The relationship between felt stigma and non-fatal overdose among rural people who use drugs.

BACKGROUND: Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs. METHODS: Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose. RESULTS: 6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14). CONCLUSIONS: Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Effects of Bundling Medication for Opioid Use Disorder With an mHealth Intervention Targeting Addiction: A Randomized Clinical Trial.

OBJECTIVE: Medication for opioid use disorder (MOUD) improves treatment retention and reduces illicit opioid use. A-CHESS is an evidence-based smartphone intervention shown to improve addiction-related behaviors. The authors tested the efficacy of MOUD alone versus MOUD plus A-CHESS to determine whether the combination further improved outcomes. METHODS: In an unblinded parallel-group randomized controlled trial, 414 participants recruited from outpatient programs were assigned in a 1:1 ratio to receive either MOUD alone or MOUD+A-CHESS for 16 months and were followed for an additional 8 months. All participants were on methadone, buprenorphine, or injectable naltrexone. The primary outcome was abstinence from illicit opioid use; secondary outcomes were treatment retention, health services use, other substance use, and quality of life; moderators were MOUD type, gender, withdrawal symptom severity, pain severity, and loneliness. Data sources were surveys comprising multiple validated scales, as well as urine screens, every 4 months. RESULTS: There was no difference in abstinence between participants in the MOUD+A-CHESS and MOUD-alone arms across time (odds ratio=1.10, 95% CI=0.90-1.33). However, abstinence was moderated by withdrawal symptom severity (odds ratio=0.95, 95% CI=0.91-1.00) and MOUD type (odds ratio=0.57, 95% CI=0.34-0.97). Among participants without withdrawal symptoms, abstinence rates were higher over time for those in the MOUD+A-CHESS arm than for those in the MOUD-alone arm (odds ratio=1.30, 95% CI=1.01-1.67). Among participants taking methadone, those in the MOUD+A-CHESS arm were more likely to be abstinent over time (b=0.28, SE=0.09) than those in the MOUD-alone arm (b=0.06, SE=0.08), although the two groups did not differ significantly from each other (∆b=0.22, SE=0.11). MOUD+A-CHESS was also associated with greater meeting attendance (odds ratio=1.25, 95% CI=1.05-1.49) and decreased emergency department and urgent care use (odds ratio=0.88, 95% CI=0.78-0.99). CONCLUSIONS: Overall, MOUD+A-CHESS did not improve abstinence relative to MOUD alone. However, MOUD+A-CHESS may provide benefits for subsets of patients and may impact treatment utilization.

Patient Preferences for Mobile Health Applications to Support Recovery.

INTRODUCTION: Smartphone apps to support individuals in recovery from substance use disorders (SUDs) are increasingly available. Although many people with SUDs express interest in recovery support apps, few try them or use them long-term. Strategies like gamification and contingency management are increasingly being considered to sustain engagement. This study sought to describe features of a recovery support app called the Addiction version of the Comprehensive Health Enhancement Support System (A-CHESS) that are most used by individuals in SUD recovery and what makes individuals more likely to use these apps. METHODS: A total of 202 people with A-CHESS accounts completed an online survey assessing their experiences using A-CHESS between April and June 2021. We described app features reported to be most beneficial for managing anxiety, loneliness, and isolation during COVID-19; reasons for not using A-CHESS; and suggested app features for future recovery support apps. RESULTS: Respondents had a mean age of 41 years, 85% were White, and 61% were female. Respondents reported that app features related to messaging (ie, open discussion boards and private messaging) and informational or motivational resources were the most useful for managing isolation, anxiety, and loneliness. Reasons for not using A-CHESS were not knowing how to use the app and the app not being part of a personalized treatment plan. The most common suggested components for future apps were rewards for meeting goals and a support meeting locator. CONCLUSIONS: Ensuring that health apps are intuitive and include features that appeal to patients and educating patients about features apps already include that help them meet goals may enhance engagement with recovery apps.

Context and correlates of providing assistance with someone's first injection in the AIDS linked to the IntraVenous Experience cohort, Baltimore, MD.

