Harm Reduction Research Articles

Harnessing Machine Learning to Predict Methadone Overdose Risk: Insights from Illinois's SUDORS Data

Knowledge of decedent characteristics associated with methadone involvement in unintentional drug overdose deaths can help to inform efforts to intervene in these deaths. ML models with existing data, offer a cost-effective means to help create effective interventions. In this study, we aim to develop an optimized ML algorithm for predicting overdose death patterns due to methadone using data from Illinois's State Unintentional Drug Overdose Reporting System (SUDORS). We utilized IL SUDORS 2019-2022 data for training (n = 11931) with selected indicators (n = 28). To address the imbalance in non-methadone-related deaths, we applied the Synthetic Minority Oversampling Technique. Next, we assessed various machine learning models, including logistic regression, support vector machine, random forest, neural network, and ridge regression. Model performance was evaluated using metrics such as accuracy, precision, area under the precision-recall curve (AUPRC), etc. Utilizing separate training (n = 15813), validation (n = 3388), and test (n = 3389) datasets, the Random Forest Model outperforms all other models with 92% accuracy, 91% precision, 93% recall, and 0.97 AUPRC. Notably, these outcomes were achieved using primarily demographic indicators. Through analyzing partial dependence plots, we were able to see how changes in each indicator dynamically influence methadone-related fatalities. This study demonstrates the potential of ML models in identification of methadone involvement in unintentional drug overdose deaths and contributes to the knowledge base for the prevention of these deaths. Leveraging SUDORS data, the Random Forest Model exhibited exceptional performance, highlighting its value for healthcare professionals, prevention and harm reduction specialists, and policymakers.

“I don’t need my kid to be high”: prioritizing harm reduction when using cannabis during pregnancy

BackgroundCannabis is the most common illicit substance used in pregnancy. As use continues to increase, understanding peoples’ behaviors surrounding cannabis use during pregnancy is needed to improve maternal and child health outcomes. The aim of this study was to better understand pregnant individuals' perceptions and knowledge of cannabis use and use patterns as well as the social and environmental factors that may influence their use.MethodsWe conducted interviews with 19 participants between December 2022 and March 2023. Individuals self-identified as BIPOC (Black, Indigenous, People of Color), were over 21 years of age, spoke English or Spanish, resided in California, and had used cannabis during pregnancy in the last 0–2 years. Using qualitative, constructivist grounded theory methods, we analyzed the contexts that contributed to participants’ lived experiences surrounding cannabis use behaviors during pregnancy.ResultsParticipants reported making conscious decisions to responsibly manage their cannabis use during pregnancy to minimize potential harm to the fetus. Participants prioritized making what they perceived to be safer adjustments to their use of cannabis: (1) changing the amount of cannabis used, (2) changing the types of cannabis products used, and (3) changing sources of cannabis procurement.DiscussionOur findings show that pregnant individuals are seeking information about safe cannabis use beyond medical supervision and are open to altering their cannabis consumption patterns. However, they are unable to find trustworthy and evidence-based harm reduction practices which can be implemented to mitigate harm to their unborn children. A harm reduction approach is needed in the field of maternal cannabis use to promote positive maternal and fetal health outcomes.ConclusionsMore data is needed on comprehensive harm reduction approaches to cannabis use during pregnancy. This requires implementation of education on these topics in healthcare settings presented by prenatal care clinicians.

What are the reasons for injected methadone use? A qualitative study of people who use drugs parenterally in Barcelona.

