Needle Exchange Research Articles

Harm reduction and health services provided by syringe services programs in 2019 and subsequent impact of COVID-19 on services in 2020

ObjectivesThis study describes harm reduction and health services provided by U.S syringe services programs (SSPs) in 2019 and changes in provision of those services in 2020. MethodsSSPs were invited to participate in the Dave Purchase Memorial survey in August 2020. We collected programmatic data on services provided in 2019 and at the time of the survey in 2020. We conducted descriptive analyses using Chi-square and McNemar’s tests. ResultsAt the time of the survey, > 60% of SSPs reported increased monthly syringe and naloxone distribution and expansion of home-based and mail-based naloxone delivery in Fall 2020 compared to 2019. Approximately three-quarters of SSPs decreased or stopped providing on-site HIV and HCV testing. Nearly half of SSPs offering on-site medications for opioid use disorder (MOUD) in 2019 increased provision of MOUD in 2020. The proportion of SSPs offering on-site mental health care services and primary care services statistically significantly decreased from 2019 to Fall 2020, but telehealth offerings of these services increased. ConclusionsMany SSPs that offered health services in 2019 and remained operational in 2020 increased telehealth provision of mental health and primary care services, increased MOUD provision, and expanded harm reduction services, but most SSPs reduced or stopped on-site HIV and HCV testing. Sustaining SSP growth and innovation is paramount for preventing overdose deaths and HIV/HCV outbreaks after the deadliest year of the opioid epidemic in 2020.

Needle exchange practitioners accounts of delivering harm reduction advice for chemsex: implications for policy and practice

Needle exchange and harm reduction programs in the UK provide a range of interventions which could be effective in reducing the risk of physical and psychological harm and minimizing the spread of blood-borne viruses for men who have sex with men (MSM) who engage in chemsex. To understand the existing practice, this qualitative study was undertaken using semi-structured interviews with 17 harm reduction practitioners working in needle exchange services in two UK cities. The following four themes were identified during data analysis: chemsex understanding and existing practice; drugs, sex, and pleasure; visibility; and inclusivity. Findings indicate that these harm reduction and needle exchange services are not equipped to meet the needs of MSM who inject drugs associated with chemsex. The heteronormative perceptions of needle exchange programs, coupled with the uncomfortableness of exploring pleasure, challenge the inclusive environment and universal offer these services promote. Practitioner perceptions of sexualized drug use and pleasure may be a barrier to reducing harm to MSM who engage in chemsex. Further research into interventions for chemsex is needed to inform a best practice model to be used across all drug and alcohol provisions in the UK.

A qualitative study of service engagement and unmet needs among unstably housed people who inject drugs in Massachusetts

IntroductionPeople who inject drugs (PWID) are disproportionately affected by HIV in the United States, and HIV prevention and care services may be inaccessible to or underutilized by PWID. In 2018, the Massachusetts Department of Public Health (MDPH) and the Centers for Disease Control and Prevention (CDC) investigated an increase in HIV diagnoses primarily among unstably housed PWID in Lawrence and Lowell. MethodsThe response team interviewed 34 PWID in Lawrence and Lowell, with and without HIV, to inform effective response strategies. Qualitative interviews were recorded, transcribed, and coded. Interviews were transcribed verbatim and coded using a thematic analysis approach structured around pre-designated research questions related to service engagement (including harm reduction services, substance use disorder treatment, medical services, shelters, and other community services), unmet needs, and knowledge gaps regarding HIV prevention. ResultsParticipants ranged in age from 20 to 54 years (median: 32); 21 of the 34 participants (62%) were male, and 21 were non-Hispanic white. Fifteen (44%) self-reported being HIV positive. All 34 participants had experienced homelessness in the past 12 months, and 29 (85%) had ever received services at syringe service programs (SSP). We identified five key themes: substance use as a barrier to accessing health and social services; experiences of trauma and mental illness as factors impacting substance use and utilization of services; unstable housing as a barrier to accessing services; negative perceptions of medication for opioid use disorder (MOUD); and the desire to be treated with dignity and respect by others. ConclusionsFindings highlight the need for well-resourced and integrated or linked service provision for PWID, which includes mental health services, housing, MOUD, harm reduction, and infectious disease prevention and care services. Co-locating and integrating low-barrier services at trusted community locations, such as SSPs, could increase service engagement and improve health outcomes for PWID. Further implementation science research may aid the development of effective strategies for services for PWID and build trusting relationships between service providers and PWID.

