Needle Exchange Research Articles

Improved health-related quality of life after hepatitis C viraemic clearance among people who inject drugs may not be durable.

Chronic infection with the hepatitis C virus (HCV) has a detrimental impact on health-related quality of life (QoL). Scale-up of HCV direct-acting antiviral (DAA) therapy among people who inject drugs (PWID) is underway in several countries since the introduction of interferon-free regimens. This study aimed to assess the impact of DAA treatment success on QoL for PWID. Cross-sectional study using two rounds of the Needle Exchange Surveillance Initiative, a national anonymous bio-behavioural survey and a longitudinal study involving PWID who underwent DAA therapy. The setting for the cross-sectional study was Scotland (2017-2018, 2019-2020). The setting for the longitudinal study was the Tayside region of Scotland (2019-2021). In the cross-sectional study PWID were recruited from services providing injecting equipment (n = 4009). In the longitudinal study, participants were PWID on DAA therapy (n = 83). In the cross-sectional study, the association between QoL (measured using the EQ-5D-5L quality of life instrument) and HCV diagnosis and treatment was assessed using multilevel linear regression. In the longitudinal study, QoL was compared at four timepoints using multilevel regression, from treatment commencement until 12 months following commencement. In the cross-sectional study, 41% (n = 1618) were ever chronically HCV infected, of whom 78% (n = 1262) were aware of their status and of whom 64% (n = 704) had undergone DAA therapy. There was no evidence for a marked QoL improvement associated with viral clearance among those treated for HCV (B = 0.03; 95% CI, -0.03 to 0.09). In the longitudinal study, improved QoL was observed at the sustained virologic response test timepoint (B = 0.18; 95% CI, 0.10-0.27), but this was not maintained at 12 months following start of treatment (B = 0.02; 95% CI, -0.05 to 0.10). Successful direct-acting antiviral therapy for hepatitis C infection may not lead to a durable improvement in quality of life among people who inject drugs, although there may be a transient improvement around the time of sustained virologic response. Economic models of the impact of scaling-up treatment may need to include more conservative quality of life benefits over and above reductions in mortality, disease progression and transmission of infection.

High Primary COVID-19 Vaccine Series Completion by People Who Inject Drugs When Colocating Services at a Syringe Services Van.

The aim of the study is to describe the impact of colocating COVID-19 vaccinations with local syringe service programs on vaccine completion among people who inject drugs. Data were derived from 6 community-based clinics. People who inject drugs who received at least one COVID-19 vaccine from a colocated clinic partnering with a local syringe service program were included in the study. Vaccine completion was abstracted from electronic medical records; additional vaccinations were abstracted using health information exchanges embedded within the electronic medical records. Overall, 142 individuals with a mean age of 51 years, predominantly male (72%) and Black, non-Hispanic (79%) received COVID-19 vaccines. More than half elected to receive a 2-dose mRNA vaccine (51.4%). Eighty-five percent completed a primary series, and 71% of those who received a mRNA vaccine completed the 2-dose series. Booster uptake was 34% in those completing a primary series. Colocated clinics are an effective means of reaching vulnerable populations. As the COVID-19 pandemic continues and need for annual booster vaccines arises, it is important to bolster public support and funding to continue low-barrier preventive clinics colocated with harm reduction services for this population.

Predictors of hepatitis C cure among people who inject drugs treated with directly observed therapy supported by peer case managers in Kenya.