Oral methadone maintenance is a widely adopted and effective treatment for heroin and other opioid dependencies. However, injectable methadone usage may pose greater risks than heroin itself. Despite decades of oral methadone treatment in Spain, there is limited understanding of the motivations for parenteral consumption. This study aimed to examine the reasons for methadone injection, delineate its specific advantages and disadvantages compared with those of heroin use, and assess the benefits and drawbacks of supervised methadone injection within a harm reduction service from the perspective of people who inject drugs. A qualitative phenomenological study was conducted in 11 patients at a safe injection facility in Barcelona. Semistructured interviews revealed that the reasons for injecting methadone were its provision of a euphoric rush, the pleasurable sensation of needle insertion, and the avoidance of gastrointestinal discomfort associated with oral methadone use. The main attraction of methadone injection was its accessibility as a legal and fully state-funded treatment option in Spain, coupled with its effectiveness in relieving withdrawal symptoms. However, notable disadvantages included the risks inherent in injection. The benefits of supervised consumption rooms were its provision of immediate medical assistance in overdose situations, ease of access, and physical safety. Drawbacks included waiting times, limited opening hours, neighborhood stigmatization, and the distance people who inject methadone had to travel when obtaining methadone from the illicit market. Based on these findings, we make several recommendations aimed at reducing the harm associated with methadone injection and emphasize the need for comprehensive harm reduction strategies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The need for a socioecological harm reduction approach to reduce illegal wildlife trade.

The burgeoning illegal trade in succulents in southern Africa presents a critical conservation and social development challenge. Drawing parallels with the trajectory of the response to rhinoceros poaching, we considered the consequences of conservation law enforcement measures, particularly the militarization of antipoaching efforts. The response to rhinoceros poaching not only resulted in so-called green militarization, but also led to extrajudicial killings, human rights abuses, and the disproportionate targeting of low-level poachers. The nature of wildlife trade prohibition is complex and often contested, and many actors operating in illegal wildlife trades dispute the label of illegal for socioeconomic, cultural, historical, or political reasons. This contestation is crucial when considering Indigenous cultural and medicinal values of succulents, with Indigenous Peoples and local communities questioning the criminalization of traditional plant harvesting practices. As the illegal trade in succulents continues to grow, it is imperative for conservationists to consider a nuanced approach. We call for a socioecological harm reduction approach that emphasizes community engagement, sustainable use, and codesigned interventions. Such an approach could help balance the scales of ecological conservation and human dignity in the face of growing wildlife trade challenges.

Self-Reported Illicitly Manufactured Fentanyl Use and Associated Health and Substance Use Risks in the United States, 2022

Objective Illicitly manufactured fentanyl (IMF) has emerged as a catalyst of the recent drug epidemic in the United States. To devise more targeted and effective prevention and treatment strategies, it is crucial to understand the demographics of the population who consumes IMF and their health and associated substance use risks. Therefore, this study explores the sociodemographic characteristics, health diagnoses, and drug injection practices of individuals reporting IMF use. Methods Data were derived from the 2022 National Survey on Drug Use Health, based on a nationally representative sample of non-institutionalized individuals aged 12 and older in the United States. Focusing on 306 adults who reported ever using IMF, we examined their sociodemographic characteristics, health diagnoses, and substance-related behaviors in comparison to adults with a drug use disorder who did not report IMF use, using logistic regression analyses. Results The majority of U.S. adults reporting IMF use were aged 35–64, male, non-Hispanic White, with a high school education or lower, never married, and had an annual household income below $40,000. Compared to adults with a drug use disorder who did not report IMF use, they were more likely to report heart conditions (AOR = 2.67, 95% CI = 1.29–5.54) and Hepatitis B or C (AOR = 8.35, 95% CI = 4.05–17.02). Nearly half of this group had an opioid use disorder (OUD) in the past year, and 65.7% (95% CI = 56.7–74.8) reported a history of injecting drugs. Conclusions To effectively curb the current drug epidemic, incorporating effective treatment for OUD and harm reduction strategies is crucial.

