Trends in Injecting Methamphetamine and Opioids Among People Who Inject Drugs in the US

HIV Prevention, Treatment, and Care for People Who Inject Drugs

Background: People who inject drugs have a greater risk of infectious disease and mortality than other substance abusers and nondrug users. Variation in risk behavior among people who inject drugs is likely associated with comorbid mental health disorders. Objectives: Examine the association between a history of mood disorder and recent risk behavior among people who inject drugs. Methods: With baseline data from a behavioral HIV prevention clinical trial in a population of people who inject drugs, we used logistic regression models to compare the risk behaviors of people who report a past diagnosis of bipolar disorder (n = 113) or depression (n = 237) to a comparison group with no history of diagnosed mental illness (n = 446). We also assessed differences between groups before and after adjusting for demographic characteristics and current depressive symptoms. Results: While there were no differences between groups in frequency of drug use, people who inject drugs who report a history of mood disorders reported more injection risk behaviors, drug overdoses, sex exchanges, and multiple partners than those with no history of mental illness. Adjusting the comparison for demographic characteristics and current depressive symptoms had little impact on these findings. Variation in risk between depression and bipolar disorder groups was minimal. Conclusions/Importance: People who inject drugs and have mood disorders have unique and significant social, clinical, and risk reduction needs. Despite the limited validity of self-reported mental health history, simply asking about a history of mood disorder may be effective for identifying a particularly vulnerable population of people who inject drugs.

An estimated 3.7 million people inject drugs in Eurasia, representing the second highest prevalence of injecting drug use worldwide. Around one in four people who inject drugs in the region are living with HIV. From 2000 to 2010, the number of people living with HIV has increased by 250% in Eurasia, and the spread of HIV remains concentrated among people who inject drugs and their sexual partners. Drug injection is also one of the main drivers of hepatitis C in the region, with the prevalence among people who inject drugs ranging from 30% in Azerbaijan to 95% in Lithuania. These trends clearly show the need for governments to prioritise the delivery of comprehensive HIV prevention services targeting people who inject drugs, including needle and syringe programmes (NSPs) and opiate substitution therapy (OST) in the region. However, since the beginning of the HIV epidemic in the mid-1990s, governments have given little or no political support to harm September 2012 reduction. As a result, these services often rely on limited financial support and operate under hostile political environments, while the overall regional approach to drug control has been focused on severe drug laws and their enforcement towards people who use drugs. This focus on repression has led to numerous examples of police practice undermining the health and social programmes that are designed to reduce drug problems in the region. The purpose of this briefing paper, written by IDPC in collaboration with the Eurasian Harm Reduction Network, is to review up-to-date evidence on the institutionalisation of police violence toward people who use drugs across the region and the implications of these practices for public health and society. The review relies on data collected from several Eurasian countries and depicts instances of police abuse against people who use drugs as systematic practices widespread across the region. The paper concludes that the quantity and quality of interactions with the police profoundly shape the behaviour of people who use drugs and result in poor public health outcomes.

High Prevalence of Indications for Pre-exposure Prophylaxis Among People Who Inject Drugs in Boston, Massachusetts

BackgroundThe ongoing volatile opioid epidemic remains a significant public health concern, alongside continued outbreaks of HIV and hepatitis C virus among people who inject drugs. The limited access to and scale-up of medications for opioid use disorder (MOUD) among people who inject drugs, coupled with multilevel barriers to pre-exposure prophylaxis (PrEP) uptake, makes it imperative to integrate evidence-based risk reduction and HIV prevention strategies in innovative ways. To address this need, we developed an integrated rapid access to HIV prevention program for people who inject drugs (iRaPID) that incorporates same-day PrEP and MOUD for this population.ObjectiveThe primary objective of this pilot study is to assess the feasibility and acceptability of the program and evaluate its preliminary efficacy on PrEP and MOUD uptake for a future randomized controlled trial (RCT). We also aim to explore information on the implementation of the program in a real-world setting using a type I hybrid implementation trial design.MethodsUsing a type I hybrid implementation trial design, we are pilot testing the nurse practitioner–led iRaPID program while exploring information on its implementation in a real-world setting. Specifically, we will assess the feasibility and acceptability of the iRaPID program and evaluate its preliminary efficacy on PrEP and MOUD uptake in a pilot RCT. The enrolled 50 people who inject drugs will be randomized (1:1) to either iRaPID or treatment as usual (TAU). Behavioral assessments will occur at baseline, and at 1, 3, and 6 months. Additionally, we will conduct a process evaluation of the delivery and implementation of the iRaPID program to collect information for future implementation.ResultsRecruitment began in July 2021 and was completed in August 2022. Data collection is planned through February 2023. The Institutional Review Boards at Yale University and the University of Connecticut approved this study (2000028740).ConclusionsThis prospective pilot study will test a nurse practitioner–led, integrated HIV prevention program that incorporates same-day PrEP and MOUD for people who inject drugs. This low-threshold protocol delivers integrated prevention via one-stop shopping under the direction of nurse practitioners. iRaPID seeks to overcome barriers to delayed PrEP and MOUD initiation, which is crucial for people who inject drugs who have had minimal access to evidence-based prevention.Trial RegistrationClinicalTrials.gov NCT04531670; https://clinicaltrials.gov/ct2/show/NCT04531670International Registered Report Identifier (IRRID)DERR1-10.2196/42585

