"Wanna cry this out real quick?": an examination of secondary traumatic stress risk and resilience among post-overdose outreach staff in Massachusetts.

BACKGROUND: Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff. METHODS: We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience). RESULTS: Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams. CONCLUSION: Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.

Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies.

BACKGROUND: The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE: This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN: We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH: We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS: We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION: TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.

Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021.

Objectives. To test the hypothesis that law enforcement efforts to disrupt local drug markets by seizing opioids or stimulants are associated with increased spatiotemporal clustering of overdose events in the surrounding geographic area. Methods. We performed a retrospective (January 1, 2020 to December 31, 2021), population-based cohort study using administrative data from Marion County, Indiana. We compared frequency and characteristics of drug (i.e., opioids and stimulants) seizures with changes in fatal overdose, emergency medical services nonfatal overdose calls for service, and naloxone administration in the geographic area and time following the seizures. Results. Within 7, 14, and 21 days, opioid-related law enforcement drug seizures were significantly associated with increased spatiotemporal clustering of overdoses within radii of 100, 250, and 500 meters. For example, the observed number of fatal overdoses was two-fold higher than expected under the null distribution within 7 days and 500 meters following opioid-related seizures. To a lesser extent, stimulant-related drug seizures were associated with increased spatiotemporal clustering overdose. Conclusions. Supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy. (Am J Public Health. 2023;113(7):750-758. https://doi.org/10.2105/AJPH.2023.307291).

The Bronze Age of drug checking: barriers and facilitators to implementing advanced drug checking amidst police violence and COVID-19.

OBJECTIVES: Unpredictable fluctuations in the illicit drug market increase overdose risk. Drug checking, or the use of technology to provide insight into the contents of illicit drug products, is an overdose prevention strategy with an emerging evidence base. The use of portable spectrometry devices to provide point-of-service analysis of the contents of illicit drugs been adopted by harm reduction organizations internationally but is only emerging in the United States. This study aimed to identify barriers and facilitators of implementing drug checking services with spectrometry devices in an urban harm reduction organization and syringe service program serving economically marginalized people who use drugs in Boston, Massachusetts (USA). METHODS: In-vivo observations and semi-structured interviews with harm reduction staff and participants were conducted between March 2019 and December 2020. We used the consolidated framework for implementation research to identify implementation barriers and facilitators. RESULTS: This implementation effort was facilitated by the organization's shared culture of harm reduction-which fostered shared implementation goals and beliefs about the intervention among staff persons-its horizontal organizational structure, strong identification with the organization among staff, and strong relationships with external funders. Barriers to implementation included the technological complexity of the advanced spectroscopy devices utilized for drug checking. Program staff indicated that commercially available spectroscopy devices are powerful but not always well-suited for drug checking efforts, describing their technological capacities as "the Bronze Age of Drug Checking." Other significant barriers include the legal ambiguity of drug checking services, disruptive and oppositional police activity, and the responses and programmatic changes demanded by the COVID-19 pandemic. CONCLUSIONS: For harm reduction organizations to be successful in efforts to implement and scale drug checking services, these critical barriers-especially regressive policing policies and prohibitive costs-need to be addressed. Future research on the impact of policy changes to reduce the criminalization of substance use or to provide explicit legal frameworks for the provision of this and other harm reduction services may be merited.

"They don't go by the law around here": law enforcement interactions after the legalization of syringe services programs in North Carolina.

