Harm Reduction Strategies Research Articles

Spatial Heterogeneity in Fatal Overdose Rate Trends in Mexican Cities: 2005-2021.

Objectives. To describe national and city-level fatal drug overdose trends between 2005 and 2021 in Mexico. Methods. We calculated fatal overdose rates at the city level in 3-year periods from 2005 to 2021 and annually at the national level for people aged 15 to 64 years in Mexico. We calculated rate differences and rate ratios for each city between periods. Results. The national fatal overdose rate was 0.53 overdose deaths per 100 000 population and was almost twice as high in urban than in nonurban areas. The national fatal overdose rate was stable over the period 2005 to 2014 and increased monotonically to a peak in 2021. Fatal overdose rates varied across cities. Cities with the 8 highest fatal overdose rates in the period were all in states along the US-Mexico border. Conclusions. Fatal overdoses have doubled over the past 15 years in Mexico. Overdose rates are particularly high and increasing in cities close to the US-Mexico border. Public Health Implications. There is a need for enhanced overdose surveillance data and coordinated harm reduction strategies, particularly in the northern border region of Mexico. (Am J Public Health. 2024;114(7):705-713. https://doi.org/10.2105/AJPH.2024.307650).

Reporting on Health Care and Social Service Provider Approaches to Promoting Alcohol Abstinence During Pregnancy

ABSTRACT Despite the known detrimental health effects of alcohol use during pregnancy, there are still health care (HCP) and social service providers (SSP) who do not promote complete abstinence. The purpose of this study was to explore the current practices of HCPs and SSPs when discussing alcohol use during pregnancy, and to understand their rationale for their specific recommendations. An online survey was completed by 1123 HCPs (n = 588) and SSPs (n = 535) that asked them to identify their approach to discussing alcohol and pregnancy. Participants had the option to further explain their current recommendations regarding alcohol use during pregnancy in an open-ended format. Open-ended responses were analyzed using a content analysis approach (n = 156). The majority of respondents recommend abstinence (83.9% of HCPs, n = 493; 78.4% of SSPs, n = 419), while 9.8% of HCPs (n = 57) and 2.2% of SSPs (n = 12) responded that low levels of consumption may be acceptable. HCPs may recommend low levels of consumption based on other international guidelines, limited evidence to suggest that one unit of alcohol is harmful, and as a harm reduction strategy. SSPs stated that they refer clients to HCPs for recommendations related to alcohol consumption, and that they prefer to provide information based on public health guidelines. This exploratory work may inform the development of resources to support HCPs and SSPs to recommend abstinence from alcohol throughout gestation.

Prison Nurseries: A Review of Maternal and Infant Rooming in Outcomes for Incarcerated Mothers

Women are the fastest growing prison population in Canada, and at incarceration, 4-10 percent of women are pregnant. These women, their correctional facilities, and Canadian health care services are increasingly forced to address the issues of motherhood and reproductive health care during incarceration. Most incarcerated women are separated from their infants soon after birth. The authors claim that prison nurseries, as a harm reduction strategy, are a positive alternative to this separation. Midwives could play a valuable role in these health care units. Methods: This paper is a literature review examining the outcomes of mother-infant dyads who have access to prison nurseries. The search strategy included 15 health research databases, applying similar search terms to all databases. This article has been peer reviewed.

Examining the Gateway Hypothesis and Mapping Substance Use Pathways on Social Media: Machine Learning Approach.

