Using virtual reality technology to prevent substance misuse and violence among university students: A pilot and feasibility study.

Objectives: New prevention approaches that use engaging and innovative technologies are needed to reduce high rates of substance use and violence among university students. The present study developed and pilot-tested virtual reality (VR) technology that presented university students with immersive environments where they practiced skills with virtual peers. Methods: After viewing e-learning modules with prevention content, students engaged with immersive VR module prototypes to practice cognitive-behavioral skills for preventing risk behaviors, including assertive communication, negotiation, compromise, conflict resolution, and bystander intervention strategies. Results: Paired t-tests showed increases in life skills knowledge and anti-violence attitudes among students from the pretest to posttest assessments. Students and educators were enthusiastic about the VR prototypes, rating them as feasible, relevant, appealing, engaging, and innovative for prevention. Participants provided feedback on ways to improve the VR experience by including a greater variety of conflict situations, more nuanced branched scenarios and response options, and a more complete representation of all scenario outcomes. Conclusions: Findings suggest that VR scenarios are a promising strategy for enhancing life skills to help prevent health risk behaviors among university students.

Europe must continue to lead on harm reduction.

Europe has been at the forefront of harm reduction since its inception. These important early steps were in large part a response to the dramatically expanding HIV epidemic, and investing in these innovative interventions early and robustly had a transformative effect. This brought about not just pioneering services but also pioneering policy changes. However, while Western Europe and Member States in the European Union often have been at the vanguard of harm reduction innovation and vocal advocates for public health and human rights-based drug policy reform, the situation has been much different in the "wider" WHO European region, which also includes Eastern and Southeastern Europe as well as Central Asia. This is a result not just of limited budgets for health, but also of punitive laws and policies and persistent stigma and discrimination. Even as harm reduction has demonstrated huge successes in Europe, there is a need to move forward a wider array of services to respond to an evolving and increasingly complex drug situation in Europe. Instead, it is a lack of political will and of political courage that is holding back the establishment, expansion, and deepening of these essential, lifesaving interventions. Responding proactively and effectively to this changing drug situation will require redoubled investment in public health and harm reduction approaches.

Opportunities and challenges for implementing drug checking services in British Columbia, Canada: A qualitative study.

BACKGROUND: Amidst the ongoing drug poisoning crisis across North America, drug checking services (DCS) are increasingly being implemented as an intervention intended to reduce drug-related harms. This study sought to identify key opportunities and challenges influencing the implementation of DCS in British Columbia (BC), Canada. METHODS: Between January 2020 and July 2021, semi-structured, in-depth interviews were conducted with 21 individuals involved in the implementation of DCS across BC (i.e., policymakers, health authority personnel, community organization representatives and service providers). The Consolidated Framework for Implementation Research (CFIR) was used to guide coding and analysis of the interviews. RESULTS: By bringing in a wealth of knowledge about community needs and concerns, in addition to a passion and energy for social justice and health equity, community members and organizations with a dedication for harm reduction played a critical role in the successful implementation of DCS in BC. Other significant facilitators to implementation included the preventive benefits of DCS that made the intervention compelling to policy influencers and decision makers, the provincial public health emergency regarding overdose that shifted the regulatory environment of DCS, the adaptability of DCS to meet concerns and needs in various contexts, including via ongoing processes of reflection and evaluation. Barriers to implementation included criminalization and stigmatization of drug use and people who use drugs and lack of funding for community-led implementation actions. CONCLUSIONS: Alongside structural reforms that address the underlying contextual factors that influence implementation (e.g., decriminalization of drugs, increased funding for DCS), centering community expertise throughout implementation is critical to the success of DCS. Our findings provide important insights into how BC can successfully implement systems-level harm reduction interventions and offer insights for other jurisdictions in their implementation of DCS.

Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis.

BACKGROUND: Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes. METHODS: In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses. FINDINGS: We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing. INTERPRETATION: There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release. FUNDING: Australian National Health and Medical Research Council.

Reframing Dutch drug policies: a new era for harm reduction.