BACKGROUND: In 2016, the US state of North Carolina (NC) legalized syringe services programs (SSPs), providing limited immunity from misdemeanor syringe possession when law enforcement is presented documentation that syringes were obtained from an SSP. This study explores the law enforcement interactions experienced by SSP participants since the enactment of this law. METHODS: This study used a convergent, mixed-methods design consisting of structured surveys and semi-structured interviews with SSP participants in seven NC counties. Survey and interview data were collected simultaneously between January and November 2019. This survey was designed to capture demographics, characteristics of drug use, SSP services used, and past-year negative experiences with law enforcement (officer did not recognize SSP card, did not believe SSP card belonged to participant, confiscated SSP card, confiscated syringes, or arrested participant for possessing syringes). Semi-structured interviews explored lived experiences with and perspectives on the same topics covered in the survey. RESULTS: A total of 414 SSP participants completed the survey (45% male, 54% female, 1% transgender or non-binary; 65% White, 22% Black, 5% American Indian/Alaskan Native, 8% some other racial identity). 212 participants (51.2%) reported at least one past-year negative experience with law enforcement. Chi-square testing suggests that Black respondents were more likely to report having experienced law enforcement doubt their SSP card belonged to them. Interview data indicate that law enforcement practices vary greatly across counties, and that negative and/or coercive interactions reduce expectations among SSP participants that they will be afforded the protections granted by NC law. CONCLUSION: Despite laws which protect SSP participants from charges, negative law enforcement responses to syringe possession are still widely reported. Evidence-based policy interventions to reduce fatal overdose are undermined by these experiences. Our findings suggest NC residents, and officers who enforce these laws, may benefit from clarification as to what is required of the documents which identify participants of registered SSPs where they may legally obtain syringes. Likewise, more thorough trainings on NC's syringe law for law enforcement officers may be merited. Further research is needed to assess geographic differences in SSP participants' law enforcement interactions across race and gender.

Student Perceptions of a University Medical Amnesty Policy Are Impacted by Race and Racism: A Qualitative Study.

BACKGROUND: Alcohol consumption on college and university campuses is a public health concern. Some universities have instituted medical amnesty policies (MAPs) to encourage calling first responders to the scene of an alcohol-related emergency. This study describes perceptions of a university MAP and the perceived risks of calling first responders among a sample of undergraduate students at a mid-sized, private, residential university. Methods: This is an exploratory, peer-led study, in which student-researchers worked under faculty supervision to devise the aims of the study, recruit and conduct qualitative interviews with participants, analyze data, and organize major findings. Results: Participants in this convenience sample (N = 42) were majority female (n = 33, 78.67%) and white (n = 35, 83.3%). White students often reported risking disciplinary consequences (i.e. suspension) if found in violation of university alcohol policy. White students who were familiar with the MAP praised it as beneficial in improving student safety. Students of color (especially Black students) reported concerns for their safety in the presence of first responders (especially police officers). Awareness of the MAP among students of color was very low, and many reported low levels of institutional trust, suggesting the protections conferred by the MAP should be taken "with a grain of salt." Conclusions: MAPs may alleviate concern about some perceived risks of calling first responders, but that benefit may not be experienced equitably among students of color. More research is needed to understand the complex relationship between alcohol policies, alcohol-related injuries, policing, and race on college and university campuses.

Painful Subjects: Treating Chronic Pain among People Living with HIV in the Age of Opioid Risk.

Public narratives often attribute the opioid overdose epidemic in the United States to liberal prescribing practices by health care providers. Consequently, new monitoring guidelines for the management of opioid prescriptions in patients with chronic pain have become recognized as key strategies for slowing this tide of overdose deaths. This article examines the social and ontological terrain of opioid-based pain management in an HIV clinic in the context of today's opioid overdose epidemic. We engage with anthropological analyses of contemporary drug policy and the nonverbal/performative ways patients and clinicians communicate to theorize the social context of the opioid overdose epidemic as a "situation," arguing that the establishment of new monitoring strategies (essentially biomedical audit strategies) trouble patient subjectivity in the HIV clinic-a place where that subjectivity has historically been protected and prioritized in the establishment of care.

HIV Physicians and Chronic Opioid Therapy: It's Time to Raise the Bar.

