Facilitators of and barriers to healthcare providers' adoption of harm reduction in cannabis use: a scoping review protocol.

INTRODUCTION: The high prevalence of cannabis use and the potential for negative effects indicate the need for effective prevention strategies and treatment of people who use cannabis. Studies show that harm reduction (HR) in cannabis use is effective in minimising the harmful consequences of the substance. However, health professionals often misunderstand it and resist its adoption due to various obstacles. To our knowledge, there has been no review of the scientific literature on the factors that facilitate or hinder practitioners' adoption of HR in cannabis use. To fill this gap, we aim to identify, through a scoping review, facilitators and barriers to healthcare providers' adoption of HR in cannabis use in Organisation for Economic Cooperation and Development (OECD) countries. METHODS AND ANALYSIS: Our methodology will be guided by the six-step model initially proposed by Arksey and O'Malley (2005). The search strategy will be executed on different databases (Medline, PsycINFO, CINAHL, Web of Science, Embase, Sociological Abstracts, Érudit, BASE, Google Web and Google Scholar) and will cover articles published between 1990 and October 2022. Empirical studies published in French or English in an OECD country and identifying factors that facilitate or hinder healthcare providers' adoption of HR in cannabis use, will be included. Reference lists of the selected articles as well as relevant systematic reviews will be scanned to identify any missed publications by the electronic searches. ETHICS AND DISSEMINATION: Ethics approval is not required. The results will be disseminated through various activities (eg, publication in peer-reviewed journals, conferences, webinars and knowledge translation activities). The results will also allow us to conduct a future study aiming to develop and implement a knowledge translation process among healthcare practitioners working with youth in Quebec in order to enhance their adoption of HR in cannabis use.

How do people who use opioids express their qualities and capacities? An assessment of attitudes, behaviors, and opportunities.

People who nonmedically use drugs (PWUD) face intricate social issues that suppress self-actualization, communal integration, and overall health and wellness. "Strengths-based" approaches, an under-used pedagogy and practice in addiction medicine, underscore the significance of identifying and recognizing the inherent and acquired skills, attributes, and capacities of PWUD. A strengths-based approach engenders client affirmation and improves their capacity to reduce drug use-related harms by leveraging existing capabilities. Exploring this paradigm, we conducted and analyzed interviews with 46 PWUD who were clients at syringe services programs in New York City and rural southern Illinois, two areas with elevated rates of opioid-related morbidity and mortality, to assess respondents' perceived strengths. We located two primary thematic modalities in which strengths-based ethos is expressed: individuals (1) being and advocate and resource for harm reduction knowledge and practices and (2) engaging in acts of continuous self-actualization. These dynamics demonstrate PWUD strengths populating and manifesting in complex ways that both affirm and challenge humanist and biomedical notions of individual agency, as PWUD refract enacted, anticipated, and perceived stigmas. In conclusion, programs that blend evidence-based, systems-level interventions on drug use stigma and disenfranchisement with meso and micro-level strengths-based interventions that affirm and leverage personal identity, decision-making capacity, and endemic knowledge may help disrupt health promotion cleavages among PWUD.

Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia.

INTRODUCTION: Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia. METHODS AND ANALYSIS: KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness. ETHICS AND DISSEMINATION: The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings. TRIAL REGISTRATION NUMBER: NCT05657106.

Safe inhalation pipe provision (SIPP): protocol for a mixed-method evaluation of an intervention to improve health outcomes and service engagement among people who use crack cocaine in England.

BACKGROUND: Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact. METHODS: The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms. ANTICIPATED IMPACT: SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally. CONCLUSION: People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform. TRIAL REGISTRATION: ISRCTN12541454  https://doi.org/10.1186/ISRCTN12541454.

Elucidating Harm Reduction Principles in a Client-Centered Representative Payee Program.

Harm Reduction seeks to mitigate harms associated with health behaviors without the expectation that these behaviors be extinguished completely. Client-Centered Representative Payee (CCRP) is an intervention that modifies the US Social Security Administration's (SSA) Representative Payee policy by incorporating relational harm reduction. We used Human-Centered Design (HCD) methods to elucidate ways that harm reduction principles are present in and integral to CCRP and to create a blueprint for replication. Thirteen individuals familiar with CCRP brainstormed 88 statements, which were parsed, consolidated, and then independently assigned by a subgroup of participants to six principles of harm reduction. After refining the data, 29 statements aligning with harm reduction principles remained. Delineating harm reduction within CCRP, which can empower and establish trust with clients, may help other providers identify how to offer representative payee services that are respectful, compassionate, rooted in harm reduction, and ultimately improve client outcomes.