Substance misuse presents significant global public health challenges. Understanding transitions between substance types and the timing of shifts to polysubstance use is vital to developing effective prevention and recovery strategies. The gateway hypothesis suggests that high-risk substance use is preceded by lower-risk substance use. However, the source of this correlation is hotly contested. While some claim that low-risk substance use causes subsequent, riskier substance use, most people using low-risk substances also do not escalate to higher-risk substances. Social media data hold the potential to shed light on the factors contributing to substance use transitions. By leveraging social media data, our study aimed to gain a better understanding of substance use pathways. By identifying and analyzing the transitions of individuals between different risk levels of substance use, our goal was to find specific linguistic cues in individuals' social media posts that could indicate escalating or de-escalating patterns in substance use. We conducted a large-scale analysis using data from Reddit, collected between 2015 and 2019, consisting of over 2.29 million posts and approximately 29.37 million comments by around 1.4 million users from subreddits. These data, derived from substance use subreddits, facilitated the creation of a risk transition data set reflecting the substance use behaviors of over 1.4 million users. We deployed deep learning and machine learning techniques to predict the escalation or de-escalation transitions in risk levels, based on initial transition phases documented in posts and comments. We conducted a linguistic analysis to analyze the language patterns associated with transitions in substance use, emphasizing the role of n-gram features in predicting future risk trajectories. Our results showed promise in predicting the escalation or de-escalation transition in risk levels, based on the historical data of Reddit users created on initial transition phases among drug-related subreddits, with an accuracy of 78.48% and an F1-score of 79.20%. We highlighted the vital predictive features, such as specific substance names and tools indicative of future risk escalations. Our linguistic analysis showed that terms linked with harm reduction strategies were instrumental in signaling de-escalation, whereas descriptors of frequent substance use were characteristic of escalating transitions. This study sheds light on the complexities surrounding the gateway hypothesis of substance use through an examination of web-based behavior on Reddit. While certain findings validate the hypothesis, indicating a progression from lower-risk substances such as marijuana to higher-risk ones, a significant number of individuals did not show this transition. The research underscores the potential of using machine learning with social media analysis to predict substance use transitions. Our results point toward future directions for leveraging social media data in substance use research, underlining the importance of continued exploration before suggesting direct implications for interventions.

Implementing a Harm Reduction Strategy by Distributing Naloxone in Birthing Hospitals

Implementing a Harm Reduction Strategy by Distributing Naloxone in Birthing Hospitals

Harm Reduction for Opioid Use Disorder: Strategies and Outcome Metrics.

Tweet: The authors discuss harm reduction strategies and associated outcome metrics in relation to the ongoing opioid crisis.

A substance use disorder training curriculum for internal medicine residents using resident-empaneled patients.

Internal Medicine (IM) residents frequently encounter, but feel unprepared to diagnose and treat, patients with substance use disorders (SUD). This is compounded by negative regard for patients with SUD. Optimal education strategies are needed to empower IM residents to care for patients with SUD. The objective of this study was to evaluate a brief SUD curriculum for IM residents, using resident-empaneled patients as an engaging educational strategy. Following a needs assessment, a 2-part SUD curriculum was developed for IM residents at the University of Chicago during the 2018-2019 academic year as part of the ambulatory curriculum. During sessions on Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD), a facilitator covered concepts about screening, diagnosis, and treatment. In session, residents completed structured worksheets applying concepts to one of their primary care patients. A post-session assessment included questions on knowledge, preparedness & attitudes. Resident needs assessment (n = 44/105, 42% response rate) showed 86% characterized instruction received during residency in SUD as none or too little, and residents did not feel prepared to treat SUD. Following the AUD session, all residents (n = 22) felt prepared to diagnose and treat AUD. After the OUD session, all residents (n = 19) felt prepared to diagnose, and 79% (n = 15) felt prepared to treat OUD. Residents planned to screen for SUD more or differently, initiate harm reduction strategies and increase consideration of pharmacotherapy. A brief curricular intervention for AUD and OUD using resident-empaneled patients can empower residents to integrate SUD diagnosis and management into practice.

The surge of bromazolam-related fatalities replacing other novel designer benzodiazepines-related fatalities in San Francisco.

