Case Reports of Heroin Injection Site Necrosis: A Novel Antecedent of Nicolau Syndrome.

Heroin injection-site necrosis (HISN) is a novel and poorly understood complication of intravenous drug abuse (IVDA). We present three cases of HISN that were evaluated and treated in Charleston, West Virginia, in 2019 and 2020. The documented cases show similarities involving patient care, follow-up, clinical progression, patient demographic, and dermatologic sequelae. We discuss these similarities, provide clinical recommendations, review proposed etiologies of HISN, and introduce Nicolau syndrome as a potential mechanism.

Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study.

BACKGROUND: Heroin pipe distribution may encourage people who use heroin (PWUH) to transition from injecting to smoking heroin, reducing harms associated with injection drug use. A syringe services program (SSP) in Seattle, Washington, led by people who use drugs developed a heroin pipe distribution program. METHODS: We conducted a pretest-posttest quasi-experimental study to evaluate the impact of heroin pipe distribution on drug consumption behaviors among PWUH between March and December 2019. SSP clients were surveyed during three weeklong timepoints before and four weeklong timepoints after heroin pipe distribution. Primary outcomes were change in proportion of SSP clients who exclusively injected heroin, exclusively smoked heroin, and both injected and smoked heroin in the past seven days comparing the pre- and post-intervention periods. RESULTS: Across the seven observation timepoints, 694 unique respondents completed 957 surveys. Multiple responses from a single respondent in a given period were collapsed, resulting in 360 pre-intervention and 430 post-intervention records. Heroin use was reported in over half of pre-intervention (56%, 201/360) and post-intervention records (58%, 251/430). Compared to pre-intervention behaviors, the proportion of respondents who exclusively injected heroin was lower after the start of heroin pipe distribution (32%, 80/251 vs 43%, 86/201, p = 0.02), while the proportion of respondents who both injected and smoked heroin was higher (45%, 113/251 vs 36%, 72/201, p = 0.048). Just under half (44%, 110/251) of respondents who used heroin during the post-intervention period used a heroin pipe obtained from the SSP, of which 34% (37/110) reported heroin pipe distribution had reduced their heroin injection frequency. Self-reported hospitalization for a pulmonary cause was not associated with using a heroin pipe. CONCLUSIONS: The proportion of SSP clients who exclusively injected heroin was lower after implementation of heroin pipe distribution. Randomized studies with longer follow-up are needed to investigate whether heroin pipe distribution reduces heroin injection and improves health outcomes associated with drug use. Limited intervention exposure, loss to follow-up, and pipe availability from other sources pose methodological challenges to evaluations of route transition interventions in community settings. This pilot highlights the potential for organizations led by people who use drugs to develop, implement, and evaluate novel public health programming.

Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis.

The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.

Syringe services programs: An examination of legal, policy, and funding barriers in the midst of the evolving opioid crisis in the U.S.

BACKGROUND: Syringe Services Programs (SSPs) have been proposed as a key intervention to address increasing rates of opioid injection, overdose, and infectious disease transmission in the U.S. In recent years, multiple states and jurisdictions have enacted laws and policies to enable implementation of SSPs. These statutory and regulatory changes have resulted in the expansion of SSPs in a short period of time under a patchwork of different regulations and policies. Understanding how SSPs are responding to this evolving policy environment in the midst of a worsening opioid crisis can inform the development of strategies to maximize the role SSPs play in the response to the opioid crisis. METHODS: In-depth, semi-structured and audio-recorded interviews were conducted with 25 individuals running 23 SSPs in the U.S. A thematic content analysis was employed to identify and group themes across the domains of interest based on inductive and deductive coding of verbatim interview transcripts. RESULTS: Despite progress in expanding the number of SSPs in recent years, programs described encountering legal, policy, funding, and community barriers that are limiting the scope, scale, and reach of SSPs. To address these barriers, programs are employing multiple strategies to educate about and advocate for SSPs, engage policymakers and communities, combat pervasive stigma, strengthen funding, and reach at-risk populations. CONCLUSION: This qualitative study of a geographically diverse sample of SSPs provides key insights into the legal and policy barriers, funding challenges, and contextual factors impacting SSPs and the strategies programs are pursuing to counter these barriers. Coupling these strategies with policy changes that address the underlying legal and financial barriers and advancing efforts to combat stigma around drug use and addiction stand to substantially expand the role of SSPs as part of the public health response to the opioid crisis in the U.S.