Harm Reduction Measures Research Articles

Commentary on the harm reduction reference group of justice health and forensic mental health network and corrective services NSW, Australia.

This commentary aims to reveal how a steering committee has effectively responded to advancing accessibility to harm reduction resources, hepatitis C virus (HCV) policy and health strategies within adult prison settings in New South Wales (NSW). By reviewing the audit approach taken by the of the Justice Health and Forensic Mental Health Network and Corrective Services New South Wales Harm Reduction Reference Group (JHFMHN/CSNSW HRRG), this commentary emphasizes the committee's success in identifying contemporary harm reduction issues that affect people in custodial settings. This commentary is a compilation of data gathered through the 2018 JHFMHN/CSNSW HRRG audit and corresponding program materials. Conclusions regarding the effectiveness of the working group's audit were drawn by critically appraising the JHFMHN/CSNSW HRRG's Final Audit Report (JHFMHN and CSNSW, 2018) with reference to current harm reduction literature. The HRRG has provided leadership, professional representation and strategic advice on the development, implementation, monitoring and evaluation of best practice harm reduction strategies in prison settings. The HRRG developed and maintained networks and information exchange between the state-wide HCV health network, corrections services and the NSW harm reduction sector at large. Public health partnerships and advocacy that involve all key players, such as the HRRG, will continue to be crucial to remove barriers to enhancing HCV harm reduction measures especially in NSW prison settings. Strategies such as primary prevention and treatment can mitigate the spread of HCV in the custodial system. This audit of access to harm reduction resources was conducted on behalf of the diverse group of professionals, scholars and stakeholders comprising the HRRG. This audit and other advocacy efforts of this committee can facilitate future access to quality healthcare and the necessary policies required to support a healthier prison population at large. Collaborating with health authorities, researchers and social service workers can enable prison health-care systems to be guided by wider health workforce programs and public health standards. This collaboration can reduce the professional isolation of custodial health-care staff and promote a balanced approach to harm reduction policies by ensuring an equitable focus on both health and security imperatives.

The uptake of foil from needle and syringe provision services and its role in smoking or snorting heroin among people who inject drugs in Scotland.

In the UK, legislation was implemented in 2014 allowing needle and syringe provision (NSP) services to offer foil to people who inject drugs (PWID) to encourage smoking rather than injecting. This paper aims to examine the association between foil uptake and smoking or snorting heroin among PWID. This is the first large scale national study to examine foil uptake and smoking or snorting heroin among PWID post legislative change. Data from 1453 PWID interviewed via Scotland's Needle Exchange Surveillance Initiative in 2017-2018 were analysed using multivariate logistic regression. Overall, 36% of PWID had obtained foil from NSP services in the past six months. The odds of smoking or snorting heroin were higher among those who had obtained foil (Adjusted Odds Ratio (AOR) 3.79 (95% CI 2.98-4.82) p<0.001) compared to those who had not. Smoking or snorting heroin was associated with lower odds of injecting four or more times daily (AOR 0.60 (95% CI 0.40-0.90) p=0.012) and injecting into the groin or neck (AOR 0.57 (95% CI 0.46-0.71) p<0.001) but increased odds of having had a skin and soft tissue infection (SSTI) (AOR 1.49 (95% CI 1.17-1.89) p=0.001) and having experienced an overdose (AOR 1.58 (95% CI 1.18-2.10) p=0.002) both in the past year. The promotion of smoking drugs via foil provision from NSP services may contribute to the package of harm reduction measures for PWID alongside the provision of injecting equipment. We found that those in receipt of foil were more likely to smoke or snort heroin, and that smoking or snorting heroin was associated with a lower likelihood of some risky injecting behaviours, namely frequent injecting and injecting into the groin or neck. But it remains uncertain if the provision of foil can lead to a reduction in health harms, such as SSTI and overdose. Future research is needed to understand PWID motivations for smoking drugs, obtaining foil from NSP services, and its uses particularly among polydrug users.