Supervised Inhalation Sites: Preventing Overdose and Reducing Health Inequities among People Who Use Drugs.

Policy and research on the implementation of services for people who inhale drugs lag behind similar efforts for people who inject drugs, limiting access to adequate harm reduction resources for people who inhale drugs. This commentary considers why supervised inhalation sites (SIS) are needed, highlights operational characteristics of four existing services, and advocates for future SIS research. Our hope is to encourage the expansion of SIS worldwide for overdose prevention and reduction of health inequities. Given the limited literature regarding SIS, more extensive study of these programs is warranted to incorporate inhalation into the implementation of supervised consumption sites to provide fair opportunities for all people who use drugs to do so safely without fear of stigma and overdose.

Prosecutorial Discretion for Self-Managed Abortion Helpers.

Elected prosecutors have pledged not to enforce abortion laws, in response to state-level abortion bans. For their pledges to be meaningful, prosecutors must exercise their discretion in cases of individuals who face legal risk, including people who help others self-manage their abortions. With a harm-reduction approach to improving abortion access, prosecutors should aim to reduce abortion helpers' involvement with the criminal justice system.

Gambling, cryptocurrency, and financial trading app marketing in English Premier League football: A frequency analysis of in-game logos.

Background & aims: The gamblification of UK football has resulted in a proliferation of in-game marketing associated with gambling and gambling-like products such as cryptocurrencies and financial trading apps. The English Premier League (EPL) has in response banned gambling logos on shirt-fronts from 2026 onward. This ban does not affect other types of marketing for gambling (e.g., sleeves and pitch-side hoardings), nor gambling-like products. This study therefore aimed to assess the ban's implied overall reduction of different types of marketing exposure. Methods: We performed a frequency analysis of logos associated with gambling, cryptocurrency, and financial trading across 10 broadcasts from the 2022/23 EPL season. For each relevant logo, we coded: the marketed product, associated brand, number of individual logos, logo location, logo duration, and whether harm-reduction content was present. Results: There were 20,941 relevant logos across the 10 broadcasts, of which 13,427 (64.1%) were for gambling only, 2,236 (10.7%) were for both gambling and cryptocurrency, 2,014 (9.6%) were for cryptocurrency only, 2,068 (9.9%) were for both cryptocurrency and financial trading, and 1,196 (5.7%) were for financial trading only. There were 1,075 shirt-front gambling-associated logos, representing 6.9% of all gambling-associated logos, and 5.1% of all logos combined. Pitch-side hoardings were the most frequent marketing location (52.3%), and 3.4% of logos contained harm-reduction content. Discussion & Conclusions: Brand logos associated with gambling, cryptocurrency, and financial trading are common within EPL broadcasts. Approximately 1 in 20 gambling and gambling-like logos are subject to the EPL's voluntary ban on shirt-front gambling sponsorship.

Costing analysis of a point-of-care drug checking program in Rhode Island.

BACKGROUND: Drug checking is a harm reduction strategy that provides greater awareness and information about the drug supply to the community. While fentanyl test strips are low-cost and available in most parts of the U.S., community-based organizations are considering using more sophisticated technologies, such as Fourier-transform infrared (FTIR) spectroscopy to test drugs. FTIR can detect multiple substances in a non-destructive manner that can be rapidly communicated to the program client by a trained technician, however implementation costs in community-based settings have not been assessed. METHODS: We conducted a costing analysis of a new pilot drug checking service that employed an FTIR spectrometer, fentanyl test strips and confirmatory testing in Rhode Island from January 2023-May 2023. We used microcosting methods to determine the overall cost during this period and cost per drug checked, reflecting realistic service capacity. RESULTS: Among 101 drug samples that were voluntarily submitted and tested, 53% tested positive for fentanyl, 39% for cocaine, 9% for methamphetamine and 13% for xylazine, a powerful sedative. The total cost during this period was $71,044 and the cost per drug checked was $474, though sensitivity analyses indicated that the cost would rise to $78,058 - $83,058 or $544 - $593 for programs needing to pay for specialized training. CONCLUSIONS: These findings demonstrate feasibility and inform the resources needed to scale-up drug checking services to reduce overdose risk.

A qualitative assessment of key considerations for drug checking service implementation.