In this article the authors offer their perspective on the changes in the Dutch harm reduction field. From the 1970s to the 1990s, the Netherlands emerged as a leader in harm reduction services, driven by grassroots movements like the Medisch-sociale Dienst Heroïne Gebruikers (MDHG) (Medisch-sociale Dienst Heroïne Gebruikers (MDHG) translates to Medical-Social Service Heroin Users in English) in Amsterdam and Junkiebond in Rotterdam. These organisations advocated for health-centred policies, initiated needle exchange programmes, and created safe consumption spaces. Their efforts led to significant public health improvements and policy shifts towards harm reduction, reducing HIV and hepatitis rates among people who use drugs. By the 1980s, harm reduction became institutionalised within local health and social care systems, leading to notable declines in drug-related harm and crime. However, from the 2000s, a shift towards security and crime prevention emerged, influenced by socio-political changes. Increased criminal justice measures and budget cuts for harm reduction services strained the system, making it harder to address emerging drug trends and the complex needs of people who use drugs. Despite challenges, there is renewed momentum for reform, particularly at the local level, advocating for the responsible regulation of psychoactive substances. Amsterdam Mayor Femke Halsema's 2024 conference on drug regulation exemplifies this shift, calling for policies that address prohibition failures and centre harm reduction. International bodies like the UN High Commissioner for Human Rights support this approach, emphasising a health and rights-based framework. As the Netherlands navigates these evolving dynamics, there is a pressing need to reinvest in harm reduction infrastructure, ensuring it meets diverse community needs and reaffirms its foundational rights-affirming principles.

Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review.

ISSUES: Overdose prevention centres (OPC) are non-residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work. APPROACH: We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs. KEY FINDINGS: Our retroductive analysis identified a causal pathway that highlights the feeling of safety - and the immediate outcome of not dying - as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can - depending on the contexts in which they operate - generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection-related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities. CONCLUSIONS: OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions.

Risk and protective factors of youth crime: An umbrella review of systematic reviews and meta-analyses.

INTRODUCTION: Several systematic reviews and meta-analyses have been conducted on the risk and protective factors of youth crime. This study aims to consolidate this evidence using an umbrella review methodology. METHODS: A systematic electronic search was conducted using multiple electronic databases. Strength of associations was evaluated using quantitative umbrella review criteria, and AMSTAR was used to assess the quality of the studies. RESULTS: Among the 58 factors identified, 11 factors were supported by highly suggestive or suggestive evidence. Evidence of association was highly suggestive (class II) for substance use (odds ratio [OR] = 2·29, 95%CI 1·58-3.01), previous history of crime (OR = 2·03, 95%CI 1·62-2·45), moral development (OR = 3·98, 95%CI 3·57-4·39), psychopathology (OR = 2·22, 95%CI 1.40-2.69), adverse childhood experiences (OR = 1·37, 95%CI = 1·36-1·38), poor parental supervision (OR = 1·85, 95%CI 1·83-1·87), maltreatment or neglect (OR = 1·34, 95%CI 1·08-1·65), attachment (OR = 1·94; 95%CI 1.93-1·95), and school bullying (OR = 2·50; 95%CI 2·03-3·08); and suggestive (class III) for peer pressure (OR = 2·11, 95%CI 2·06-2·16) and supportive school environments (OR = 0·56; 95%CI 0·55-0·57). CONCLUSION: The evidence-based atlas of key risk and protective factors identified in this umbrella review could be used as a benchmark for advancing research, prevention, and early intervention strategies for youth crime.

Essential/precursor chemical control research: Giommoni's review, understanding multi-replication interrupted time series analysis, and next steps.

Controls on essential/precursor chemicals from commercial companies have been associated with many large downturns in illicit drug markets and attendant problems. My colleagues and I brought this to light in the studies that are the subject of Giommoni's review. McKetin et al. in an earlier review considered several of our studies on chemical controls for methamphetamine, all centered in North America. Giommoni discusses not only those studies but also our later work on chemical controls for cocaine and heroin. This later work evaluates US essential/precursor chemical policies targeting illicit drug producers outside of North America, and it examines impacts on illicit drug availability and use (the studies reviewed by McKetin et al. predominantly focused on outcomes such as drug-related hospitalizations, arrests, and treatment). Giommoni's review is a new resource that will help make the varied topics in essential/precursor chemical control research more accessible to many readers. After noting this, I discuss some common methodological misconceptions about our studies. For example, our studies generally used multi-replication interrupted time series analysis, a research design among the most powerful of all quasi-experimental designs. Authors, however, typically discuss the studies as if they used single-intervention interrupted time series analysis, a less powerful design. Multi-replication and single-intervention interrupted time series analyses also differ regarding likely confounders; awareness of this is critical to accurately assessing our findings and critiquing alternative explanations. Finally, I note that commercial chemical companies function as the silent, albeit usually unwitting, partners in the large-scale production of several illicit drugs, including fentanyl. And many governments are implementing essential/precursor chemical controls to help stymie this partnership. But they are doing so largely without evaluation and study-a poor policy practice. To remedy this, I suggest establishing multi-disciplinary applied research teams to help assess, guide and improve essential/precursor chemical control efforts.