BACKGROUND: The social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual's first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID. METHODS: Participants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019-2020 about assisting with another person's first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics. RESULTS: At baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1-4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4-4.6]), syringe sharing (2.2 [1.2-3.9]), and injecting ≥3 times per day (2.0 [1.2-3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person's lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury. CONCLUSION: PWID with a history of assisting with another person's first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.

Effects of COVID-19 on Overdose Risk Behaviors Among People Who Inject Drugs in Wisconsin.

BACKGROUND: The United States is currently experiencing the worst epidemic of drug overdose in the country's history. We sought to understand whether changes in drug use behavior and access to prevention services during the COVID-19 pandemic may have contributed to increased drug overdose. METHODS: We recruited adults with a history of injection drug use to complete an online survey during March through June 2021 to assess whether overdose experiences, drug use behaviors, and access to prevention services changed due to the pandemic. RESULTS: Diminished social support during the pandemic was correlated with reporting disrupted access to harm reduction services (P = 0.006) and experiencing an overdose (P = 0.005). Disrupted access to harm reduction services also was correlated with being female (P = 0.03) and reporting feeling pressure to share drugs or equipment (P = 0.01), worrying about withdrawal (P = 0.03), and changes to how and where individuals got their drugs, drug price and availability, with whom and where drugs were used, and the quantity or properties of drugs purchased (all P < 0.01). DISCUSSION: The cumulative impact of COVID-19-related disruptions may have resulted in heightened risk for overdose, as these findings suggest that, in many cases, experiencing one risk factor was suggestive of experiencing several risk factors.

Temporal trends in HCV treatment uptake and success among people who inject drugs in Baltimore, MD since the introduction of direct acting antivirals.

Background: Although hepatitis C virus (HCV) can be cured by direct acting antivirals (DAA), uptake is not well characterized for people who inject drugs (PWID). Methods: Among 1,130 participants of a community-based cohort of PWID with chronic HCV, we longitudinally characterized HCV treatment uptake and cure early (2014-2016) and later (2017-2020). Results: Cumulative HCV treatment uptake increased from 4% in 2014 to 68% in 2020 and the percent with HCV viremia declined from nearly 100% to 33%. Predictors of treatment uptake varied across periods. Age (incidence rate ratio [IRR] per 5-year increase: 1.28; 95% confidence interval [CI]: 1.15, 1.42), educational attainment (IRR for ≥ high school diploma: 1.31; 95% CI: 1.04, 1.66), HIV coinfection with suppressed viral load (IRR vs. HIV negative: 2.08; 95% CI: 1.63, 2.66) and alcohol dependence (IRR vs. no alcohol use: 0.63; 95% CI: 0.43, 0.91) were associated with treatment uptake in the early period, but not later. HIV coinfection with a detectable viral load (IRR vs. HIV negative: 0.46; 95% CI: 0.23, 0.95) and daily injecting (IRR: 0.46 vs. no injection; 95% CI: 0.27, 0.79) were significantly associated with lower treatment uptake later. Homelessness was associated with significantly reduced likelihood of viral clearance in the late DAA era (IRR: 0.51; 95% CI: 0.30, 0.88). Conclusion: Treatment uptake improved substantially in this cohort of PWID in the first five years of DAA availability with commensurate declines in viremia. Additional efforts are needed to treat those actively injecting and unstably housed in order to realize elimination goals.

Prevalence and correlates of using opioids alone among individuals in a residential treatment program in Michigan: implications for overdose mortality prevention.