ABSTRACTBackground: Perceived experiences of stigma have been found to be associated with poorer psychosocial outcomes and engagement in risk practices among people who inject drugs. Yet the extent to which people internalize or accept the stigma surrounding their injecting drug use, and whether this is associated with risky injecting practices, is not well known. Objectives: The aim of this study was to assess the extent of internalized stigma among a sample of people who inject drugs in Australia and identify socio-demographic, injecting risk, and mental health correlates. Methods: People who inject drugs were recruited from a needle and syringe program located in Sydney, Australia to complete a brief survey. The survey included measures of internalized stigma, severity of drug dependence, self-esteem, depression, and shared use of injecting equipment. Results: The sample comprised 102 people who inject drugs. Internalized stigma was higher among participants who reported being depressed in the past month, and was also associated with greater severity of drug dependence and diminished self-esteem. There was no relationship between internalized stigma and shared use of needles or other injecting equipment in the past month. Conclusions/Importance: Findings underscore the need for further investigation of internalized stigma among people who inject drugs. In particular, future research should assess the impact of implicit (i.e., subconscious) internalized stigma on mental health.

The perception that people who use illicit drugs are deviant has contributed to the stigmatization of this population. The primary aim of this review is to examine the links among injection-related discrimination, mental health, physical health, and quality of life in people who inject drugs. We also identify settings, perpetrators of discrimination, and coping strategies developed by people who inject drugs to deal with the issue. Online databases MEDLINE (PubMed), EMBASE, CINAHL (EbscoHost), and PsycINFO (APA PsycNET) were searched for articles focusing on injection-related discrimination against people who inject drugs. Findings were compared for consistency. Qualitative and quantitative articles were evaluated separately. Eleven articles were included in the final review. Several links between discrimination and negative health outcomes were identified. Discrimination was associated with engagement in risky injecting behavior as well as psychological distress. The perpetrators of discrimination against people who inject drugs included general community members and service providers. Attempts to hide addiction was the main strategy used to cope with discrimination. Injection-related discrimination was associated with higher psychological distress levels, unhealthy behaviors, and low quality of life in people who inject drugs. By addressing the stigma of deviance, discrimination and associated negative health outcomes may be reduced.

The introduction of interferon-free direct-acting antiviral therapy for HCV has been a defining moment in medicine. These new medications have begun the discussion about potential hepatitis C elimination. In the developed world, the majority of new and existing hepatitis C infections occur among people who inject drugs. Although considerable barriers exist to link and engage people who inject drugs in medical care, these barriers should not exclude them from hepatitis C treatment. It has been clearly demonstrated that people who inject drugs can be effectively treated for hepatitis C with high rates of adherence and sustained virologic response and low rates of re-infection. To maximize the impact of direct-acting antivirals on the hepatitis C epidemic, more people who inject drugs need to be cured. Further research is needed to examine novel strategies and care models to find, link, engage, and cure hepatitis C-infected people who inject drugs.