Clinical practice that utilizes chronic opioid therapy has been recognized as one major cause of the opioid crisis. Among patients living with HIV, the risks associated with chronic opioid therapy may be complicated by factors such as co-occurring mental health diagnoses, substance use, and economic marginalization. Improving opioid prescribing practices in HIV clinics requires attention to these and other characteristics common to HIV care. In the context of a randomized controlled trial testing an intervention to improve opioid prescribing practices in HIV outpatient clinics, we interviewed physicians about their perspectives on chronic opioid therapy. Overwhelmingly, physicians voiced ambivalence about their own knowledge and comfort with prescription opioids. They raised concerns about the impact of opioid prescribing on patient-provider relationships and the increasing workload associated with prescribing and monitoring patients. In this report, we explore these concerns and propose several strategies for improving clinical care in which chronic opioid therapy is addressed.

Perceived Risk Among Human Immunodeficiency Virus Serodiscordant Couples in East Africa Taking Oral Pre-Exposure Prophylaxis.

OBJECTIVES: Perceived risk of human immunodeficiency virus (HIV) infection is thought to drive low adherence in pre-exposure prophylaxis (PrEP) trials. We explored the level of perceived risk of incident HIV infection in the Partners PrEP Study, in which adherence was generally high. METHODS: A cross-sectional questionnaire assessed perceived risk of HIV at 12 months after enrollment. Logistic regression was used to analyze the relationship between perceived risk and other demographic and behavioral variables. RESULTS: Three thousand two hundred twenty-six couples from the Partners PrEP Study were included in this analysis. Only 15.4% of participants reported high or moderate perceived risk. Participants at high risk of acquiring HIV were slightly more likely to report high perceived risk (odds ratio, 1.60; 95% confidence interval, 1.30-1.95; P < 0.001); nevertheless, only 20% of participants with high-risk reported high perceived risk. CONCLUSIONS: Participants reported low perceived risk of HIV but were adherent to PrEP. Perceptions of risk are likely socially determined and more complex than Likert scale questionnaires capture.

Gendered differences in the perceived risks and benefits of oral PrEP among HIV-serodiscordant couples in Kenya.

Pre-exposure prophylaxis (PrEP) is effective for preventing HIV among HIV-serodiscordant heterosexual couples. Gender roles may influence perceived personal and social risks related to HIV-prevention behaviors and may affect use of PrEP. In this study, interviews and focus groups were conducted with 68 individuals from 34 mutually disclosed serodiscordant heterosexual partnerships in Thika, Kenya. Sociocultural factors that affect adherence to PrEP were explored using grounded analysis. Three factors were identified, which shape perceptions of PrEP: gendered power dynamics and control over decision-making in the household; conflicts between risk-reduction strategies and male sexual desire; culture-bound definitions of women's work. Adherence to PrEP in the Partners PrEP Study was high; however, participants articulated conflicting interests related to PrEP in connection with traditional gender roles. The successful delivery of PrEP will require understanding of key social factors, particularly related to gender and dyadic dynamics around HIV serostatus.

Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports From Front-Line Health Workers in 7 US States.

BACKGROUND: Xylazine, an adrenergic alpha-2 agonist increasingly present in the US drug supply, is associated with severe skin ulcers and other harms. Expert knowledge from front-line harm reduction and healthcare professionals is an essential component of evidence-based practice. The purpose of this study is to describe the progression and treatment of xylazine-associated wounds, other xylazine-related health concerns, and the most urgent research priorities as reported by front-line harm reduction and healthcare professionals serving people who use drugs. METHODS: A convenience sample of 17 healthcare and harm reduction professionals who serve people who use drugs in the US states of Maryland, Massachusetts, Michigan, Minnesota, North Carolina, Pennsylvania, and Texas participated in semi-structured interviews. Participants were asked about the appearance and progression of xylazine-associated wounds; preferred treatment strategies; other xylazine-related harms experienced by people who use drugs; and the most urgent priorities for xylazine-related research. FINDINGS: Xylazine-associated wounds were broadly described as small lesions appearing mostly on extremities both at and away from injection sites, often within hours or days of exposure, that quickly developed into large, complex, chronic wounds. Reported risk of secondary infection was generally low but appeared more common among unhoused populations. Most participants preferred conservative treatment strategies that included regular wound care, enzymatic debridement, and hygiene. Xylazine-associated wounds and xylazine withdrawal reportedly act as significant barriers to care, including addiction treatment. Participants reported urgent need for scientific research and evidence-based guidance on the management of xylazine-associated wounds and withdrawal. CONCLUSIONS: High-quality scientific evidence on risk factors for xylazine-associated wounds and on their biologic mechanisms is needed. Such studies could inform new strategies for the prevention and treatment of these wounds. Efforts to improve the management of xylazine withdrawal and to reduce stigma by incorporating harm reduction professionals into healthcare settings may improve access to and retention in care.