The perceived risk of illicit drug use and views on drug policy in the general population

This article analyzes the riskiness attached to illicit drug use by means of a social representations framework. The implications of these social representations are further studied through their associations with views on drug policy: restrictive control and harm reduction measures. The data for the study is from a Finnish Drug Survey (N = 3229). Latent class analysis (LCA) and multinomial logistic regression analysis were used to analyze the data. Four representational profiles of perceived risk were identified: high-risk (70% of respondents), cannabis OK (15%), experimenting OK (10%), and low-risk (2%). All illicit drug use was considered as a moderate or high risk in the high-risk profile. Cannabis was considered less risky than other substances in the cannabis OK profile and experimenting was a less risky way of use in the experimenting OK profile. Most people in the low-risk profile considered the risks related to illicit drug use as nonexistent or minor. These representational profiles were also connected to opinions on drug policy: those who saw the most risks with use tended to support restrictive control measures, while those who considered illicit drug use to be less risky were more accepting toward harm reduction measures.

Population-level estimates of hepatitis C reinfection post scale-up of direct-acting antivirals among people who inject drugs

Background & AimsScale-up of highly effective direct-acting antivirals (DAAs) for HCV among people who inject drugs (PWID) in Scotland has led to a reduction in the prevalence of viraemia in this population. However, the extent of reinfection among those treated with DAAs remains uncertain. We estimated HCV reinfection rates among PWID in Scotland by treatment setting, pre- and post-introduction of DAAs, and the potential number of undiagnosed reinfections resulting from incomplete follow-up testing.MethodsThrough linkage of national clinical and laboratory HCV data, a retrospective cohort of PWID who commenced treatment between 2000-2018 and achieved a sustained virological response (SVR) were followed up for reinfection to December 2019. Reinfection was defined as a positive HCV antigen or RNA test.ResultsOf 5,686 SVRs among 5,592 PWID, 4,126 (73%) had an HCV RNA or antigen test post-SVR. Of those retested, we identified 361 reinfections (3.9/100 person-years [PY]). The reinfection rate increased from 1.5/100 PY among PWID treated in 2000-2009 to 8.8/100 PY in 2017-2018. The highest reinfection rates were observed among those treated in prison (14.3/100 PY) and community settings (9.5/100 PY). Among those treated in the DAA era (2015-2018), 68% were tested within the first year post-SVR but only 30% in the second year; while 169 reinfections were diagnosed in follow-up, an estimated 200 reinfections (54% of the estimated total) had gone undetected.ConclusionsHCV reinfection rates among PWID in Scotland have risen alongside the scale-up of DAAs and broadened access to treatment for those at highest risk, through delivery in community drug services. Promotion of HCV testing post-SVR among PWID is essential to ensure those reinfected are identified and retreated promptly.Lay summaryIncreased rates of hepatitis C reinfection in Scotland were observed following the rapid scale-up of highly effective direct-acting antiviral (DAA) treatments among people who inject drugs. This demonstrates that community-based treatment pathways are reaching high-risk groups, regarded vital in efforts to eliminate the virus. However, we estimate that less than half of reinfections have been detected in the DAA era because of inadequate levels of retesting beyond the first year following successful treatment. Sustained efforts that involve high coverage of harm reduction measures and high uptake of annual testing are required to ensure prompt diagnosis and treatment of those reinfected if the goals of elimination are to be met.

Rationalities of Space and Drug-Related Harms: Accounts of People Who Inject Drugs in Nigeria

ABSTRACT Background Studies have examined how people who inject drugs (PWID) navigate public spaces for drug consumption, but little is known about consumption of drugs in private apartments. This study explores social, structural and physical environment factors influencing injecting practices and the rationalities shaping how PWID make decisions about where to consume drugs. Methods The study is based on qualitative data from 41 in-depth interviews conducted with both homeless and housed PWID recruited through snowball sampling in Uyo, Nigeria. Thematic analysis, framed by the theoretical constructs of structural and everyday violence, and situated rationality theories, was undertaken on transcripts. Results Analysis revealed different socio-spatial rationalities underlying decisions about where to use drugs: avoidance of police arrest, convenience and relaxation, avoidance of drug sharing, avoidance of drug-scene violence, and stigma and shame. These factors show the impacts of social, structural and physical environment factors on the lived experiences of PWID. Injecting in private apartments potentially offset the risk of stigma, police arrest and violence linked to public injecting, but increase the risk of overdose and sharing of drugs and needle-syringes based on social relations of trust. Conclusions Findings show that PWID chose between competing risks when deciding on where to inject drugs. Interventions should consider the situated contexts of risk, and adapt harm reduction measures to the risk profile of different populations of PWID.