Directly observed therapy (DOT) maximizes adherence and minimizes treatment gaps. Peer case managers (PCM) have also shown promise as a component of integrated HCV treatment strategies. DOT and PCM-support have been underexplored, particularly in low- and middle-income countries (LMICs). The objective of this study was to evaluate predictors of sustained virologic response (SVR) among people who inject drugs (PWID) attending medication-assisted treatment (MAT) and needle and syringe programs (NSP) sites in Kenya. We recruited PWID accessing MAT and NSP in Nairobi and Coastal Kenya. PWID were treated with ledipasvir/sofosbuvir using DOT supported by PCMs. We used bivariate and multivariate logistic regression to examine the impact of sociodemographic, behavioral, and clinical factors on SVR. Among 92 PWID who initiated HCV treatment, 79 (86%) were male with mean age of 36.3 years (SD=±6.5); 38 (41%) were HIV-positive, and 87 (95%) reported injecting drugs in the last 30 days. Just over half of participants were genotype 1a (55%), followed by genotype 4a (41%) and mixed 1a/4a (3%). Most participants, 85 (92%) completed treatment and 79 (86%) achieved SVR. While sociodemographic and behavioral factors including recent injection drug use were not significantly associated with achieving SVR, being fully adherent (p=0.042), number of doses taken (p=0.008) and treatment completion (p= 0.001) were associated with higher odds of achieving SVR. DOT with PCM-support was an effective model for HCV treatment among PWID in this LMIC setting. Adherence was the most important driver of SVR suggesting DOT and PCM support can overcome other factors that might limit adherence. Further research is necessary to ascertain the effectiveness of other models of HCV care for PWID in LMICs given NSP and MAT access is variable, and DOT may not be sustainable with limited resources.

Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study

Background: At the start of the pandemic, relaxation of buprenorphine prescribing regulations created an opportunity to create new models of medications for opioid use disorder (MOUD) delivery and care. To expand and improve access to MOUD, we adapted and implemented the Tele-Harm Reduction (THR) intervention; a multicomponent, telehealth-based and peer-driven intervention to promote HIV viral suppression among people who inject drugs (PWID) accessing a syringe services program (SSP). This study examined buprenorphine initiation and retention among PWID with opioid use disorder who received the adapted THR intervention at the IDEA Miami SSP. Methods: A retrospective chart review of participants who received the THR intervention for MOUD was performed to examine the impact of telehealth on buprenorphine retention. Our primary outcome was three-month retention, defined as three consecutive months of buprenorphine dispensed from the pharmacy. Results: A total of 109 participants received the adapted THR intervention. Three-month retention rate on buprenorphine was 58.7%. Seeing a provider via telehealth at baseline or any follow up visit (aOR = 7.53, 95% CI: [2.36, 23.98]) and participants who had received an escalating dose of buprenorphine after baseline visit (aOR = 8.09, 95% CI: [1.83, 35.87]) had a higher adjusted odds of retention at three months. Participants who self-reported or tested positive for a stimulant (methamphetamine, amphetamine, or cocaine) at baseline had a lower adjusted odds of retention on buprenorphine at three months (aOR = 0.29, 95% CI: [0.09, 0.93]). Conclusions: Harm reduction settings can adapt dynamically to the needs of PWID in provision of critical lifesaving buprenorphine in a truly destigmatising approach. Our pilot suggests that an SSP may be an acceptable and feasible venue for delivery of THR to increase uptake of buprenorphine by PWID and promote retention in care. KEY MESSAGES The Tele-Harm Reduction intervention can be adapted for initiating and retaining people who inject drugs with opioid use disorder on buprenorphine within a syringe services program setting Using telehealth was associated with increased three-month buprenorphine retention Baseline stimulant use was negatively associated with three-month buprenorphine retention

How do contextual factors influence naloxone distribution from syringe service programs in the USA: a cross-sectional study

BackgroundNaloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution—they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA.MethodsWe surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone.ResultsSSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09–4.51; p < 0.001) and 110% (p = 0.022) higher rate of people receiving naloxone (aIRR = 2.10; 95% CI 1.46–3.02; p < 0.001) in the past 12 months. The legal status of SSPs and the level of need was not significantly associated with naloxone distribution. Regarding inner setting, SSPs with proactive refill systems (aIRR = 2.08; 95% CI 1.27–3.41; p = 0.004), greater number of distribution days (aIRR = 1.09 per day; 95% CI 1.06–1.11; p < 0.001) and older programs (aIRR = 1.06 per year; 95% CI 1.02–1.11; p = 0.004) were associated with higher levels of naloxone distribution. Also, SSPs with proactive refill systems (aIRR = 2.23; 95% CI 1.38–3.58; p = 0.001); greater number of distribution days (aIRR = 1.04; 95% CI 1.02–1.07; p < 0.001) and older programs (aIRR = 1.11; 95% CI 1.05–1.17; p < 0.001) were associated with a higher number of people receiving naloxone.ConclusionWe identified outer and inner setting factors of SSPs that were associated with greater naloxone distribution. It is critical to ensure SSPs are adequately resourced to build community support for services and develop service delivery models that maximize naloxone distribution to address the nation’s opioid overdose crisis.

Participation in screening for breast and cervical cancer among women with current or previous drug use: a survey study

BackgroundWomen with current or previous drug use (WCPDU) have an increased risk of poor breast and cervical cancer outcomes. Screening is known to decrease the mortality of these common cancer forms, but screening participation has been sparsely investigated among women with drug dependency. The aim of this study was to assess participation in screening for breast and cervical cancer among WCPDU.MethodsWe recruited WCPDU to a survey study, from six opioid substitution treatment (OST) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. The survey was constructed according to results from focus group discussions about cancer screening in a sample of women in OST. Survey data were analyzed using descriptive statistics. We analyzed associations between non-compliance to screening and healthcare contact (OST, NEP or none) by logistic regression analysis; unadjusted and adjusted for age, native language, housing situation, educational attainment and main source of income.ResultsA total of 298 women (median age 43 years) responded to the survey. The self-reported compliance with cancer screening recommendations was 29% for breast cancer screening and 41% for cervical cancer screening. Non-compliance with cervical cancer screening was associated with NEP participation in univariate but not multivariate analysis. We did not find an association between non-compliance with breast cancer screening and healthcare contact. Non-compliance with screening for cervical cancer was also associated with unstable housing in univariate and multivariate analyses, and inversely associated with increasing age in a univariate analysis. Non-compliance with breast cancer was associated with unstable housing in a univariate analysis, and inversely associated with not having Swedish as a native language in a multivariate analysis.ConclusionThe self-reported compliance with the national cancer screening programs for breast cancer and cervical cancer of WCPDU is notably lower than in the Swedish general population. Women with unstable housing seem to be particularly vulnerable to non-compliance with cancer screening. Interventions to minimize barriers to cancer screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

Comprehensive needle and syringe program and opioid agonist therapy reduce HIV and hepatitis c virus acquisition among people who inject drugs in different settings: A pooled analysis of emulated trials.

Although the Netherlands, Canada and Australia were early adopters of harm reduction for people who inject drugs (PWID), their respective HIV and hepatitis C (HCV) epidemics differ. We measured the pooled effect of needle and syringe program (NSP) and opioid agonist therapy (OAT) participation on HIV and HCV incidence in these settings. For each cohort, we emulated the design and statistical analysis of a target trial using observational data. We included PWID at risk of HIV or HCV infection from the Amsterdam Cohort Studies (1985-2013), Vancouver Injection Drug Users Study (1997-2009) and Melbourne Injecting Drug User Cohort Study (SuperMIX) (2010-2021). Separately for each infection and cohort (only HCV in SuperMIX), marginal structural models were used to compare the effect of comprehensive (on OAT and 100% NSP coverage or on OAT only if no recent injection drug use) versus no/partial NSP/OAT (no OAT and/or <100% NSP coverage) participation. Pooled hazard ratios (HR) and 95% CI were calculated using random-effects meta-analysis. We observed 94 HIV seroconversions and 81 HCV seroconversions among 2023 and 430 participants, respectively. Comprehensive NSP/OAT led to a 41% lower risk of HIV acquisition (pooled HR = 0.59, 95% CI = 0.36-0.96) and a 76% lower risk of HCV acquisition (pooled HR = 0.24, 95% CI = 0.11-0.51), compared with no/partial NSP/OAT, with little heterogeneity between studies for both infections (I2 = 0%). In the Netherlands, Canada and Australia, comprehensive needle and syringe program and opioid agonist therapy participation appears to substantially reduce HIV and hepatitis C acquisition compared with no or partial needle and syringe program/opioid agonist therapy participation. These findings from an emulated trial design reinforce the critical role of comprehensive access to harm reduction in optimizing infection prevention for people who inject drugs.