Prosecuting overdose: An exploratory study of prosecutorial motivations for drug-induced homicide prosecutions in North Carolina.

BACKGROUND: Prosecutorial use of drug-induced homicide (DIH) laws varies, and their public health impacts are poorly understood. This mixed-methods study explores associations between the number of DIH charges filed in North Carolina's 42 prosecutorial districts and district-level characteristics. Further, it documents the experience and views of North Carolina prosecutors on DIH cases. METHODS: We conducted a descriptive, exploratory analysis of DIH enforcement by prosecutorial district in North Carolina to assess associations between overdose deaths, number of prosecutors employed, and rurality of the district. We also sent a survey to all N.C. prosecutors requesting that they detail their experience with and views on DIH prosecutions. RESULTS: We found no association between overdose deaths or the number of prosecutors and DIH charges within a district. Survey data suggests that perceived justice for the deceased and perceived imperatives to "do something" about overdose influence prosecutorial use of DIH charges. Prosecutors generally appeared to agree that DIH cases had the potential to reduce substance use and/or drug dealing and/or fentanyl dealing and/or drug overdose in their districts, though how DIH cases would produce those effects was not clarified. Many prosecutors framed people who use drugs as helpless victims and forged categorical distinctions between (1) people who use drugs and sell drugs to support their addiction and (2) people who use drugs and sell drugs and are motivated by profit. Several prosecutors suggested that charging one person with homicide for another person's consensual acts may not appear logical to all jurors. CONCLUSIONS: DIH prosecutions do not appear to be predicted by district characteristics commonly believed to shape prosecutorial action. Many prosecutors endorsed claims about the community-level impacts of DIH prosecutions that are unproven and generally contradict the available evidence. More research on the implementation and community-level outcomes of DIH prosecutions is needed.

Privacy and confidentiality in Massachusetts' post-overdose outreach programs: Mixed methods analysis of outreach staff surveys and interviews.

BACKGROUND: Public health-public safety partnerships for post-overdose outreach have emerged in many communities to prevent future overdose events. These efforts often identify overdose survivors through emergency call data and seek to link them with relevant services. The aim of this study was to describe how post-overdose outreach programs in Massachusetts manage the confidentiality of identifiable information and privacy of survivors. METHODS: In 2019, 138 Massachusetts programs completed surveys eliciting responses to questions about program operations. Descriptive statistics were calculated from the closed-ended survey responses. Thirty-eight interviews were conducted among outreach staff members during 2019-2020. Interview transcripts and open-ended survey responses were thematically analyzed using deductive and inductive approaches. RESULTS: Of programs that completed the survey, 90 % (n = 124/138) reported acting to protect the privacy of survivors following overdose events, and 84 % (n = 114/135) reported implementing a protocol to maintain the confidentiality of personal information. Interviews with outreach team members indicated substantial variation in practice. Outreach programs regularly employed discretion in determining actions in the field, sometimes undermining survivor privacy and confidentiality (e.g., by disclosing the overdose event to family members). Programs aiming to prioritize privacy and confidentiality attempted to make initial contact with survivors by phone, limited or concealed materials left behind when no one was home, and/or limited the number of contact attempts. CONCLUSIONS: Despite the establishment of privacy and confidentiality protocols within most post-overdose outreach programs, application of these procedures was varied, discretionary, and at times viewed by staff as competing with engagement efforts. Individual outreach overdose teams should prioritize privacy and confidentiality during outreach to protect overdose survivors from undesired exposure. In addition to individual program changes, access to overdose survivor information could be changed across all programs to bolster privacy and confidentiality protocols. For example, transitioning the management of overdose-related information to non-law enforcement agencies would limit officers' ability to disseminate such information at their discretion.