New WHO guidance for country validation of viral hepatitis B and C elimination

The 2016 WHO Global Health Sector Strategy (GHSS) on viral hepatitis provided a roadmap for the elimination of viral hepatitis as a public health problem by 2030. 1 WHOGlobal health sector strategy on viral hepatitis 2016–2021: towards ending viral hepatitis. World Health Organization, Geneva2016https://apps.who.int/iris/handle/10665/246177Date accessed: May 20, 2021 Google Scholar Elimination is defined as a 90% reduction in incidence (95% for hepatitis B virus [HBV] and 80% for hepatitis C virus [HCV] infection) and a 65% reduction in mortality by 2030, compared with a 2015 baseline, that can be achieved through scale-up of five key synergistic preventive approaches (HBV birth-dose and infant vaccination, blood and injection safety, and harm reduction measures) alongside testing and treatment interventions. New estimates for viral hepatitis based on data from 130 countries in the latest global progress report on HIV, viral hepatitis, and sexually transmitted infections 2 WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization, GenevaJuly 15, 2021https://www.who.int/publications/i/item/9789240027077Date accessed: July 26, 2021 Google Scholar show that in 2019 there were 296 million people living with chronic HBV infection and 58 million people living with chronic HCV infection, and 3 million new infections and 1·1 million deaths from viral hepatitis B and C combined. The 2020 Sustainable Development Goals and GHSS target of reducing the incidence of hepatitis B has been met (as measured by a global HBsAg prevalence in 2019 among children younger than 5 years of less than 1%, at 0·94%). 2 WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization, GenevaJuly 15, 2021https://www.who.int/publications/i/item/9789240027077Date accessed: July 26, 2021 Google Scholar However, most other global 2020 targets have been missed, and accelerated action is needed to reach elimination, especially in access to timely HBV birth-dose vaccination (coverage of 42% in 2019), harm reduction for people who inject drugs, and testing and treatment coverage (testing coverage of 10%, of whom 22% have been treated, for chronic HBV infection, and testing coverage of 21%, of whom 62% have been treated, for chronic HCV infection). 2 WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization, GenevaJuly 15, 2021https://www.who.int/publications/i/item/9789240027077Date accessed: July 26, 2021 Google Scholar Around 124 countries have developed national viral hepatitis plans 2 WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization, GenevaJuly 15, 2021https://www.who.int/publications/i/item/9789240027077Date accessed: July 26, 2021 Google Scholar and several countries have already made substantial progress and requested guidance from WHO on criteria and processes for validation of elimination.

Fentanyl epidemic hits the U.S. West Coast: Opioid-related deaths in San Francisco from 2009–2019

BackgroundOpioid-use disorders have led to a nationwide epidemic of accidental overdoses in the United States. In recent years this opioid epidemic has worsened due to the increased availability of fentanyl in the illicit drug market. The increase in fentanyl-related deaths is well known on the U.S. East Coast, however, limited comprehensive information of mortality data exists from major West Coast cities. MethodsFollowing comprehensive medico-legal death and toxicological investigations, a retrospective cohort study was performed on all accidental opioid overdose deaths (AOOD) from 2009 – 2019 in San Francisco. The sex, age and race of decedents, location, and date and time of death were described and statistically compared by the type of opioid(s) causing death. ResultsSince 2016, fentanyl deaths started to replace heroin deaths leading to a sharp increase in fatal overdoses involving fentanyl, surpassing heroin and/or medicinal opioids by 2018. Fentanyl contributed to between 3% and 12% of deaths per year from 2009 to 2015, and between 20% and 73% per year from 2016 to 2019. White and Black males represented 91.5% of all AOOD. Age groups younger than 45 died using fentanyl and heroin significantly more often than older populations (60.7% of ≤45 vs. 40.7% of >45 year-olds, χ2p<0.001). ConclusionsThis study shows an upward trend in fentanyl fatal accidental overdoses in recent years in a major West Coast U.S. city. These patterns appear to follow patterns seen in eastern states, albeit with an approximate 3-year delay, and may be indicative of other western populations. The described observations provide detailed demographic, chronological and toxicological information to public health and policy-making agencies for drug harm reduction measures.

