Heroin Injection Research Articles

T48 - Naloxone Expansion is Not Associated With Increases in Adolescent Heroin Use and Injection Drug Use: Evidence From 44 U.S. States

T48 - Naloxone Expansion is Not Associated With Increases in Adolescent Heroin Use and Injection Drug Use: Evidence From 44 U.S. States

Injection Drug Use Alters Plasma Regulation of the B Cell Response.

The opioid epidemic continues to be a major public health issue that includes millions of people who inject drugs (PWID). PWID have increased incidence of serious infections, including HIV as well as metabolic and inflammatory sequelae. We sought to discern the extent of systemic alterations in humoral immunity associated with injection drug use, including alterations in the plasma proteome and its regulation of B cell responsiveness. Comprehensive plasma proteomics analysis of HIV negative/hepatitis C negative individuals with a history of recent injection heroin use was performed using mass spectrometry and ELISA. The effects of plasma from PWID and healthy controls on the in vitro proliferation and transcriptional profile of B cell responses to stimulation were determined by flow cytometry and RNA-Seq. The plasma proteome of PWID was distinct from healthy control individuals, with numerous immune-related analytes significantly altered in PWID, including complement (C3, C5, C9), immunoglobulin (IgD, IgM, kappa light chain), and other inflammatory mediators (CXCL4, LPS binding protein, C-reactive protein). The plasma of PWID suppressed the in vitro proliferation of B cells. Transcriptome analysis indicated that PWID plasma treatment increased B cell receptor and CD40 signaling and shifted B cell differentiation from plasma cell-like toward germinal center B cell-like transcriptional profiles. These results indicate that the systemic inflammatory milieu is substantially altered in PWID and may impact their B cell responses.

Prolonged diacetylmorphine take-home during the COVID-19 pandemic-Results of a retrospective cohort study.

Legal regulations for dispensing in Swiss heroin-assisted treatment were relaxed during the COVID-19 pandemic, allowing prolonged take-home of up to 7 days instead of two to reduce patient contact and the risk of infection. Our study aimed to measure the consequences of this new practice. This was a retrospective cohort study set in Switzerland's largest outpatient centre for opioid agonist therapy. One hundred and thirty-four (72.4%) of the 185 patients receiving oral diacetylmorphine (DAM) participated in the study. Through the utilization of electronic medication prescription and dispensing software, as well as the electronic medical record, the following data were extracted to explore the potential consequences: dose of DAM, the number of antibiotic therapies, emergency hospitalizations and incarcerations. Age, gender, prescriptions for psychotrophic drugs and additional prescription for injectable DAM were tested to assess an increased risk of losing prolonged take-home privileges. Data in the year since prolonged take-home (period 2) were compared with data from the equivalent prior year (period 1). DAM take-home was not associated with a change in DAM dose (P = 0.548), the number of emergency hospitalizations (P = 0.186) or the number of incarcerations (P = 0.215); 79.1% of all patients were able to maintain their extended take-home privileges. However, patients who had injectable DAM experienced significant reductions in their prolonged take-home privileges. Allowing patients to take home oral diacetylmorphine for up to 7days as treatment for opioid use disorder does not appear to pose any demonstrable health risk. It is generally manageable for the large majority of patients. However, careful consideration of prolonged take-home for patients with additional injectable diacetylmorphine is recommended, as these patients are more likely to lose take-home privileges.

Building Capacity for Injectable Diacetylmorphine and Hydromorphone for the Treatment of Opioid Use Disorder: Identifying Typical Doses

ABSTRACT Identifying typical doses of existing opioid use disorder medications, such as injectable opioid agonist treatment (iOAT), can support client and program needs, and potentially increase iOAT expansion. Longitudinal data from participants in a cohort study (n = 131), along with clinic dispensation records from August 2014 to April 2020, were used to examine physician prescribed as well as used doses of injectable diacetylmorphine and hydromorphone. Dosage groups, by medication and prescribed dose per session, were created for both hydromorphone and diacetylmorphine. A total of 534, 522 injections were registered during the study period among 129 participants. Mean received diacetylmorphine doses ranged from 106 to 989 mg per day, with most clients using 125–262 mg per session (mean 192.99 mg) and attending 2.40 sessions per day. Mean received hydromorphone doses ranged from 51.09 to 696.06 mg per day, with the majority using 88–154 mg per session (mean 121.32 mg; 2.43 sessions). Average daily doses remained stable overtime and, while mid-range doses were most typical, participants used the whole spectrum of allowable dose prescriptions. Evidence supporting typical doses of iOAT can be integrated into program planning to better allow providers and prescribers to anticipate program needs and engage in individualized care.

