy-in from outside stakeholders, including pharmacists who fill the prescriptions and longitudinal care providers in the community.

Conclusions

Innovative delivery models can help expand OUD care access to individuals who are poorly served by traditional treatment infrastructure. Our findings provide valuable insight to improve and sustain CareConnect and can guide the development and implementation of future programs nationally.

Background

Enhancing care integration and coordination to improve patient outcomes in opioid use disorder treatment is a growing focus in the field. Understanding of how the treatment system implements coordination and integration, particularly in the aftermath of the COVID-19 pandemic, remains limited. In this study, we explored the implementation of medications for opioid use disorder (MOUD) and the evolution of service delivery toward a more comprehensive approach. We examined providers’ perspectives from high-achieving programs in Los Angeles County, the largest and most diverse U.S. county, including barriers to integrating and coordinating care and strategies for integrating MOUD service delivery.

Methods

We gathered qualitative interview data from 30 high-performing programs in Los Angeles County, each represented by a manager or supervisor. High performance was defined by empirical indicators of access, retention, and program completion. Our data collection and analysis followed the constructivist grounded theory approach, explicating the social processes used by participating managers during the pandemic and subsequent organizational shifts. This approach yielded 14 major and six minor codes. Interrater reliability tests yielded a pooled Cohen's kappa statistic of 93%.

Results

Expert providers exhibited a strong commitment to destigmatizing MOUD and worked to overcome obstacles in delivering care to clients by advocating its efficacy to fellow health care providers. Along with their endorsement of MOUD, they identified challenges in integrating and coordinating MOUD care. Barriers included stigma at both patient and provider levels, inadequate education about MOUD, limited access to MOUD, and the complexities of operating in a fragmented health care framework. Despite these challenges, high-performing providers used strategies to harmonize and align MOUD service delivery with health and social services. These included establishing service colocation, adopting a multidisciplinary team-based approach, forming partnerships with the community, offering telehealth services, integrating and sharing data, and embracing a harm reduction philosophy.

Discussion

Through the adoption of these strategies, providers enhanced care accessibility, boosted patient engagement, sustained retention in treatment, and enhanced treatment outcomes. Even among highly skilled treatment providers in Los Angeles County, barriers to integrating and coordinating care using MOUD remain intricate and multifaceted. Addressing these challenges necessitates a comprehensive strategy involving provider education and training, increased availability of MOUD, enhanced coordination and communication among health care providers, resolution of regulatory hurdles, and addressing patient hesitancy toward MOUD.

Background

Recovery-oriented systems of care have been a widely supported approach to transforming existing substance treatment programs across different states through developing recovery programs and interagency networks. However, little is known about the facilitators and barriers influencing their development and implementation.

Methods

Qualitative study of 5 different recovery-oriented systems of care in Illinois. Nineteen respondents completed individual interviews.

Results

A total of 124 codes and 2 themes were identified, reflecting constraints and opportunities. Theme 1 focused on how ROSC programs developed bonding, bridging, and linking social capital. Theme 2 focused on the ROSC coordinator and lead agency's power and accountability.

Conclusions

The roles of lead agencies and ROSC coordinators were highlighted in the development and implementation of ROSCs. ROSC membership structures allow for bonding, bridging, and linking social capital. Still, additional technical support is needed to improve accountability, reduce power differentials and turf battles, and ensure greater participation among more diverse stakeholders.