Gamification approach to addiction education for internal medicine residents

Background: People with a substance use disorder (SUD) outnumber the trained provider workforce. The Accreditation Council for Graduate Medical Education (ACGME) recognized this gap in 2022 and now requires addiction education for internal medicine (IM) residents. However, traditional lecture formats struggle to deliver education on this stigmatized condition with meaningful retention and changes in attitudes. Gamification is an evidence-based educational strategy with positive outcomes in graduate medical education, but to our knowledge, has not been used for an entire addiction curriculum. Intervention: This six session IM-focused, stigma-free, interactive curriculum used published physician competencies for content selection. Games were matched to topics based on complexity and need for skill practice. Each hourly session included 10 minutes on introduction, 45 minutes on gameplay, and 5 minutes on feedback. This addiction curriculum was incorporated into existing didactics for IM residents where participants’ comfort, psychological safety, and learning expectations were pre-established. Methods: Sixteen IM residents participated in the curriculum. Curriculum evaluation was conducted using Kirkpatrick’s four levels of evaluation. Resident feedback was obtained via online survey software at the conclusion of each session and behavior impact through an anonymous single question prompt. We used descriptive statistics and summative content analysis to evaluate findings, respectively. Results: All residents were highly satisfied with the curriculum design and use of gamification. Residents reported high levels of engagement and learning, despite use of various games. Findings support an increase in medication prescribing and utilization of harm reduction strategies following curriculum implementation. Conclusion: Gamification may be a preferred educational strategy for addiction curriculum for IM residents. We plan to distribute our curriculum widely for further evaluation in health professions’ programs.

Exploration of Mental Health Elements in Chemsex Behavior: Interventions, Influencing Factors, and Attitudes towards Risk and Harm Reduction in Spain.

A qualitative descriptive phenomenological study was conducted in the community of Madrid, Spain to explore the depth of the chemsex phenomenon through a thematic analysis. Between April and June 2024, interviews were conducted with 15 MSM (gay, bisexual, and other men who have sex with men) who participate in these practices, using purposive and snowball sampling. three main themes were identified, namely, (T1) contextualization of the practice, (T2) factors associated with chemsex, and (T3) strategies and interventions for risk and harm reduction. Chemsex is a phenomenon that combines sexual practices with substance use in complex social environments, presenting significant risks to physical, mental, and sexual health. It is necessary to implement public health interventions to mitigate these risks.

Understanding Students’ Protective Behaviours Across Drinking Contexts

Protective behavioural strategies (PBS) for alcohol use are being widely studied to encourage safe and responsible drinking practices for student populations (Peterson et al., 2021), including harm reduction, limiting, and manner of drinking strategies. Contexts such as planned versus unplanned drinking days, as well as social and solitary drinking, may influence PBS use. The current study uses surveys (EMA) administered over 14 weeks between Thursdays and Sundays to test whether drinking contexts are related to students' use of different protective strategies. Linear regression analyses were used to assess whether the type of drinking day (planned vs. unplanned) interacts with social and solitary contexts to predict PBS use. Findings suggest that students drinking on planned days used more protective strategies across all three categories, with social drinking predicting greater PBS use across both unplanned and planned days. Future research should explore the efficacy of strategies with context-specificity to develop targeted interventions and policies to address the challenges associated with drinking among students.

Descriptive analysis of recommendations made by county-level overdose fatality review teams in indiana to combat the opioid epidemic

Overdose fatality review teams (OFRTs) are becoming more common across U.S. communities as a means of addressing the overdose epidemic and improving local overdose prevention strategies; however, empirical examinations of the work of OFRTs are lacking. The current study seeks to characterize recommendations for local overdose prevention strategies made by county-level OFRTs across Indiana in order to understand their practices. MethodsA qualitative descriptive content analysis was conducted on recommendations made by 19 county-level OFRTs across Indiana in 2022. ResultsOFRTs generated 1512 recommendations during 2022 based on case reviews of 291 overdose deaths occurring across 19 Indiana counties; of those, 26.8 % (n=405) were specific to the case reviewed, rather than relevant to the broader community, and were not further coded. The remaining 1109 recommendations were coded according to their overall scope, recommendation strategy, and target agency. The most common recommendations addressed substance use more broadly (e.g., improving substance use screening/assessment in healthcare settings), followed by recommendations directly addressing overdose risk (e.g., naloxone distribution, increasing harm reduction programs). Other common recommendations related to mental health, OFRT practices, and addressing social determinants of health. Common recommendation strategies were to implement new services or service improvements. ConclusionResults highlight the extent of further efforts needed to improve overdose prevention and the need for further research and support of OFRTs across the United States.