Exploring the Impacts of Rurality on Service Access and Harm Among Image and Performance Enhancing Drug (IPED) Users in a Remote English Region

Image and performance enhancing drugs (IPEDs) have been highlighted in recent years as posing a potential risk to public health, with much research dedicated to exploring the use of these drugs and associated harms. While recent work has considered harm reduction for IPED users, the geographic and cultural impacts of rurality on IPED use and harms, particularly in relation to harm reduction service access, remains comparatively under-explored. Features of rurality relating to levels of economic distress, the inheritance and decline of manual labor, and rural conceptions of masculinity are important in shaping drug harms. Consequently, the “rural risk environment” for IPED users is in need of exploration. This research examines the experiences of IPED users in a remote two-county region of rural England, drawn from a multi-year ethnography and 18 qualitative interviews with IPED users, to explore the impacts of rurality and the “rural risk environment” on service access and harm (reduction) within this population. Findings highlight a number of ways in which rurality impacted on IPED users’ access to harm reduction services such as needle and syringe programs (NSP), as well as engagement with healthcare practitioners (HCP). Issues included the distances required to access services and lack of public transport between towns; the impacts of stigma in a small town context where there is little anonymity; Distrust of HCP relating to cultural mindsets and regionally derived fears regarding impacts on employment prospects, particularly military; and the impacts of rural masculinities and perceptions of the self-sufficient “real man” on help-seeking when experiencing harm. The research highlights the need to incorporate cultural geographic understandings into harm reduction policy for IPED users, and the significance of rurality on experiences of harm.

Service Utilization among Persons Who Inject Drugs Attending a Syringe Exchange Program in New York State

Background: Epidemiologic studies commonly recommend the integration of harm reduction programs with health and social services to improve the well-being of persons who inject drugs (PWIDs). This study identified service utilization clusters for PWIDs attending a syringe exchange program (SEP) in 2017 to better understand in-house service usage. Methods: We applied Multiple Correspondence Analysis and Hierarchical Clustering on Principal Components to classify 475 PWIDs into clusters using anonymized, SEP records data from New York. Multinomial logistic regression was used to identify sociodemographic and program engagement correlates of cluster membership. Results: Only 22% of participants utilized at least one service. We identified three clusters of service utilization defined by 1) Nonuse; 2) Support, Primary Care, & Maintenance service use; and 3) HIV/STD, Support, Primary Care, & Maintenance service use. Cluster 2 members were less likely to be living alone compared to Cluster 1 (AOR = 0.08, 95% CI: 0.04, 0.17) while Cluster 3 members were less likely to be White (AOR = 0.19, 95% CI: 0.07, 0.50) or living alone (AOR = 0.16, 95% CI: 0.06, 0.44) and more likely to be Medicaid recipients (AOR = 2.89, 95% CI: 1.01, 8.36) compared to Cluster 1. Greater than one SEP interaction, lower syringe return ratios, and being a long-term client increased the odds of service utilization. Discussion: Overall, PWID clients had a low prevalence of in-house service use particularly those who live alone. However, higher service utilization was observed among more vulnerable populations (i.e., non-White and LGBT). Future research is needed to profile services used outside of the SEP.

Project T-SHARP: study protocol for a multi-site randomized controlled trial of tele-harm reduction for people with HIV who inject drugs

BackgroundThe resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue.MethodsThe T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed.DiscussionThe T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes.Trial registrationClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.

