The effect of injecting alone on the use of drug checking services among people who inject drugs

ObjectivesDrug checking services aim to provide people who use drugs with information on the content and purity of their substances as a harm reduction intervention. The objective of this study was to determine the relationship between injecting alone and use of drug checking services in Vancouver, Canada.MethodsData were derived from three prospective cohort studies of people who inject drugs (PWID). We conducted bivariable and multivariable logistic regression analysis to estimate the effect of injecting alone on use of drug checking services.ResultsBetween May 2018 and December 2018, a total of 793 people who inject drugs were included in the study: 579 (73.0%) reported injecting alone and 177 (22.3%) reported use of drug checking services. In a multivariable model adjusted for various confounders (including various sociodemographic variables, drug use patterns, and whether participants had suffered physical attacks/violence), injecting alone was negatively associated with use of drug checking services (Adjusted Odds Ratio = 0.65; 95% Confidence Interval: 0.44–0.97).ConclusionsWe observed a negative association between injecting drugs alone and use of drug checking services, which may be due in part to a number of exogenous factors that prevent people who inject alone from accessing drug checking services (e.g., stigma, location of services). As these individuals are at heightened risk of experiencing overdoses, there is a need to pursue other strategies to reach this group of people who use drugs.     

Patterns of Peer Distribution of Injecting Equipment at an Authorized Distribution Site in Sydney,Australia

Background: Extended distribution refers to the practice whereby people who inject drugs pass on sterile injecting equipment to their networks and can be a means to access people who inject drugs who do not attend state-sanctioned needle and syringe programs. While it is legal, to possess a sterile syringe for the purpose of injecting drugs in New South Wales, Australia, it is a criminal offence to pass this equipment on for others to use. In 2013 a pilot project was established to trial the authorization of “extended” peer distribution. This research describes patterns of distribution among attendees participating in this trial. Methods: A cross-sectional survey was conducted during one week in October 2014 of the trial with 200 clients. The survey focused on the extent, characteristics, and perceived risks and benefits of extended distribution practices within peer groups. Results: Extended distribution is widespread, not in an organized or intentional manner but as a consequence of day-to-day drug using activities. The profiles of those who do and do not distribute were similar. Willingness to distribute small quantities of equipment to others was higher than willingness to distribute larger quantities, and willingness to distribute was related to perceived benefits of extended distribution. Police scrutiny was a key reason for not wanting to distribute. Conclusion: Extended peer distribution is widespread though mostly not organized. This study supports the evidence that drug users act responsibly to prevent harm and promote the use of sterile equipment among their peers.     

Exposure to injecting drug use and hepatitis C knowledge among an online sample of young people

Aim: Young people who are socially engaged with people who inject drugs are at higher risk of transitioning to injecting drug use. We aimed to examine rates of exposure to injecting among young people in an online survey, and whether exposure to injecting was related to hepatitis C (HCV) knowledge. Methods: A cross-sectional, online survey was completed by 827 young people (aged 16–26 years) in New South Wales, Australia. Exposure to injecting in the preceding 12 months was measured by asking participants whether close friends and romantic/sexual partners had injected, and whether somebody had offered them an injection. HCV knowledge was measured using items adapted from a survey of Australian secondary school students. Findings: Eleven percent of participants reported recent exposure to injecting. Participants exposed to injecting were significantly more likely than other participants to report use of injectable drugs. Some aspects of HCV transmission were poorly understood, and exposure to injecting was not significantly associated with higher HCV knowledge. Conclusions: While online methods were only moderately successful in recruiting people exposed to injecting, higher rates of use of injectable drugs and HCV knowledge deficits in this group suggests that they are an important target for HCV education and prevention.     

Implicit and explicit internalized stigma: Relationship with risky behaviors,psychosocial functioning and healthcare access among people who inject drugs

IntroductionPeople who inject drugs (PWID) are stigmatized by society. Over time people may begin to internalize the stigma about their group. This research examines how implicit and explicit internalized stigma among PWID relates to health care and treatment access, psychosocial functioning, and engagement in risky behaviors.MethodsPWID were recruited from a needle and syringe program (NSP) located in Sydney, Australia. Participants completed a survey examining explicit and implicit internalized stigma, risky behaviors (e.g., sharing injecting equipment, unprotected sex), health care and treatment access (e.g., comfort attending NSPs), and psychosocial functioning (e.g., mental health). Detailed demographic variables were also collected.ResultsA total of 115 clients completed the measures. To the degree that participants had internalized the stigma about their group (measured explicitly), they felt less comfortable attending NSPs, had greater severity of dependence, and experienced more depressive symptoms. The implicit measure of internalized stigma was related to treatment engagement and needle sharing, although the direction of these effects was unexpected.ConclusionsThis research highlights the importance of ongoing research into the implications of internalized stigma for PWID. Assessing both explicit and implicit internalized stigma appears to be beneficial as these are related to different health and behavioral outcomes.     