BACKGROUND: Avoiding use of opioids while alone reduces overdose fatality risk; however, drug use-related stigma may be a barrier to consistently using opioids in the presence of others. METHODS: We described the frequency of using opioids while alone among 241 people reporting daily heroin use or non-prescribed use of opioid analgesic medications (OAMs) in the month before attending a substance use disorder treatment program in the Midwestern USA. We investigated drug use-related stigma as a correlate of using opioids while alone frequently (very often vs. less frequently or never) and examined overdose risk behaviors associated with using opioids while alone frequently, adjusted for sociodemographic and clinical characteristics. RESULTS: The sample was a median age of 30 years, 34% female, 79% white, and nearly all (91%) had experienced an overdose. Approximately 63% had used OAMs and 70% used heroin while alone very often in the month before treatment. High levels of anticipated stigma were associated with using either opioid while alone very often (adjusted PR: 1.20, 95% CI: 1.04-1.38). Drinking alcohol and taking sedatives within two hours of OAMs very often (vs. less often or never) and using OAMs in a new setting very often (vs. less often or never) were associated with using OAMs while alone very often. Taking sedatives within two hours of using heroin and using heroin in a new setting very often (vs. less often or never) were associated with using heroin while alone very often. CONCLUSION: Anticipated stigma, polysubstance use, and use in a new setting were associated with using opioids while alone. These findings highlight a need for enhanced overdose harm reduction options, such as overdose detection services that can initiate an overdose response if needed. Addressing stigmatizing behaviors in communities may reduce anticipated stigma and support engagement and trust in these services.

Pilot testing a tool to determine the costs and time associated with community pharmacy-based administration of injectable naltrexone.

BACKGROUND: Medications for opioid use disorder (MOUD), including injectable naltrexone (IN), are part of evidence-based OUD treatments. MOUD access often is limited, especially in rural communities. When authorized to administer non-vaccination injections, pharmacists can increase IN accessibility. However, inadequate reimbursement for pharmacist-administered IN can hinder widespread adoption. OBJECTIVES: To pilot test a process to obtain a preliminary estimate of the total costs and time associated with community-pharmacist administered IN. METHODS: A purposively-selected sample of key informants at community pharmacies administering IN were surveyed about time and cost for best practice IN activities. Respondents estimated the time to perform activities and average pharmacist/pharmacy technician hourly salary, which were used to calculate administration costs. RESULTS: The approach to estimate time and costs was feasible. Administrative costs (mean = $93, range: $48-$164) and time (mean = 123 min., range: 63-220 min.) to administer IN varied widely. Pharmacists'/pharmacy technicians' roles varied by pharmacy. CONCLUSIONS: Pharmacists allocate significant time and resources to administer IN. Insufficient reimbursement may disincentivize pharmacy-involved OUD treatment and ultimately slow needed expansion of MOUD services. Increasing IN services requires engaging pharmacies to expand their practice through educational campaigns, along with a commitment to reimburse the cost of medications and related administration activities.

Trends in fatal and nonfatal overdose by race among people who inject drugs in Baltimore, Maryland from 1998 to 2019.

OBJECTIVE: The objective of this study was to examine trends in fatal and nonfatal overdose in a community-based sample of current and former people who inject drugs (PWID). METHODS: Data from 4826 current and former PWID from the AIDS Linked to the IntraVenous Experience (ALIVE) observational cohort study in Baltimore, Maryland, were used to characterize fatal and nonfatal overdose rates from 1998 to 2019. Poisson regression was used to examine factors associated with nonfatal overdose and differences by race among 1052 PWID between 2014 and 2019. RESULTS: Fatal overdose rates reached a high of 13 per 1000 person-years in 2018. Among 1052 current and former PWID, of whom 75% were Black and one-third were female, the nonfatal overdose rate of 529 per 1000 person-years in 2019 was 8 times higher than 2014 (incidence rate ratio [IRR]=7.76, 95% CI: 3.35, 18.0). The annual adjusted increase in nonfatal overdose rate was 53% among Black PWID (IRR=1.53, 95% CI: 1.34, 1.75), compared to 14% among White PWID (IRR=1.14, 95% CI: 0.88, 1.46). Urban residence, opioid use, depressive symptoms, and hepatitis C infection were positively associated with nonfatal overdose among Black PWID. Recent injection drug use and tranquilizer use was associated with increased overdose among Black and White PWID. CONCLUSIONS: Rates of fatal and nonfatal overdose were high and increased from 2014 to 2019 among current and former PWID, with the most dramatic increases in nonfatal overdose observed among Black PWID. These findings highlight the urgent need for additional resources to reduce the differential harms associated with opioids by race.