Fragile femininity, embodiment, and self-managing harm: an interpretative phenomenological study exploring the lived experience of females who use anabolic-androgenic steroids

ABSTRACT Little research exists on the lived experiences of female anabolic-androgenic steroid (AAS) use from a harm reduction perspective. This study aims to address this gap and explore the experiences, perceptions, and perspectives of AAS-using females through their journeys of starting, using, and coming off AAS to facilitate appropriate public health policies. Four females, recruited using opportunistic purposive sampling, participated in semi-structured interviews. Using Interpretative Phenomenological Analysis (IPA), four superordinate themes clarify the experiences and narratives detailed by the participants: preparation and anxiety (before using AAS); deviation from feminine identity (during AAS use); turbulence of cessation (end of AAS use); and rediscovering femininity (post-AAS cessation reflections). The results show how harm arising from AAS use is characterised by the development of virilising effects and the complex framing of their feminine identity, providing a clearer image of how harm is defined and managed by this population. While participants anticipated adverse side effects, this did not prevent negative emotions arising from their development. Our results also suggest that gender identity in this unique population is inseparable but not irreconcilable with the changing body. Illuminating this specific facet of AAS use can inform holistic, meaningful, and more inclusive harm reduction measures by adding experiential information from this unique but understudied and hard-to-reach group.

Rural-urban differences in hospitalizations for opioid use-associated infective endocarditis in Kentucky, 2016-2019.

In 2016, the US rate of opioid use-associated infective endocarditis (OUA IE) hospitalizations was 3.86/100,000 for rural and 3.49/100,000 for urban residents. This study estimates the Kentucky OUA IE hospitalization rates, 2016-2019, describing differences in rural-urban residency trends, demographics, relevant comorbidities, and discharge disposition. OUA IE hospitalization rates between counties with and without syringe services programs (SSPs) are also compared. We used Kentucky statewide inpatient discharge records from 2016 to 2019. An OUA IE hospitalization was identified by an infective endocarditis discharge diagnosis in any diagnosis field and a concurrent diagnosis indicating opioid use. Rurality was determined based on the 2013 Rural-Urban Continuum Codes (RUCC). Kentucky's rate of OUA IE hospitalizations in 2016 was 8.9/100,000, with no significant variation between rural and urban residents. By 2019, the average rate for urban residents doubled to 17.9/100,000, significantly higher than the rural resident rate, 13.2/100,000. There were no significant rural-urban differences in percentages of those with concurrent diagnoses of HIV (<1%) or HCV (>60%). Counties that established SSPs in 2017-2018 had a 39.4% increase in OUA IE rates from 2016 to 2019, while counties without SSPs had a 79.5% increase. The estimated 2016 Kentucky rates of OUA IE hospitalizations are 2 times higher than reported national rates, highlighting Kentucky as one of the areas most affected by this particular opioid use disorder complication. Despite challenges and barriers to the effectiveness of SSPs as a harm reduction measure, our study suggests a positive effect that should be further investigated.

Using a Harm Reduction Model to Reduce Barriers to Vaccine Administration.