The effect of intravenous heroin injection on gene expression in HIV-1 infected people

The effect of intravenous heroin injection on gene expression in HIV-1 infected people

The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States

BackgroundCo-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality.MethodWe recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant.ResultsA clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand.ConclusionTransformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs’ market dominance at this location and possible interventions.

Extent and patterns of drug use in prison in Burkina Faso: findings from a cross-sectional study in central prison of Ouagadougou

PurposeDrug use in prisons remains a public health concern because it is often the place of drug initiation. The purpose of this study was to analyze the drug use in prison in Burkina Faso.Design/methodology/approachWe conducted cross-sectional study in the prison of Ouagadougou. The adult prisoners (male and female) incarcerated for more than one month at the largest prison of Burkina Faso were included in the study. Participants were selected using a systematic random sampling. Data were collected from October 28 to November 26, 2018. The face-to-face interviews were conducted in the prison grounds. Logistic multivariate regression was used to identify factors associated with in prison drug use. All analysis was done using Stata.FindingsA total of 379 prisoners were included in this study. Approximately one-third inmates (32.71%; n = 124) experienced illicit drug in lifetime. Nearly one-third (28.76%; n = 109) of the prisoners were drug users before incarceration and 11.87% (n = 45) used drug inside the prison, of which 33.33% (n = 15) initiated drug use in the prison. Cannabis was the first drug used by the prisoners (71.11%) followed by tramadol (62.22%), diazepam (13.33%) and cocaine (2.22%). Four prisoners (3.63%) had reported Heroin use before incarceration. Cannabis was mainly smoked. Tramadol, diazepam and amphetamines were swallowed or mixed with food. Cocaine is smoked and snorted. Case of injection of cocaine and heroin was reported before incarceration. Main factors independently associated with drug use in prison is drug use before prison and young age of inmates. Indeed, inmates who had reported drug use before prison had 4.01 time {adjusted odd ratio (AOR: 4.01 [95% CI: 1.91–8.41])} higher odds to use drug in prison.Research limitations/implicationsTo conduct the interviews in the prison grounds could be a limitation due to social desirability bias. Indeed, the prisoners may understate drug use in prison for the fear of likely additional sentence. Availability of biological tests for drug markers might help addressed this bias. Nevertheless, the findings of this study should help to plan effective drug use prevention and care programs for prisoners.Practical implicationsThe actions must include the implementation of a medical and psychological care in continuum of healthcare system in Burkina Faso. This system should include screening at entry and adequate health and psychological care in prison for drug users for an effective control of drugs use in prison.Social implicationsMost of these drug users in prison have a low level of education and are unemployed. Education activities and training on occupational activities to prepare drug users for a successful social reintegration less dependent on drugs is essential. This study can be a basis to explore more possibilities and find out what is available to help those with substance use disorder, manage these cases in prison and prevent relapse on release.Originality/valueTo the best of the authors’ knowledge, this study is the first study on drug use in prison in Burkina Faso. It indicates that the repressive strategy against drug use seems ineffective because former users continue their consumption inside and also new users are initiated to use drugs in prison.

Penile Pearls and Pearling: Characteristics and Social Identity from the Perspective of Forensic Pathologists.