Bromazolam, a novel designer benzodiazepine (NBD), exhibits potent sedative, hypnotic and anxiolytic effects, raising concerns regarding its potential for misuse and fatal outcomes, particularly when combined with opioids such as fentanyl. Despite limited documented fatalities globally, its use poses a significant threat, exacerbated by under-reporting and a lack of routine testing. This study analysed NBD-related deaths in a major US city over a 4-year period. Analysis of accidental overdose deaths involving NBDs in San Francisco, CA, USA from 2020 to 2023, was performed utilizing medico-legal death investigations including comprehensive forensic toxicology, pathology and demographic information. San Francisco conducts thorough investigations into all non-natural and sudden unexpected deaths, including routine alcohol and drug testing of decedents under its jurisdiction, including etizolam, flualprazolam, flubromazolam and bromazolam analysis. There was a sudden surge in bromazolam-related deaths, with 44 fatalities documented in 2023, contrasting with relatively fewer deaths related to other NBDs. Bromazolam fatalities frequently involved co-ingestion with opioids, primarily fentanyl, and stimulants such as methamphetamine and cocaine. Demographic characteristics indicated a predominance of males, with a significant proportion lacking fixed addresses. Blood concentrations of bromazolam increased during the study period, suggesting heightened availability and/or purity in the community. There was a surge in bromazolam-related deaths during 2023 in San Francisco, CA, USA, contrasting with relatively stable numbers of deaths associated with other NBDs over the preceding years. The findings underscore the urgency for enhanced death investigation, testing and reporting to facilitate targeted harm reduction strategies for individuals at risk of bromazolam-related morbidity and mortality.

'Insulin is super dangerous if you don't know what you're doing': Situating the risks of insulin within the image and performance enhancing drug community.

Insulin is an essential treatment within diabetes management; however, it takes on a role of enhancement within image and performance enhancing drug (IPED) communities due to its anabolic effects. This study sought to provide insight into how IPED users perceive and manage the risks linked to insulin. We conducted semi-structured interviews with 10 individuals from Australia and United Kingdom who used insulin as part of their IPED protocols. The analysis followed an iterative categorisation approach and applied the lens of situated rationality theory. The decision to incorporate insulin was influenced by peers' experiences and preferences. Participants highlighted the risks and responsibilities associated with insulin use, emphasising the need for precise lifestyle habits. They recognised the potential dangers and called for comprehensive harm reduction strategies within IPED communities to respond to such concerns. Some participants expressed reluctance to discuss insulin openly, underlining the importance of education and awareness to mitigate health risks associated with underground and uninformed use. While people who use IPEDs demonstrate awareness of the risks associated with insulin, their practices of routinisation moderate these risks within the context of IPED use. Silence as a risk-reduction strategy highlights vulnerabilities among certain prospective users, while the hierarchical structure of IPED use establishes expertise and status within the community. Reconsidering insulin risks entails reframing harm reduction messages to better match the social dynamics of IPED communities. Closer ties between IPED communities can enhance support accessibility, particularly through peers, who, with their firsthand knowledge, can offer tailored guidance.

Use of harm reduction strategies by individuals with a history of incarceration: A short report using baseline data collected from the STAMINA clinical trial

BackgroundDue to the considerably heightened risk of overdose immediately following jail or prison release, expansion of harm reduction interventions for citizens returning to the community after an incarceration episode should be of utmost concern. However, there are no studies examining the adoption and use of harm reduction among this population. This short report examines the use of individual-level harm reduction strategies (HRS) among people who use drugs, comparing those who have lifetime histories of incarceration with those who do not. MethodsThis study included baseline data (N = 274) from a larger clinical trial, which recruited participants at two syringe service programs. Fisher's exact tests examine correlations between HRS and lifetime incarceration. ResultsSignificant variation in HRS use were observed by demographic characteristics. Those with lifetime incarceration histories were less likely to report ensuring naloxone was available when using, using when others were present, using fentanyl test strips, using a trusted drug supplier, and using some other HRS compared to those without lifetime incarceration histories. Similarly, those with lifetime incarceration histories were also less likely to report using non-prescribed buprenorphine and methadone, which could potentially reduce overdose risk even if not explicitly used as an HRS. ConclusionThe results suggest that one of the populations at highest risk of overdose is least likely to use strategies that may reduce overdose risk. Targeted efforts to increase exposure to HRS learning opportunities and access to these resources could help reduce overdose disparities for people returning to the community after incarceration.