Vaccination is a strategic public health measure designed to reduce the adverse effects of many infectious diseases. Although national recommendations exist for vaccine administration across the life span, immunization rates are affected by barriers to vaccine access and hesitancy in vaccine acceptance. Midwives and women's health clinicians are optimally poised to assess their client's vaccination status and provide vaccinations during clinical encounters. In order to address client concerns about vaccine safety and administration, each clinician is expected to be knowledgeable about vaccine benefits, recommendations, side effects, and potential adverse reactions. Socioeconomic factors, social policies, and historic and continued experiences related to racism have been identified as barriers to ready access to vaccinations and vaccine acceptance. Midwives can act as leaders within their practice sites and communities through participation in projects that reduce barriers to vaccine access and uptake. Community vaccine outreach programs and relationship-based care can increase vaccine uptake through improved health literacy and associated behavioral changes including greater vaccine acceptance. This article focuses on identifying barriers to vaccine uptake and describing harm reduction measures designed to improve uptake of vaccines. A variety of leadership activities are discussed that can improve clinicians' understanding of their role in optimizing vaccination.

Expert stakeholder perspectives on the acceptability of treatment-as-prevention in prison: a qualitative substudy of the 'Surveillance and Treatment of Prisoners with Hepatitis C' project (SToP-C).

Mathematical modelling has demonstrated the theoretical feasibility of HCV treatment-as-prevention strategies in custodial settings, yet limited empirical data exists. The Australian 'Surveillance and Treatment of Prisoners with Hepatitis C' study is the world's first trial of hepatitis C virus (HCV) treatment-as-prevention in prison. This study aimed to analyse how expert stakeholders involved in the Australian HCV response assessed the acceptability of HCV treatment-as-prevention in prison using interview data from the SToP-C qualitative substudy. Qualitative analysis using semi-structured interviews in Australia. Nineteen key HCV experts. Drawing upon Sekhon's theoretical framework of acceptability, data were organized thematically under four component constructs of acceptability: affective attitude; ethicality; opportunity costs; and perceived effectiveness. Most differences in participant assessments of acceptability were a matter of relative emphasis and prioritization rather than absolute polarity. Nonetheless, a small minority of participants was overtly critical of the approach. Arguing against the focus on treatment, they instead advocated for prevention-as-prevention, including the improvement and expansion of existing harm reduction measures. Qualitative analysis of expert stakeholder assessments of the acceptability of hepatitis C virus treatment-as-prevention in Australian prisons found no opposition to the universal rollout of direct-acting anti-virals, but most voiced concern regarding the lack of effective primary prevention in Australian prisons.

Compounding Racialized Vulnerability: COVID-19 in Prisons, Jails, and Migrant Detention Centers.

Carceral institutions are among the largest clusters of COVID-19 in the United States. In response, activists and detainees have rallied around decarceration demands: the release of detainees and inmates to prevent exposure to COVID-19. This article theorizes the compounding racial vulnerability that has led to such a marked spread behind bars, mainly among race-class subjugated (RCS) communities. The authors provide an in-depth account of COVID-19 in American correctional facilities and the mobilization to reduce contagions. They also use two survey experiments to describe public support for harm reduction and decarceration demands and to measure the effects of information about racial inequalities in prison and poor conditions inside migrant detention centers. The authors found only one-third to one-half of respondents believe that response to COVID-19 in prisons and immigrant detention centers should be a high priority. They also found Americans are more supportive of harm reduction measures than decarceration efforts. Information about racial disparities increases support decarceration. They did not find any significant effect of information about poor conditions in migrant detention centers. The conditions in carceral institutions during the pandemic-and public opinion about them-highlight the realities of compounding racialized vulnerability in the United States.

Systematic Evaluation of State Policy Interventions Targeting the US Opioid Epidemic, 2007-2018