Penile pearls are artificial implants placed beneath the skin of a penis to provide enhanced sexual experience for the partner or present a stigma of a particular social subgroup (e.g., prisoner, member of a gang). This genital modification is usually encountered in men of low socioeconomic status and prisoners who might (self) implant improvised pearls under poor sanitary conditions. We have only recently started to encounter penile pearls on autopsy, incidentally. The aim of this study was to analyze our autopsy cases with penile pearls to assess the characteristics of these subjects regarding their socioeconomic status, history of imprisonment, substance abuse, as well as the characteristics of implants. Nineteen men were included. Most were born in the 1970s and 1980s, with only elementary/vocational school education (n = 10). Only five men graduated from high school. At least 14 were in prison at some point in life and 13 were unemployed. Ten men were unmarried. In 11 men, regular alcohol consumption was reported. 12 used illicit substances, most with a history of heroin injection. Penile pearls were improvised and made of rigid plastic in 10 men, eight were of soft silicone-like material, and one was of metal. A distinct characteristic was a ribbed contour of some implants. Although this genital modification seems to gain more attention outside of described vulnerable groups, it mostly remains limited to them in our region. It is most likely performed in improvised, non-professional, unsanitary conditions, probably in prisons.

Psychiatric comorbidities and concurrent substance use among people who inject drugs: a single-centre hospital-based study

The management of people who inject drugs (PWID) is compounded by the presence of psychiatric comorbidities leading to frequent relapses and poor treatment outcomes. Early identification and treatment of psychiatric comorbidities should be included in the management to enhance treatment outcomes. The objective of this study was to estimate the prevalence of psychiatric comorbidities and concurrent substance use among opioid injectors. This hospital-based, cross-sectional study was conducted from March 2021 to August 2022. This study included opioid injectors of all ages and both sexes. The Mini International Neuropsychiatric Interview-7 (MINI-7) and WHO-ASSIST were used to determine psychiatric comorbidities and concurrent substance use, respectively. Both crude and adjusted odds ratios were calculated to assess associations among demographic variables, concurrent substance use and psychiatric comorbidities. Among the 328 opioid injectors, the overall prevalence of psychiatric comorbidities was 88.1%, with the majority (68.6%) having more than one comorbidity. The most common psychiatric comorbidities were panic disorder (41.2%), social anxiety disorder (40.5%), and antisocial personality disorder (39.3%). Concurrent use of alcoholic beverages doubled the risk of ASPD (odds ratio 2.14 (1.24–3.72)). Cocaine (odds ratio 2.36 (1.10–5.03)) and amphetamines (odds ratio 7.68 (2.21–26.65)) increased the risk of OCD. Daily heroin injections were negatively associated (odds ratio 0.18 (0.03–0.94)) with psychotic disorders. Younger age (adjusted odds ratio 0.20 (0.79–0.53)) and never married status (adjusted odds ratio 2.62 (1.06–6.47)) were the only significant variables in the regression analysis. In conclusion, opioid injectors had a higher prevalence of numerous psychiatric comorbidities. The most common comorbidity was anxiety disorders. Concurrent use of tobacco, cannabis, cocaine, inhalants, etc., greatly increased the risk of psychiatric comorbidities.