Positive effects of community attachment on internalised stigma and wellbeing among people who inject drugs

BackgroundInternalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment.MethodsPWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing.ResultsGreater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment.ConclusionsThis research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma.     

Transition to and from injecting drug use among regular ecstasy users

There is a scant amount of research investigating injecting drug use among people not selected on the basis of their injecting behaviour, and less attention has been given to stimulant users who may have a different experience with injecting drug use than opioid users who are more commonly studied. The current study aimed to investigate initiation to, and transition from, injecting drug use among a sentinel sample of regular ecstasy users in Australia. Participants were regular ecstasy users recruited across Australia in 2007 who were administered a structured interview that contained questions regarding initiation to injecting, reasons for injecting cessation, and likelihood of future injecting. Among those with a history of injecting drug use, injecting first occurred at a similar age to that of first ecstasy use. The majority did not inject themselves at the first occasion, and two-fifths were under the influence of other drugs at the time. Two-fifths of injectors had not injected in the past 6 months, with many relating this to concerns surrounding stigma. Route of drug administration is clearly not static, and the findings from this study suggest that some who have ceased injecting may still be at risk for future injecting.     

People Who Inject Drugs and Have Mood Disorders—A Brief Assessment of Health Risk Behaviors

Background: People who inject drugs have a greater risk of infectious disease and mortality than other substance abusers and nondrug users. Variation in risk behavior among people who inject drugs is likely associated with comorbid mental health disorders. Objectives: Examine the association between a history of mood disorder and recent risk behavior among people who inject drugs. Methods: With baseline data from a behavioral HIV prevention clinical trial in a population of people who inject drugs, we used logistic regression models to compare the risk behaviors of people who report a past diagnosis of bipolar disorder (n = 113) or depression (n = 237) to a comparison group with no history of diagnosed mental illness (n = 446). We also assessed differences between groups before and after adjusting for demographic characteristics and current depressive symptoms. Results: While there were no differences between groups in frequency of drug use, people who inject drugs who report a history of mood disorders reported more injection risk behaviors, drug overdoses, sex exchanges, and multiple partners than those with no history of mental illness. Adjusting the comparison for demographic characteristics and current depressive symptoms had little impact on these findings. Variation in risk between depression and bipolar disorder groups was minimal. Conclusions/Importance: People who inject drugs and have mood disorders have unique and significant social, clinical, and risk reduction needs. Despite the limited validity of self-reported mental health history, simply asking about a history of mood disorder may be effective for identifying a particularly vulnerable population of people who inject drugs.     

Characteristics and attendance patterns of a fixed-site NSP and nearby SVM: The benefits of 24-hour access to sterile injecting equipment

Aims: This article describes the characteristics and attendance patterns of clients of a co-located fixed-site needle and syringe program (NSP) and syringe vending machine (SVM) to assess the utilisation and benefits of providing access to multiple distribution services. Methods: Data were collected through cross-sectional surveys with a convenience sample of NSP (n?=?98) and SVM (n?=?91) recruited attendees in Sydney, Australia. Surveys collected demographic data, self-reported injecting patterns, self-reported receptive equipment sharing, knowledge of hepatitis C and utilisation of the fixed-site NSP and SVM services. Findings: The demographic profile and characteristics of these NSP and SVM groups were similar; no differences were evident in knowledge about hepatitis C risk practices or type of drug used, frequency of injecting, sharing of injecting equipment and place of injecting. Both fixed-site NSP- and SVM-recruited attendees primarily accessed equipment from the fixed-site NSP in the last month. The SVM was usually accessed outside the opening hours of the fixed-site NSP, between 8?pm and 4 am, or in circumstances where equipment could not be obtained from the NSP. Conclusions: Findings support the argument that SVMs act as a complementary service alongside fixed-site NSP services and indicate that providing 24-h access to syringes through multiple mechanisms has benefits for provision of sterile equipment to people who inject drugs.     