Opportunities to boost naloxone awareness among people who misuse opioid analgesics who have not used illegal opioids.

BACKGROUND: Increasing naloxone awareness and carrying among individuals who misuse opioid analgesic medications (OAs) could reduce opioid overdose mortality. Methods: Self-report surveys were completed by 322 adults receiving residential addiction treatment who misused OAs in the past year. Descriptive analyses and prevalence ratios (using Poisson generalized estimating equations) examined whether illegal opioid (e.g., heroin) initiation was associated with naloxone awareness. Results: Among this sample of participants who misused OAs, naloxone awareness was lowest among those who never used illegal opioids (26%) and highest among those who transitioned from OAs to illegal opioid use over time (83%). Naloxone awareness remained higher among participants who had used illegal opioids after adjustment for sociodemographic and substance use characteristics. Those who used OAs before initiating illegal opioids were 2.3-fold (95% CI: 1.5-3.3) more likely to have naloxone awareness than those who had only misused OAs after adjustment. Half of participants who had only used OAs had experienced an overdose, 75% had witnessed an overdose, and 61% were prescribed OAs to treat pain in the past 6 months. Conclusions: Implementing overdose education and naloxone distribution programs during addiction treatment could bolster naloxone awareness among people who misuse OAs but who have not used illegal opioids.

Opioid agonist and antagonist use and the gut microbiota: associations among people in addiction treatment.

Murine models suggest that opioids alter the gut microbiota, which may impact opioid tolerance and psychopathology. We examined how gut microbiota characteristics related to use of opioid agonists and antagonists among people receiving outpatient addiction treatment. Patients (n = 46) collected stool samples and were grouped by use of opioid agonists (heroin, prescription opioids), antagonists (naltrexone), agonist-antagonist combinations (buprenorphine-naloxone), or neither agonists nor antagonists within the month before enrollment. We sequenced the V4 region of the 16S rRNA gene using Illumina MiSeq to examine how alpha diversity, enterotypes, and relative abundance of bacterial genera varied by opioid agonist and antagonist exposures. Compared to 31 participants who used neither agonists nor antagonists, 5 participants who used opioid agonists (without antagonists) had lower microbiota diversity, Bacteroides enterotypes, and lower relative abundance of Roseburia, a butyrate producing genus, and Bilophila, a bile acid metabolizing genus. There were no differences in gut microbiota features between those using agonist + antagonists (n = 4), antagonists only (n = 6), and neither agonists nor antagonists. Similar to murine morphine exposure models, opioid agonist use was associated with lower microbiota diversity. Lower abundance of Roseburia and Bilophila may relate to the gut inflammation/permeability and dysregulated bile acid metabolism observed in opioid-exposed mice.

Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use.

Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.

Hepatitis C treatment uptake among people who inject drugs in the oral direct-acting antiviral era.

BACKGROUND: Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) will be critical to achieve HCV elimination goals. There are limited data on HCV treatment uptake among PWID recruited from community-based settings in the HCV direct-acting antiviral (DAA) era. METHODS: We analysed data from PWID with HCV newly recruited into the Baltimore, Maryland-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort between 2015 and 2018. We characterized the HCV care continuum and evaluated factors associated with HCV treatment uptake. RESULTS: Of the 418 PWID with HCV, the median age was 49 years and most (88%) reported recent injection drug use (IDU). Overall, 23% had ever been evaluated by a provider for HCV treatment, 17% ever initiated DAA treatment and 13% were cured of HCV infection. Treatment uptake approximately doubled between 2015 and 2018 (13% to 26%, P = .01). In multivariable analyses, HIV infection (adjusted Odds Ratio [aOR] 2.5 [95% Confidence Interval (CI) 1.3, 4.8]), current employment (aOR 4.1 [CI 1.2, 14.4]), having a primary care provider (aOR 4.3 [CI 1.2, 14.9) and longer duration of IDU (aOR 1.3 [CI 1.1, 1.6]) were positively associated with HCV treatment. PWID with a lower annual income (≤$5000) were less likely to have initiated HCV treatment (aOR 0.5 [CI 0.3, 0.98]). CONCLUSIONS: Although HCV treatment uptake among PWID in this community-based setting in the DAA era remains suboptimal, it is encouraging that treatment uptake has increased in recent years. Innovative strategies are needed to reach all PWID infected with HCV.