Collecting Data During the COVID-19 Pandemic: Lessons From an In-Person Survey of People Who Use Opioids.

In response to the COVID-19 pandemic, much in-person data collection has been suspended or become tele-remote. However, tele-remote methods often exclude marginalized groups, including people who use drugs, many of whom lack the technology to participate. To inform future surveillance and research during the pandemic and other public health disasters, we report methods and lessons learned from an in-person survey of people who use opioids conducted by the New York City Department of Health and Mental Hygiene (DOHMH) during the COVID-19 pandemic. This public health surveillance was a component of the Centers for Disease Control and Prevention Overdose Data to Action initiative and aimed to inform overdose prevention efforts. Survey domains inquired about participants' drug use patterns, risk behaviors, overdose history, and service use. From June 16 through September 9, 2020, DOHMH staff members conducted 329 surveys with participants from 4 syringe service programs (n = 148, 44.9%) and via street intercept (n = 81, 55.1%). To survey participants safely and effectively, it was important to build rapport upfront so that requests to maintain distance were not perceived as stigmatizing. DOHMH staff members offered all participants, regardless of survey eligibility, Narcan and hygiene products, including face masks and soap. Surveys administered outdoors during the COVID-19 pandemic should be limited to 30 minutes. Although conducting in-person surveys poses unique challenges, this method should be considered so marginalized populations are included in data collection and public health responses.

COVID-19 Vaccination and Communicable Disease Testing Services' Integration Within a Syringe Services Program: A Program Brief.

People who inject drugs often have a higher prevalence of risk factors associated with coronavirus disease 2019 (COVID-19) infection and associated morbidity and mortality, compounded by challenges in health care access. This increased vulnerability underscores the critical need to prioritize people who inject drug in ongoing COVID-19 vaccination efforts. Co-location of syringe services, COVID-19 vaccination services, and other communicable disease testing has proved an effective model to provide necessary interventions without creating additional barriers. Here, we describe a partnership between the Baltimore City Health Department, Johns Hopkins Mobile Vaccine Unit, and the Center for Infectious Disease and Nursing Innovation at the Johns Hopkins School of Nursing to provide COVID-19 vaccination, HIV and sexually transmitted infection testing, wound care, and linkage to care services co-located with a long-running syringe services program. We describe the services offered by each partner and lessons learned from this community-based co-location of services initiative.

A plea of those who are affected most by HIV: The utterances by women who inject Nyaope residing in City of Tshwane Municipality, Gauteng

Background: Nyaope injecting practice has brought the field of HIV prevention and substance abuse together. It has called for an integrative approach. Women who use drugs face multiple individual, social, and structural factors that fuel their vulnerability to HIV and other blood-borne infections. The effects of drug use are more severe on women than on their male counterpart. In order to address HIV epidemic among women who inject nyaope it is imperative that they form part of solution finding.Aim: Study aimed at exploring the strategies to curb HIV incidence amongst women who inject nyaope residing in City of Tshwane Municipality, Gauteng.Setting: The research was conducted within COSUP. COSUP was considered more appropriate as it is a harm reduction based organisation.Methods: The study utilized qualitative research approach to explore the strategies to curb HIV incidence amongst women who inject nyaope residing in City of Tshwane Municipality, Gauteng. In-depth interview was conducted with 24 women with history of injecting nyaope aged between 19 to 35 years. The data was analyzed using thematic data analyzing method.Results: Health intervention, Economic intervention and Educational intervention was stressed as key strategies to curb HIV among women who inject nyaope. Needle exchange programme, Condom distribution, PrEP, HIV Testing and Counselling, Employment opportunities, Support groups and awareness campaigns if implemented can yield positive outcome in curbing HIV among women who inject drugs.Conclusion: Mechanism to curb HIV among women who inject nyaope exist and when implemented, they have potential to address high HIV incidence among women who inject nyaope.

