Perceptions and experiences with police among people who use drugs in the initial year of British Columbia's decriminalization of illegal drugs policy

BackgroundThe first case of SARS-CoV-2 in Greece was identified in February 2020. During the COVID-19 pandemic two lockdowns took place (March-May 2020/November 2020-ongoing). People who use drugs (PWUD), as well as the homeless, constitute vulnerable social groups. The main aim of this study is to assess the impact of social distancing measures during the COVID-19 pandemic on these groups.MethodsA program was implemented in Athens between December 2020 and January 2021 in a sample of PWUD and homeless recruited both in Substitution Treatment Units and the Homeless Shelters. The interview was conducted with a structured questionnaire.ResultsThe study included 303 participants (215 PWUD and 88 homeless individuals (HI)). The mean (SD) age was 49.2 (9.7) and 61.9 (10.2) years for PWUD and HI respectively. Chronic hepatitis C was reported by 33% of PWUD and 1.1% of HI. HIV infection was reported in 9.3% of PWUD. Testing for SARS-CoV-2 was reported by 55% and 100% of PWUD and HI respectively; 0.8% of PWUD and 5.7% of HI were found positive. Compliance with individual measures against SARS-CoV-2 was reported to be high (98-100%) during lockdowns. 88.8% and 98.9% of PWUD and HI reported change in the quality life. Feelings of isolation were reported by 46.6% and 11.5% on PWUD and HI, respectively. PWID enrollment in OST programmes during the 1st and 2nd lockdown was 67.1% and 92.9% respectively. OST attendees did not report changes in treatment during lockdowns. Access to hygiene materials was 9.8% and 100% in 1st and 2nd lockdown. Access to drugs was high (91.5% and 94.3%) in both lockdowns. The illegal drug use as compared to regular use was increased 12.2%/14.3%, decreased 40.2%/40%, stable 47.6%/45.7% for 1st/2nd lockdown respectively.ConclusionsThe population studied is well-aware and compliant with the prevention measures against COVID-19 with access to frequent laboratory testing, low levels of SARS-CoV-2 and access to prevention materials.Key messages Among PWUD the OST services provision was stable. Provision of antiseptics was higher during the 2nd lockdown while changes in drug use were similar during the 1st and 2nd lockdown.Limitation: This study does not assess PWUD with limited access to OST and HI living in the streets.

From drug prohibition to regulation: a public health imperative

COVID-19 vulnerability among people who use drugs: recommendations for global public health programmes and policies.

Background: Human immunodeficiency virus (HIV), hepatitis B (HBV) and C (HCV) viruses infect millions of people around the world. People who use drugs (PWUD) are at high risk of such viral diseases and could be the source of these infections to other people. Shared needle, unsafe extra-marital sexual contact, skin popping and other risky behaviors are well-known risk factors for the prevalence of these infections among PWUD worldwide. There is no valid information regarding the danger and rate of the above-mentioned viral infections and associated risk factors among PWUD referred to healthcare facilities in Kabul, Afghanistan for the treatment and support. Objectives: The main objective of this study was to determine the prevalence and risk factors of HBV, HCV, and HIV among PWUD in Kabul, healthcare facilities. Methods: This study was conducted in 7 public and private healthcare facilities at the primary care level in Kabul, which provides social support and medical care to PWUD. All patients who referred to the healthcare facilities from May 2016 to October 2016 and signed the consent were included in this study. Results: Out of 410 PWUD, 15 (3.7%) were positive for the HBV surface antigen (HBsAg), 45 (11%) were positive for HCV antibody, and one (0.2%) was positive for HIV antibody. Among the risk factor variables studied, the administration of drugs by injection was considered the most important for HCV (OR = 3.80, P < 0.01) and viral infections among PWUD (OR = 5.40, P < 0.01). Conclusions: This study draws attention to the high prevalence and spread of viral hepatitis among PWUD in Kabul, Afghanistan. The prevalence of HCV and HBV was higher among PWUD compared to general populations, and drug use via injection was an important risk factor for transmitting viral infections. Based on our results, active preventive programs focusing on educational campaigns targeted at the youth populations should be undertaken in Afghanistan. Further studies, especially among PWUD living without shelter in Kabul and other major cities of Afghanistan, are recommended in order to better analyze the dangers among drug addicts in Afghanistan.