Abstract LB086: Measuring oral DNA damage to evaluate electronic cigarette use as a tobacco harmreduction strategy

Abstract Background: Smokers increase their risk of numerous types of diseases, including lung and oral cancer. Despite this knowledge, approximately 18.7% of U.S. adults are smokers, and millions of smokers across the U.S. struggle to quit tobacco every day. Although difficult due to nicotine addiction, you can increase your chances of quitting with the tools available, and help is an important part of any quitting plan. The prevalence of electronic cigarette (e-cigarette) use has increased as users perceive them to be safer than traditional tobacco smoke. Studies have shown that e-cigarettes contain fewer chemicals than tobacco smoke. Therefore, addressing the effectiveness of e-cigarette use in reducing tobacco harm is essential and is currently a priority for the FDA. Aim: To determine whether combustible tobacco users who are provided with free e-cigarettes and free e-liquids reduce the levels of DNA damage in their oral epithelial cells. Methods: Adult smokers who smoked at least 5 cigarettes per day over the past year and did not plan to quit smoking in the next 3 months were enrolled in a randomized 3-arm clinical trial (NCT03113136): “Usual Brand Cigarettes” (UBC), Low Wattage e-cigarettes (LWe), and High Wattage e-cigarettes (HWe). Free combustible cigarettes or e-cigarettes plus e-liquid were provided during the first 12 weeks according to assigned group. Tobacco product use details, CO level, and oral mucosa samples were collected at 0, 4, and 12 weeks. DNA was extracted from oral cells and damage was quantified by q-PADDA, at three time points (Week 0, 4, 12). Data analysis was performed using ANOVA model. Results: Participants who provided samples at all time points were included in this DNA damage study. 201 complete data sets (UBC=77, LWe=61 and HWe=66) were available for DNA damage quantification at the time of this report. At enrolment (week 0), there were no significant differences in age, sex or tobacco product use across groups. At 12 weeks, combustible tobacco use was significantly reduced in smokers also using LWe or HWe (dual users). At 4 and 12 weeks, the CO levels were reduced in dual users of combustible tobacco and e-cigarettes (LWe or HWe), compared to exclusive combustible tobacco users. Compared to combustible tobacco users, dual users of combustible tobacco and LWe or HWe showed a significant reduction in the levels of oral mucosa DNA damage at 4 and 12 weeks (3 to 5 fold). Conclusion: Our study shows that when provided with free e-cigarette devices and e-liquids, smokers who were dual users or completely switched to LWe or HWe significantly reduced the levels of DNA damage in their oral mucosa compared with exclusive combustible tobacco users. These data suggest that LW and HW e-cigarette devices are an effective harm reduction tool and might help to reduce tobacco-associated health effects. Funding: NIH/NCI (R01CA204891, Wagener; R01CA242168, Queimado). Citation Format: Vengatesh Ganapathy, Mayilvanan Chinnaiyan, Daniel Brobst, Balaji Sadhasivam, Jean D. Nshimiyimana, Yan Zhao, Theodore Wagener, Lurdes Queimado. Measuring oral DNA damage to evaluate electronic cigarette use as a tobacco harmreduction strategy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB086.