Substance Use, Hospitalizations, and Co-Occurring Disorders among Patients Transferred from a Needle Exchange Program to Opioid Maintenance Treatment.

Opioid use disorders (OUD) is a relapsing condition with high mortality. Opioid maintenance treatment (OMT) reduces heroin use, and overall morbidity and mortality. The prevalence of psychiatric and substance use disorders, potential baseline predictors for psychiatric hospitalization, and psychiatric diagnoses at follow-up were investigated and may give hints about possible preventative strategies. The medical records for 71 patients were reviewed 36 months following referral to OMT from a needle exchange program (NEP). Their psychiatric diagnoses and hospitalizations were identified. Their baseline characteristics were assessed for potential differences between hospitalized versus non-hospitalized patients and between patients with and without psychiatric diagnoses in a longitudinal observational study without controls. A regression analysis was performed to identify predictors for hospitalization when controlling for OMT status. Sixty-five percent of the patients were hospitalized at least once with a psychiatric diagnosis. Substance-related reasons were prevalent, and detoxification occurred among 59% of patients, with sedative- hypnotics (benzodiazepines, zopiclone, zolpidem, and pregabalin) being the substance used by 52% of patients. Baseline use of these drugs and/or buprenorphine predicted for hospitalization when controlling for OMT status. During the follow-up period, 72% of patients met the criteria for a psychiatric diagnosis other than OUD. The prevalence of non-substance use disorders overlapping with SUD was 41%, and that overlapping with anxiety disorder was 27% of all participants. Increased attention to psychiatric co-occurring disorders in the treatment of OUD is required and the importance of addressing sedative-hypnotics use when initiating OMT is highlighted.

Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians.

Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions. The "Six Moments of Infection Prevention in Injection Drug Use" provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool's effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction. Seventy-five respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling people who inject drugs (PWID). Sixty respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP); of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (P < .0001), 65 respondents (86.6%) reported they planned to use the Six Moments model in their own practice, and 100% said they would consider referring patients to an SSP in the future. The Six Moments model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.

Supportive environments during the substance use disorder epidemic in the rural United States: Provider support for interventions and expectations of interactions with providers

BackgroundHarm reduction interventions, including SSP (Syringe Services Programs) and MAT (Medications for Addiction Treatment) have demonstrated the potential to help stem the epidemic of opioid use disorder. However, for that potential to be realized, people must expect that healthcare providers will be supportive if they ever seek care for substance use. MethodsThis cross-sectional study investigated perceptions of provider support for SSP and MAT in the general population of 14 states selected specifically for 50 percent of the sample to include participants from rural counties with high rates of non-medical opioid use and injection. A survey of 3096 adults in 14 states and 675 counties within the Appalachian and Midwestern regions of the United States (collected between November of 2019 and May of 2020) examined the association between perceptions of provider support for harm reduction interventions, community members’ trust of community healthcare providers, and expectations for patient-provider interactions involving disclosure of non-medical drug use. Results and conclusionPath analysis supported the hypothesis that perceptions of provider support for harm reduction interventions predict positive expectations about patient-provider interactions and that trust in providers mediates this association. The model fit well among participants who reported past non-medical use of drugs and those who did not. In contrast to other research suggesting that trust in providers may be inconsequential during the initial stages of care, the current research suggests that trust may shape expectations about patient-provider interactions even before people use drugs. Communication of support for harm reduction interventions by providers may play an important role in promoting health care-seeking in populations that use drugs currently or who may use drugs in the future in high-risk rural areas of the United States.

Awareness, perception and utilization of a mobile health clinic by people who use drugs

Introduction People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs. Methods Semi-structured interviews were conducted with 31 PWUD – 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) – to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory. Results Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients. Discussion MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment. KEY MESSAGES People who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma. People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.

