A Strait or an Ocean? Exploring Risks and Resources among People who use Drugs in Denmark and Sweden.

Introduction Resource overload describes the feeling medical students experience in choosing formal (faculty-prescribed) and informal study resources (not faculty-prescribed). This study aims to characterize students’ use and perceptions of formal and informal study resources to inform their use in medical education.Methods This is a mixed-methods study utilizing a convenience sample of first-year medical students enrolled at the University of Central Florida College of Medicine during the academic year 2020-2021. A 40-question, five-point Likert scale, survey based on Keller’s Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Motivational Design was distributed to medical students during the end of their first year of medical school. Multivariate analysis of variance determined differences between formal and informal resources for each construct. Interviews were also conducted by first-year medical students and analyzed using thematic analysis. Learning logs were completed during the beginning of the medical students' second year to assess daily study habits.Results Fifty-one students completed the survey with a response rate of 42.5%. Informal resources scored higher across all constructs: attention (formal: 3.4±1.2, informal: 4.0±1.1; p<.0125), relevance (formal: 3.8±1.1, informal: 4.3±1.0; p<.0125), confidence (formal: 3.2±1.2, informal: 4.1±1.1; p<.0125), satisfaction (formal: 2.8±1.2, informal: 3.6±1.2; p<.0125) (Likert scale 1-5, Mean±SD). Students found formal resources lacked depth and organization while informal resources allowed for concise understanding with retention cues. Learning log data reported similar use of formal and informal resources during week 1 (88.2% formal vs. 87.8% informal) and week 2 (84.6% formal vs. 82.6% informal).Conclusions Students preferred informal resources based on ARCS constructs. However, the actual usage of formal and informal resources was similar. Formal resources align more with curricular assessments, but informal resources aid student retention and understanding. Therefore, students find both formal and informal resources necessary for success. Faculty should consider integrating informal curriculum resources to optimize student learning.

In 2009, Mexico passed a national drug policy reform decriminalizing the possession of small amounts of certain drugs for personal use with the aim of diverting drug-dependent individuals from prison and towards addiction treatment. However, the public health approach codified by the reform has not yet led to a meaningful change in local police practices nor contributed to the meaningful scale-up of harm reduction and addiction treatment services in many Mexican cities. Specifically, in Tijuana, Baja California, there continues to be a variety of local level barriers – including arbitrary police behaviours – that hinder the ability of people who inject drugs (PWID) from accessing vital harm reduction services. This has implications for the growing HIV epidemic in Mexico’s northern border region, given that access to harm reduction interventions has been shown to effectively reduce the risk of HIV infection among PWID. In contrast to the largely enforcement-based local response seen in Tijuana, the municipal Four Pillars approach implemented in Vancouver, Canada in 2001 was passed as a public-health oriented response to the rising prevalence of HIV/AIDS among PWID in the Downtown Eastside of Vancouver. Centered on the balancing of four approaches – harm reduction, treatment, prevention and enforcement – the Four Pillars approach in Vancouver has led to a well-resourced local harm reduction and addiction treatment system. This local emphasis on harm reduction contrasts with the Canadian federal government’s opposition to harm reduction approaches. However, police-public health partnerships along with strong political support have led to the substantial scale up of harm reduction services as well as the reduction of HIV/AIDS among people who inject drugs in Vancouver, unlike what has been observed in Tijuana. This commentary therefore aims to assess the discrepancies between federal policy and local responses to drug-related harms in order to fully understand the impact and implications of national drug policies in shaping local response to drug related harms among populations of PWID. Through a comparison of the drug policy landscape in two cities linked by a large North American drug trafficking route—Tijuana, Mexico and Vancouver, Canada—this commentary suggests that drug policy reform in and of itself will have little impact at the local level unless it is appropriately resourced and meaningfully supported by key stakeholders.

Illicit drug use and harms in Australia in the context of COVID-19 and associated restrictions: Anticipated consequences and initial responses.