Assessing support for substance use policies among the general public and policy influencers in two Canadian provinces

BackgroundExamining support for substance use policies, including those for harm reduction, among the general public and policy influencers is a fundamental step to map the current policy landscape and leverage policy opportunities. Yet, this is a knowledge gap in Canada. Our paper identifies the level of support for substance use policies in two provinces in Canada and describes how the level of support is associated with intrusiveness and sociodemographic variables.MethodsData came from the 2019 Chronic Disease Prevention Survey. The representative sample included members of the general public (Alberta n = 1648, Manitoba n = 1770) as well as policy influencers (Alberta n = 204, Manitoba n = 98). We measured the level of support for 22 public policies concerning substance use through a 4-point Likert-scale. The Nuffield Council on Bioethics Intervention Ladder framework was applied to assess intrusiveness. We used cumulative link models to run ordinal regressions for identification of explanatory sociodemographic variables.ResultsOverall, there was generally strong support for the policies assessed. The general public in Manitoba was significantly more supportive of policies than its Alberta counterpart. Some differences were found between provinces and samples. For certain substance use policies, there was stronger support among women than men and among those with higher education than those with less education.ConclusionsThe results highlight areas where efforts are needed to increase support from both policy influencers and general public for adoption, implementation, and scaling of substance use policies. Socio-demographic variables related to support for substance use policies may be useful in informing strategies such as knowledge mobilization to advance the policy landscape in Western Canada.

Evaluating fentanyl test strips as a harm reduction strategy in rural and urban counties: study protocol for a randomized controlled trial

BackgroundOpioid-related fatalities are a leading cause of death in Ohio and nationally, with an increasing number of overdoses attributable to fentanyl. Rapid fentanyl test strips can identify fentanyl and some fentanyl analogs in urine samples and are increasingly being used to check illicit drugs for fentanyl before they are used. Fentanyl test strips are a promising harm reduction strategy; however, little is known about the real-world acceptability and impact of fentanyl test strip use. This study investigates fentanyl test strip distribution and education as a harm reduction strategy to prevent overdoses among people who use drugs.MethodsThe research team will recruit 2400 individuals ≥ 18 years with self-reported use of illicit drugs or drugs purchased on the street within the past 6 months. Recruitment will occur at opioid overdose education and naloxone distribution programs in 16 urban and 12 rural Ohio counties. Participating sites will be randomized at the county level to the intervention or non-intervention study arm. A brief fentanyl test strip educational intervention and fentanyl test strips will be provided to participants recruited from sites in the intervention arm. These participants will be eligible to receive additional fentanyl test strips for 2 years post-enrollment. Participants recruited from sites in the non-intervention arm will not receive fentanyl test strip education or fentanyl test strips. All participants will be followed for 2 years post-enrollment using biweekly, quarterly, and 6-month surveys. Primary outcomes include (1) identification of perceived barriers and facilitating factors associated with incorporating fentanyl test strip education and distribution into opioid overdose education and naloxone distribution programs; (2) differences in knowledge and self-efficacy regarding how to test drugs for fentanyl and strategies for reducing overdose risk between the intervention and non-intervention groups; and (3) differences in non-fatal and fatal overdose rates between the intervention and non-intervention groups.DiscussionFindings from this cluster randomized controlled trial will contribute valuable information about the feasibility, acceptability, and impact of integrating fentanyl test strip drug checking in rural and urban communities in Ohio and help guide future overdose prevention interventions.Trial registrationClinicalTrials.gov NCT05463341. Registered on July 19, 2022. https://clinicaltrials.gov/study/NCT05463341

Changes in HIV Pre-exposure Prophylaxis Awareness and Use Among Males Who Inject Drugs Who Have Sex with Men by Sexual Identity, 19 US Urban Areas, 2018 & 2022.