Onsite buprenorphine inductions at harm reduction agencies to increase treatment engagement and reduce HIV risk: Design and rationale

BackgroundDespite dramatic increases in opioid use disorder (OUD) and overdose deaths, the U.S. has been unable to consistently deliver OUD treatment to those who need it. Syringe services programs (SSPs) can engage an out-of-treatment population of people with OUD that has elevated overdose risk. Buprenorphine treatment is safe and effective, and US regulations allow for prescribing from diverse locations, including SSPs. This study's objective is to test buprenorphine treatment initiation at SSPs. We hypothesize that offering onsite buprenorphine treatment initiation will improve OUD treatment engagement without reducing buprenorphine treatment effectiveness or safety. MethodsWe will recruit 250 out-of-treatment SSP participants with OUD in a large urban area. Participants will be randomized to onsite buprenorphine treatment initiation or enhanced referral. Over 2 weeks, participants in the onsite treatment arm will see a buprenorphine provider twice at the SSP, receive weekly medication packs, and then their care will be transferred to a community health center for treatment continuation. In the control arm, within one week, participants will receive an appointment at the same community health center as in the intervention arm for buprenorphine initiation and continuation. Participants will be assessed with urine drug tests, questionnaires, and medical record review. The primary outcome will be engagement in buprenorphine treatment at 30 days. Secondary outcomes include buprenorphine diversion, opioid-free urine drug tests, and intervention cost-effectiveness. DiscussionOur study will contribute to the growing literature on SSPs as a conduit to OUD treatment. SSPs hold promise to deliver needed care to people with OUD.

Using an Evidence-based Framework to Guide the Implementation of Syringe Services Programs in Jackson, Mississippi

The opioid epidemic in the United States (U.S.) has been coupled with increases in blood-borne infections, including viral hepatitis and human immunodeficiency virus (HIV), which can be spread through injection drug use. The Department of Health and Human Services (HHS) recommends syringe services programs (SSPs) as an evidence-based intervention to address the spread of infectious diseases and to link people who inject drugs (PWID) to appropriate care. Jackson, Mississippi, has one of the highest HIV infection rates in the U.S., yet the city is the only urban area among the top ten incident areas for HIV infections that does not have a sanctioned SSP. The Mississippi State Legislature can request an ‘at-risk’ designation from the Centers for Disease Control and Prevention (CDC), granting them power and funding to establish a SSP to help address increasing blood-borne infections among populations of people who inject drugs. This evidence-based commentary follows the Consolidated Framework for Implementation Research (CFIR) to outline the necessary steps and implementation challenges toward the development of a SSP in Jackson, Mississippi. This framework-based analysis revealed that SSPs have few weaknesses and carry many strengths: SSPs are adaptable, cost-effective, and beneficial for individuals and communities engaged with the programs. SSP development does come with complex political and legal obstacles that have to be untangled, particularly in states like Mississippi, where syringes are classified as drug paraphernalia. In addition to revising laws relating to syringe exchange, implementation of a SSP in Jackson must be accompanied by a grassroots, broad-based marketing and communication campaign led by public health experts who can discuss the benefits of SSPs and combat stigma surrounding injection drug use.

Study protocol for a pilot randomized controlled trial to increase COVID-19 testing and vaccination among people who inject drugs in San Diego County