A case study of the DULF compassion club and fulfillment centre-A logical step forward in harm reduction.

In 2022, the Drug User Liberation Front's Compassion Club and Fulfillment Centre emerged as a groundbreaking initiative and research endeavor aimed at addressing the alarming rise in overdose deaths within Vancouver's Downtown Eastside. As the first of its kind, this pioneering model operated as a non-profit, low-barrier, and non-medicalized approach to regulating the volatility of the content of the illicit drug market in order to prevent overdose deaths. Going beyond traditional overdose prevention methods, the Drug User Liberation Front's Compassion Club and Fulfillment Centre not only provided supervised consumption services, but also supplied rigorously tested cocaine, heroin, and methamphetamine at cost to club members. This intrinsic case study offers a unique perspective on the operation of Drug User Liberation Front's Compassion Club and Fulfillment Centre, delving into its inception, development, implementation, and the challenges it faced in its operation. Ultimately, the insights garnered from the Drug User Liberation Front's Compassion Club and Fulfillment Centre hold significant value for others interested in establishing similar programs or exploring de-medicalized approaches regulating substances in order to prevent overdose deaths.

[The characteristics of prevention of drug addiction and narcotism in municipal formation of city of Novorossiysk].

The drug addiction is one of most serious deviant behavior seriously harming both addict person and one's relationship. The drug using is considered as deviant because means using substances from non-legal turn-over or applied in non-medical purposes. Then follows degradation of health of person and one's positioning into physical and mental dependence on them. With time, personal dependence on drugs becomes stronger. The addicted person looses possibility to experience joy from natural stimuli and more difficulties in controlling drug using appear. Persons using drugs frequently commit crimes to have money to maintain one's dependence. Therefore, issues of prevention narcotism and struggle with drug addiction are fundamental ones for whole system of prevention in Novorossiysk. The article presents analysis of implemented activities and adopted measures of struggle with drug addiction in population of Novorossiysk.

Can mind-altering prescription medicines be safe? Lessons from ketamine and esketamine.

INTRODUCTION: Recent decades have witnessed an extraordinary global crisis of drug misuse. Although opioid analgesics receive the most attention, numerous other drugs have increased rates of misuse. KETAMINE AND ESKETAMINE: Ketamine and esketamine offer a unique natural experiment to explore two medications that are similar pharmacologically but differ in their availability to users and in their regulation by government agencies. MISUSE AND ABUSE OF KETAMINE AND ESKETAMINE: Multisystem "mosaic" surveillance of many drugs using real-world data has emerged in recent years. Ketamine and esketamine have been monitored concurrently. Ketamine is much more widely available than esketamine and shows clear signs of increasing misuse and abuse. In contrast, esketamine is difficult to detect in postmarket surveillance even though availability is increasing. DISCUSSION: Ketamine and esketamine offer insights regarding the safety of prescription medications with the potential for misuse. Since the pharmacology of ketamine and esketamine are similar, the regulatory apparatus may be the primary difference that limits misuse. Ketamine has few restrictions and can be prescribed or administered by many healthcare providers, and is available as an illicit drug. In contrast, the product labeling for esketamine has rigorous restrictions on its use. Many important issues remain to be addressed. We need a more rigorous evaluation of the natural experiment of ketamine and esketamine. How does this experience relate to the introduction of new psychedelics? CONCLUSIONS: Ketamine misuse use and misuse are increasing while esketamine use in increasing, but misuse is not increasing. It is reasonable to reevaluate the regulatory controls on ketamine to reduce its misuse and abuse.

Leveraging A Digital Pill System to Understand Prevention-Effective Adherence to Oral Hiv Pre-Exposure Prophylaxis Among Men Who Have Sex with Men with Substance Use.