In response to the increase in opioid overdose deaths in the United States, many states recently have implemented supply-controlling and harm-reduction policy measures. To date, an updated policy evaluation that considers the full policy landscape has not been conducted. To evaluate 6 US state-level drug policies to ascertain whether they are associated with a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths. This cross-sectional study used drug overdose mortality data from 50 states obtained from the National Vital Statistics System and claims data from 23 million commercially insured patients in the US between 2007 and 2018. Difference-in-differences analysis using panel matching was conducted to evaluate the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, the prescription of MAT, and drug overdose deaths before and after implementation of 6 state-level policies targeting the opioid epidemic. A random-effects meta-analysis model was used to summarize associations over time for each policy and outcome pair. The data analysis was conducted July 12, 2020. State-level drug policy changes to address the increase of opioid-related overdose deaths included prescription drug monitoring program (PDMP) access, mandatory PDMPs, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws. The outcomes of interests were quarterly state-level mortality from drug overdoses, known indicators for prescription opioid abuse and doctor shopping, MAT, and prevalence of drug overdose and opioid use disorder. This cross-sectional study of drug overdose mortality data and insurance claims data from 23 million commercially insured patients (12 582 378 female patients [55.1%]; mean [SD] age, 45.9 [19.9] years) in the US between 2007 and 2018 found that mandatory PDMPs were associated with decreases in the proportion of patients taking opioids (-0.729%; 95% CI, -1.011% to -0.447%), with overlapping opioid claims (-0.027%; 95% CI, -0.038% to -0.017%), with daily morphine milligram equivalent greater than 90 (-0.095%; 95% CI, -0.150% to -0.041%), and who engaged in drug seeking (-0.002%; 95% CI, -0.003% to -0.001%). The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs (0.015%; 95% CI, 0.002% to 0.028%), pain clinic laws (0.013%, 95% CI, 0.005%-0.021%), and prescription limit laws (0.034%, 95% CI, 0.020% to 0.049%). Mandatory PDMPs were associated with a decrease in the number of overdose deaths due to natural opioids (-518.5 [95% CI, -728.5 to -308.5] per 300 million people) and methadone (-122.7 [95% CI, -207.5 to -37.8] per 300 million people). Prescription drug monitoring program access policies showed similar results, although these policies were also associated with increases in overdose deaths due to synthetic opioids (380.3 [95% CI, 149.6-610.8] per 300 million people) and cocaine (103.7 [95% CI, 28.0-179.5] per 300 million people). Except for the negative association between prescription limit laws and synthetic opioid deaths (-723.9 [95% CI, -1419.7 to -28.1] per 300 million people), other policies were associated with increasing overdose deaths, especially those attributed to non-prescription opioids such as synthetic opioids and heroin. This includes a positive association between naloxone access laws and the number of deaths attributed to synthetic opioids (1338.2 [95% CI, 662.5 to 2014.0] per 300 million people). Although this study found that existing state policies were associated with reduced misuse of prescription opioids, they may have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. This finding suggests that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the US.

Tracing a path for opium gum from Mexico as a safe supply harm reduction measure for Canada

Historically, the poppy plant has had multiple uses including as a food product and with medical uses in pain relief; today it is most commonly known as the plant from which heroin is derived. The United Nations international drug control regime currently only allows legal poppy production for medical use in 19 countries. Although Mexico is the third largest illegal poppy producer in the world, no Latin American country is currently allowed to legally produce poppies. Meanwhile, the United States and Canada are experiencing an overdose crisis due in large part to the adulteration and substitution of heroin with fentanyl and its analogues, while the price of opium gum has dropped 80% in the last two years in poppy producing areas of Mexico. The prohibition of opium has wide ranging health and development impacts that bring up a moral imperative regarding the safe supply of diverse opium-based products –including opium gum and heroin– that urgently need to be explored and addressed. Opium gum can be used orally or smoked, reducing riskier modes of administration and possible fatal overdoses. This article discusses the political and legal possibilities of safely supplying opium gum and manually extracted heroin from Mexico to Canada as a public health, harm reduction and development policy.

A Perspective on Age Restrictions and Other Harm Reduction Approaches Targeting Youth Online Gambling, Considering Convergences of Gambling and Videogaming.