BackgroundPeople who inject drugs (PWID) have low rates of COVID-19 testing and vaccination and are vulnerable to severe disease. We partnered with a local, community-based syringe service program (SSP) in San Diego County, CA, to develop the single-session theory- and evidence-informed “LinkUP” intervention to increase COVID-19 testing and vaccination. This paper details the protocol for a pilot randomized controlled trial (RCT) of the LinkUP intervention.MethodsWith significant community input into study design considerations, including through our Community and Scientific Advisory Board, the LinkUP pilot RCT leverages an ongoing cohort study with adult (≥ 18 years) PWID in San Diego County to recruit participants who have not recently undergone voluntary COVID-19 testing and are unvaccinated. Eligible participants are referred to SSP locations randomized to offer the active intervention (involving tailored education, motivational interviewing, and problem-solving strategies) or a didactic attention-control condition (information sharing only). Both conditions are delivered by trained peer counselors hired by the SSP and were designed to be delivered at mobile (outdoor) SSP sites in ~ 30 min. Intake data assesses COVID-19 testing and vaccination history, health status, and harm reduction needs (to facilitate SSP referrals). At the end of either intervention condition, peer counselors offer onsite rapid COVID-19 antigen testing and COVID-19 vaccination referrals. Out-take and follow-up data (via SSP and state health department record linkages) confirms whether participants received the intervention, COVID-19 testing (and results) onsite or within six months, and vaccination referrals (and uptake) within six months. Planned analyses, which are not powered to assess efficacy, will provide adequate precision for effect size estimates for primary (COVID-19 testing) and secondary (vaccination) intervention outcomes. Findings will be disseminated widely including to local health authorities, collaborating agencies, and community members.DiscussionLessons from this community-based pilot study include the importance of gathering community input into study design, cultivating research-community partnerships based on mutual respect and trust, and maintaining frequent communication regarding unexpected events (e.g., police sweeps, neighborhood opposition). Findings may support the adoption of COVID-19 testing and vaccination initiatives implemented through SSPs and other community-based organizations serving vulnerable populations of people impacted by substance use and addiction.Trial registration This trial was registered prospectively at ClinicalTrials.gov (identifier NCT05181657).

Participants of a mail delivery syringe services program are underserved by other safe sources for sterile injection supplies.

In the United States, accessing sterile injection supplies remains challenging for many people who inject drugs (PWID). Although women are less likely to inject drugs than men, women who do inject are disproportionately affected by IDU-related complications. Needle Exchange Technology (NEXT), the first formal online accessed mail delivery syringe services program (SSP) in the US, may overcome access barriers. We evaluated whether NEXT was reaching women participants and people without access to other safe sources of sterile injection supplies. This cross-sectional study examined NEXT participants who enrolled in the mail-delivery SSP from February 2018 through March 2021. All NEXT participants completed an online questionnaire during enrollment, which included sociodemographic and clinical characteristics and injection-related risk factors (including prior sources of sterile injection supplies). Multivariable logistic regression (MVR) was used to examine associations between gender and prior use of safe sources of injection supplies (i.e., SSPs or pharmacies). 1,032 participants received injection supplies. Median age was 34 and participants were mostly cis-gendered women (55%) and white (93%). 34% reported infection with HCV; women were more likely to report HCV infection than men (38% vs 28%; p<0.01). 68% of participants acquired injection supplies from less safe sources. Few participants exclusively used safe sources for injection supplies (26%). In adjusted MVR analysis, women participants had significantly lower odds than men of having exclusively used safe sources for injection supplies (adjusted OR 0.71, 95% CI 0.52, 0.98). Our findings suggest that NEXT services are utilized by women and people without prior access to sterile injection supplies. Women participants were less likely than men to have exclusively used safe sources for sterile injection supplies. Future research should explore women's preference for mail-delivery over in-person SSPs and determine whether online accessed mail delivery services can reach other underserved populations of PWID.

Communicating During an HIV Outbreak Among People Who Inject Drugs-West Virginia 2019.

In 2019, the West Virginia Bureau for Public Health (WV BPH), Cabell-Huntington Health Department (CHHD), and CDC collaborated to respond to an HIV outbreak among people who inject drugs (PWID). CDC, WV BPH, and CHHD formed a cross-agency communications team to establish situational awareness, identify knowledge gaps, and establish key audiences for messages, including the general population, PWID, and clinical and social service providers. The team disseminated up-to-date information about the outbreak, and prioritized messages addressing stigma related to drug use, syringe services programs, and HIV. Messages were continually updated to address the evolving situation and to resonate with local values. Messages were disseminated via advertisements, local news media, and directly to PWID, people experiencing homelessness, and providers. The response supplemented CHHD's assets, including strong relationships and community knowledge, with staff capacity and expertise from state and federal agencies. This collaborative approach is a useful model to address communication needs.