29 Human Immunodeficiency Virus (HIV) Status, Injection Drug Use, and Cognitive Effects in a Spanish-Speaking Population

Objective:Injection drug use is a significant public health crisis with adverse health outcomes, including increased risk of human immunodeficiency virus (HIV) infection. Comorbidity of HIV and injection drug use is highly prevalent in the United States and disproportionately elevated in surrounding territories such as Puerto Rico. While both HIV status and injection drug use are independently known to be associated with cognitive deficits, the interaction of these effects remains largely unknown. The aim of this study was to determine how HIV status and injection drug use are related to cognitive functioning in a group of Puerto Rican participants. Additionally, we investigated the degree to which type and frequency of substance use predict cognitive abilities.Participants and Methods:96 Puerto Rican adults completed the Neuropsi Attention and Memory-3rd Edition battery for Spanish-speaking participants. Injection substance use over the previous 12 months was also obtained via clinical interview. Participants were categorized into four groups based on HIV status and injection substance use in the last 30 days (HIV+/injector, HIV+/non-injector, HIV/injector, HIV-/non-injector). One-way analysis of variance (ANOVA) was conducted to determine differences between groups on each index of the Neuropsi battery (Attention and Executive Function; Memory; Attention and Memory). Multiple linear regression was used to determine whether type and frequency of substance use predicted performance on these indices while considering HIV status.Results:The one-way ANOVAs revealed significant differences (p’s < 0.01) between the healthy control group and all other groups across all indices. No significant differences were observed between the other groups. Injection drug use, regardless of the substance, was associated with lower combined attention and memory performance compared to those who inject less than monthly (Monthly: p = 0.04; 2-3x daily: p < 0.01; 4-7x daily: p = 0.02; 8+ times daily: p < 0.01). Both minimal and heavy daily use predicted poorer memory performance (p = 0.02 and p = 0.01, respectively). Heavy heroin use predicted poorer attention and executive functioning (p = 0.04). Heroin use also predicted lower performance on tests of memory when used monthly (p = 0.049), and daily or almost daily (2-6x weekly: p = 0.04; 4-7x daily: p = 0.04). Finally, moderate injection of heroin predicted lower scores on attention and memory (Weekly: p = 0.04; 2-6x weekly: p = 0.048). Heavy combined heroin and cocaine use predicted worse memory performance (p = 0.03) and combined attention and memory (p = 0.046). HIV status was not a moderating factor in any circumstance.Conclusions:As predicted, residents of Puerto Rico who do not inject substances and are HIVnegative performed better in domains of memory, attention, and executive function than those living with HIV and/or inject substances. There was no significant difference among the affected groups in cognitive ability. As expected, daily injection of substances predicted worse performance on tasks of memory. Heavy heroin use predicted worse performance on executive function and memory tasks, while heroin-only and combined heroin and cocaine use predicted worse memory performance. Overall, the type and frequency of substance is more predictive of cognitive functioning than HIV status.

Individual-Level Risk Prediction of Return to Use During Opioid Use Disorder Treatment

No existing model allows clinicians to predict whether patients might return to opioid use in the early stages of treatment for opioid use disorder. To develop an individual-level prediction tool for risk of return to use in opioid use disorder. This decision analytical model used predictive modeling with individual-level data harmonized in June 1, 2019, to October 1, 2022, from 3 multicenter, pragmatic, randomized clinical trials of at least 12 weeks' duration within the National Institute on Drug Abuse Clinical Trials Network (CTN) performed between 2006 and 2016. The clinical trials covered a variety of treatment settings, including federally licensed treatment sites, physician practices, and inpatient treatment facilities. All 3 trials enrolled adult participants older than 18 years, with broad pragmatic inclusion and few exclusion criteria except for major medical and unstable psychiatric comorbidities. All participants received 1 of 3 medications for opioid use disorder: methadone, buprenorphine, or extended-release naltrexone. Predictive models were developed for return to use, which was defined as 4 consecutive weeks of urine drug screen (UDS) results either missing or positive for nonprescribed opioids by week 12 of treatment. The overall sample included 2199 trial participants (mean [SD] age, 35.3 [10.7] years; 728 women [33.1%] and 1471 men [66.9%]). The final model based on 4 predictors at treatment entry (heroin use days, morphine- and cocaine-positive UDS results, and heroin injection in the past 30 days) yielded an area under the receiver operating characteristic curve (AUROC) of 0.67 (95% CI, 0.62-0.71). Adding UDS in the first 3 treatment weeks improved model performance (AUROC, 0.82; 95% CI, 0.78-0.85). A simplified score (CTN-0094 OUD Return-to-Use Risk Score) provided good clinical risk stratification wherein patients with weekly opioid-negative UDS results in the 3 weeks after treatment initiation had a 13% risk of return to use compared with 85% for those with 3 weeks of opioid-positive or missing UDS results (AUROC, 0.80; 95% CI, 0.76-0.84). The prediction model described in this study may be a universal risk measure for return to opioid use by treatment week 3. Interventions to prevent return to regular use should focus on this critical early treatment period.

