Drug-related Harm Research Articles

Dynamics of drug overdose in the 20th and 21st centuries: The exponential curve was not inevitable, and continued increases are preventable.

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's “public policy instrument and instrumentation” framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection.Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700 h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks).First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics.Montreal SIS were conceptualized under a “health banner” and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of “zero risk” and “harm reduction”, and ambiguity about how injection should be supervised and what parts of drug use could be managed.

Reply commentary by Jalal and Burke.

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's “public policy instrument and instrumentation” framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection.Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700 h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks).First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics.Montreal SIS were conceptualized under a “health banner” and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of “zero risk” and “harm reduction”, and ambiguity about how injection should be supervised and what parts of drug use could be managed.

Between zero risk and harm reduction: An ethnography of Montreal supervised injection services as a public policy instrument.

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's "public policy instrument and instrumentation" framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection. Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks). First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics. Montreal SIS were conceptualized under a "health banner" and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of "zero risk" and "harm reduction", and ambiguity about how injection should be supervised and what parts of drug use could be managed.

A qualitative study exploring the impact of the COVID-19 pandemic on People Who Inject Drugs (PWID) and drug service provision in the UK: PWID and service provider perspectives.

BackgroundPeople Who Inject Drugs (PWID) are subject to distinct socio-structural inequalities that can expose them to high risks of COVID-19 transmission and related health and social complications. In response to COVID-19 mitigation strategies, these vulnerabilities are being experienced in the context of adapted drug treatment service provision, including reduced in-person support and increased regulatory flexibility in opioid substitution therapy (OST) guidelines. This study aimed to explore the longer-term impact of the pandemic on the health and wellbeing of PWID in the UK, including provider and client experiences of treatment changes.MethodsInterviews were conducted with 19 PWID and 17 drug treatment providers between May and September 2021, recruited from drug and homelessness charities providing treatment services and healthcare in the UK. Data were analysed using reflexive thematic analysis.ResultsMost participants expressed ongoing fears of COVID-19 transmission, although socio-structural inequalities limited the contexts in which physical distancing could be practised. In addition, virus mitigation strategies altered the risk environment for PWID, resulting in ongoing physical (e.g. changing drug use patterns, including transitions to crack cocaine, benzodiazepine and pregabalin use) and socio-economic harms (e.g. limited opportunities for sex work engagement and income generation). Finally, whilst clients reported some favourable experiences from service adaptations prompted by COVID-19, including increased regulatory flexibility in OST guidelines, there was continued scepticism and caution among providers toward sustaining any treatment changes beyond the pandemic period.ConclusionsWhilst our findings emphasize the importance of accessible harm reduction measures attending to changing indices of drug-related harm during this period, there is a need for additional structural supports to ensure pre-existing disparities and harms impacting PWID are not exacerbated further by the conditions of the pandemic. In addition, any sustained policy and service delivery adaptations prompted by COVID-19 will require further attention if they are to be acceptable to both service users and providers.

Drug Consumption Rooms and Public Health Policy: Perspectives of Scottish Strategic Decision-Makers.

There is widespread support for the introduction of Drug Consumption Rooms (DCRs) in Scotland as part of a policy response to record levels of drug-related harm. However, existing legal barriers are made more complex by the division of relevant powers between the UK and Scottish Governments. This paper reports on a national, qualitative study of key decision-makers in both local and national roles across Scotland. It explores views on the political barriers and enablers to the adoption of Drug Consumption Rooms and the potential role of these facilities in the wider treatment system. It also considers approaches to evidence, especially the types of evidence that are considered valuable in supporting decision-making in this area. The study found that Scottish decision-makers are strongly supportive of DCR adoption; however, they remain unclear as to the legal and political mechanisms that would make this possible. They view DCRs as part of a complex treatment and support system rather than a uniquely transformative intervention. They see the case for introduction as sufficient, on the basis of need and available evidence, thus adopting a pragmatic and iterative approach to evidence, in contrast to an appeal to traditional evidence hierarchies more commonly adopted by the UK Government.

Controlled Delivery of Illegal Drug Parcels in Scotland: Does Policing Practice Align With a Public Health Approach Focused on Drug-Related Harm?

An increase in the flow of drugs into the UK via international postal systems poses challenges for law enforcement. ‘Controlled delivery’ can be used to disrupt supply networks and secure intelligence for prosecution; however, critics argue that law enforcement should instead focus on reducing drug-related harm. In Scotland, national drugs strategy adopts a public health approach but it is unclear whether this extends to policing practice. Therefore, this paper examines whether controlled delivery of drug parcels aligns with a public health policing approach. We find evidence of alignment in terms of potential harm to individual users, particularly in relation to legal highs, but not in terms of drug-related harms within the communities to which parcels were destined. We argue that further investigation is required in order to assess the extent to which political intent and policing practice in Scotland align around the principles of harm reduction and public health.

Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada.

People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019. We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS). Median age of participants (N=1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits). HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.

Deal or no-deal? Using administrative data to explore buyer motivation in online drug purchases and its association with community risk factors in Scotland.

The expansion of online drugs markets has widened opportunities to purchase drugs, for both personal use and wider distribution, thus creating new potential public health risks. However, there is little research on the motivation of online drug purchasers or the level of risk that such transactions pose to different communities. Greater insights into the intended use of drug parcels arriving by post, and how this varies across communities could help law enforcement and health services develop more effective policies and better allocate resources to reduce drug-related harms. We use Scottish administrative data about illegal drug parcels seized by the UK Border Force to create a new classification of 'buyer motivation' (based on type of drug, estimated number of doses purchased, and patterns of drug consumption). We identify three potential types of buyer motivation: personal consumption, heavy use or social dealing, and wholesale dealing; and examine the extent to which each type is associated with a range of drug-related community risk factors, thereby identifying potential variation in levels of public health risk. Communities to which drug parcels were destined differed significantly from the Scottish average across a range of factors; however, this varied by buyer motivation. Parcels thought to be purchased for heavy use or social dealing appeared to pose a greater risk within communities characterised by general deprivation, but especially health-related deprivation, with a high youth population but low unemployment rates; whereas those purchased for wholesale dealing appear most likely to pose a risk in communities with higher crime and unemployment rates. Administrative data about intercepted drug parcels could be helpful in classifying the motivation of online drug purchasers and monitoring patterns of variation in potential public health risks at a community level. This could support law enforcement and public health agencies to develop more targeted drug-harm reduction strategies.

Marking a Quiet Community: Analyzing Narratives of Community Reentry Among Filipino Plea Bargainers

Since President Rodrigo Duterte launched his war on drugs campaign in 2016, there has been a growing scholarship documenting the empirical analyses of the policy’s drug-related harms. Eighteen Filipino plea bargainers were interviewed and asked to narrate their experiences of eventually returning back to the community after release. Their stories were analyzed using Stephens and Breheny’s (2013) integrated approach to narrative analysis. Three broader categories were evident that evoke the interplay between wider systemic conditions and one’s exercise of restricted agency. Under first broader category of reentering a spatially marked and quiet community, four personal narratives are evident, namely: I don’t want to go out anymore, I just keep away from that place, I don’t see them anymore, and I’m living in a dead town. Under the second broader category of my family upon reentering the community, two personal narratives are evident: I felt ashamed and Where are you going? Don’t use anymore. Under the third broader category of reentering the community without work, three personal narratives are evident: I could not give anything to my children, I did all the work at home, and I’m looking for work, but. Our findings contribute to the examination of interlocking systemic conditions surrounding the accounts of those incarcerated in local police crackdowns. In this context, there is a strong need to respond to the challenges of rebuilding community processes (e.g., permanently delisted from the community drug watchlist) and strengthening employment opportunities in partnership with the local government.

Towards Housing First and harm reduction: addressing opioid dependence and homelessness in Tshwane during the COVID-19 pandemic

Pandemics can increase mortality and drug-related harms among people experiencing homelessness. The Housing First approach prioritises housing and service access. Harm reduction, a principle of Housing First, minimises the consequences of drug use. This chapter presents lessons learnt from the application of Housing First and harm reduction principles with homeless people in Tshwane, South Africa, between April 2020 and March 2021. Quantitative service delivery data were retrospectively reviewed and analysed using descriptive statistics. Accounts by authors who participated in the COVID-19 response were collectively discussed in relation to the Housing First and harm reduction actors and process. Issues were synthesised in relation to two six-month periods. A task team was established to co-ordinate Tshwane’s response. In the first six months, 1 440 temporary bed-spaces were created at 25 shelters, and 2 066 people at shelters received food, social support and on-site healthcare services. Across shelters, 1 076 residents were started on methadone to manage opioid withdrawal. By the second six-month period, many gains were lost. Changes in political leadership stalled plans to reintegrate people housed in temporary shelters, and reduced funding led to shelter closures. By April 2021, more shelters operated than in pre- COVID-19 times, harm reduction capacitation for shelter staff continued, and local government committed to establish a street homelessness unit. Through a combination of funding and collaboration, progress was made towards Housing First and harm reduction for homeless people in Tshwane. A national policy on homelessness should be developed, funded and implemented. This should be informed by additional research, developed in partnership with affected populations, and built on a common understanding of Housing First and harm reduction.