The effects of COVID-19 on New York State’s Drug User Health Hubs and syringe service programs: a qualitative study

BackgroundSyringe service programs (SSPs) deliver critical harm reduction services to people who inject drugs (PWID). Some SSPs in New York State received enhanced funding to provide additional services to combat opioid overdose fatalities. These SSPs, known as Drug User Health Hubs, provide buprenorphine for the treatment of opioid use disorder and other health-related services in addition to their syringe services. While the COVID-19 pandemic posed widespread challenges to the delivery of health services nationwide, the effect of the pandemic on SSPs uniquely impacts PWID. This study examines the impact of COVID-19 on service delivery of Drug User Health Hubs and stand-alone SSPs in New York State.MethodsBetween July 2020 and September 2020, we performed eleven semi-structured virtual interviews with staff from three Health Hub SSPs and three stand-alone SSPs. The interviews explored the effect of the COVID-19 pandemic on SSPs and their clients as well as the changes implemented in response. Interviews were recorded and transcribed. We performed content analysis to identify emerging themes from the data.ResultsDue to the COVID-19 pandemic, some SSPs temporarily shut down while others limited their hours of operation. SSPs modified their service delivery to maintain syringe services and naloxone distribution over other services such as STI and HCV testing. They virtualized components of their services, including telemedicine for the provision of buprenorphine. While SSPs found virtualization to be important for maintaining their services, it negatively impacted the intimate nature of client interactions. Participants also described the impact of the pandemic on the well-being of PWID, including isolation, worsened mental health challenges, and increased drug overdoses.ConclusionsIn response to the COVID-19 pandemic, SSPs demonstrated innovation, adaptability, and togetherness. Despite the challenges posed by the pandemic, SSPs continued to be key players in maintaining access to sterile supplies, buprenorphine, and other services for PWID. In addition to adapting to COVID-19 restrictions, they also responded to the dynamic needs of their clients. Sustainable funding and recognition of the critical role of SSPs in supporting PWID can help to improve outcomes for PWID.

Bedside visualisation tool for prediction of deviation from intended dosage in multi-infusion therapy.

In multi-infusion therapy, multiple infusion pumps are connected to one single vascular access point. Interaction between pressure changes from different pumps may result in temporary dosing errors, which can be very harmful to the patient. It is known that these dosing errors occur. However, clinicians tend to find it hard to estimate the order of magnitude of these errors. This research uses an existing mathematical model to create a bedside prediction tool that is able to provide clinicians with the dosing errors that will occur after flow rate changes in multi-infusion therapy. A panel of clinicians, consisting of both nurses and doctors, was formed, and, in order to assess the level of knowledge about dosing errors in multi-infusion, the panel was presented with four medication schedules in which a syringe exchange or change in flow rate took place. The panel was asked to predict the resulting dosing errors. A prediction tool was developed that describes a two pump multi-infusion system and predicts dosing errors resulting from changing the flow rate at one pump. 44% of the panel members wrongly predicted the impact of changing the set flow of liquid A on the flow of liquid B that reaches the patient. Nobody was able to correctly predict the dosing deviation if a very small catheter was used. After the prediction tool was shown, the clinicians indicated they had a improved understanding of what deviations to expect and that the tool would be useful in understanding multi-infusion dosing errors. Using the predictive tool to visualise the deviations from the set flow rate is an effective method to allow clinicians to gain insight in dosing errors in multi-infusion therapy. This knowledge can be used to better anticipate future dosing errors in clinical situations.