BackgroundIn 2019, 62% of new HIV infections occurred among key populations (KPs) and their sexual partners. The World Health Organization (WHO) recommends implementation of bio-behavioral surveys every 2-3 years to obtain HIV prevalence data for all KPs. However, the collection of these data is often less frequent and geographically limited.ObjectiveThis study intended to assess the availability and quality of HIV prevalence data among sex workers (SWs), men who have sex with men (MSM), people who inject drugs, and transgender women (transwomen) in low- and middle-income countries.MethodsData were obtained from survey reports, national reports, journal articles, and other grey literature available to the Global Fund, Joint United Nations Programme on HIV/AIDS, and WHO or from other open sources. Elements reviewed included names of subnational units, HIV prevalence, sampling method, and size. Based on geographical coverage, availability of trends over time, and recency of estimates, data were categorized by country and grouped as follows: nationally adequate, locally adequate but nationally inadequate, no recent data, no trends available, and no data.ResultsAmong the 123 countries assessed, 91.9% (113/123) presented at least 1 HIV prevalence data point for any KP; 78.0% (96/123) presented data for at least 2 groups; and 51.2% (63/123), for at least 3 groups. Data on all 4 groups were available for only 14.6% (18/123) of the countries. HIV prevalence data for SWs, MSM, people who inject drugs, and transwomen were available in 86.2% (106/123), 80.5% (99/123), 45.5% (56/123), and 23.6% (29/123) of the countries, respectively. Only 10.6% (13/123) of the countries presented nationally adequate data for any KP between 2001 and 2017; 6 for SWs; 2 for MSM; and 5 for people who inject drugs. Moreover, 26.8% (33/123) of the countries were categorized as locally adequate but nationally inadequate, mostly for SWs and MSM. No trend data on SWs and MSM were available for 38.2% (47/123) and 43.9% (54/123) of the countries, respectively, while no data on people who inject drugs and transwomen were available for 76.4% (94/123) and 54.5% (67/123) of the countries, respectively. An increase in the number of data points was observed for MSM and transwomen. Overall increases were noted in the number and proportions of data points, especially for MSM, people who inject drugs, and transwomen, with sample sizes exceeding 100.ConclusionsDespite general improvements in health data availability and quality, the availability of HIV prevalence data among the most vulnerable populations in low- and middle-income countries remains insufficient. Data collection should be expanded to include behavioral, clinical, and epidemiologic data through context-specific differentiated survey approaches while emphasizing data use for program improvements. Ending the HIV epidemic by 2030 is possible only if the epidemic is controlled among KPs.

Background Despite the growing relevance of rural areas in the overdose crisis, research on rural people who inject drugs and their experiences with law enforcement remains limited. This research examines how rural policing and stigma uniquely shape the lives of people who inject drugs. Methods Forty-one semi-structured qualitative interviews were conducted with people who inject drugs in southern Illinois. For this analysis, we focused on participants who mentioned police in response to the question, “Have you ever been treated differently because you used drugs?” Results We identified three interrelated manifestations of stigma in rural people who inject drugs’ interactions with police—verbal degradation and discrediting, unwarranted searches, and dehumanization—that align with Earnshaw’s (2020) model distinguishing between stigma components (stereotypes, prejudice, discrimination) and health impact pathways. Conclusion This study emphasizes the impact of stigma on people who use drugs, particularly in their interactions with law enforcement.