Opioid agonist treatment (OAT) experiences and release plans among federally incarcerated individuals with opioid use disorder (OUD) in Ontario, Canada: a mixed-methods study

BackgroundIncarcerated populations experience an elevated prevalence of opioid use disorder (OUD). Federal correctional institutions in Canada have increasingly treated OUD among correctional populations via opioid agonist treatment (OAT) – an evidence based pharmacotherapy that works to reduce drug use and related health harms. However, there is limited evidence regarding incarcerated individuals’ experiences with institutional-based OAT, as well potential OAT-related community release prospects. This information is important for optimal treatment retention and improved health. To address this knowledge gap, we conducted a longitudinal follow-up study examining OAT-related experiences among federally incarcerated individuals before and after community release. This article focuses on the baseline (pre-release) data.MethodsThis mixed-methods study examined OAT-related experiences and release prospects among n = 46 individuals scheduled for community release, recruited from seven federal prisons located in Ontario, Canada. Participants underwent a comprehensive interviewer-administered on-site assessment, including quantitative and qualitative items. Assessment data was furthermore linked to administrative correctional data. Data were analyzed using thematic qualitative and descriptive quantitative approaches.ResultsParticipants had complex histories with opioid use including related negative health outcomes. Experiences with institutional OAT were divergent and provision was not standardized; those with OAT engagement pre-admission did not experience many challenges, whereas those initiating OAT during incarceration experienced barriers such as treatment waitlists and adverse process experiences. Most participants expressed a preference for buprenorphine-naloxone over methadone, but described difficulties accessing it. Participants were keen to transition into community-based treatment, yet envisaged prospective barriers and facilitators concerning successful reintegration and treatment continuity.ConclusionsMajor barriers towards the current administration of OAT in federal correctional systems in Canada exist, including extensive waitlists, non-standardized practices, and challenges accessing preferred OAT formulations; this contributes to sub-optimal treatment. Eliminating waitlists, standardizing OAT provision, providing additional OAT options, and more comprehensive release planning may be essential for treatment retention and positive outcomes.

Overdose prevention centres in the UK

Overdose prevention centres in the UK

The co-production of shifting intoxications: synthetic cannabinoids, stigma, risk and harm

Synthetic cannabinoids (also referred to as ‘Spice’ and synthetic cannabinoid receptor agonists (SCRAs)) have become part of the global drug landscape. The rise of new psychoactive substances (NPS) presents unique challenges for policy makers and those who seek to reduce drug-related harms. Synthetic cannabinoids are often noted as having intense effects due to their interactions with receptors in the brain. In recent years, they have become popular amongst disadvantaged groups who suffer from multiple health and other social harms. The association of synthetic cannabinoids with groups such as those who are homeless, has led to the intensification of stigma around this particular drug. This conceptual paper seeks to explore shifting intoxications in relation to synthetic cannabinoids, including a discussion of debates about stigma and the co-production of knowledge about drugs and their users. The legislative responses to NPS and synthetic cannabinoids will also be examined focusing on the notion of ‘success’ and global legislation. Recent NPS legislation is positioned as part of the co-production of synthetic cannabinoid users and their construction as abject and disorderly. As such, it becomes part of the assemblage of synthetic cannabinoids and creates an environment that produces risks and harms for specific marginalised groups.

The Impact of the COVID-19 Pandemic on Drug Use Behaviors, Fentanyl Exposure, and Harm Reduction Service Support among People Who Use Drugs in Rural Settings.

Background: The COVID-19 pandemic has worsened the opioid overdose crisis in the US. Rural communities have been disproportionately affected by opioid use and people who use drugs in these settings may be acutely vulnerable to pandemic-related disruptions due to high rates of poverty, social isolation, and pervasive resource limitations. Methods: We performed a mixed-methods study to assess the impact of the pandemic in a convenience sample of people who use drugs in rural Illinois. We conducted 50 surveys capturing demographics, drug availability, drug use, sharing practices, and mental health symptoms. In total, 19 qualitative interviews were performed to further explore COVID-19 knowledge, impact on personal and community life, drug acquisition and use, overdose, and protective substance use adaptations. Results: Drug use increased during the pandemic, including the use of fentanyl products such as gel encapsulated “beans” and “buttons”. Disruptions in supply, including the decreased availability of heroin, increased methamphetamine costs and a concomitant rise in local methamphetamine production, and possible fentanyl contamination of methamphetamine was reported. Participants reported increased drug use alone, experience and/or witness of overdose, depression, anxiety, and loneliness. Consistent access to harm reduction services, including naloxone and fentanyl test strips, was highlighted as a source of hope and community resiliency. Conclusions: The COVID-19 pandemic period was characterized by changing drug availability, increased overdose risk, and other drug-related harms faced by people who use drugs in rural areas. Our findings emphasize the importance of ensuring access to harm reduction services, including overdose prevention and drug checking for this vulnerable population.