Secondary exchange of sterile injecting equipment in a high distribution environment: a mixed method analysis in south east Sydney, Australia

BackgroundIn Australia, sterile needles are distributed to people who inject drugs through formal services for the purposes of limiting the transmission of blood borne viruses (BBV). Secondary exchange (SE) involves people acquiring needles from formal services and redistributing them to others. This paper describes the extent, patterns and contexts of SE in south east Sydney, Australia and examines whether SE is independently associated with BBV risk practices.MethodsQuantitative and qualitative data were collected through a cross-sectional study using surveys and in-depth interviews. Respondents were people using community-based pharmacies to obtain sterile needles and syringes.ResultsData were collected from 229 survey respondents, over half of whom (54%) reported SE in the previous month. Of these, 40% engaged in distribution only, 25% in receipt only and 36% in both. Respondents reported passing on 21.7% of their needles to others in the last month, most commonly to friends (51.6%) and partners (27.4%). Recipients of SE were four times more likely than non-secondary exchangers to report borrowing used syringes in the last month. Respondents reported supplying sterile equipment to others to prevent reuse and to reduce risks associated with unplanned drug use.ConclusionSE is a common activity in south east Sydney but does not appear to be highly organised, usually taking place in small networks of friends and/or partners for altruistic reasons. Harm reduction programs could capitalise on the prevalence of SE to reach injecting drug users who do not use formal distribution services.     

Health care engagement behaviors of men who use performance- and image-enhancing drugs in Australia

Abstract

Background: Although people who inject performance- and image-enhancing drugs (PIEDs) report fewer unsafe injecting practices, stigma and discrimination may negatively impact their access to help and information. Engagement with health care services, compared with social networks (friends, relatives, and gym associates) and the Internet and media (steroid user forums, information sites, and magazines), may be important for harm minimization. Methods: A cross-sectional Internet or in-person survey of men who use PIEDs in Australia in 2014–2015 examined differences in sources for PIEDs, injecting equipment, and anabolic-androgenic steroids (AAS) information and factors associated with having periodical medical checks related to PIEDs issues using multivariate logistic regression. Results: In total, 267 men (mean age: 25?years, SD: 8.7?years; 246 of 267 [92%] reported recent AAS injection) were recruited. Most participants sourced injecting equipment from health professionals, PIEDs from their social networks, and AAS information from the Internet and media. Self-reported AAS knowledge was high and frequent. Higher income (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.03, 4.00), ≥2 different PIEDs used in addition to AAS (AOR: 1.94, 95% CI: 1.08, 3.49), and sourcing AAS information from health care professionals (AOR: 3.14, 95% CI: 1.81, 5.46) were independently associated with periodical medical checks. Participants nominated preference for improved health services through needle-syringe programs, primary care services, and peer educator support groups. Conclusion: Men who use PIEDs in Australia consider themselves well informed but tend to use Internet and media sources, providing potentially misleading or inaccurate information. Increasing trust between men who use PIEDs and health care providers may enable delivery of PIEDs-specific information to those at greatest need.     

The prevalence and characteristics of injecting drug users in Australia

The prevalence of injecting drug use has increased significantly in Australia in recent years. Using the nationally representative 1998 National Drug Strategy Household Survey we estimate the size of the lifetime prevalence injecting drug use population at 302710 people, compared to 67474 in 1988. Those who have injected drugs in the previous year are estimated at 108750 people in 1998. Amphetamines have displaced heroin as the most popular drug to inject among the general population. Those who have ever injected are more likely to be male, young, unemployed and to possess fewer educational qualifications. A variety of factors are discussed which may account for increases in injecting drug use. \[McAllister I, Makkai T. The prevalence and characteristics of drug users in Australia. Drug Alcohol Rev 2001;20:29-36]     

Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney,Australia

Introduction and Aims. Cleaning needles/syringes is an important second‐line harm reduction strategy, yet there is limited information on practices employed by people who inject drugs in Australia. This study attempts to identify and assess cleaning practices in terms of the techniques involved and the social contexts in which cleaning takes place. Design and Methods. As part of an exploratory qualitative study in south‐west Sydney, in‐depth interviews and simulated cleaning exercises were conducted with 12 people who inject drugs. Interviews were digitally recorded and transcribed verbatim. Open coding was used to inductively classify data into themes, and data were examined for patterns and variations in the relationships within and between themes. Results. Data indicate that cleaning and reuse of needles/syringes was common in this small sample. The most frequently utilised reagent was cool water. While all participants reported cleaning and reusing only their own equipment, none of the techniques demonstrated would have been sufficient to deactivate human immunodeficiency virus or hepatitis C virus. Discussion and Conclusions. Results suggest that even where cleaning of needles and syringes is widespread, people who inject drugs may not engage in efficacious cleaning. The combination of the complexity of current cleaning messages and a lack of accurate information about efficacious techniques are likely to contribute to poor cleaning practice. Australia could benefit from the development of a nationally consistent cleaning message; however, the evidence would suggest that this would need to be accompanied by strategies designed to simplify and disseminate this information in order to increase the uptake of efficacious cleaning methods by people who inject drugs [Nathani J, Iversen J, Shying K, Byrne J, Maher L. Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney, Australia. Drug Alcohol Rev 2010]     