HCV serostatus and injection sharing practices among those who obtain syringes from pharmacies and directly and indirectly from syringe services programs in rural New England

BackgroundAmong people who inject drugs (PWID), obtaining syringes via syringe services programs (SSPs) and pharmacies reduces injection sharing practices associated with hepatitis C virus (HCV). Whether indirect use of SSPs via secondary exchange confers a similar benefit remains unknown, particularly in rural settings. We compared HCV serostatus and injection sharing practices by primary syringe source among a sample of rural PWID.MethodsData are from a cross-sectional study of adults who use drugs recruited from eleven rural counties in New Hampshire, Vermont, and Massachusetts using respondent-driven sampling (2018–2019). Study staff performed HCV antibody testing. An audio computer-assisted self-interview assessed sociodemographic characteristics, past 30-day injection practices, and past 30-day primary syringe source. Primary syringe source was classified as direct SSP, pharmacy, indirect SSP (secondary exchange), or “other” (friend/acquaintance, street seller, partner/relative, found them). Mixed effects modified Poisson models assessed the association of primary syringe source with HCV seroprevalence and injection sharing practices.ResultsAmong 397 PWID, the most common primary syringe source was “other” (33%), then pharmacies (27%), SSPs (22%), and secondary exchange (18%). In multivariable models, compared with those obtaining most syringes from “other” sources, those obtaining most syringes from pharmacies had a lower HCV seroprevalence [adjusted prevalence ratio (APR):0.85, 95% confidence interval (CI) 0.73–0.9985]; however, the upper bound of the 95% CI was close to 1.0. Compared with those obtaining most syringes from other sources, PWID obtaining most syringes directly from SSPs or pharmacies were less likely to report borrowing used syringes [APR(SSP):0.60, 95% CI 0.43–0.85 and APR(Pharmacies):0.70, 95% CI 0.52–0.93], borrowing used injection equipment [APR(SSP):0.59, 95% CI 0.50–0.69 and APR (Pharmacies):0.81, 95% CI 0.68–0.98], and backloading [APR(SSP):0.65, 95% CI 0.48–0.88 and APR(Pharmacies):0.78, 95% CI 0.67–0.91]. Potential inverse associations between obtaining most syringes via secondary exchange and injection sharing practices did not reach the threshold for statistical significance.ConclusionsPWID in rural New England largely relied on informal syringe sources (i.e., secondary exchange or sources besides SSPs/pharmacies). Those obtaining most syringes from an SSP or pharmacy were less likely to share injection equipment/syringes and had a lower HCV seroprevalence, which suggests using these sources reduces the risk of new HCV infections or serves as proxy for past injection behavior.

Access to safer injection equipment among people who inject drugs utilizing medical services in an urban hospital in the United States

Injection drug use carries significant risks for injury and infection, particularly when injection supplies are reused or shared. Syringe service programs and pharmacy nonprescription sale of syringes minimize this risk by promoting access to supplies. This study aimed to characterize how individuals accessing medical care obtain supplies and the impact of perceived barriers to accessing safer injection supplies. One hundred and twenty participants reporting past seven-day injection drug use were recruited from a large urban academic medical center. Participants completed a survey about their injection drug use practices, access to injection supplies, as well as barriers to accessing supplies. Most participants (68%) reported obtaining syringes from multiple sources over the past 3 months, most commonly syringe service programs (78%) or a pharmacy (68%). Few (3%) reported obtaining supplies from medical settings. Participants who found syringes easy to obtain were less likely to report reusing a syringe >10 times (25% vs. 81%, p < .001). More participants were comfortable obtaining syringes through syringe service programs (89%) than nonprescription sale of syringes (60%, p = .001). Perceiving syringe service programs as not convenient or not comfortable reduced the odds of obtaining syringes there by 90% (p < .001) and 88% (p < .003), respectively. Perceiving pharmacies as not comfortable or not affordable reduced the odds of obtaining syringes there by 82% (p < .001) and 75% (p < .002), respectively. Even in regions with legalized syringe service programs and nonprescription sale of syringes, barriers to accessing safer injection supplies remain, and may be partially addressed by expanding syringe service program hours and locations, addressing cost of nonprescription sale of syringes, pharmacy staff training, and expansion of injection supply distribution in medical settings.