Men who inject drugs who have sex with men (MWIDSM) may acquire HIV through injecting drugs or sex. Interventions to increase awareness of HIV preexposure prophylaxis (PrEP) have focused on gay/bisexual MSM and may not be reaching heterosexual-identifying men or people who inject drugs (PWID). We explored changes in PrEP awareness and use among MWIDSM from 2018 to 2022 by sexual identity. We used data from the 2018 and 2022 National HIV Behavioral Surveillance among PWID recruited via respondent-driven sampling in 19 urban areas in the US. We examined changes in PrEP awareness and use over time by sexual identity among HIV-negative men who inject drugs and who had sex with another man in the past 12 months using log-linked Poisson regression models with robust standard errors with an interaction term between year and sexual identity. Among 758 HIV-negative MWIDSM (463 in 2018; 295 in 2022), nearly all sample participants were likely indicated for PrEP (94.2 and 92.9%, respectively). PrEP awareness increased from 2018 to 2022 among gay/bisexual-identifying MWIDSM [45.5-65.5%; aPR = 1.49, 95% confidence interval (95% CI) = 1.30-1.70] but remained stable for heterosexual-identifying MWIDSM (39.4-40.8%; aPR = 1.01, 95% CI 0.75-1.36). PrEP use remained low among all MWIDSM (2.5-7.7%, among heterosexually identifying; 15.3 to 10.2% among gay/bisexual-identifying). PrEP awareness increased among gay/bisexual-identifying MWIDSM but not among heterosexual-identifying. PrEP use was low for all MWIDSM. Public health initiatives catered to MWIDSM should focus on improved campaigns and expanding PrEP accessibility in existing healthcare, harm reduction, and social services.

Experiences Accessing Health and Social Services during and after Natural Disasters among People Who Use Drugs in Houston, Texas.

People who use drugs (PWUD) disproportionately experience health-related and social vulnerabilities, which may affect service needs and access during and after natural disasters. We conducted qualitative interviews with N = 18 PWUD recruited via a syringe services program in Houston, Texas. We assessed their health and social service needs, as well as related service access experiences, during and after natural disasters using a combined inductive-deductive approach. Participants described a range of service-related needs related to illicit drug use, poverty, neighborhood disadvantage, acute and chronic health problems, and housing insecurity. They endorsed decreased access to medical and substance-related services and difficulty accessing disaster relief aid. Interviews highlighted the importance of mutual aid for sharing harm reduction supplies and meeting practical needs. Results suggest that some PWUD experience disproportionate vulnerability after natural disasters related to multiple marginalized identities that intersect with illicit drug use.

Peer power: how drug user groups navigate harm reduction in Surrey, British Columbia and resist the carceral state

Abstract The article discusses the Surrey Union of Drug Users (SUDU) in British Columbia, emphasizing harm reduction, safe supply, and destigmatization for drug users. As a peer-led group, SUDU actively resists carceral state policies. The analysis explores challenges faced by peer-led groups, including formation, sustainability, and mobilization efforts. It highlights the need for supportive frameworks to enhance peer-led harm reduction initiatives and argues that such advocacy enables alternative knowledge and institutional innovations that are conducive to building a real world abolitionist future.