Deconstructing injecting risk of hepatitis C virus transmission: Using strategic positioning to understand “higher risk” practices

Aims: Currently, efforts to prevent hepatitis C virus (HCV) focus on the message that all sharing of injecting equipment is risky. This obscures the strategies undertaken by people who inject drugs (PWID) to reduce risk of transmission to themselves and others. Methods: Self-complete survey of clients of Needle and Syringe Programs (NSPs) in a metropolitan area of Sydney, Australia. Among those who reported sharing injecting equipment, two categories of risk were constructed based on self-perceived HCV status and self-reported distributive and receptive sharing of injecting equipment. The “higher risk” category contained participants who reported being either HCV-positive and distributive sharing or HCV-negative and receptive sharing. The “lower risk” category contained participants who reported being either HCV-positive and receptive sharing or HCV-negative and distributive sharing. Findings: Around a third of the total sample were categorised as “higher risk”. In multivariate analysis, being in the higher risk category was associated with perceived difficultly in managing drug use (adjusted odds ratio (AOR)?=?2.37; 95% CI 1.34–4.18; p?=?0.003) and having less trust in drug and alcohol workers (AOR?=?0.68; 95% CI 0.52–0.90; p?=?0.007). Conclusions: This exploratory study highlights gaps in the way that the HCV prevention sector understands and addresses risk. Further research is required to guide prevention efforts that are meaningful and relate to the strategies that PWID undertake to reduce HCV risk.     

Polydrug Use and HIV Risk Among People Who Inject Heroin in Tijuana,Mexico: A Latent Class Analysis

Background: Although most people who inject drugs (PWID) in Tijuana, Mexico, primarily inject heroin, injection and non-injection use of methamphetamine and cocaine is common. We examined patterns of polydrug use among heroin injectors to inform prevention and treatment of drug use and its health and social consequences. Methods: Participants were PWID residing in Tijuana, aged ≥18 years who reported heroin injection in the past six months and were recruited through respondent-driven sampling (n = 1,025). Latent class analysis was conducted to assign individuals to classes on a probabilistic basis, using four indicators of past six-month polydrug and polyroute use: cocaine injecting, cocaine smoking or snorting, methamphetamine injecting, and methamphetamine smoking or snorting. Latent class membership was regressed onto covariates in a multinomial logistic regression. Results: Latent class analyses testing 1, 2, 3, and 4 classes were fit, with the 3-class solution fitting best. Class 1 was defined by predominantly heroin use (50.2%, n = 515); class 2 by methamphetamine and heroin use (43.7%, n = 448), and class 3 by methamphetamine, cocaine, and heroin use (6.0%, n = 62). Bivariate and multivariate analyses indicated a group of methamphetamine and cocaine users that exhibited higher-risk sexual practices and lower heroin injecting frequency, and a group of methamphetamine users who were younger and more likely to be female. Conclusions: Discrete subtypes of heroin PWID were identified based on methamphetamine and cocaine use patterns. These findings have identified subtypes of heroin injectors who require more tailored interventions to reduce the health and social harms of injecting drug use.     

Stigma and drug use settings as correlates of self-reported,non-fatal overdose among people who use drugs in Baltimore,Maryland

BackgroundFatalities from opioid overdose quadrupled during the last 15 years as illicit opioid use increased. This study assesses how stigma and drug use settings are associated with non-fatal overdose to identify targets for overdose risk reduction interventions and inform overdose education and naloxone distribution programs.MethodsWe surveyed 444 people who used drugs in Baltimore, Maryland, USA, from 2009 to 2013 as part of a randomized clinical trial of a harm reduction intervention. Participants reported demographic characteristics, drug use, overdose history, use of a local syringe services program, involvement in the local drug economy, and whether they experienced discrimination from others (i.e., enacted stigma) or stigmatized themselves (i.e., internalized stigma) related to their drug use. We used multinomial logistic regression models to identify correlates of experiencing a non-fatal overdose within the past year or >1 year ago relative to participants who never experienced an overdose.ResultsStigma was positively associated with experiencing a non-fatal overdose in the past year (adjusted Odds Ratio [aOR]: 1.7, 95% Confidence Interval [CI]: 1.1–2.7) and >1 year ago (aOR [95% CI]: 1.5 [1.1–2.0]) after adjustment for demographic and substance use characteristics. The association of stigma with overdose was stronger for enacted versus internalized stigma. The number of public settings (shooting gallery, crack house, abandoned building, public bathroom, outside) where participants used drugs was also positively associated with experiencing an overdose.ConclusionsStigma related to drug use and using drugs in more settings may increase overdose risk. The effectiveness of overdose prevention and naloxone training may be improved by reducing discrimination against people who use drugs in community and medical settings and diversifying the settings in which overdose prevention trainings are delivered. These efforts may be enhanced by use of peer outreach approaches in which people who use drugs diffuse prevention messages through their social networks and within settings of drug consumption outside the medical setting.     