Daily oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, though efficacy depends on adherence. Digital pill systems (DPS) can enable direct, real-time adherence measurement. HIV-negative men who have sex with men (MSM) with substance use (excluding alcohol) utilized a DPS over 90 days and completed weekly surveys reporting sexual activity, condom use, and substance use. Responses indicating (1) any sexual activity and substance use or (2) condomless anal intercourse (CAI) in the prior week were categorized as high risk for HIV acquisition. PrEP adherence data for the 7-day period preceding each response was dichotomized as ≤ 3 and ≥ 4 doses/week, indicating prevention-effective adherence, and compared by HIV risk level. Thirteen MSM were analyzed (median age: 32). Of 113 surveys, 48.7% indicated high HIV risk, with 12.4% reporting CAI alone, 16.8% any sexual activity and substance use, and 19.5% both CAI and substance use. Weekly mean PrEP adherence was 90.3% (6.3 of 7 doses/week), with ≥ 4 doses/week recorded during 92.0% of weeks. The proportion of participants with ≥ 4 recorded doses/week was 88.9% during weeks with CAI alone, 89.5% during weeks with any sexual activity and substance use, 92.0% during weeks with both CAI and substance use, and 92.8% during lower risk weeks. Participants ingested ≥ 4 doses/week during 89.1% of all high-risk weeks and 94.8% of low-risk weeks. Overall, participants maintained high levels of PrEP adherence while engaging in HIV risk behaviors. DPS can be deployed concurrently with data collection tools to assess ingestion patterns during periods of elevated risk.

Sustainability of an intervention for the prevention of substance use within Native American communities.

The outcomes of this study revealed the importance of recruiting local Native American tribal community members as participants in an Adult Facilitator Trainee Program for a cultural based intervention, Intertribal Talking Circle (ITC), that addresses prevention of substance use among Native American youth. Survey results indicate that Native-Reliance (cultural identity) and self-efficacy increased among the trainees from base-line to 3-months post the training session. Themes emerged from qualitative interviews conducted with the participants that described their readiness to implement and sustain the Talking Circle intervention program within their tribal communities after the research project was completed.

"What I should be doing is harm reduction, if I'm doing my job right": Engagement with harm reduction principles among prosecutors enacting drug policy reform in the United States.

BACKGROUND: Prosecutorial discretion to pursue or decline criminal charges is a powerful mechanism determining criminal justice outcomes among people who use drugs (PWUD). In the US, prosecutors are increasingly employing this tool to prevent arrest, incarceration, and subsequent health and social harms among PWUD. Many cite harm reduction as a basis for these reforms; however, the extent of prosecutors' knowledge and understanding of harm reduction principles, and how they are operationalized in the policy process, remains unclear. METHODS: We assess references to and application of harm reduction in the policy design and implementation process of prosecutorial drug policy reform in 14 US jurisdictions. In-depth-interviews (N = 16) were conducted with elected prosecutors and their policy staff from November 2021-April 2022. Through initial structured analysis, policymakers' understanding and utilization of the term 'harm reduction' emerged as a salient theme which we conducted secondary thematic analysis to further explore. RESULTS: While all participants identified as progressive, there was wide variation in their ideologies, policy provisions, and engagement with harm reduction principles. Eleven participants explicitly referred to 'reducing harms of drug use' or 'harm reduction' as guiding their policy approach; the remainder did not invoke 'harm reduction' by name but highlighted relevant concepts like racial equity and 'public health approaches' as core policy tenets. While some prosecutors demonstrated familiarity with traditional harm reduction principles (meeting PWUD where they are, reducing harms to them), others focused on harm to the wider community (the 'public,' businesses, etc). Invocation of harm reduction was not always consistent with specific policy provisions: prosecutors implemented policies ranging from unconditional non-prosecution of drug possession to diversion, some of which were odds with core harm reduction principles of dignity and justice (i.e., involving coercive treatment incentives/requirements). CONCLUSIONS: As prosecutors shift their approach to redress the harms caused by drug criminalization, clarity is needed on what a harm reduction approach to using discretionary powers entails. Targeting reform-minded prosecutors with messaging on the principles, evidence base, and best practices of harm reduction is merited.

Mobile App Intervention to Reduce Substance Use, Gambling, and Digital Media Use in Vocational School Students: Exploratory Analysis of the Intervention Arm of a Randomized Controlled Trial.