Legal framework for health policy to reduce the level of substance abuse in the United States

The purpose of this study was to identify and legally assess the key legal instruments and strategies employed in the United States of America to combat substance abuse and their impact on the development of national health policy in this area. The study used quantitative and qualitative methods of analysis, including the processing of statistical data on the financing of addiction prevention and treatment programmes, analysis of federal and regional legislative acts, and comparative analysis of the policies of different states on the regulation of psychoactive substances. The key findings showed a significant evolution of the legal approach to the problem of substance abuse. The study revealed a gradual shift from a purely punitive approach to a balanced strategy that combines elements of prevention, treatment, and harm reduction. Furthermore, the analysis of funding showed a 35% increase in federal support for prevention programmes between 2018 and 2022, which led to improved access to healthcare for drug users and the development of recovery programmes. The results of a comparative analysis of state policies on the regulation of psychoactive substances showed a considerable difference in approaches, specifically regarding the legalisation of marijuana, which creates legal and regulatory challenges due to contradictions between federal and local laws. Specifically, in states where marijuana is legalised for medical or recreational use, the level of trafficking offences has decreased, but questions arise concerning the regulation of cultivation and distribution. It was also found that the introduction of telemedicine has significantly increased the effectiveness of drug treatment in a pandemic, allowing more patients to be reached, but this approach needs further improvement in the field of regulation and control. The findings of the study point to the need for closer integration of prevention, healthcare, and legal measures at all levels of government, unification of legislation on the regulation of psychoactive substances at the federal and state levels, as well as decriminalisation of drugs for personal use, which can reduce the level of criminalisation of society and contribute to a more effective fight against substance abuse

Contextualising Experiences of Co-Occurring Mental Ill-Health and Substance Use Among Trans, Non-Binary, and Gender Diverse Young People: Implications for Tailored Harm Reduction Approaches.

Though significant research highlights higher rates of mental ill-health and substance use among trans, non-binary and gender diverse (henceforth 'trans') young people, little research has considered patterns, contextual characteristics, and correlates of co-occurring experiences of mental ill-health and substance use among trans young people. Using data from the Trans Pathways study, we used prevalence ratios and age- and gender-adjusted logistic regression models to examine prevalence and differences of co-occurring substance use (past six-month cigarette use, alcohol use, and other drug use) and contextual characteristics of substance use (past six-month solitary alcohol and/or drug use, substance use for coping) by mental ill-health (depression disorder, anxiety disorder, past 12-month self-harm thoughtsand behaviours,suicidal thoughts, planning, and attempt/s). Age- and gender-adjusted models assessed associations between co-occurring depressive and anxiety disorders and recent cigarette, alcohol, and other drug use (six co-occurring items total) and 18 interpersonal stressors. Significantly increased odds of smoking or recentuse of cannabis or sedatives was observed among trans young people reporting depressive disorder, anxiety disorder (aORs ranging 1.8-3.1). Trans young people who reported recent smoking or use of cannabis, inhalants, or sedatives, had 40% to 80% reduced odds of past 12-month self-harm thoughts, self-harm behaviours,suicidal thoughts, and suicide attempt/s (aORs ranging 0.2-0.6). On the other hand, solitary alcohol and/or other drug use and substance use for coping was significantly associated with increased odds of all mental ill-health outcomes. Issues with school, secure housing, and intimate partner abuse were themost robust correlates of co-occurring mental ill-health and substance use. Trans young people using substances, especially cigarettes, cannabis, and sedatives, often so do with co-occurring experiences of depression and anxiety though limited substance use in more 'social' contexts may confer benefits for preventingself-harm and suicide thoughts and behaviours. Continued research in partnership with trans young people is warranted to conceptualise more nuanced and precise conceptualparameters of trans-affirming substance useharm reduction approaches.