Health Inequities Among People Who Use Drugs in a Post-Dobbs America: The Case for a Syndemic Analysis.

Punitive policy responses to substance use and to abortion care constitute direct attacks on personal liberty and bodily autonomy. In this article, we leverage the concept of "syndemics" to anticipate how the already synergistic stigmas against people who use drugs and people who seek abortion services will be further compounded the Dobbs decision.

The police paradox: A qualitative study of post-overdose outreach program implementation through public health-public safety partnerships in Massachusetts.

BACKGROUND: Post-overdose outreach has emerged in the United States as an increasingly common response to non-fatal overdose. This qualitative study investigates the implementation of such programs through public health-public safety partnerships in Massachusetts. METHODS: We conducted semi-structured interviews with post-overdose outreach team members, overdose survivors, and family members who received outreach. Interview transcripts were inductively analyzed to identify emergent themes and subsequently organized within the framework of Ecological Systems Theory. RESULTS: Forty-nine interviews were conducted, including 15 police officers (80% male, 100% non-Hispanic White); 23 public health partners (48% male, 87% non-Hispanic White); 8 overdose survivors who received outreach services and 3 parents of survivors who received services (collectively 27% male, 64% non-Hispanic White). Implementation factors identified across all levels (macrosystem, exosystem, mesosystem, and microsystem) of Ecological Systems Theory included key program facilitators, such as access to police data and funding (macro), interagency collaboration (exo), shared recognition of community needs (exo), supportive relationships among team members (meso), and program champions (micro). Common barriers included inherent contradictions between policing and public health mandates (macro), poor local treatment and service capacity (exo), divergent staff views of program goals (exo), overdose survivors' prior negative experiences with law enforcement (meso), difficulty locating overdose survivors (meso), and police officers' lack of qualifications or training in providing psycho-social services (micro). CONCLUSIONS: Most post-overdose outreach programs in this study were dependent on funding and data-sharing partnerships, which police agencies largely controlled. Yet, police participation, especially during outreach visits presented numerous challenges for engaging overdose survivors and establishing non-coercive linkages with evidence-based services, which may undermine the public health goals of these programs. These findings should inform state and federal efforts to expand the role of law enforcement in behavioral health initiatives.

The impacts of COVID-19 on structural inequities faced by people living with HIV who inject drugs: A qualitative study in St. Petersburg, Russia.

BACKGROUND: People who inject drugs (PWID) living with HIV may be disproportionately impacted by pandemic restrictions. This study qualitatively explored the impacts of the SARS-CoV-2 pandemic on PWID with HIV in St. Petersburg, Russia. METHODS: In March and April 2021, we conducted remote, semi-structured interviews with PWID with HIV, health care providers, and harm reductionists. RESULTS: We interviewed 25 PWID with HIV (aged 28-56 years, 46% female) and 11 providers. The pandemic exacerbated economic and psychological challenges experienced by PWID with HIV. Simultaneously, barriers to HIV care access, ART prescription refill and dispensing and police violence, which hindered the health and safety of PWID with HIV, were themselves hindered from normal operations by the pandemic, significantly reducing these burdens. CONCLUSION: Pandemic responses should account for the unique vulnerabilities of PWID with HIV to avoid worsening the structural violence they already experience. Wherever the pandemic decreased structural barriers, such as institutional, administrative, and bureaucratic challenges and state violence enacted by police and other elements of the criminal justice system, such changes should be protected.

Characteristics of post-overdose outreach programs and municipal-level opioid overdose in Massachusetts.

BACKGROUND: Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated. METHODS: Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects. RESULTS: There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66-0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78-0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches. CONCLUSION: Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design.