BACKGROUND: During adolescence, substance use and digital media exposure usually peak and can become major health risks. Prevention activities are mainly implemented in the regular school setting, and youth outside this system are not reached. A mobile app ("Meine Zeit ohne") has been developed specifically for vocational students and encourages participants to voluntarily reduce or abstain from a self-chosen addictive behavior including the use of a substance, gambling, or a media-related habit such as gaming or social media use for 2 weeks. Results from a randomized study indicate a significant impact on health-promoting behavior change after using the app. This exploratory study focuses on the intervention arm of this study, focusing on acceptance and differential effectiveness. OBJECTIVE: The aims of this study were (1) to examine the characteristics of participants who used the app, (2) to explore the effectiveness of the mobile intervention depending on how the app was used and depending on participants' characteristics, and (3) to study how variations in app use were related to participants' baseline characteristics. METHODS: Log data from study participants in the intervention group were analyzed including the frequency of app use (in days), selection of a specific challenge, and personal relevance (ie, the user was above a predefined risk score for a certain addictive behavior) of challenge selection ("congruent use": eg, a smoker selected a challenge related to reducing or quitting smoking). Dichotomous outcomes (change vs no change) referred to past-month substance use, gambling, and media-related behaviors. The relationship between these variables was analyzed using binary, multilevel, mixed-effects logistic regression models. RESULTS: The intervention group consisted of 2367 vocational students, and 1458 (61.6%; mean age 19.0, SD 3.5 years; 830/1458, 56.9% male) of them provided full data. Of these 1458 students, 894 (61.3%) started a challenge and could be included in the analysis (mean 18.7, SD 3.5 years; 363/894, 40.6% female). Of these 894 students, 466 (52.1%) were considered frequent app users with more than 4 days of active use over the 2-week period. The challenge area most often chosen in the analyzed sample was related to social media use (332/894, 37.1%). A total of 407 (45.5%) of the 894 students selected a challenge in a behavioral domain of personal relevance. The effects of app use on outcomes were higher when the area of individual challenge choice was equal to the area of behavior change, challenge choice was related to a behavior of personal relevance, and the individual risk of engaging in different addictive behaviors was high. CONCLUSIONS: The domain-specific effectiveness of the program was confirmed with no spillover between behavioral domains. Effectiveness appeared to be dependent on app use and users' characteristics. TRIAL REGISTRATION: German Clinical Trials Register DRKS00023788; https://tinyurl.com/4pzpjkmj. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-022-06231-x.

Effectiveness of a culturally tailored HIV intervention in promoting PrEP among black women who use drugs in community supervision programs in New York City: a randomized clinical trial.

BACKGROUND: In the U.S. there are significant racial and gender disparities in the uptake of pre-exposure prophylaxis (PrEP). Black Americans represented 14% of PrEP users in 2022, but accounted for 42% of new HIV diagnoses in 2021 and in the South, Black people represented 48% of new HIV diagnoses in 2021 but only 21% of PrEP users in 2022. Women who use drugs may be even less likely than women who do not use drugs have initiated PrEP. Moreover, women involved in community supervision programs (CSP) are less likely to initiate or use PrEP, More PrEP interventions that focus on Black women with recent history of drug use in CSPs are needed to reduce inequities in PrEP uptake. METHODS: We conducted a secondary analysis from a randomized clinical trial with a sub-sample (n = 336) of the total (N = 352) participants from the parent study (E-WORTH), who tested HIV negative at baseline were considered PrEP-eligible. Black women were recruited from CSPs in New York City (NYC), with recent substance use. Participants were randomized to either E-WORTH (n = 172) an HIV testing plus, receive a 5-session, culturally-tailored, group-based HIV prevention intervention, versus an HIV testing control group (n = 180). The 5 sessions included an introduction to PrEP and access. This paper reports outcomes on improved awareness of PrEP, willingness to use PrEP, and PrEP uptake over the 12-month follow-up period. HIV outcomes are reported in a previous paper. RESULTS: Compared to control participants, participants in this study assigned to E-WORTH had significantly greater odds of being aware of PrEP as a biomedical HIV prevention strategy (OR = 3.25, 95% CI = 1.64-6.46, p = 0.001), and indicated a greater willingness to use PrEP as an HIV prevention method (b = 0.19, 95% CI = 0.06-0.32, p = 0.004) over the entire 12-month follow-up period. CONCLUSIONS: These findings underscore the effectiveness of a culturally-tailored intervention for Black women in CSP settings in increasing awareness, and intention to initiate PrEP. Low uptake of PrEP in both arms highlight the need for providing more robust PrEP-on-demand strategies that are integrated into other services such as substance abuse treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02391233 .

What Would Equitable Harm Reduction Look Like?

Structural determinants of health frameworks must express antiracism to be effective, but racial and ethnic inequities are widely documented, even in harm reduction programs that focus on person-centered interventions. Harm reduction strategies should express social justice and health equity, resist stigma and discrimination, and mitigate marginalization experiences among people who use drugs (PWUD). To do so, government and organizational policies that promote harm reduction must acknowledge historical and ongoing patterns of racializing drug use. This article gives examples of such racialization and offers recommendations about how harm reduction programming can most easily and effectively motivate equitable, antiracist care for PWUD.