Internet gambling has become a popular activity among some youth. Vulnerable youth may be particularly at risk due to limited harm reduction and enforcement measures. This article explores age restrictions and other harm reduction measures relating to youth and young adult online gambling. A systematic rapid review was conducted by searching eight databases. Additional articles on online gambling (e.g., from references) were later included. To place this perspective into context, articles on adult gambling, land-based gambling, and substance use and other problematic behaviors were also considered. Several studies show promising findings for legally restricting youth from gambling in that such restrictions may reduce the amount of youth gambling and gambling-related harms. However, simply labeling an activity as “age-restricted” may not deter youth from gambling; in some instances, it may generate increased appeal for gambling. Therefore, advertising and warning labels should be examined in conjunction with age restrictions. Recommendations for age enforcement strategies, advertising, education, and warning labels are made to help multiple stakeholders including policymakers and public health officials internationally. Age restrictions in online gambling should consider multiple populations including youth and young adults. Prevention and harm reduction in gambling should examine how age-restriction strategies may affect problem gambling and how they may be best enforced across gambling platforms. More research is needed to protect youth with respect to online gambling.

Injecting as a sexual practice: Cultural formations of ‘slamsex’

‘Slamsex’ has emerged in gay vernacular in recent years to denote a particular way of taking drugs and a particular kind of sex. Slamming refers in this context to the practice of injecting drugs – typically crystal methamphetamine – intravenously. To pair ‘slamming’ with ‘sex’ is to propose that a particular mode of drug administration is constitutive of a particular kind of sex – a relatively novel idea that deserves some unpacking. What does it mean to make a route of drug administration definitional in the delineation of a sexual practice? What does this move reveal about contemporary practices of sex and drug consumption? In this article, we explore these questions with reference to theories of drug effects and practitioners’ accounts of slamsex. We conclude by considering the implications of our analysis for slamsex relations and associated harm reduction measures.

Peer-assisted injection as a harm reduction measure in a supervised consumption service: a qualitative study of client experiences

BackgroundPeer assistance is an emerging area of study in injection drug use. When Canada’s first supervised consumption site (SCS) opened in 2003 in Vancouver, Canada, clients were prohibited from injecting their peers; only recently has this practise been introduced as a harm reduction measure at these sites. In 2018, Health Canada granted federal exemption to allow peer-assisted injection at certain SCS sites, under the Controlled Drugs and Substances Act. Literature pertaining to peer-assisted injection addresses several topics: interpersonal relationships between the injection provider and recipient; the role of pragmatism; trust and expertise; and gender relations.MethodsIn this qualitative study, participants (n = 16) were recruited to be interviewed about their experiences in a peer-assisted injection program (PAIP) at one SCS regulated by Health Canada. Interview data were transcribed and thematically analyzed. Quantitative administrative data were used to provide context and to describe the study population, comprised of people in the PAIP (n = 248).ResultsPAIP clients made up 17.4% of all SCS clients. PAIP clients were more likely to be female and Indigenous. Injection providers expressed being moved by compassion to help others inject. While their desire to assist was pragmatic, they felt a significant burden of responsibility for the outcomes. Other prominent factors related to the injection provider-recipient relationship were social connection, trust, safety, social capital, and reciprocity. Participants also made suggestions for improving the PAIP which included adding more inhalation rooms so that if someone was unable to inject they could smoke in a safe place instead. Additionally, being required by law to divide drugs outside of the SCS, prior to preparing and using in the site, created unsafe conditions for clients.ConclusionsRegular use of the SCS, and access to its resources, enabled participants to lower their risk through smoking and to practice lower-risk injections. At the federal level, there is considerable room to advocate for allowing clients to divide drugs safely within the SCS, and to increase capacity for safer alternatives such as inhalation.