Background Nearly 20% of people in the United States use drugs each year. People who use drugs (PWUD) are predisposed to complex infections that require long term intravenous (IV) antibiotics. A frequent clinical quandary in PWUD is safe administration of extended IV antibiotics. Current standard of care is IV antibiotic administration in skilled nursing facilities. In this system, PWUD frequently do not finish antibiotic therapy, resulting in avoidable complications of untreated infections and increased healthcare utilization. We present a pilot study of ten patients with a history of addiction who required long-term IV antibiotics to evaluate the feasibility of self administered outpatient parenteral antibiotic therapy (S-OPAT) for PWUD. Methods Ten patients who had a history of mild addiction and stable housing, social support and transportation were enrolled at Parkland Health and Hospital System to complete S-OPAT. We extracted demographic, drug use, clinical and access to care variables and patients were followed with weekly clinical appointments. Addiction severity was defined using the National Institute of Drug Abuse (NIDA) -Modified ASSIST Score. We completed post-intervention surveys to evaluate the impact of the intervention on provider-patient trust. Results A total of 10 patients were enrolled in S-OPAT (Table 1). The patients were 48 years old on average, all were male and seven were Hispanic. All patients had stimulant use disorder and no patients had commercial insurance. Treated infections were bone/ joint and skin/soft tissue in origin. All patients completed their antibiotic course, nearly all appointments were attended (96%) and there were no 30-day hospital readmissions (Table 2). More than two-third of patients experienced improvement in addiction severity with progress in multiple psychosocial factors including housing instability, social support and legal problems (Figure 1; Table 2). Table 1. Demographic, substance use and clinical variables among people who use drugs enrolled in the pilot project for S-OPAT (N=10). Table 2. Clinical, drug use and psychosocial outcomes among people who use drugs and received S-OPAT (N=10). Addiction severity was defined using the National Institute of Drug Abuse (NIDA) -Modified ASSIST Score. Figure 1. Progression of addiction severity before and after completion of self-administered outpatient parenteral antibiotic therapy pilot among patients with a history of drug use (N=10). Addiction severity was defined using the National Institute of Drug Abuse (NIDA) -Modified ASSIST Score. Conclusion We demonstrate that PWUD can successfully complete S-OPAT with simultaneous improvement in addiction severity and psychosocial factors. We hope to create a framework for the patient-centered administration of extended courses of antibiotics for PWUD and to advocate for the expansion of individualized approaches to extended courses of IV antibiotics for PWUD. Disclosures All Authors: No reported disclosures

BackgroundHIV prevalence among people who use drugs (PWUD) in Tanzania is 4–7 times higher than in the general population, underscoring an urgent need to increase HIV testing and treatment among PWUD. Drug use stigma within HIV clinics is a barrier to HIV treatment for PWUD, yet few interventions to address HIV-clinic drug use stigma exist. Guided by the ADAPT-ITT model, we adapted the participatory training curriculum of the evidence-based Health Policy Plus Total Facility Approach to HIV stigma reduction, to address drug use stigma in HIV care and treatment clinics (CTCs).MethodsThe first step in the training curriculum adaptation process was formative research. We conducted 32 in-depth interviews in Dar es Salaam, Tanzania: 18 (11 men and 7 women) with PWUD living with HIV, and 14 with a mix of clinical [7] and non-clinical [7] CTC staff (5 men and 9 women). Data were analyzed through rapid qualitative analysis to inform initial curriculum adaptation. This initial draft curriculum was then further adapted and refined through multiple iterative steps of review, feedback and revision including a 2-day stakeholder workshop and external expert review.ResultsFour CTC drug use stigma drivers emerged as key to address in the curriculum adaptation: (1) Lack of awareness of the manifestations and consequences of drug use stigma in CTCs (e.g., name calling, ignoring PWUD and denial of care); (2) Negative stereotypes (e.g., all PWUD are thieves, dangerous); (3) Fear of providing services to PWUD, and; (4) Lack of knowledge about drug use as a medical condition and absence of skills to care for PWUD. Five, 2.5-hour participatory training sessions were developed with topics focused on creating awareness of stigma and its consequences, understanding and addressing stereotypes and fears of interacting with PWUD; understanding drug use, addiction, and co-occurring conditions; deepening understanding of drug use stigma and creating empathy, including a panel session with people who had used drugs; and working to create actionable change.ConclusionUnderstanding context specific drivers and manifestations of drug use stigma from the perspective of PWUD and health workers allowed for ready adaptation of an existing evidence-based HIV-stigma reduction intervention to address drug use stigma in HIV care and treatment clinics. Future steps include a pilot test of the adapted intervention.