Using Learning Experience Design (LXD) to Promote Decreasing Stigma in Creating a Video Series about Syringe Services Programs (SSP)

Despite being a vital resource for persons who inject drugs (PWID), syringe services programs (SSPs) often face stigma from the general community and medical profession. To de-stigmatize and illustrate the collaborative practices of SSPs, the authors collaborated with three syringe services programs across Connecticut to create an animated video series called “Syringe Services Programs: Community Building, Testing, and Stigma.” This design case describes how the aspects of the learning experience design (LXD) were used to create the animated videos. In addition, the authors discuss how the theory of intersectionality was used to inform the video design.

"I know my body better than anyone else": a qualitative study of perspectives of people with lived experience on antimicrobial treatment decisions for injection drug use-associated infections.

People who inject drugs (PWID) are at risk for severe bacterial and fungal infections including skin and soft tissue infections, endocarditis, and osteomyelitis. PWID have high rates of self-directed discharge and are often not offered outpatient antimicrobial therapies, despite studies showing their efficacy and safety in PWID. This study fills a gap in knowledge of patient and community partner perspectives on treatment and discharge decision making for injection drug use (IDU)-associated infections. We conducted semi-structured interviews with patients (n = 10) hospitalized with IDU-associated infections and community partners (n = 6) in the Portland, Maine region. Community partners include peer support workers at syringe services programs (SSPs) and outreach specialists working with PWID. We transcribed and thematically analyzed interviews to explore perspectives on three domains: perspectives on long-term hospitalization, outpatient treatment options, and patient involvement in decision making. Participants noted that stigma and inadequate pain management created poor hospitalization experiences that contributed to self-directed discharge. On the other hand, patients reported hospitalization provided opportunities to connect to substance use disorder (SUD) treatment and protect them from outside substance use triggers. Many patients expressed interest in outpatient antimicrobial treatment options conditional upon perceived efficacy of the treatment, perceived ability to complete treatment, and available resources and social support. Finally, both patients and community partners emphasized the importance of autonomy and inclusion in medical decision making. Although some participants acknowledged their SUD, withdrawal symptoms, or undertreated pain might interfere with decision making, they felt these medical conditions were not justification for health care professionals withholding treatment options. They recommended open communication to build trust and reduce harms. Patients with IDU-associated infections desire autonomy, respect, and patient-centered care from healthcare workers, and may self-discharge when needs or preferences are not met. Involving patients in treatment decisions and offering outpatient antimicrobial options may result in better outcomes. However, patient involvement in decision making may be complicated by many contextual factors unique to each patient, suggesting a need for shared decision making to meet the needs of hospitalized patients with IDU-associated infections.

Changes in Perceptions of First Responders After Witnessing a Drug Overdose: Individual and Contextual Variations Among People Who Use Opioids in West Virginia.

Success of opioid overdose interventions involving first responders is dependent on the comfort level that bystanders have with first responders and their willingness to call for assistance. Positive or negative experiences with first responders following witnessing an overdose may influence a person's willingness to call a first responder for assistance in the future. The objective of this study was to examine changes in bystanders' perceptions of first responders following witnessing an overdose attended by emergency medical services or a law enforcement official. It specifically explored perception changes among a sample of individuals residing in Appalachia who use prescription opioids nonmedically. Individuals from West Virginia who used prescription opioids nonmedically were interviewed to examine changes in perceptions of first responders following witnessing an overdose. The analytic sample (N = 50) consisted of participants who witnessed an overdose for which 911 was called and stayed until a first responder arrived. Chi-square contingency tables and ANOVA were conducted to assess relationships between individual and contextual characteristics with changes in perceptions. Findings indicate that the majority (63%) had improved perceptions of first responders, 6% had diminished perceptions, and 24% were unchanged. Changes in perceptions varied by income, presence during substance use, and prior concerns about first responders. Individuals who reported experiencing a positive interaction with first a responder after witnessing an overdose may be more likely to call 911 during an overdose and support other interventions by first responders (e.g., referral to syringe service programs or treatment with medications for opioid use disorder).