Incidence and Predictive Factors Associated with Beta-Lactam Neurotoxicity in the Critically Ill: A Retrospective Cohort Study.

Beta-lactam neurotoxicity is a relatively uncommon yet clinically significant adverse effect in critically ill patients. This study sought to define the incidence of neurotoxicity, derive a prediction model for beta-lactam neurotoxicity, and then validate the model in an independent cohort of critically ill adults. This retrospective cohort study evaluated critically ill patients treated with ≥ 48h of cefepime, piperacillin/tazobactam, or meropenem. Two separate cohorts were created: a derivation cohort and a validation cohort. Patients were screened for beta-lactam neurotoxicity by using search terms and diagnosis codes, followed by clinical adjudication using a standardized adverse event scoring tool. Multivariable regression models and least absolute shrinkage and selection operator were used to identify surrogates for neurotoxicity and develop a multivariable prediction model. The overall incidence of beta-lactam neurotoxicity was 2.6% (n/N = 34/1323) in the derivation cohort and 2.1% in the validation cohort (n/N = 16/767). The final multivariable neurotoxicity assessment tool included weight, Charlson comorbidity score, age, and estimated creatinine clearance as predictors of neurotoxicity. Incidence of neurotoxicity reached 4% in those with a body mass index more than 30kg/m2. Use of the candidate variables in the neurotoxicity assessment tool suggested that a score more than 35 would identify a patient at high risk for neurotoxicity with 75% sensitivity and 54% specificity. In this single center cohort of critically ill patients, beta-lactam neurotoxicity was demonstrated less frequently than previously reported. We identified obesity as a novel risk factor for the development of neurotoxicity. The prediction model needs to be further refined before it can be used in clinical practice as a tool to avoid drug-related harm.

Vulnerability, Risk and Harm for People Who Use Drugs and Are Engaged in Transactional Sex: Learning for Service Delivery.

Against a backdrop of high levels of drug related harms in Scotland, this research aimed to inform training development to aid the upskilling of the workforce to support people who use drugs and are involved in transactional sex. Sixteen qualitative interviews were conducted with participants recruited across four health board areas and a range of services covering sexual health and/or harm reduction. Interviews explored initiation, frequency, and the nature of transactional sex; drug use, and experience of services. A thematic analysis was undertaken. Vulnerability was a key emerging theme when discussing drug use, sexual behavior, and service use. Vulnerability increased risk of a range of harms from sexual assault to injecting harms and overdose. Participants were often, but not always, introduced to drugs and transactional sex by someone who had power over them or was more experienced in drug use and/or sex. High risk drug use was evident in terms of polydrug use, consuming large quantities of drugs, sharing crack pipes/injecting equipment. There is a need for information and services to reduce the risk of harm from drugs, sexual violence, and unprotected sex as well as non-judgmental, trauma aware services. The workforce needs to be skilled to recognize and manage these potentially complex syndemics.

'Keeping a lid on it': Exploring 'problematisations' of prescribed medication in prisons in the UK.

The non-medical use of prescription medication and risk of diversion have become policy and practice concerns within prison settings in the UK. These issues have been highlighted by the Advisory Council on the Misuse of Drugs, Her Majesty's Inspectorate of Prisons and Her Majesty's Prison and Probation Service (2019) prison drugs strategy. In 2019, new prescribing guidance was issued by the Royal College of General Practitioners for clinicians working within prison settings. Informed by Bacchi's (2009) What's the problem represented to be? framework, the ways in which the 'problem' of prescribed medication in prisons have been represented is interrogated through an analysis of the prescribing guidance framework for clinicians working in prisons. Restrictive prescribing practices are recommended as a solution to the 'problem' of diversion and misuse of prescribed medication. Prescribers are advised to consider de-prescribing, non-pharmacological treatments and alternative prescriptions with less diversionary potential. They are represented as responsible for the 'problems' that prescribed medication bring to prisons. The guidance is underpinned by the assumption that prescribers lack experience, knowledge and skills in prison settings. People serving prison sentences are assumed to be 'untrustworthy' and their symptoms treated with suspicion. This representation of the 'problem' has a number of effects including the possibility of increasing drug-related harm, damaging the patient-doctor relationship and disengagement from healthcare services. The representation of prescribed medication as problems of diversion and prescribing practices inhibits alternative representations of the problem which would inform different policy directions including improvements to regime and healthcare provision and would include a range of practitioners in prison settings to address the 'problem' more holistically.