In January 2023, the province of British Columbia (BC) decriminalized the possession of certain illegal drugs for personal use. The province’s primary intent was to reduce the stigma associated with drug use, as well as barriers for people who use drugs (PWUD) to access treatment and supports. However, less than ten months into the decriminalization policy, due to growing concerns about public safety voiced by municipal governments and communities, the provincial government made amendments to the policy to ban the public consumption of illicit drugs in additional locations, and subsequently introduced additional legislation, Bill 34, aimed at regulating public consumption of drugs in public spaces. Some communities have also implemented local bylaws similarly regulating public drug use. Bill 34 and local bylaws may serve as tools to promote community health and safety and minimize direct and indirect harms associated with public drug use. However, such legislation may re-criminalize PWUD and reinforce negative perceptions surrounding drug use, especially if these policies are not paired with strategies to expand the availability and accessibility of critical harm reduction and housing services. Without ample access to these services, limitations on public drug use can potentially displace individuals to areas where they are more likely to use alone, further exposing them to substance use-related harms, and undermining the goals of decriminalization. The potential effects of these restrictions may also disproportionately impact marginalized populations. As of April 2024, Bill 34 remains on hold. Moving forward, it will be important to monitor this bill, as well as other public consumption bylaws and legislation, and their impact on BC’s overall decriminalization initiative. Decision-makers are urged to increase engagement with PWUD and relevant stakeholders in the design and implementation of policies pertaining to public consumption to ensure that they effectively address the evolving needs and realities of PWUD, and align with decriminalization goals.

Sweden has a history of a restrictive drug policy, with a national policy focus on achieving a “drug free society.” This has led to a relatively slow development of “harm reduction” services, those services which aim to reduce risk and vulnerability for people who use drugs (PWUD), without requiring drug abstention. The harm reduction services which do exist are inequitably distributed across the country. In this context, this project aims to explore the attitudes of social work professionals (SWP) towards harm reduction, and the experiences of Swedish PWUD. The data consist of a survey of SWP (208 responses), interviews with PWUD in an area of limited harm reduction (11), and interviews with PWUD who had travelled to Denmark, a country with a less restrictive drug policy approach (17). Article I utilizes survey data to explore the perspectives of Swedish SWP regarding the philosophy of harm reduction and specific harm reduction initiatives. The study reveals a generally positive attitude towards harm reduction, albeit with significant geographical variances. There were low levels of support concerning the adoption of newer harm reduction strategies. Less positive attitudes and negativity regarding new interventions were significantly associated with SWP in areas with lesser exposure to harm reduction practices. Article II examines how PWUD in a small urban center handle the absence of local harm reduction services. The participants’ experiences are interpreted using the theoretical concept of “risk environment” which highlights how various environmental factors interact to produce risk of drug-related harm. Strategies ranged from traveling to external needle exchange programs, relying on unofficial secondary distribution, to risk behaviours such as stealing, reusing, or sharing injection equipment. Many were homeless, articulating a continuous struggle to find temporary shelter. They injected drugs in unsafe places, such as public toilets, increasing risk of overdose or infection. They also expressed 10 feeling stigmatized and excluded from society which compounded their stress, risk of disease transmission and overdose, and poor overall wellbeing. Article III explores the motivations behind the mobility of PWUD from Sweden to Denmark. The “risk environment” framework was used to contextualize decision-making and risks, based on the physical, social, policy, and economic environments. The study identifies harm reduction service availability, stigma, social networks, the drug scene, and policing practices, as key drivers for relocation. Despite the perceived benefits of moving, such as improved access to harm reduction services, participants also reported exposure to new risks, including violence, potential exclusion from a range of services, and exposure to new drugs. Article IV analyzes the reflections of PWUD on their experiences in Sweden and Denmark in the context of each nation’s drug policy. The analysis explored experiences of stigma and coupled these to concepts of identity and social exclusion. In daily interactions, participants felt ignored and dehumanized in Sweden’s zero-tolerance environment, whereas in Denmark, a country with a harm reduction approach, they felt visible and valued as individuals. This, combined with more developed services and a less punitive policing approach, led participants to feel included in society in Denmark. Contrasts between experiences in the two countries were also echoed in participants’ interactions with the healthcare system, relating to feeling controlled in Sweden, or being given autonomy and trust over their care in Denmark. Collectively, this thesis highlights the interplay between drug policies, care formats, policing practices, social interactions, the attitudes of SWP, and the lived experiences of PWUD. While overall positive, the attitudes towards care goals and interventions differ between different areas, among professionals who provide care to PWUD. PWUDs’ movement to and experiences in different settings can be used to offer an insight into their own policy preferences. The project demonstrates the role of constructions, and resulting drug policy, in how they influence PWUDs’ experiences of stigma and exclusion, and their risk environments.