A public health approach to drug use crucial to ending AIDS

The HIV epidemic continues to rage in eastern Europe and central Asia. In the face of global decline in incidence and mortality, this remains the only region in the world where both new HIV infections and AIDS-related deaths persistently increase.1 The situation is largely attributable to unmet prevention and treatment needs among people who inject drugs (PWID), who account for 43% of new HIV infections in the region.1 On a regional level, just a negligible proportion of 3 million PWID living in eastern Europe and central Asia are engaged in harm reduction services such as needle or syringe exchange programmes and opioid agonist therapy (which is not available in Russia and Uzbekistan), and a minority are tested for HIV and receive antiretroviral therapy (ART).

Injecting drug use & HIV prevalence among female sex workers: Evidence from the National Integrated Biological & Behavioural Surveillance, India.

Female sex workers (FSWs) who inject drugs (FSW-IDs) have a higher risk of HIV infection and transmission. Understanding the socio-demographic characteristics and other risk behaviours among FSW-IDs will help in strengthening targeted interventions for HIV prevention and management. In the present study, the HIV prevalence, associated socio-demographic characteristics and risk behaviours among FSWs who injected drugs (FSW-IDs) and those who did not ID (FSW-NIDs) was determined in India. The national cross-sectional, community-based, integrated biological and behavioural surveillance was conducted in 2014-2015 at 73 randomly selected FSW domains across 28 States and Union Territories in India. The sample size was fixed at 400 for each domain, and a probability-based sampling method was followed. The data were analyzed by logistic regression methods. Data from 27,007 FSWs were included in the analysis, of which 802 (3%) were FSW-IDs. HIV prevalence among FSW-IDs was significantly higher than that in FSW-NIDs (4.5 vs. 1.9%). Univariate analysis showed that factors significantly associated with higher HIV prevalence among FSW-IDs were older age, sex work as the only source of income, dissolved marriage, living with a sex worker, urban locality of sex work and consumption of alcohol or oral drugs. In multivariable analysis, factors such as older age of FSW-IDs (35 yr and above), having a dissolved marriage and sex work being the only source of income were observed to be independently and significantly associated with higher HIV prevalence. Scaling up the HIV preventive interventions for FSW-IDs, such as facilitating awareness and improved access to needle and syringe exchange programme (NSEP) and opioid substitution therapy (OST), encouraging safe sex and injecting practices, educating on the harmful effects of alcohol and drugs and providing alternative vocation options to secure their financial needs are several strategies that may reduce HIV transmission among FSWs.

Community harm reduction initiatives: Essential investments for illicit drug prevention and control in the future

Harm reduction is an approach that reduces the negative consequences of health behaviours without necessarily eliminating them. It is generally accepted that the first harm reduction model emerged in the 1970s and 1980s as a response to infectious diseases such as HIV and hepatitis B. Benefits of harm reduction programs have been recognised widely since the 1990s with the emergence of methadone and other maintenance drugs.1 Popular harm reduction programs include needle and syringe exchange, targeted and low-threshold primary health care counselling, supervised injection sites, opioid replacement therapy, naloxone distribution, drug checking for content and purity, and psychosocial support.

Malmö Treatment Referral and Intervention Study (MATRIS)—36-Month Follow-Up on Retention and Substance Use Among Patients Referred from a Needle Exchange Program to Opioid Substitution Treatment

Malmö Treatment Referral and Intervention Study (MATRIS)—36-Month Follow-Up on Retention and Substance Use Among Patients Referred from a Needle Exchange Program to Opioid Substitution Treatment

The Choice of Manual Catecholamine Syringe Exchange Methods by Nurses in Critical Care Units

The Choice of Manual Catecholamine Syringe Exchange Methods by Nurses in Critical Care Units