Sticking points: Incarcerated women's views on barriers to a prison needle exchange program

While prison needle exchange programs, or prison needle and syringe programs, have existed in different parts of the world since the 1990s, little is known about how currently incarcerated people perceive them—particularly in Canada, where such programs have only recently been implemented. This study explores incarcerated women's perceptions of a recently implemented prison needle exchange program using in-depth, semi-structured qualitative interviews with 56 federally incarcerated women in Western Canada. In particular, we explore the barriers that women perceive in accessing the prison needle exchange program. These perceived barriers contributed to our participants’ negative views of the prison needle exchange program as well as their overwhelming lack of support for its implementation. Our participants felt that the prison needle exchange program acts as an obstacle to sobriety and could increase different types of harm—including encouraging injection drug use and contributing to overdoses—within the prison. Participants also identified other barriers to using the prison needle exchange program, including a perceived lack of confidentiality/anonymity for users of the program and that the prison needle exchange program itself is structurally incompatible with the rules and operations of a prison system that continues to criminalize drugs. Using an implementation science framework, we argue that this situation accentuates the need for significant consultations with incarcerated people about the operation of such programs, and for funds to support other programs that target participant-identified root causes of substance misuse, such as programs that address past trauma and victimization. At the same time, we caution that some barriers may be inherent in how prisons are structured.

“We shouldn't encourage drug use”: Unpacking correctional officer opposition and support of the Prison Needle Exchange Program

BackgroundThe Prison Needle Exchange Program (PNEP) is a harm reduction initiative which involves providing people who are incarcerated (PWAI) with sterile injection equipment to avoid harms associated with unsterilized needle use, such as the spread of infectious diseases. While current evidence strongly supports the implementation and monitoring of PNEP, the program's success requires institutional support along with staff and prisoner commitment. MethodsThe current study draws on interview data to examine policies surrounding PNEP and correctional officers’ (COs) (n = 134) perceptions and attitudes toward PNEP. ResultsThe COs in our sample were strongly in opposition to PNEP, with only a handful supporting PNEP. Emergent themes underpinning their opposition related to a sense of injustice and an inherent tension between introducing needles into the prison versus how they understand their occupational role and responsibilities. ConclusionWe conclude with a discussion of policy recommendations aimed at implementing PNEP collaboratively with staff to ensure the benefits of harm reduction are fostered and realized.

Making community pharmacies psychologically informed environments (PIE): a feasibility study to improve engagement with people using drug services in Scotland.

This developmental study tested the feasibility of training pharmacy staff on the psychologically informed environments (PIE) approach to improve the delivery of care. Community pharmacies provide key services to people who use drugs (PWUD) through needle exchange services, medication-assisted treatment and naloxone distribution. PWUD often have trauma backgrounds, and an approach that has been demonstrated to work well in the homeless sector is PIEs. Bespoke training was provided by clinical psychologists and assessed by questionnaire. Staff interviews explored changes made following PIE training to adapt the delivery of care. Changes in attitude of staff following training were assessed by questionnaire. Peer researchers interviewed patient/client on observed changes and experiences in participating pharmacies. Staff interviews were conducted six months after training to determine what changes, if any, staff had implemented. Normalisation process theory (NPT) provided a framework for assessing change. Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rated training structure and delivery as 'very good' or 'excellent'. There was no statistically significant change in attitudes. COVID-19 lockdowns restricted follow-up data collection. Staff interviews revealed training had encouraged staff to reflect on their practice and communication and consider potentially discriminatory practice. PIE informed communication skills were applied to manage COVID-19 changes. Staff across pharmacies noted mental health challenges for patients. Five patients were interviewed but COVID-19 delays in data collection meant changes in delivery of care were difficult to recall. However, they did reflect on interactions with pharmacy staff generally. Across staff and patient interviews, there was possible conflation of practice changes due to COVID-19 and the training. However, the study found that training pharmacy teams in PIE was feasible, well received, and further development is recommended. There was evidence of the four NPT domains to support change (coherence, cognitive participation, collective action and reflexive monitoring).