"All it's gonna tell you is if it has fentanyl or not:" Perceptions of fentanyl and drug checking among first responders and people who use drugs.

People who use drugs (PWUD) experience stigma from multiple sources due to their drug use. HIV seroprevalence for PWUD in Tanzania is estimated to range from 18 to 25%. So, many PWUD will also experience HIV stigma. Both HIV and drug use stigma have negative health and social outcomes, it is therefore important to measure their magnitude and impact. However, no contextually and linguistically adapted measures are available to assess either HIV or drug use stigma among PWUD in Tanzania. In response, we translated and culturally adapted HIV and drug use stigma measures among Tanzanian PWUD and described that process in this study. This was a cross-sectional study. We translated and adapted existing validated stigma measures by following a modified version of Wild's ten steps for translation and adaptation. We also added new items on stigmatizing actions that were not included in the original measures. Following translation and back translation, we conducted 40 cognitive debriefs among 19 PWUD living with and 21 PWUD not living with HIV in Dar es Salaam to assess comprehension of the original and new items. For challenging items, we made adaptations and repeated cognitive debriefs among ten new PWUD participants where half of them were living with HIV. Most of the original items (42/54, 78%), response options and all items with new 12 stigmatizing actions were understood by participants. Challenges included response options for a few items; translation to Swahili; and differences in participants' interpretation of Swahili words. We made changes to these items and the final versions were understood by PWUD participants. Drug use and HIV stigma measures can successfully be translated and culturally adapted among Tanzanian PWUD living with and without HIV. We are currently conducting research to determine the stigma measures' psychometric properties and we will report the results separately.

Quality of life among people who use drugs living in poor urban communities in the Philippines.

BackgroundAfter the 2008 Global Financial Crisis and resulting economic austerity, the rise in illicit drug use engendered an increased need for people who use drugs (PWUD) to access medical care, compounded by the COVID-19 pandemic. Research shows that perceptions of medical staff towards PWUD facilitate or act as a barrier to accessing health care. This study provides a better understanding of health and social work professionals’ perceptions by assessing stigma levels towards PWUD in Athens, Greece.MethodsThis is a mixed-method study. It calculates the stigma score for professionals (n = 60) and the stigma score associated with specific drugs based on the Medical Condition Regard Scale through a quantitative analysis of responses to a semi-structured online survey about attitudes of health and social work professionals towards PWUD. It draws on the qualitative analysis of 12 semi-structured interviews with 16 service managers, providers, and health services advocates working in the charity sector to determine whether perceptions of PWUD affect writing and implementing policy and protocols for services.ResultsStigma towards PWUD exists amongst health and social work professionals in Athens. Professionals who have worked with PWUD for longer periods of time, professionals who have had specific training on working with PWUD, and professionals who feel that they have the necessary training to work with PWUD all demonstrated a higher stigma score than those reporting the opposite. Cannabis and opioids were associated with lower stigma scores while shisha had the highest level of stigma associated with it. Finally, professional environments are not conducive to alleviating stigma as the lack of training specific to stigma, the lack of professional supervision, and worker burn-out are key barriers faced by professionals in their everyday practice.ConclusionsReducing and eliminating stigma towards PWUD among health and social workers requires immediate action. Measures to be taken include: introducing training programs focused on stigma towards PWUD to healthcare providers, social workers, lawyers, police, the media; increasing professional supervision on field work for health and social workers; introducing low barrier health care and specialist units. Peers and field-focused organisations should meaningfully participate in drug and alcohol policymaking, program development, and implementation.