Rates of overdose deaths involving synthetic opioids remain high, increasingly involve stimulants combined with opioids, and are increasing rapidly in racially and ethnically minoritized communities, yet little is known about access to harm reduction and treatment services in these groups. To characterize access and barriers to harm reduction and treatment in a racially and ethnically diverse population of people who use drugs. A cross-sectional telephone survey of people recruited from 39 treatment, harm reduction, and social service organizations in Milwaukee County, Wisconsin; Flint and Detroit, Michigan; and statewide in New Jersey was conducted from January 30 to July 28, 2023. Adults who used cocaine, methamphetamine, or opioids in the past 30 days called a study hotline and completed an interview in English or Spanish. Overdose experience, drug types used (opioids only, stimulants only, and polysubstance), and social risk factors (eg, financial instability and criminal legal involvement). Recent use of any harm reduction services, fentanyl test strips, naloxone possession, treatment, and self-reported barriers to services. Of the total sample of 1240 adults, 486 (39.2%) were Black non-Hispanic, 183 (14.8%) were Hispanic, and 464 (37.4%) were White non-Hispanic. In the past 30 days, 826 individuals (66.6%) were polysubstance users, 135 (10.9%) used only opioids, and 279 (22.5%) used only stimulants. A total of 349 respondents (28.1%) experienced a prior-year overdose. Compared with those without a prior-year overdose, people with overdose were more likely to possess naloxone (80.7% vs 68.2%; P < .001), possess fentanyl test strips (36.8% vs 23.5%; P < .001), and use harm reduction services (63.4% vs 53.0%; P = .003), while differences in treatment use were nonsignificant (52.0% vs 46.6%; P = .24). Among stimulant-only users, 51.4% possessed naloxone compared with 77.3% of opioid-only users (P < .001) and 77.6% of polysubstance users (P < .001), with similar disparities in fentanyl test strip possession. In this cross-sectional study of people who used drugs in the past 30 days, findings highlighted low use of harm reduction and treatment services among people who use stimulants. Additional communication regarding their importance may help increase the use of the services amidst a rapidly changing drug supply.

Framing harm reduction as part of an integrated approach to reduce drug overdose: A randomized message testing experiment in a nationally representative sample of U.S. adults, 2022.

Public health messaging and harm reduction in the time of COVID-19

This briefing paper is the first of a series focusing on drug-related issues in SEE. It provides an overview of the current situation regarding harm reduction services and national drug policies in the region. The paper analyses the difficulties and challenges NGOs are facing in their harm reduction work, along with gaps and shortcomings in this field, and provides recommendations for the further development of appropriate harm reduction programmes in the region. The paper is based on the inputs of the members of the Network provided at the meeting in Ohrid in September 2010, and papers and reports on the drug situation and drug policy in South East Europe.

BackgroundThis study examines the use of new psychoactive substances (NPS) and the harm reduction response in six Eurasian countries: Belarus, Moldova, Serbia, Kazakhstan, Kyrgyzstan, and Georgia. The aim is to identify current patterns of NPS use and related harms in each country through recording the perspectives and lived experience of people who use drugs and people who provide harm reduction services in order to inform the harm reduction response.MethodologyThe study involved desk-based research and semi-structured interviews/focus groups with 124 people who use drugs and 55 health and harm reduction service providers across the six countries.ResultsPeople who use drugs in all countries were aware of NPS, primarily synthetic cathinones and synthetic cannabinoids. NPS users generally reflected two groups: those with no prior history of illicit drug use (typically younger people) and those who used NPS on an occasional or regular basis due to the lack of availability of their preferred drug (primarily opiates). In many cases, these respondents reported they would not use NPS if traditional opiates were available. Common factors for choosing NPS included cost and accessibility. Respondents in most countries described NPS markets that use the DarkNet and social media for communication, secretive methods of payment and hidden collection points. A recurring theme was the role of punitive drug policies in driving NPS use and related harms. Respondents in all countries agreed that current harm reduction services were important but needed to be enhanced and expanded in the context of NPS.ConclusionsThe study identified patterns and drivers of NPS use, risk behaviours and drug-related harms. It identified gaps in the current harm reduction response, particularly the needs of non-injectors and overdose response, as well as the harmful effects of punitive drug policies. These findings may inform and improve current harm reduction services to meet the needs of people who use NPS.

Since the 1980s, Swedish drug policy has combined a restrictive zero tolerance approach with the vision of a "drug-free society". However, in recent years, access to harm reduction services has increased through local initiatives and new national guidelines. The possible success of these services may be affected in part by police drug law enforcement. The aim of this study was to explore how Swedish police officers act toward and view harm reduction services in a national drug policy setting of zero tolerance toward drug use. Applying a qualitative research design, we conducted 19 in-depth interviews with police officers who worked with drug law enforcement in Malmö. We conducted a qualitative textual analysis of the data. Officers largely supported harm reduction services and refrained from overtly enforcing drug laws in their vicinity. Officers engaged in boundary work that assigned the responsibility of care of marginalized people who use drugs (PWUD) to the health care system, while including policing of drug market problems, young PWUD and dealers in their own jurisdiction. Opioid substitution treatment was seen as positive, although diversion of medicines was pointed out as a problem. Needle exchange programs were seen as offering important public health services and a no-go zone for the police. Several officers wanted to carry naloxone on duty but requested more information about its use. The general support among police officers for harm reduction services is an indication of a changing drug policy landscape in Sweden. Drug policy should take police officers' views into consideration and there is a need for collaboration between police and harm reduction services. Further research should focus on how the police conduct boundary work since police actions may impact on the success of harm reduction services.