Precarity Factors of Street-Based Sex Work Within Criminalised Contexts: A Study in Athens, Greece

This community research study aims to investigate the intersecting self-identified precarity factors and identities associated with street-based sex work in a criminalised context, specifically in Athens, Greece, to improve the effectiveness of individualised care interventions. Interviews of 264 cis and trans female sex workers were conducted from June 2021 to December 2022, at a community day centre for sex workers in Athens. The community-based precarity index for sex workers was used, which was developed at the community centre, using factors identified by sex workers themselves. Street-based sex workers more commonly reported interrelated precarious factors, such as perceived problematic substance use, homelessness, client violence, medical issues, and trouble with the police. Trans and refugee identities were both associated with street-based sex work as well. Harm reduction, gender-affirmative and multilingual and multicultural interventions are essential in street-based sex work intervention programs. Decriminalisation of sex work is recommended to reduce the harms and risks associated with sex work.

Community-Based Medications First for Opioid Use Disorder - Care Utilization and Mortality Outcomes.

A large treatment gap exists for people who could benefit from medications for opioid use disorder (MOUD). People OUD accessing services in harm reduction and community-based organizations often have difficulty engaging in MOUD at opioid treatment programs and traditional health care settings. We conducted a study to test the impacts of a community-based medications first model of care in six Washington (WA) State communities that provided drop-in MOUD access. Participants included people newly prescribed MOUD. Settings included harm reduction and homeless services programs. A prospective cohort analysis tested the impacts of the intervention on MOUD and care utilization. Intervention impacts on mortality were tested via a synthetic comparison group analysis matching on demographics, MOUD history, and geography using WA State agency administrative data. 825 people were enrolled in the study of whom 813 were matched to state records for care utilization and outcomes. Cohort analyses indicated significant increases for days' supply of buprenorphine, months with any MOUD, and months with any buprenorphine for people previously on buprenorphine (all results p<0.05). Months with an emergency department overdose did not change. Months with an inpatient hospital stay increased (p<0.05). The annual death rate in the first year for the intervention group was 0.45% (3 out of 664) versus 2.2% (222 out of 9893) in the comparison group in the 12 months; a relative risk of 0.323 (95% CI 0.11-0.94). Findings indicated a significant increase in MOUD for the intervention group and a lower mortality rate relative to the comparison group. The COVID-19 epidemic and rapid increase in non-pharmaceutical-fentanyl may have lessened the intervention impact as measured in the cohort analysis. Study findings support expanding access to a third model of low barrier MOUD care alongside opioid treatment programs and traditional health care settings.

Semaglutide, Testosterone and Sildenafil advertising on social media: The Normalisation of lifestyle enhancement drugs

Recently, there has been a sharp increase in advertising for the ‘prescription-only’ medicines semaglutide and testosterone on social media platforms in the UK, along with the ‘pharmacy medicine’ sexual enhancer Sildenafil. These promoted adverts appear to come from both legitimate clinics in the case of testosterone replacement therapy (TRT) and Sildenafil, and illicitly operating suppliers with the attempted appearance of legitimacy in the case of semaglutide. This commentary explores the extent to which the prevalent advertising of these lifestyle medicines on social media is normalising their use, and the potential harms associated with each.For testosterone / TRT, we consider the over-medicalisation of men's general wellbeing concerns and potential harms relating to dependency if use is promoted and encouraged beyond medical need, paralleling prior observations for the sexual enhancer sildenafil. This is followed by an exploration of harms relating to black market semaglutide supply on social media to individuals who are often unaware they are not accessing legitimate pharmaceutical product, including the dangers of product contamination and substitution, as well as uninformed use linked to a lack of information on safe dosages provided by suppliers. Following these discussions, this commentary examines the potential harm reduction impacts that direct to consumer (DTC) supply of prescription medicines could have, and considers how policy could encourage these beneficial effects without further normalising or encouraging drug use in otherwise healthy individuals. However, we also note the importance of tackling prevailing cultural pressures towards lifestyle drug use and the need to address these through education and similar policies.

Improving access to integrated community-based HIV, HCV and harm reduction services for people who inject drugs in Putao district, North Myanmar.

Improving access to integrated community-based HIV, HCV and harm reduction services for people who inject drugs in Putao district, North Myanmar.