BackgroundA Cross-sectional Rapid Situational Assessment of People Who Inject Drug (PWIDs) applying Respondent Driven sampling techniques (RDS) was used to recruit subjects/participants in a study aimed at assessing HIV prevalence and risk behaviors among injecting drug users in Nairobi and Coastal regions of Kenya. There is paucity of data and information on injecting drug use in sub-Saharan Africa and there is sufficient evidence of existence of the environment for development and growth of injecting drug use. Past studies on PWID and its association to HIV and AIDS that have been conducted in Kenya do not provide sufficient information to support effective planning and comprehensive national response to the HIV and AIDS epidemic.MethodsA cross-sectional study design was adopted in which a set of initial subjects referred to as ‘seeds’ were first identified from which an expanding chain of referrals were obtained, with subjects from each wave referring subjects of subsequent waves. The seeds were drawn randomly from the population and interviewed to pick the one with the largest network and other unique characteristics. A maximum of twelve seeds were recruited. The second stage involved conducting assessment visits to the sites to identify potential collaborators that included non-governmental organizations (NGOs), drug treatment centres, health facilities, community based organizations (CBO’s) among others. Three NGOs located in the coast region and one in Nairobi region were identified to assist in identifying drug injection locations and potential participants. Key informant interviews (KIIs) and Focus Group Discussions (FGDs) were also conducted using interview guides.ResultsA total of 646 individuals (344 in Nairobi and 302 at the coast) were recruited for the study between January and March 2010. Of these 590 (91%) were male and 56 (9%) were female. Findings showed that most PWIDs initiated injecting drug use between the ages of 20–29 years, with the youngest age of initiation being 11 years and oldest age being 53 years. Most commonly injected drug was heroin (98%), with a small (2%) percentage injecting cocaine. Other non-injecting methods such as smoking or combining these two drugs with other drugs such as cannabis or Rohypnol were also common. Most PWIDs used other substances (cigarettes, alcohol, and cannabis) before initiating injecting drug use. The adjusted national HIV prevalence of PWIDs was 18.3% (19.62% unadjusted) with PWIDs in Nairobi region registering 18.33% (20.58% unadjusted) compared PWIDs for Coastal region indicating 18.27% (18.59% - unadjusted). The gender based HIV prevalence showed that women were more at risk of acquiring HIV (44.51%-adjusted) compared to men (15.97%-adjusted). The age specific HIV prevalence showed that PWIDs who initiated injecting at 11–19 years (44.7% adjusted) were most at risk in Nairobi compared to those who initiated injecting at age 20–24 years (23.2% - adjusted) in the coastal region. While all PWIDs continue to be at risk in the two regions, those from the Western parts of Nairobi, Kenya were at a relatively higher risk given their increased propensity for sharing injecting equipment and solutions.ConclusionsCompared to the national HIV prevalence of (4.9%), the results show that People Who Inject Drugs (PWIDs) are at particularly high risk of infection in Kenya and there is urgent need for intervention (KenPHIA, 2018). This study also showed clear evidence that 70% of PWIDs are primary school educated, engage in high risk injecting and sexual behaviors comprising sharing of injecting equipment, unprotected heterosexual and homosexual sex. Given that initiation of injecting drug use begins early and peaks after formal school years (20–29 years), prevention programmes should be targeted at primary and secondary school students, college and out of school youth. Further, to protect People who inject drugs (PWIDs) from HIV infection, the country should introduce free Needle Syringe Programs (NSP) with provision of condoms and Methadone Assisted Therapy (MAT) as a substitute for drug use.

Violence experience has been consistently associated with HIV risks and substance use behaviors. Although many studies have focused on intimate partner violence (IPV), the role of violence at a structural level (i.e., police abuse) remains relevant for people who inject drugs. This study evaluated the association of IPV and police-perpetrated violence experiences with HIV risk behaviors and substance use in a cohort of HIV-positive people who inject drugs in Ukraine. We also evaluated possible moderation effects of gender and socioeconomic status in the links between violence exposure and HIV risk and polysubstance use behaviors. Data came from the Providence/Boston-CFAR-Ukraine Study involving 191 HIV-positive people who inject drugs conducted at seven addiction treatment facilities in Ukraine. Results from logistic regressions suggest that people who inject drugs and experienced IPV had higher odds of polysubstance use than those who did not experience IPV. Verbal violence and sexual violence perpetrated by police were associated with increased odds of inconsistent condom use. The odds of engaging in polysubstance use were lower for women in relation to police physical abuse. We found no evidence supporting socioeconomic status moderations. Violence experiences were associated with substance use and sexual HIV risk behaviors in this cohort of HIV-positive people who inject drugs in Ukraine. Trauma-informed prevention approaches that consider both individual and structural violence could improve this population's HIV risks.

Contract with the patient with injection drug use and infective endocarditis: Surgeons perspective

ABSTRACTIntroductionPeople who inject drugs are at elevated risk of hepatitis B virus (HBV) infection, which is preventable by vaccination. We examined susceptibility to HBV infection among a sample of people who inject drugs and live in Montreal, Canada.MethodsData were obtained from HEPCO, a prospective cohort study of people who had recently (within the past six months) injected drugs, between November 2022 and March 2024. The absence of hepatitis B surface antibody indicated susceptibility to HBV infection. These results were compared to self‐report immune status. Logistic regression was used to identify factors associated with HBV susceptibility.ResultsOverall, 28.1% (108/384) of participants were susceptible to HBV infection. Over half (60.2%, 231/384) of participants correctly reported their immune status. Individuals born in Canada prior to the introduction of universal childhood vaccination programs had higher odds of susceptibility to HBV infection (adjusted odds ratio: 2.63, 95% confidence interval: 1.34–5.61), while those in opioid agonist treatment (0.60, 0.37–0.98) and with a history of hepatitis C infection (0.51, 0.32–0.83) had lower odds of HBV susceptibility.Discussion and ConclusionsAn important minority of people who inject drugs in Montreal remain susceptible to HBV infection. Moderate concordance between self‐report and serological results indicates that serology or vaccine registry information should continue to be used to inform immunisation provision. People who inject drugs who were born prior to childhood vaccination programs and/or are not in opioid agonist treatment are subpopulations who require targeted interventions to increase vaccination coverage.