BackgroundPeople who inject drugs (PWID) are at increased risk of HIV acquisition and often encounter barriers to accessing healthcare services. Uganda has high HIV prevalence among PWID and lacks integrated pre-exposure prophylaxis (PrEP) and harm reduction services. Understanding PWID experiences accessing and using harm reduction services and PrEP will inform strategies to optimize integration that align with PWID needs and priorities.MethodsBetween May 2021 and March 2023, we conducted semi-structured interviews with PWID in Kampala, Uganda. We recruited participants with and without previous experience accessing harm reduction services and/or PrEP using purposive and snowball sampling. Interviews were audio recorded, translated, and transcribed. We used thematic analysis to characterize motivations for uptake of harm reduction and HIV prevention services, and strategies to optimize delivery of needle and syringe programs (NSP), medications for opioid use disorder (MOUD), and PrEP.ResultsWe conducted interviews with 41 PWID. Most participants were relatively aware of their personal HIV risk and accurately identified situations that increased risk, including sharing needles and engaging in transactional sex. Despite risk awareness, participants described engaging in known HIV risk behaviors to satisfy immediate drug use needs. All reported knowledge of harm reduction services, especially distribution of sterile needles and syringes, and many reported having experience with MOUD. Participants who had accessed MOUD followed two primary trajectories; limited resources and relationships with other PWID caused them to discontinue treatment while desire to regain something they believed was lost to their drug use motivated them to continue. Overall, PrEP knowledge among participants was limited and few reported ever taking PrEP. However, participants supported integrating PrEP into harm reduction service delivery and advocated for changes in how these services are accessed. Stigma experienced in healthcare facilities and challenges acquiring money for transportation presented barriers to accessing current facility-based harm reduction and HIV prevention services.ConclusionsMeeting the HIV prevention needs of PWID in Uganda will require lowering barriers to access, including integrated delivery of PrEP and harm reduction services and bringing services directly to communities. Additional training in providing patient-centered care for healthcare providers may improve uptake of facility-based services.

BackgroundMortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered.MethodsWe conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: “clients” (individuals who use drugs and receive harm reduction services) and “providers” (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis.ResultsWe found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels.ConclusionThis study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

BackgroundSubstance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic.MethodsWe recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs.ResultsWe collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services.ConclusionsIn many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.

Drug policy, harm and human rights: A rationalist approach

Rural caregivers are often underserved by caregiving services, yet little is known about how the intersectionality of geographic context and race/ethnicity relates to caregiving resources among dementia caregivers. We examined whether 1) caregiving resources and experiences differ across metro and non-metro areas; and 2) the use of caregiving resources is associated with geographic context by race/ethnicity, controlling for age, gender, and education. We analyzed a sample of caregivers of care recipients aged 65 years or older with ‘probable’ dementia (n= 808) in the 2017 National Health and Aging Trends Study (NHATS) and the associated National Study of Caregiving (NSOC). We defined geographic context by the recipient’s residence in metro (urban) or non-metro (rural) counties and grouped formal (respite care, support groups, caregiving training) and informal (family or friend help) resources. Among minority caregivers, 47% of those living in metro and 36% in non-metro areas used a formal service, and 83% and 72%, respectively, used informal resources. Among White caregivers, estimates were 44%, 48%, 76%, and 66%, respectively. Multivariate regression analyses revealed that non-metro White dementia caregivers had 2.04 times higher odds (95% CI=1.10-3.78) of using formal resources than metro White dementia caregivers. This pattern was not observed among minority dementia caregivers. The use of informal resources did not differ across geographic contexts by race/ethnicity. Findings suggest the influence of geographic context on the use of formal caregiving resources varies by race/ethnicity. With higher rates of dementia in non-metro areas, formal caregiving resources among non-metro minority dementia caregivers need more attention.

Harm reduction has been increasingly finding its way into public drug policies and healthcare practices worldwide, with successful intervention measures justifiably focussing on the highest-risk groups, such as injecting drug users. However, there are also other types of drug users in need for harm reduction, even though they pose less, low, or no public health risk. Occasionally, drug users may autonomously organise themselves into groups to provide advocacy, harm reduction, and peer-help services, sometimes online. The http://www.daath.hu website has been operated since 2001 by the “Hungarian Psychedelic Community”, an unorganised drug user group with a special interest in hallucinogenic and related substances. As of today, the website serves about 1200 visitors daily, and the online community comprises of more than 8000 registered members. The Daath community is driven by a strong commitment to the policy of harm reduction in the form of various peer-help activities that aim to expand harm reduction without promoting drug use. Our review comprehensively summarises Daath’s user-led harm reduction services and activities from the last ten years, firstly outlining the history and growth phases of Daath, along with its self-set guidelines and policies. Online services (such as a discussion board, and an Ecstasy pill database) and offline activities (such as Ecstasy pill field testing, and a documentary film about psychedelics) are described. In order to extend its harm reduction services and activities in the future, Daath has several social, commercial, and legislative challenges to face. Starting with a need to realign its focus, outlooks for the upcoming operation of Daath are pondered. Future trends in harm reduction, such as separating harm-decreasing from benefit-increasing, are also discussed. We aim to share these innovative harm reduction measures and good practices in order to be critically assessed, and – if found useful – adapted and applied elsewhere.