Polysubstance use in treatment seekers who inject amphetamine: Drug use profiles,injecting practices and quality of life

BackgroundThe injection of amphetamine is becoming increasingly common. However, there has been a lack of research examining people who inject amphetamine as the primary drug of use, limiting the potential to ensure services address the unique needs of this group. The current study used latent class analysis to identify classes of polydrug use among people who report injecting amphetamine during the past 12 months. It also examined differences between classes and drug use patterns, injecting practices, quality of life and psychological distress.MethodsParticipants who were attending non-government specialist alcohol and other drug treatment across New South Wales, Australia and had identified amphetamine as their principle drug of concern and reported injecting amphetamine in the previous 12 months were included in the current study (N = 827). Latent class analysis was performed to identify polydrug profiles of participants.ResultsThe large majority of people in the current study (85%) demonstrated low probability of heroin or other opiate use. Three distinct classes of polydrug use were identified: (1) Low-polydrug (n = 491), (2) Opiates-polydrug (n = 123), and (3) Alcohol-polydrug (n = 213). There was a trend for the Low-polydrug class to demonstrate better functioning and safer injecting practices than the Opiates-polydrug and Alcohol-polydrug classes.ConclusionThe results suggest that the majority of people accessing treatment who inject amphetamine as their primary drug of choice have a low probability of heroin or other opiate use. It is important that future research consider whether traditional harm minimisation strategies are appropriate for people who primarily inject amphetamine.     

Hepatitis C testing for people who inject drugs in the United Kingdom: Why is uptake so low?

Background: Hepatitis C virus (HCV) related morbidity and mortality will continue to rise unless HCV testing and treatment uptake increases. People who inject drugs constitute those at highest risk for HCV in the UK, yet over a third who access drug and alcohol services have never received an HCV test.

Method: We conducted qualitative life history research with people who have injected drugs for over six years to explore the social conditions of long-term HCV avoidance. In order to ascertain previous HCV exposure, participants were required to have an HCV antibody test at a recruiting service. We concentrate here on analyses of participant accounts in relation to HCV testing, and specifically, barriers to uptake. Thirty-seven participants were interviewed two to three times over three months. Data were analyzed according to grounded theory principles.

Results: Participants had injected an average of nine years before their first HCV test. Key themes in participant accounts included: concerns regarding the process of HCV testing, including phlebotomy practices; concerns regarding the impacts of HCV diagnosis, exacerbated by confusion regarding test results and HCV effects, and fears of concomitant HIV diagnosis; optimism that testing was unnecessary given HCV risk potentials; and institutional mistrust, often internalized as felt stigma, especially in hospital settings.

Conclusions: To maximize HCV testing uptake among people who inject drugs, we emphasize the need for: testing at community-based drug services; on-site skilled and non-judgemental phlebotomists; the decoupling of HCV and HIV testing; and peer-supported testing interventions.     

Benefits and barriers to expanding the availability of take-home naloxone in Australia: A qualitative interview study with service providers

Aims: To investigate the perspectives and experiences of service providers regarding provision of take-home naloxone to people who use opioids in Victoria, Australia. Methods: Content analysis of qualitative semi-structured interviews with 15 service providers who are either involved with take-home naloxone programs or whose work brings them in contact with people who use opioids. Findings: Statements about take-home naloxone were universally positive. Both direct and indirect benefits of take-home naloxone were described. Alongside potential reductions in opioid overdose-related harms, service providers highlighted the empowering effects of providing people who use opioids with take-home naloxone. No significant risks were described. Service providers supported the expansion of naloxone availability, but also identified several intertwined barriers to doing so. Key among these were costs, current regulations and scheduling, availability of prescribers and stigma related to illicit and injecting drug use. Conclusions: Expanding the availability of naloxone is a key component of strategies to reduce harms associated with opioid overdose. Our article provides Australian evidence of the successful operational implementation of peer-to-peer THN delivery within a range of drug primary health services and needle syringe programs. Further research is required to better understand the implications of and impediments to scale-up of this potentially life-saving public health intervention.