BACKGROUND: With many drug-related deaths driven by potent synthetic opioids tainting the illicit drug supply, drug checking services are becoming a key harm reduction strategy. Many drug checking technologies are available, ranging from fentanyl test strips to mass spectrometry. This study aimed to identify key considerations when implementing drug checking technologies and services to support harm reduction initiatives. METHODS: Key informant interviews were conducted with harm reduction stakeholders throughout Illinois. Participants included members of existing drug checking services and recovery centers. Interviews were recorded, transcribed, and coded by two researchers using the framework method. Findings were contextualized according to micro (client)-, meso (organization)-, and macro (policy)-level themes. RESULTS: Seven interviews were conducted with ten participants. Fourier transform infrared spectroscopy was consistently identified as a technology of choice given its accuracy, range of substance detection, portability, and usability. Recommendations included the use of confirmatory testing, which can help address the limitations of technologies and provide a mechanism to train technicians. Locations of drug checking services should maximize public health outreach and leverage existing harm reduction agencies and staff with lived experience, who are critical to developing trust and rapport with clients. Criminalization and loss of privacy were major concerns for clients using drug checking services. Additional issues included the need to raise awareness of the legitimacy of services through public support from governing bodies, and funding to ensure the sustainability of drug checking services. CONCLUSIONS: This research facilitated the identification of issues and recommendations from stakeholders around key considerations for the adoption of drug checking technologies, which not only included the cost and technical specifications of instrumentation, but also broader issues such as accessibility, privacy, and well-trained personnel trusted by clients of the service. Successful implementation of drug checking services requires knowledge of local needs and capacity and an in-depth understanding of the target population.

Community-level determinants of stakeholder perceptions of community stigma toward people with opioid use disorders, harm reduction services and treatment in the HEALing Communities Study.

BACKGROUND: Community stigma toward people with opioid use disorder (OUD) can impede access to harm reduction services and treatment with medications for opioid use disorder (MOUD). Such community OUD stigma is partially rooted in community-level social and economic conditions, yet there remains a paucity of large-scale quantitative data examining community-level factors associated with OUD stigma. We examined whether rurality, social inequity, and racialized segregation across communities from four states in the HEALing Communities Study (HCS) were associated with 1) greater perceived community stigma toward people treated for OUD, 2) greater perceived intervention stigma toward MOUD, and 3) greater perceived intervention stigma toward naloxone by community stakeholders in the HCS. METHODS: From November 2019-January 2020, a cross-sectional survey about community OUD stigma was administered to 801 members of opioid overdose prevention coalitions across 66 communities in four states prior to the start of HCS intervention activities. Bivariate analyses assessed pairwise associations between community rural/urban status and each of the three stigma variables, using linear mixed effect modeling to account for response clustering within communities, state, and respondent sociodemographic characteristics. We conducted similar bivariate analyses to assess pairwise associations between racialized segregation and social inequity. RESULTS: On average, the perceived community OUD stigma scale score of stakeholders from rural communities was 4% higher (ß=1.57, SE=0.7, p≤0.05), stigma toward MOUD was 6% higher (ß=0.28, SE=0.1, p≤0.05), and stigma toward naloxone was 10% higher (ß=0.46, SE=0.1, p≤0.01) than among stakeholders from urban communities. No significant differences in the three stigma variables were found among communities based on racialized segregation or social inequity. CONCLUSION: Perceived community stigma toward people treated for OUD, MOUD, and naloxone was higher among stakeholders in rural communities than in urban communities. Findings suggest that interventions and policies to reduce community-level stigma, particularly in rural areas, are warranted.

Corporate Harm Minimisation: Promises and Perils Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019".

Taxes on sugary drinks are often used to encourage companies to reformulate their products to reduce the sugar content. This comment discusses how product reformulation can strengthen the market and political power of the food industry, and questions whether these political risks outweigh the public health benefits. It proposes the term 'corporate harm minimisation' to describe the strategic adaptation of a public health harm reduction strategy to align with company or industry goals. It concludes by reflecting on the other ways that corporations influence health beyond the production and marketing of 'unhealthy commodities,' and why public health actors must explore other strategies to challenge powerful corporations.

Nursing harm reduction education and care for people who use drugs or who engage in sex work.

Harm reduction is an evidence-based approach that could promote health equity through the implementation of pragmatic strategies for people who use drugs or who engage in sex work. The purposes of this study were to describe whether nurses received harm reduction education in their nursing programs, whether nurses are practicing harm reduction, and strategies for integrating harm reduction within nursing curriculum. An online survey was delivered to nurses and an interview with a nurse harm reductionist was conducted. Among the 30 survey participants, only 17% (n = 5) stated they were taught about harm reduction in their nursing programs. On average, survey participants practiced harm reduction less than "half of the time" by meeting people where they are in their drug use or sex work. The nurse harm reductionist described how harm reduction should be taught as a skillset for evidence-based nursing practice. By incorporating harm reduction principles into nursing education and nursing practice, nurses can provide competent care for people who use drugs or who engage in sex work.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs.