"When You're Getting High You Just Don't Want to Be Around Anybody." A Qualitative Exploration of Reasons for Injecting Alone: Perspectives from Young People Who Inject Drugs.

BACKGROUND: Rates of death from opioid overdose continue to rise in the United States. One harm reduction strategy designed to reduce fatal overdose risk among people who inject drugs (PWID) is an advisory to not use drugs alone. However, the feasibility and acceptability of this message have not been evaluated. Objectives: This paper explores the drug use practices of young PWID related to injecting alone and reasons for doing so. Methods: From 2015 to 2016, 23 in-depth interviews were completed in Baltimore, Maryland with young PWID. Participants were recruited through street/venue-based outreach and word of mouth. Inclusion criteria were 1) age 18-30 and 2) self-report injection drug use in past 6 months. Participants were asked about drug use history, overdose knowledge/experiences, and injection-related practices including when, where, and with whom drugs were injected. Results: Injecting drugs alone was common among members of this sample. Reasons for injecting alone included 1) the desire to alleviate withdrawal symptoms, 2) feelings of shame regarding one's drug use, 3) lack of knowledge about Good Samaritan Laws, 4) financial circumstances, and 5) a lack of trusted peers with whom to inject, often due to disrupted social networks. Conclusions: Young PWID inject alone for a variety of reasons, putting them at increased risk of fatal overdose. These findings demonstrate that "don't use alone" messages may not be sufficient given the complex realities of PWID's injection practices. Harm reduction programs employing such messaging should also offer alternative options for overdose prevention/risk reduction for those who do inject alone.

Links between suicidal intent, polysubstance use, and medical treatment after non-fatal opioid overdose.

BACKGROUND: Suicidal thinking during non-fatal overdose may elevate risk for future completed suicide or intentional overdose. Long-term outcomes following an intentional non-fatal overdose may be improved through specific intervention and prevention responses beyond those designed for unintentional overdoses, yet little research has assessed suicidal intent during overdoses or defined characteristics that differentiate these events from unintentional overdoses. METHODS: Patients with a history of opioid overdose (n = 274) receiving residential addiction treatment in the Midwestern United States completed self-report surveys to classify their most recent opioid overdose as unintentional, actively suicidal (wanted to die), or passively suicidal (didn't care about the risks). We characterized correlates of intent using descriptive statistics and prevalence ratios. We also examined how intent related to thoughts of self-harm at the time of addiction treatment. RESULTS: Of opioid overdoses, 51 % involved suicidal intent (44 % passive and 7 % active). Active suicidal intent was positively associated with hospitalization. Active/passive intent (vs. no intent, aPR: 2.2, 95 % CI: 1.4-3.5) and use of ≥5 substances (vs. 1 substance, aPR: 3.6, 95 % CI: 1.2-10.6) at the last opioid overdose were associated with having thoughts of self-harm or suicide in the 2 weeks before survey completion in adjusted models. Participants who reported active/passive intent more commonly used cocaine or crack (27 %) with opioids during their last overdose relative to unintentional overdoses (16 %). CONCLUSIONS: Over half of opioid overdoses among individuals in addiction treatment involved some degree of suicidal thinking. Identifying patients most at risk will facilitate better targeting of suicide prevention and monitoring services.

Fatal overdose prevention and experience with naloxone: A cross-sectional study from a community-based cohort of people who inject drugs in Baltimore, Maryland.