Motives for MDMA Use: A Comparative Study with Alcohol and Cannabis

IntroductionWhile research on drug use motives has primarily focused on widely used substances like alcohol, tobacco, and cannabis, understanding the motivations behind MDMA use is crucial for developing targeted therapeutic, preventive, and harm reduction strategies.ObjectivesThe objective of this study is to present the findings of an online survey that evaluates the motives behind the use of 3,4-methylenedioxymethamphetamine (MDMA) and draws comparisons between these motives and those for alcohol and cannabis consumption.Methods Data were collected through an online survey, available in both English and French, with 99 participants. The survey included five sections, including a substance abuse screening test (ASSIST) and the Pahnke-Richards Mystical Experience Questionnaire. The primary focus was on motives for MDMA use, assessed using an adapted version of the Marijuana Motives Measure (MMM), comparing them with alcohol and cannabis motives.Results The most reported motive for MDMA use was enhancement, followed by expansion motives. Social motives were the third most common, while coping motives ranked fourth, and conformity was the least common motive. Comparisons with alcohol and cannabis use motives revealed differences in motives for each substance. MDMA showed a unique pattern of motives.ConclusionsEnhancement emerged as the most prevalent motive for MDMA use, consistent with previous research on MDMA motive use. Expansion motives, which involve altering perceptions and increasing self-awareness, ranked second, reflecting the growing interest in MDMA-assisted therapy for conditions like PTSD. Surprisingly, social motives were less common for MDMA compared to alcohol and cannabis, suggesting unique social dynamics associated with MDMA use. Conformity motives were also less significant for MDMA users, possibly due to the age of initiation and user maturity. Understanding the motives behind MDMA use is essential for designing effective interventions and harm reduction strategies. The distinct motives for MDMA, as compared to alcohol and cannabis, highlight the need for tailored approaches to address its use. Further research should explore the complex interplay of motives, age of initiation, social context, and cultural factors to inform comprehensive strategies related to MDMA use.Disclosure of InterestNone Declared

“There’s Always a Way to Get Around the Guidelines”: Nonsuicidal Self-Injury and Content Moderation on TikTok

The stigmatized nature of nonsuicidal self-injury may render TikTok, a short-form, video-sharing social media platform, appealing to individuals who engage in this behavior. Since this community faces biased scrutiny based on stigmatization surrounding mental health, nonsuicidal self-injury users may turn to TikTok, which offers a space for users to engage in discussions of nonsuicidal self-injury, exchange social support, experience validation with little fear of stigmatization, and facilitate harm reduction strategies. While TikTok’s Community Guidelines permit users to share personal experiences with mental health topics, TikTok explicitly bans content that shows, promotes, or shares plans for self-harm. As such, TikTok may moderate user-generated content, leading to exclusion and marginalization in this digital space. Through semi-structured interviews with 8 TikTok users and a content analysis of 150 TikTok videos, we explore how users with a history of nonsuicidal self-injury experience TikTok’s algorithm to engage with content on nonsuicidal self-injury. Findings demonstrate that users understand how to circumnavigate TikTok’s algorithm through hashtags, signaling, and algospeak to maintain visibility while also circumnavigating algorithmic detection on the platform. Furthermore, findings emphasize that users actively engage in self-surveillance, self-censorship, and self-policing to create a safe online community of care. Content moderation, however, can ultimately hinder progress toward the destigmatization of nonsuicidal self-injury.

Trends in HIV-Related Services Offered by Substance Abuse Treatment Facilities.

Introduction In the United States, persons who inject drugs (PWID) represent an increasingly vulnerable population, with a high risk of HIV transmission related to needle sharing. This paper aims to investigate the availability of HIV-related services within substance abuse treatment facilities while emphasizing the need for implementing comprehensive harm-reduction strategies in such facilities. Methods This study explores the prevalence and trends regarding HIV-related services within substance abuse treatment facilities in the United States including testing, counseling, early intervention, and medication provision. Data from the National Survey of Substance Abuse Treatment Services (N-SSATS) were analyzed in order to assess trends in HIV-related services from 2013 to 2020. Results Facility response rates revealed an increase in the availability of HIV testing and specialized programs for individuals with HIV. However, there was a contrasting trend with the decline in early intervention and counseling services, only with a slight increase in 2020. Additionally, government-owned facilities demonstrated superior performance in delivering HIV services compared to private facilities. Conclusion This study highlights the dire need for implementing routine opt-out HIV testing within substance abuse treatment facilities in order to identify new cases. Additionally emphasized is the importance of early intervention for this at-risk population. To effectively address these challenges, we suggest considering the adoption of the "Seek, Test, Treat, Retain" model as a potential solution. Increasing access to HIV-related services within substance abuse facilities requires enhanced resource allocation as well as integrated programs. Identifying deficiencies in HIV service integration is crucial to enhancing care and reducing HIV transmission among PWID.