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Transdisciplinary pragmatic melioration for the plastic life cycle: Why the social, natural, and technical sciences should prioritize reducing harm.

Plastics underpin modern society but also threaten to choke it. Only 9 % of all plastic waste is recycled, usually with loss of quality ("downcycling"); the rest is landfilled or dumped (79 %) or incinerated (12 %). Put bluntly, the "plastic age" needs a "sustainable plastic culture." Consequently, we urgently need to develop a global and transdisciplinary approach not only to fully recycle plastics but also to manage the harms across their life cycle. The past decade has witnessed an explosion in research on new technologies and interventions that purport to help solve the plastic waste challenge; however, this work has, in most cases, been carried forward within single disciplines (for example, researching novel chemical and bio-based technologies for plastic degradation, engineering processing equipment innovations, and mapping recycling behaviours). In particular, although there has been vast progress within individual scientific fields, such work does not address the complexities of various plastic types and waste management systems. Meanwhile, research on the social contexts (and constraints) of plastic use and disposal is rarely in conversation with the sciences to drive innovation. In short, research on plastics typically lacks a transdisciplinary perspective. In this review, we urge the adoption of a transdisciplinary approach that focuses on pragmatic melioration; such an approach combines the natural and technical sciences with the social sciences to focus on the mitigation of harms across the plastic life cycle. To illustrate our case, we review the status of plastic recycling from these three scientific perspectives. Based on this, we advocate 1) foundational studies to identify sources of harm and 2) global/local interventions aimed at those plastics and aspects of the plastic life cycle that cause maximal harm, both in terms of planetary welfare and social justice. We believe this approach to plastic stewardship can be a showcase for tackling other environmental challenges.

Experiências de pessoas em situação de rua com o uso de substâncias psicoativas: um estudo no contexto do Distrito Federal / Experiences of homeless people with use of psychoactive substances: a study in the context of federal distric / experiencias de personas en situación de calle con el uso de sustancias psicoactivas: un estudio en el contexto del distrito federal

Investigou-se vivências de pessoas em situação de rua que usam/usaram substâncias psicoativas, a partir de um programa de reinserção social e geração de renda, no Distrito Federal. Trata-se de estudo realizado com quatro adultos a partir de entrevistas semiestruturadas. As informações foram analisadas pela Análise de Conteúdo, gerando as categorias: caracterização do uso de substâncias psicoativas; experiência com programas para usuários de álcool e outras drogas; história de vida e a situação de rua; projeto social e uso de substâncias psicoativas. Como resultados, evidenciou-se como os participantes se relacionam com substâncias psicoativas, como o projeto social investigado se configura como potencializador para transformação de vidas. Conclui-se que a história de vida dos sujeitos está ligada à situação de rua e uso de substâncias psicoativas, destacando-se o potencial transformador de programas sociais, possibilitadores de desenvolvimento econômico e social, e que modelos baseados em abstinência se mostraram ineficazes como forma de tratamento. (AU)

The experiences of homeless people who use/have used psychoactive substances were investigated, based on a program of social reintegrationand income generation, in the Federal District. This is a study carried out with four adults through semi-structured interviews. The information was analyzed by Content Analysis, generating the following categories: characterization of the use of psychoactive substances; experience with programs for users of alcohol and other drugs; life history and the street situation; social project and use of psychoactive substances. As a result, it was evidenced how the participants relate to psychoactive substances, how the investigated social project is configured as a potentiator for the transformation of lives. It is concluded that the life history of the subjects is linked to the homeless situation and the use of psychoactive substances, highlighting the transforming potential of social programs, enabling economic and social development, and that models based on abstinence proved to be ineffective as a way to of treatment. (AU)

Se indagaron las experiencias de personas en situación de calle que consumen/han utilizado sustancias psicoactivas, a partir de un programa de reinserción social y generación de ingresos, en el Distrito Federal. Se trata de un estudio realizado con cuatro adultos a través de entrevistas semiestructuradas. La información fue analizada por Análisis de Contenido, generando las siguientes categorías: caracterización del uso de sustancias psicoactivas; experiencia con programas para usuarios de alcohol y otras drogas; historia de vida y situación de la calle; proyecto social y consumo de sustancias psicoactivas. Como resultado, se evidenció cómo los participantes se relacionan con las sustancias psicoactivas, cómo el proyecto social investigado se configura como un potenciador para la transformación de vidas. Se concluye que la historia de vida de los sujetos está vinculada a la situación de calle y al uso de sustancias psicoactivas, destacando el potencial transformador de los programas sociales, viabilizando el desarrollo económico y social, y que los modelos basados en la abstinencia demostraron ser ineficaces como vía de tratamiento. (AU)