INTRODUCTION: Overdose is a leading cause of death in the United States, especially among people who inject drugs (PWID). Improving naloxone access and carrying among PWID may offset recent increases in overdose mortality associated with the influx of synthetic opioids in the drug market. This study characterized prevalence and correlates of several naloxone outcomes among PWID. METHODS: During 2018, a survey to assess experience with naloxone was administered to 915 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, an ongoing community-based observational cohort of people who currently inject or formerly injected drugs in Baltimore, Maryland. We examined the associations of naloxone outcomes (training, supply, use, and regular possession) with socio-demographic, substance use and healthcare utilization factors among PWID in order to characterize gaps in naloxone implementation among this high-risk population. RESULTS: Median age was 56 years, 34% were female, 85% were African American, and 31% recently injected. In the past six months, 46% (n = 421) reported receiving training in overdose prevention, 38% (n = 346) had received a supply of naloxone, 9% (n = 85) had administered naloxone, and 9% (n = 82) reported usually carrying a supply of naloxone. Recent non-fatal overdose was not associated with any naloxone outcomes in adjusted analysis. Active opioid use (aOR = 2.10, 95% CI: 1.03, 4.28) and recent treatment of alcohol or substance use disorder (aOR = 2.01, 95% CI: 1.13, 3.56) were associated with regularly carrying naloxone. CONCLUSION: Further work is needed to encourage PWID to carry and effectively use naloxone to decrease rates of fatal opioid overdose. While accessing treatment for substance use disorder was positively associated with carrying naloxone, EMS response to 911 calls for overdose, the emergency department, and syringe services programs may be settings in which naloxone access and carrying could be encouraged among PWID.

Injection drug use, unknown HIV positive status, and self-reported current PrEP use among Black men who have sex with men attending U.S. Black pride events, 2014-2017.

OBJECTIVE: Black gay, bisexual, and other men who have sex with men (BMSM) are at elevated risk for HIV infection in the United States. BMSM who inject drugs may be face even higher HIV risk. METHODS: Random time-location sampling was used to survey BMSM attending Black Pride events in 6 U.S. cities about HIV risk and protective behaviors, including injection drug use, prior HIV testing, and pre-exposure prophylaxis (PrEP). 3429 individuals who reported a HIV negative/unknown serostatus at enrollment were included in the analysis. HIV status was determined by in-field rapid HIV testing. RESULTS: 3.6% of BMSM had injected drugs in their lifetime and 58.5% of BMSM who had injected drugs reported sharing syringes in the past six months. BMSM who had injected drugs more commonly reported current PrEP use than BMSM who had never injected (32.5% vs. 8.2%, p < 0.001). BMSM who had injected drugs were 3.6-fold (95% CI: 2.4, 5.4) more likely to report currently using PrEP than BMSM who had never injected after adjustment for sociodemographic, substance use, and sexual risk characteristics. Among BMSM who reported ever injecting drugs (n = 123), 31.7% tested HIV positive. HIV prevalence did not differ by self-reported PrEP use among BMSM who had injected drugs (p = 0.59). CONCLUSIONS: BMSM who inject drugs who reported currently using PrEP were no less likely to test positive for HIV than those who did not use PrEP. Wrap-around services to support consistent PrEP use and long-acting PrEP formulations may improve the effectiveness of PrEP among BMSM who inject drugs.

More than just availability: Who has access and who administers take-home naloxone in Baltimore, MD.

BACKGROUND: Fatal opioid overdose is a pressing public health concern in the United States. Addressing barriers and augmenting facilitators to take-home naloxone (THN) access and administration could expand program reach in preventing fatal overdoses. METHODS: THN access (i.e., being prescribed or receiving THN) was assessed in a Baltimore, Maryland-based sample of 577 people who use opioids (PWUO) and had a history of injecting drugs. A sub-analysis examined correlates of THN administration among those with THN access and who witnessed an overdose (N = 345). Logistic generalized estimating equations with robust standard errors were used to identify facilitators and barriers to accessing and using THN. RESULTS: The majority of PWUO (66%) reported THN access. In the multivariable model, decreased THN access was associated with the fear that a person may become aggressive after being revived with THN (aOR: 0.55, 95% CI: 0.35-0.85), police threaten people at an overdose event (aOR: 0.68, 95% CI: 0.36-1.00), and insufficient overdose training (aOR: 0.43, 95% CI: 0.28-0.68). Enrollment in medication-assisted treatment, personally experiencing an overdose, and graduating from high school were associated with higher access. About half (49%) of PWUO with THN access and who had witnessed an overdose reported having administered THN. THN use was positively associated with "often" or "always" carrying THN (aOR: 3.47, 95% CI: 1.99-6.06), witnessing more overdoses (aOR:5.18, 95% CI: 2.22-12.07), experiencing recent homelessness, and injecting in the past year. THN use was reduced among participants who did not feel that they had sufficient overdose training (aOR: 0.56, 95% CI: 0.32-0.96). CONCLUSION: THN programs must bolster confidence in administering THN and address barriers to use, such as fear of a THN recipient becoming aggressive. Normative change around carrying THN is an important component in an overdose prevention strategy.