Switching Away From Smoking and Reduction in Cigarette Consumption Among U.S. Adult Purchasers of the JUUL System Across 24 Months Including Diverse Subpopulations Disproportionately Affected by Cigarette Smoking.

Electronic nicotine-delivery systems (ENDS) can reduce tobacco-related health risks for adults who smoke cigarettes (AWS) by facilitating complete switching away from cigarettes. However, little is known about ENDS use and switching among subpopulations that have been disproportionately affected by smoking. AWS (age ≥ 21 years) were recruited following their first purchase of a JUUL Starter Kit in 2018. Participants who self-reported switching (no past-30-day cigarette smoking) at 1-, 2-, 3-, 6-, 9-, 12-, 15-, 18-, 21-, and 24-month follow-ups. Percent switched and percent with substantial smoking reduction (≥50% decrease in cigarettes per day among those who continued smoking) were calculated. Analyses focused on racial and ethnic minorities, persons with low income and education levels, sexual minorities, and those with mental and physical health conditions. Overall rates of switching away from cigarettes increased across follow-ups to 51.2% (month-12) to 58.6% (month-24, 87% of whom used ENDS). Among those who continued to smoke at 24 months, 45.4% reduced cigarettes per day by ≥ 50%. Rates of switching and substantial smoking reduction were largely similar across subgroups, with some statistically significant, but small, differences in month-24 switching rates (eg, education, mental and physical health conditions; switch rate range: 42%-57%). AWS demonstrated progressively increasing switching rates over 2 years after purchasing JUUL products. Similar trends in switching and smoking reduction were observed across populations disproportionately affected by smoking. By facilitating switching and smoking reduction, ENDS products such as JUUL may provide an opportunity to reduce smoking-related harm among some populations disproportionately affected by smoking, potentially reducing tobacco-related health disparities. ENDS have the potential to benefit population health if they can replace cigarettes. This benefit must extend to populations disproportionately affected by smoking. In this real-world study, 59% of JUUL purchasers reported complete switching 2 years later (no past-30-day smoking, with most continuing to use ENDS). Furthermore, 45% of those who continued to smoke reduced cigarette consumption by at least half. These rates of switching and smoking reduction were largely comparable across populations disproportionately affected by smoking (defined, eg, by ethnicity and income). ENDS can serve as an effective harm reduction strategy to complement current efforts to reduce tobacco-related disparities.

Is there anything beyond addiction psychotherapy in patients with cannabis use disorder? A rationale for prescribing medical marihuana as a harm reduction strategy

Marihuana has been known to people for hundreds of years. Today, marihuana is either legal or decriminalized in many countries, particularly in Europe and the Americas, which may encourage use of the drug. Cannabis and its derivatives are used in medicine on the recommendation of doctors, including for the treatment of multiple sclerosis or drug-resistant epilepsy. There is a group of people who turn to marihuana on the street without regard to contraindications and side effects, and these are the recreational users who struggle with problematic use or addiction . Buying marihuana outside of the medical market means that the user may not realize the negative health effects of their use, and there are serious risks associated with the negative effects of the natural substances found in marihuana or the numerous and common marihuana contaminants, such as mercury and pesticides, among others. This review justifies the prescription of pharmaceutical-grade medical marihuana as part of health harm reduction for a group of cannabis use disorder patients who are unlikely to stop using marihuana from untested or illicit sources, while also discussing ethical and economic issues.

Does cannabis use substitute for opioids? A preliminary exploratory survey in opioid maintenance patients.

Various studies showed that people with substance use disorder use cannabis to reduce withdrawal or dose of their main drug. Using a questionnaire about their cannabis use, 118 participants in an opioid maintenance treatment (OMT) in Germany were examined regarding this strategy. 60% reported to use cannabis. Of those, 72% were using cannabis in the suggested way. Cannabis was used to substitute for, e.g., heroin (44.8%) and benzodiazepines (16.4%). We also asked for an estimation of how good cannabis was able to substitute for several substances (in German school grades (1 till 6)); heroin average grade: 2.6 ± 1.49. Besides that we asked about the idea of cannabis as "self-medication", e.g., to reduce pain (47%) and about negative consequences from cannabis use. Our results suggest to consider the use of cannabis by patients in OMT rather as a harm reduction strategy to reduce the intake of more dangerous drugs.