Differences in use of inhalants among sexual minorities in the USA in 2015–2018

ObjectivesInhalants are substances with underestimated abuse potential associated with cardiac problems, dizziness, seizures, and decreased level of consciousness. Inhalants are commonly used by the LGB population, who are vulnerable to their harms. US epidemiologic inhalants data are scarce. The aims of this study are to: i) investigate associations between inhalant use and sexual identity groups; ii) examine associations with use of other drugs among lesbian/gays who use inhalants. MethodsData came from the 2015–2018 NSDUH (n = 168,560). Participants ages 18 or older were asked if they had used any inhalants in their lifetime and past-year. We investigated the associations between inhalant use with sexual identity categories heterosexual, lesbian/gay, and bisexual using logistic regression models with complex survey design. ResultsTotal prevalences of lifetime and past-year use of inhalants were 9.4% and 0.5%, respectively. Lesbian/gay population (L/G) and bisexuals (B) reported higher odds of lifetime (L/G: aOR = 3.71, 95%CI = [3.19,4.30], B: aOR = 1.82, 95%CI = [1.64,2.03) and past-year (L/G: aOR = 11.57, 95%CI = [8.95,14.96], B: aOR = 2.81, 95%CI = [2.02,3.92]) inhalant use compared to heterosexuals. Among L/G, men had higher odds of lifetime (aOR = 4.11, 95%CI = [3.06,5.52]) and past-year (aOR = 15.67, 95%CI = [7.27,33.76]) inhalant use versus women. Use of marijuana (aOR = 2.76, 95%CI = [1.48,5.16]), other illegal drugs (aOR = 2.70, 95%CI = [1.60,4.56]), and non-medical use of psychotherapeutics (aOR = 2.67, 95%CI = 1.77,4.05) were associated with past-year use of inhalants among L/G. ConclusionLGB population is at elevated risk of inhalant use and of concurrent use with other drugs. Gay men had significantly higher odds of inhalant use compared to lesbians and bisexuals. Informative and in-site harm reduction measures are warranted to prevent harms from inhalant use.

Relevance of cryptomarkets, characteristics of purchasers and possibilities for survey research: experience from the European Web Survey on Drugs

Purpose The purpose of this paper is to assess the relevance of cryptomarkets, characteristics of purchasers and possibilities for survey research by approaching users directly on cryptomarkets. Design/methodology/approach Cross-country comparison of the results from the European Web Survey on Drugs (EWSD) and summarizing lessons learned during the data collection was carried out. Findings Purchasers of drugs on cryptomarkets are still a rather small segment of all drug purchasers, and most people who use cryptomarkets also use other sources of supply to buy drugs. The percentage of people using cryptomarkets is unevenly distributed across countries and substances. Purchasers on cryptomarkets in most countries are more likely to be men and more likely, on average, to use more substances. Other characteristics such as age or place of residence do not show a consistent pattern across countries. Recruitment of respondents on cryptomarkets calls for specific techniques and procedures. Specific attention should be paid to build trust and guarantee credibility and anonymity. Research limitations/implications Interpretation of the quantitative results is limited by nonprobabilistic sampling and different recruitment strategies in different countries. Practical implications Users of cryptomarkets show some specific characteristics, providing a challenge for research and prevention agencies to keep up with digital technology. Increasing knowledge about characteristics of users of cryptomarkets may help to create adequate responses for harm reduction measures in different supply settings. However, collecting self-reported data from users on cryptomarkets is limited owing to significant privacy concerns and requires specific skills and strategies. Originality/value The EWSD provides a rare opportunity for detailed analyses of consumption patterns and characteristics of active drug users across several European countries. Furthermore, experiences of a new recruitment strategy are discussed.

Harm Reduction and Moral Desert in the Context of Drug Policy

The target of my discussion is intuitions lay people have about justice in the context of drug policy—intuitions that take on a more or less moral-desert-based shape. I argue that even if we think desert is the right measure of how we ought to treat people, we ought still be in favour of Harm Reduction measures for people who use drugs. Harm Reduction measures are controversial with members of the public, and much of the opposition seems to come from something like an appeal to a desert conception of justice—the notion that a just state of affairs is one in which everybody gets what they deserve, no more, no less. A recent study, for example, found that ‘moral outrage’ predicts a preference for prevalence reduction (criminal sanction, etc.) over Harm Reduction. The thinking seems to be that, since drug use is wrong, letting people who use drugs suffer and/or die as a consequence of their use is just. Aiding their health and safety, while perhaps compassionate, is unjust. I argue that there is a bad desert fit between using drugs and suffering avoidable harm even if using drugs is morally wrong. Many of the possible harms of drug use are socially/policy driven, and much problematic drug use is context dependent, not cleanly attributable to the decisions of the person who uses drugs. This means that even if drug use is wrong, people who use drugs deserve Harm Reduction policies, at minimum.