Access to appropriate oral healthcare is vital for overall health and well-being. However, people who use drugs (PWUD) often face significant barriers in accessing oral healthcare services. This qualitative study focused on exploring the perspectives of public oral health service providers and harm reduction workers to understand the barriers that they perceived were experienced by PWUD in accessing oral healthcare and identified potential strategies to address these barriers. Thirty-five participants (20 public oral health service providers and 15 harm reduction workers) were recruited from both metropolitan and regional areas of Victoria, Australia, through purposive sampling and a snowballing technique. Individual online semi-structured interviews were conducted, and data were analysed using a hybrid approach to thematic analysis. Service providers felt that continuous drug use impacted PWUD's ability to perceive dental pain, which delayed identification of oral health symptoms at the individual level. Major life crises meant that PWUD had limited awareness about the oral health consequences of their drug use, which further hindered their access to care. Service providers described how negative experiences and perceived judgements by PWUD about the visual effects of drugs created barriers to accessing dental care. Triggers of memories of traumatic abuse associated with the dental environments were also identified as a distressing factor for PWUD. Perceived service-level barriers included the lack of explicit recognition of PWUD as eligible for priority access in public dental clinics, financial impediments and coercive tactics from some oral health service providers. Service providers with experience of working in rural areas shared how the lack of anonymity and the risk of being identified as a drug user was an additional challenge for PWUD in accessing oral health services in rural areas. The participants proposed several potential strategies including drop-in oral health sessions at harm reduction facilities involving case managers to address appointment issues and training oral health service providers in trauma-informed care. They emphasised the need for interprofessional collaboration between oral health and harm reduction sectors. One key recommendation proposed by the participants was to establish oral health integrated harm reduction programmes that require careful consideration of feasibility, acceptability, resource allocation and potential implications on service quality. This study highlighted previously unrecognised perceived barriers by service providers working with PWUD that could impact the implementation of any interventions that aim to improve access to dental services by PWUD. By addressing the individual and service level barriers comprehensively, healthcare systems can better address the oral health needs of PWUD and reduce disparities in access to care.

BackgroundResearch collaborations between people who use drugs (PWUD) and researchers are largely underutilized, despite the long history of successful, community-led harm reduction interventions and growing health disparities experienced by PWUD. PWUD play a critical role in identifying emerging issues in the drug market, as well as associated health behaviors and outcomes. As such, PWUD are well positioned to meaningfully participate in all aspects of the research process, including population of research questions, conceptualization of study design, and contextualization of findings.Main bodyWe argue PWUD embody unparalleled and current insight to drug use behaviors, including understanding of novel synthetic drug bodies and the dynamics at play in the drug market; they also hold intimate and trusting relationships with other PWUD. This perfectly situates PWUD to collaborate with researchers in investigation of drug use behaviors and development of harm reduction interventions. While PWUD have a history of mistrust with the medical community, community-led harm reduction organizations have earned their trust and are uniquely poised to facilitate research projects. We offer the North Carolina Survivors Union as one such example, having successfully conducted a number of projects with reputable research institutions. We also detail the fallacy of meaningful engagement posed by traditional mechanisms of capturing community voice. As a counter, we detail the framework developed and implemented by the union in hopes it may serve as guidance for other community-led organizations. We also situate research as a mechanism to diversify the job opportunities available to PWUD and offer a real-time example of the integration of these principles into public policy and direct service provision.ConclusionIn order to effectively mitigate the risks posed by the fluid and volatile drug market, research collaborations must empower PWUD to play meaningful roles in the entirety of the research process. Historically, the most effective harm reduction interventions have been born of the innovation and heart possessed by PWUD; during the current overdose crisis, there is no reason to believe they will not continue to be.

Evidence that opioid agonist therapy (OAT) is associated with increased odds of hepatitis C virus (HCV) treatment initiation among people who use drugs (PWUD) is emerging. The objective of this study was to determine the association between current OAT and HCV treatment initiation among PWUD in a population-level linked administrative dataset. The British Columbia Hepatitis Testers Cohort was used for this study, which includes all people tested for or diagnosed with HCV in British Columbia, linked to medical visits, hospitalizations, laboratory, prescription drug, and mortality data from 1992 until 2019. PWUD with injecting drug use or opioid use disorder and chronic HCV infection were identified for inclusion in this study. HCV treatment initiation was the main outcome, and subdistribution proportional hazards modeling was used to assess the relationship with current OAT. In total, 13 803 PWUD with chronic HCV were included in this study. Among those currently on OAT at the end of the study period, 47% (2704/5770) had started HCV treatment, whereas 22% (1778/8033) of those not currently on OAT had started HCV treatment. Among PWUD with chronic HCV infection, current OAT was associated with higher likelihood of HCV treatment initiation in time to event analysis (adjusted hazard ratio 1.84 [95% confidence interval {CI}, 1.50, 2.26]). Current OAT was associated with a higher likelihood of HCV treatment initiation. However, many PWUD with HCV currently receiving OAT have yet to receive HCV treatment. Enhanced integration between substance use care and HCV treatment is needed to improve the overall health of PWUD.