Predicting heroin potency from the analysis of paraphernalia: A tool for overdose prevention projects

In recent years, fatal and non-fatal heroin-related overdoses have increased in northeastern Italy, and the change in potency of heroin available at street level has been identified as a prominent factor associated with acute toxicity. Two very different products, high-potency and low-potency heroin were becoming available on the street, and no clear morphological characteristics could be used to easily distinguish them. A theoretical model for predicting heroin potency from rapid analysis of cigarette filters was developed as part of an overdose prevention project. The model was derived from the analysis of real heroin samples and exploits the common presence of caffeine in heroin as an adulterant. It was tested on laboratory prepared filters, real filters used to prepare heroin injections, and other paraphernalia. The model showed strong predictive ability and was used to implement a rapid alert system to inform drug users and healthcare institutions about the potency of heroin or other psychoactive substances circulating in the area. Cigarette filters were used as standard material, but other paraphernalia were successfully tested. The developed model is a dynamic tool whose parameters can be updated according to the market characteristics, so it can be useful for laboratories involved in drug analysis and similar prevention programs.

Role of dopamine D1 receptor in the modulation of memory consolidation by passive and self-administered heroin and associated conditioned stimuli

It has been proposed that opiates modulate memory consolidation, but recent work has indicated that this effect may be mediated by how the drug is experienced (i.e., passive injections vs. self-administration). Because the dopamine (DA) D1 receptor is involved in processing of learning signals and attribution of salience to events experienced by an organism, two studies in male Sprague-Dawley rats tested the effect of blocking this receptor on modulation of memory consolidation by passive and self-administered heroin, in addition to conditioned memory modulation by heroin-paired cues. Using the object location memory task, Study 1 employed SCH23390 (0, 0.05, 0.10 mg/kg, SC) to modulate enhancement of memory consolidation induced by post-training injections of heroin (1 mg/kg, SC) as well as by exposure to the environment paired with heroin injections (6 pairings, 1 h each, 1 mg/kg). Study 2 was conducted in rats that could self-administer heroin (0.05 mg/kg/infusion, IV) and tested whether SCH23390 (0 and 0.1 mg/kg, SC) could prevent memory modulation induced by a change in schedule of self-administration (from fixed to variable ratio). It was found that while repeated passive injections of heroin retained their enhancing effect on memory, when self-administered, heroin enhanced consolidation of object location memory only at the beginning of self-administration and after a change in schedule. Importantly, SCH23390 blocked memory modulation by heroin when passively administered and when the drug was self-administered on a novel schedule. SCH23390 also blocked conditioned memory modulation induced by post-training exposure to heroin-paired cues. Taken together, these results suggest that modulation of memory consolidation by unconditioned and conditioned opiate reinforcers involve a D1-dependent mechanism of salience attribution linked to the anticipation of drug effects.

Cocaine-involved suspected suicide attempts in individuals age 50 and older reported to United States Poison Centers

Context Despite a rapidly growing number of older cocaine users, the link between cocaine use and suicide attempt in older adults has not been examined. We examined associations between co-used other substances and (1) suspected suicide attempts versus other intentional misuse, and (2) major medical outcomes (major effect or death) of suspected suicide attempts and other intentional misuse. Methods We used the 2015–2021 United States National Poison Data System (N = 5,191 cases age 50 and older). Descriptive statistics and generalized linear models for a Poisson distribution with a log link function were used to examine the study questions. Results Cocaine exposures steadily increased from 2015 through 2021. Over the seven years, 52.3% and 47.7% were suicide attempts and other intentional misuse cases, respectively. Co-use of alcohol (incidence rate ratios = 1.24, 95% confidence interval = 1.14–1.35) and psychotropic (e.g., antidepressants: incidence rate ratios = 1.37, 95% confidence interval = 1.24–1.53) and cardiovascular medications were associated with a higher likelihood of suicide attempt, but co-use of prescription opioids, heroin, or other illicit drugs was associated with a lower likelihood of suicide attempt compared to other intentional misuse. Prescription opioids and amfetamine were associated with a higher likelihood of major effect or death in both suicide attempts and intentional misuse and heroin use and injection use were associated with a higher likelihood of major effect/death among intentional misuse cases. Conclusions These findings show that significant proportions of older cocaine users who attempted suicide also used psychotropic and cardiovascular medications. We suggest that healthcare providers screen for suicidal ideation among cocaine users, with special attention to an increased risk of suicide attempts among those who co-use cocaine with alcohol and psychotropic and other prescription medications.

Syndemic factors associated with non-fatal overdose among young opioid users in New York City.