A national study of clinical discussions about cannabis use among Veteran patients prescribed opioids

BackgroundThe Veterans Health Administration tracks urine drug tests (UDTs) among patients on long-term opioid therapy (LTOT) and recommends discussing the health effects of cannabis use.ObjectiveTo determine the occurrence of cannabis-related discussions between providers and patients on LTOT during six months following UDT positive for cannabis, and examine factors associated with documenting cannabis use.DesignWe identified patients prescribed LTOT with a UDT positive for cannabis in 2019. We developed a text-processing tool to extract discussions around cannabis use from their charts.SubjectsTwelve thousand seventy patients were included. Chart review was conducted on a random sample of 1,946 patients.Main measuresThe presence of a cannabis term in the chart suggesting documented cannabis use or cannabis-related discussions. Content of those discussions was extracted in a subset of patients. Logistic regression was used to examine the association between patient factors, including state of residence legal status, with documentation of cannabis use.Key ResultsAmong the 12,070 patients, 65.8% (N = 7,948) had a cannabis term, whereas 34.1% (N = 4,122) of patients lacked a cannabis term, suggesting that no documentation of cannabis use or discussion between provider and patient took place. Among the subset of patients who had a discussion documented, 47% related to cannabis use for medical reasons, 35% related to a discussion of VA policy or legal issues, and 17% related to a discussion specific to medical risks or harm reduction strategies. In adjusted analyses, residents of states with legalized recreational cannabis were less likely to have any cannabis-related discussion compared to patients in non-legal states [OR 0.73, 95% CI 0.64–0.82].ConclusionsOne-third of LTOT patients did not have documentation of cannabis use in the chart in the 6 months following a positive UDT for cannabis. Discussions related to the medical risks of cannabis use or harm reduction strategies were uncommon.

A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA

BackgroundXylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the illicit drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who use drugs (PWUD). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida.Case presentationA 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at a Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits were informed by best clinical judgement due to lack of formal guidelines at the time. Wound outcomes are unknown as the patient has not returned to clinic.ConclusionsMany PWUD at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system due to stigma. There is an urgent need for access to XTS for PWUD and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.

“It gets you high as a kite but not unsick”: Characterizations of and responses to a changing local drug supply by people who use drugs in Rhode Island

BackgroundThe North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths occurring in the United States (US) in 2022. Overdose deaths have increasingly been polysubstance-involved, with novel substances (e.g., xylazine) complicating overdose risk and health outcomes. Understanding the effects of—and responses to—a changing drug supply among people who use drugs is critical to modifying harm reduction strategies to be more responsive to people's needs. MethodsThis qualitative study draws on data collected from May to December 2022 in Rhode Island. Data include in-depth interviews with 50 people who use drugs and observational fieldwork in spaces frequented by participants (e.g., encampments, drop-in centers). Qualitative data were analyzed thematically drawing on concepts of situated rationality. ResultsParticipants described significant changes in the drug supply, with many attributing these transitions to COVID-19. Most participants characterized the local supply as “synthetic” with textures, color, and taste evolving. Notably, participants emphasized adverse outcomes related to available supplies, including during use (e.g., intense burning sensations) and post-consumption (e.g., heavy sedation, ongoing withdrawal, necrosis). Given the complex supply, participants highlighted the increased risk of overdose and shared how they altered their use practices to manage evolving health risks. ConclusionOur results underscore how people who use drugs characterized the local drug supply, including perceived changes to supply contents. Implementing and scaling up harm reduction interventions that reduce risk and reinforce the agency of people who use drugs are urgently needed to effectively address the overdose crisis.