A qualitative study on pharmacy policies toward over-the-counter syringe sales in a rural epicenter of US drug-related epidemics

BackgroundExpanding access to sterile syringes in rural areas is vital, as injection-related epidemics expand beyond metropolitan areas globally. While pharmacies have potential to be an easily accessible source of sterile syringes, research in cities has identified moral, legal and ethical barriers that preclude over-the-counter (OTC) sales to people who inject drugs (PWID). The current study builds on prior urban-based research by elucidating (1) pharmacy OTC policies and (2) pharmacists’ rationale for, and barriers and facilitators to, OTC syringe sales in a US rural area hard hit by drug-related epidemics.MethodsWe conducted 14 semi-structured interviews with pharmacists recruited from two Eastern Kentucky health districts. Interview domains included experiences with, and attitudes toward, selling OTC syringes to PWID. Constructivist grounded theory methods were used to analyze verbatim transcripts.ResultsMost pharmacists operated “restrictive OTC” pharmacies (n = 8), where patients were required to have a prescription or proof of medical need to purchase a syringe. The remainder (n = 6) operated “open OTC” pharmacies, which allowed OTC syringe sales to most patients. Both groups believed their pharmacy policies protected their community and pharmacy from further drug-related harm, but diverging policies emerged because of stigma toward PWID, perceptions of Kentucky law, and belief OTC syringe sales were harmful rather than protective to the community.ConclusionOur results suggest that restrictive OTC pharmacy policies are rooted in stigmatizing views of PWID. Anti-stigma education about substance use disorder (SUD), human immunodeficiency virus (HIV), and Hepatitis C (HCV) is likely needed to truly shift restrictive pharmacy policy.

A syndemic examination of injecting drug use, incarceration and multiple drug-related harms in French opioid users.

People who inject drugs (PWID) face multiple health problems, including infectious diseases and drug overdoses. Applying syndemic and risk environment frameworks, this paper aims to examine the co-occurrence and clustering of drug-related harms and their association with incarceration experience with or without in-prison drug injection. The authors used data from a cross-sectional survey conducted in 2015 among 557 active opioid injectors. Self-reported data were collected through face-to-face or online questionnaires. They distinguished three harm categories, namely, viral infections, bacterial infections and overdoses, and built an index variable by summing the number of harm categories experienced, yielding a score from 0 to 3. Association between incarceration experience and co-occurrence of harms was modelled using a multinomial logistic regression. Of the 557 participants, 30% reported lifetime experience of drug-related viral infection, 46% bacterial infection and 22% drug overdose. Multinomial logistic models showed that those who injected drugs during incarceration were more likely to report two (aOR = 2.35, 95% CI: 1.03-5.36) and three (aOR = 9.72, 95% CI: 3.23-29.22) harm categories than those who had never been incarcerated. They were also more likely to report three harm categories than formerly incarcerated respondents who did not inject drugs in prison (aOR = 5.14, 95% CI: 1.71-15.48). This study provides insights of the syndemic nature of drug-related harms and highlights that drug injection during incarceration is associated with co-occurring harms. Public health interventions and policy changes are needed to limit the deleterious impact of prison on PWID.

Understanding and Responding to Substance Use and Abuse in the Palestinian Refugee Camps in Lebanon Prior to and During COVID-19 Times

Due to its geographical proximity to the Syrian conflict and the occupied territories, Lebanon has experienced an influx of refugees in recent times. Palestinian refugees are an identified key vulnerable population, with displaced communities increasingly experiencing camp insecurity, vulnerability to drug use and related health harms. A qualitative study consisting of in-depth interviews and focus group discussions (FGDs) was undertaken as part of a regional exercise investigating Palestinian community experiences of substance and drug use in refugee camps. Thematic analysis triangulated the perspectives of 11 professional stakeholders representing United Nations, human rights and non-governmental organizations (NGOs), and eight Palestinian community members. Emerging themes centered on the interplay between socio-economic instability, lack of law enforcement and camp governance contributing to concerning levels of familial, drug and camp violence, trafficking and availability of drugs. Transactional sex and the exploitation of women and children in drug dealing, diversification toward drug manufacture and dealing of drugs with the outside community were described. There is a lack of harm reduction and rehabilitation supports for those in need. This study highlights the complexities in tackling drug dealing and related criminal activity within refugee camps and humanitarian settings, and the vulnerabilities of those living within to harmful drug use.