Rates of illicit opioid use are particularly high among young adults, yet research on overdose experience and factors associated with overdose in this population remains limited. This study examines the experiences and correlates of non-fatal overdose among young adults using illicit opioids in New York City (NYC). 539 participants were recruited via Respondent-Driven Sampling in 2014-2016. Eligibility criteria included: aged 18-29 years old; current residence in NYC; and nonmedical prescription opioid (PO) use and/or heroin use in the past 30 days. Participants completed structured interviews to assess their socio-demographics, drug use trajectories, current substance use and lifetime and most recent overdose experiences, and were tested on-site for hepatitis C virus (HCV) antibodies. 43.9% of participants reported lifetime overdose experience; of these, 58.8% had experienced two or more overdose events. The majority of participants' most recent overdoses (63.5%) were due to polysubstance use. In bivariable analyses, after RDS adjustment, having ever overdosed was correlated with: household income of >$100,00 growing up (vs. $51,000-100,000); lifetime homelessness; HCV antibody-positive status; lifetime engagement in regular nonmedical benzodiazepine use, regular heroin injection and regular PO injection; and using a non-sterile syringe in the past 12 months. Multivariable logistic regression identified childhood household income >$100,00 (AOR=1.88), HCV-positive status (AOR=2.64), benzodiazepine use (AOR=2.15), PO injection (AOR=1.96) and non-sterile syringe use (AOR=1.70) as significant independent correlates of lifetime overdose. A multivariable model with multiple overdoses (vs. one) found only lifetime regular heroin use and PO injection to be strong correlates. Results indicate a high prevalence of lifetime and repeated overdose among opioid-using young adults in NYC, highlighting a need for intensified overdose prevention efforts for this population. The strong associations of HCV and indices of polydrug use with overdose suggest that prevention efforts should address the complex risk environment in which overdose occurs, attending to the overlapping nature of disease-related risk behavior and overdose risk behavior among young people who inject opioids. Overdose prevention efforts tailored for this group may find it useful to adopt a syndemic conception of overdose that understands such events as resulting from multiple, and often interrelated, risk factors.

‘This is hardcore’: a qualitative study exploring service users’ experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England

BackgroundHeroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context.MethodsWe conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT.ResultsParticipants’ accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement.ConclusionsThe Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.

High levels of interest in access to free safer smoking equipment to reduce injection frequency among people who inject drugs in Seattle, Washington

BackgroundDrug use route transition interventions promote safer consumption by facilitating a switch from injection to safer routes such as smoking or oral consumption. MethodsWe performed a descriptive analysis using data from questions about “free, clean equipment for smoking” heroin, methamphetamine and/or crack from the Seattle 2018 National HIV Behavioral Surveillance survey of people who inject drugs (N = 555). We estimated the proportion of respondents with access to free safer smoking equipment, and among these participants, the proportion who reported that this access reduced their injection frequency. Among respondents without access to free safer smoking equipment, we described the proportion who were interested in getting access, and whether they thought this access would reduce their injection frequency. ResultsAmong participants who reported prior year heroin (n = 495), methamphetamine (n = 372), or crack (n = 88) injection, 11%, 11% and 12% reported access to free safer smoking equipment, respectively. Of those with access, the proportion that reported that access reduced their injection frequency ranged from 12% to 44%. Among participants without access, 28% who used heroin, 45% who used methamphetamine, and 49% who used crack were interested in access. Of interested participants, a majority reported that they thought this access would reduce their frequency of injection. ConclusionsAccess to free safer smoking equipment was limited. Many participants were interested in getting free safer smoking equipment and reported that this access may reduce their injection frequency. Safer smoking equipment is a harm reduction strategy that should be available to reduce risks from opioid and stimulant injection.