Back to table of contents Previous article Next article Clinical & ResearchFull AccessSevere Grief Tied to Experiencing, Witnessing OverdoseTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:23 Sep 2022https://doi.org/10.1176/appi.pn.2022.10.10.16AbstractRepeated exposure to overdose events has a cumulative effect on how people who use illicit substances feel grief in response to loss.Experiencing or witnessing multiple overdose events is associated with severe grief among people who inject drugs, a study in Drug and Alcohol Dependence has found.Repeated exposure to overdose events can shape how people who use illicit substances understand the world and violate their sense of safety, says Kathleen S. Kenny, Ph.D.“We know that grief can have significant deleterious effects, and we wanted to understand how it was being experienced by people in the context of the opioid overdose crisis and its unceasing onslaught of overdose deaths and near deaths,” lead author Kathleen S. Kenny, Ph.D., told Psychiatric News. She is a Canadian Institutes of Health Research postdoctoral fellow at the Manitoba Centre for Health Policy in the Department of Community Health Sciences at the University of Manitoba. “A main takeaway from the study is that cumulative, rather than single, overdose events were associated with severity of responses to grief and loss.”Kenny and colleagues examined data from a survey of 244 people who injected drugs in four community-based harm reduction programs in Toronto. Participants were 16 years of age or older and had injected drugs in the past three months. The researchers defined three types of overdose events: the participant’s own overdose, an overdose witnessed by the participant, and the overdose death of a person important to the participant. They then asked whether participants agreed with seven statements about how they were affected by overdose-related losses. The statements included “I feel like I’ve lost parts of myself,” “I feel like life has really changed,” “I feel like things I use to cope don’t help anymore,” “I feel numbed out,” “I’m not sure how to make sense of all the losses I’ve experienced,” “I feel angry,” and “I feel like I’ve lost a lot of my community.” The participants who answered “yes” to a higher number of statements were considered to have more severe responses to grief and loss.Among all participants, 28.7% reported two or more personal overdoses of their own, 70.9% witnessed two or more overdoses in other people, and 28.3% had experienced the loss of two or more people important to them in the previous six months. The researchers found that participants who experienced two or more personal overdoses, witnessed one overdose in someone else, or witnessed two or more overdoses in other people had the greatest likelihood of having severe responses to grief and loss. Severe responses were also more common among participants who were exposed to all three types of overdose events (their own overdose, overdose in other people, and overdose death in other people).Psychiatrists should be careful not to overlook a patient’s grief, even as they seek to treat the patient’s substance use disorder, says Frances R. Levin, M.D.Columbia UniversityKenny said that the results suggest that multiple, repeat exposure to overdose events may lead to a disrupted assumptive world among people who use drugs.“People’s core beliefs around everyday functioning, understanding of the world, and sense of safety are violated due to the continued, repeated experience of overdoses in their own lives, and the unrelenting loss of people in their communities to overdose,” Kenny explained.Frances R. Levin, M.D., the Kennedy-Leavy Professor of Psychiatry at Columbia University Irving Medical Center and chief of the Division on Substance Use Disorders at New York State Psychiatric Institute at Columbia, stressed the need for psychiatrists to create space in which patients who use drugs or have substance use disorder may grieve their losses.“When someone comes in for treatment, we tend to focus on treating the addiction, but it’s important not to overlook the patient’s grief,” said Levin, who was not involved in the research. “Explore with them what they’ve experienced, how they’ve experienced it, and how they have tried to cope with it, and provide support in handling their grief.”This study was supported by funding from the Canadian Institutes of Health Research. One of the researchers is also supported by a postdoctoral fellowship from the Canadian Network on Hepatitis C. ■Resources“Frequency of Fatal and Non-Fatal Overdoses and Response to Grief and Loss Among People Who Inject Drugs: An Unexplored Dimension of the Opioid Overdose Crisis” ISSUES NewArchived