The Role of Drugs in Alcohol Poisoning and Blackout Events: A Latent Class Analysis of a Residential Treatment Sample.

BACKGROUND: Alcohol can lead to fatal and nonfatal overdose (OD) through its neurobiological inhibitory effects when used alone or with other drugs. Little research has examined alcohol OD characteristics in the context of concomitant drug use. METHODS: This study utilized alcohol OD data (defined as alcohol poisoning, passing out, or blacking out) collected in a large residential addiction treatment facility (N = 660). Latent class analysis identified classes of alcohol OD events based on concomitant drug use at the time of OD. We evaluated correlates of alcohol OD classes, including depression, emergency medical services, and hospitalization, using latent class regression. RESULTS: Only 20% of alcohol ODs involved alcohol alone. Marijuana was the most commonly used drug during the most recent alcohol OD (43.2%), followed by sedatives (27.9%), cocaine or crack (25.9%), prescription opioids (26.1%), and heroin (20%). The final latent class model included 3 classes: no/low drug involvement (61%), moderate drug involvement (33%), and high drug involvement (6%). Relative to the no/low drug involvement class, participants admitted to the hospital were 6.4-fold more likely to be in the high drug involvement class (95% CI: 2.4 to 16.6) and 2.9-fold more likely to be in the moderate drug involvement class (95% CI: 1.2 to 7.2). Participants receiving emergency medical services were more likely to be in the high drug involvement class (aOR: 2.2, 95% CI: 2.2, 1.1 to 4.5) and less likely to be in the moderate drug involvement class (aOR 0.39, 95% CI: 0.2 to 0.96). CONCLUSIONS: Combining drug classes with alcohol prior to OD was common and associated with a higher likelihood of hospitalization. Overdose prevention efforts should address acute risks of alcohol ingestion with other drugs.

Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment.

BACKGROUND: Persons in addiction treatment are likely to experience and/or witness drug overdoses following treatment and thus could benefit from overdose education and naloxone distribution (OEND) programs. Diverting individuals from the criminal justice system to addiction treatment represents one treatment engagement pathway, yet OEND needs among these individuals have not been fully described. METHODS: We characterized justice involvement patterns among 514 people who use opioids (PWUO) participating in a criminal justice diversion addiction treatment program during 2014-2016 using a gender-stratified latent class analysis. We described prevalence and correlates of naloxone knowledge using quasi-Poisson regression models with robust standard errors. RESULTS: Only 56% of participants correctly identified naloxone as an opioid overdose treatment despite that 68% had experienced an overdose and 79% had witnessed another person overdose. We identified two latent justice involvement classes: low involvement (20.3% of men, 46.5% of women), characterized by older age at first arrest, more past-year arrests, and less time incarcerated; and high involvement (79.7% of men, 53.5% of women), characterized by younger age at first arrest and more lifetime arrests and time incarcerated. Justice involvement was not associated with naloxone knowledge. Male participants who had personally overdosed more commonly identified naloxone as an overdose treatment after adjustment for age, race, education level, housing status, heroin use, and injection drug use (prevalence ratio [95% confidence interval]: men 1.5 [1.1-2.0]). CONCLUSIONS: All PWUO in criminal justice diversion programs could benefit from OEND given the high propensity to experience and witness overdoses and low naloxone knowledge across justice involvement backgrounds and genders.