Interest in treatment with injectable diacetylmorphine among people who use opioids in Baltimore City, Maryland (USA)

Introduction Treatment for opioid use disorder (OUD) with diacetylmorphine is an evidence-based form of drug treatment, but it is not available in the United States (US). Better understanding acceptability of treatment with injectable diacetylmorphine among people who use opioids (PWUO) in the US may expedite future initiatives designed to engage persons in this form of treatment should it become available. The purpose of this research is to examine factors associated with interest in treatment with injectable diacetylmorphine among a sample of PWUO in the US. Methods Data are from a cross-sectional study of PWUO in Baltimore City, Maryland. Participants were given a brief description of treatment with injectable diacetylmorphine and then asked to rate their level of interest. We used Poisson regression with robust variance to assess factors associated with interest in treatment with injectable diacetylmorphine. Results The average age of participants was 48 years, 41% were women, and most (76%) identified as non-Hispanic, Black. The most commonly used substances were non-injection heroin (76%), opioid pain relievers (73%), and non-injection crack/cocaine (73%). Two-thirds of participants (68%) indicated interest in treatment with injectable diacetylmorphine. Factors significantly associated with interest in injectable diacetylmorphine treatment included: having at least a high school education (adjusted prevalence ratio [aPR]: 1.23; 95% confidence interval [CI]: 1.04–1.45), not having health insurance (aPR: 1.23; 95% CI: 1.06–1.44), having ever overdosed (aPR: 1.20; 95% CI: 1.01–1.42), and past utilization of medications for opioid use disorder (aPR: 1.22; 95% CI: 1.01–1.47). Recent non-injection cocaine use was inversely associated with interest in treatment with injectable diacetylmorphine (aPR 0.80; 95% CI: 0.68–0.94). Conclusion The majority of participants reported interest in treatment with injectable diacetylmorphine. Given worsening trends in the addiction and overdose crisis in the US, treatment with injectable diacetylmorphine should be considered as another evidence-based option for treating OUD. KEY MESSAGES Interest in treatment with injectable diacetylmorphine was high among a sample of people who use opioids in the United States. Factors associated with increased interest in treatment with injectable diacetylmorphine included having at least a high school education, having ever overdosed, and not having health insurance. Past utilization of medications for opioid use disorder was associated with interest in treatment with injectable diacetylmorphine.

“As long as that place stays open, I’ll stay alive”: Accessing injectable opioid agonist treatment during dual public health crises

BackgroundSince the onset of the COVID-19 pandemic, overdose rates in North America have continued to rise, with more than 100,000 drug poisoning deaths in the past year. Amidst an increasingly toxic drug supply, the pandemic disrupted essential substance use treatment and harm reduction services that reduce overdose risk for people who use drugs. In British Columbia, one such treatment is injectable opioid agonist treatment (iOAT), the supervised dispensation of injectable hydromorphone or diacetylmorphine for people with opioid use disorder. While evidence has shown iOAT to be safe and effective, it is intensive and highly regimented, characterized by daily clinic visits and provider–client interaction—treatment components made difficult by the pandemic.MethodsBetween April 2020 and February 2021, we conducted 51 interviews with 18 iOAT clients and two clinic nurses to understand how the pandemic shaped iOAT access and treatment experiences. To analyze interview data, we employed a multi-step, flexible coding strategy, an iterative and abductive approach to analysis, using NVivo software.ResultsQualitative analysis revealed the ways in which the pandemic shaped clients’ lives and the provision of iOAT care. First, client narratives illuminated how the pandemic reinforced existing inequities. For example, socioeconomically marginalized clients expressed concerns around their financial stability and economic impacts on their communities. Second, clients with health comorbidities recognized how the pandemic amplified health risks, through potential COVID-19 exposure or by limiting social connection and mental health supports. Third, clients described how the pandemic changed their engagement with the iOAT clinic and medication. For instance, clients noted that physical distancing guidelines and occupancy limits reduced opportunities for social connection with staff and other iOAT clients. However, pandemic policies also created opportunities to adapt treatment in ways that increased patient trust and autonomy, for example through more flexible medication regimens and take-home oral doses.ConclusionParticipant narratives underscored the unequal distribution of pandemic impacts for people who use drugs but also highlighted opportunities for more flexible, patient-centered treatment approaches. Across treatment settings, pandemic-era changes that increase client autonomy and ensure equitable access to care are to be continued and expanded, beyond the duration of the pandemic.

Naloxone expansion is not associated with increases in adolescent heroin use and injection drug use: Evidence from 44 US states.

Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated. We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding. Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings. Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages.