Sexually transmitted and blood-borne infection risk reduction with methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder: Findings from a Canadian pragmatic randomized trial.

INTRODUCTION: People who use drugs are disproportionally affected by sexually transmitted and blood-borne infections (STBBIs). While the benefits of methadone in reducing injecting-risk behaviours are well documented, less is known on its impacts on sexual-related risks, as well as its comparative effectiveness to buprenorphine/naloxone, particularly in the context of highly potent opioids. The aim of this study was to estimate the relative effects of buprenorphine/naloxone and methadone on injecting and STBBI risks among people with prescription-type opioid use disorder (POUD). METHODS: Secondary analysis of a pan-Canadian pragmatic 24-week randomized clinical trial comparing methadone and buprenorphine/naloxone models of care among 272 people with POUD (including licit or illicit opioid analgesics, fentanyl). The Risk Behaviour Survey was used to collect injecting and sexual risks at baseline, and weeks 12 and 24. RESULTS: In total, 210 participants initiated treatment (103 buprenorphine/naloxone and 107 methadone). At baseline, 113/205 (55.1%) participants reported recently injecting drugs, 37/209 (17.7%) unsafe injection practices and 67/162 (41.4%) high-risk sex. Both methadone and buprenorphine/naloxone were associated with reductions in the prevalence of injection drug use and high-risk sex at weeks 12 and 24 with no interactions between treatment arm and time. CONCLUSION: Methadone and buprenorphine/naloxone were similarly effective in reducing injecting and sexual risk behaviours among people with POUD. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov NCT03033732.

Impact of baseline methamphetamine/amphetamine use on discontinuation of methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder in Canada.

BACKGROUND AND OBJECTIVES: Although concurrent stimulant use is common among people with opioid use disorder (OUD), there is little evidence on its impacts on opioid agonist therapy (OAT) outcomes. This study sought to determine the impact of baseline methamphetamine/amphetamine use on discontinuation of OAT among individuals with prescription-type OUD (POUD) initiating methadone or buprenorphine/naloxone as part of a pragmatic randomized trial in Canada. METHODS: Secondary analysis of a pan-Canadian pragmatic trial conducted between 2017 and 2020 comparing supervised methadone versus flexible take-home dosing buprenorphine/naloxone models of care. Cox proportional hazard models were used to evaluate the effect of baseline methamphetamine/amphetamine use (measured by urine drug test [UDT]) on two discontinuation outcomes (i.e., assigned OAT discontinuation, any OAT discontinuation). RESULTS: Two hundred nine (n = 209) participants initiated OAT, of which 96 (45.9%) had positive baseline methamphetamine/amphetamine UDT. Baseline methamphetamine/amphetamine use was associated with shorter median times in assigned OAT (21 vs. 168 days, hazard ratio [aHR] = 2.45, 95% confidence interval [CI] = 1.60-3.76) and any OAT (25 days vs. 168 days, aHR = 2.06, CI = 1.32-3.24). No interaction between methamphetamine/amphetamine and assigned OAT was observed for either outcome (p > .05). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This study offers novel insights on the impact of methamphetamine/amphetamine use on OAT outcomes among people with POUD. Methamphetamine/amphetamine use was common and was associated with increased risk of OAT discontinuation. Supplementary interventions, including treatment for stimulant use, are needed to improve retention in OAT and optimize treatment outcomes in this population.

The Association Between Self-Reported Anxiety and Retention in Opioid Agonist Therapy: Findings From a Canadian Pragmatic Trial.

BACKGROUND: Prescription-type opioid use disorder (POUD) is often accompanied by comorbid anxiety, yet the impact of anxiety on retention in opioid agonist therapy (OAT) is unclear. Therefore, this study investigated whether baseline anxiety severity affects retention in OAT and whether this effect differs by OAT type (methadone maintenance therapy (MMT) vs. buprenorphine/naloxone (BNX)). METHODS: This secondary analysis used data from a pan-Canadian randomized trial comparing flexible take-home dosing BNX and standard supervised MMT for 24 weeks. The study included 268 adults with POUD. Baseline anxiety was assessed using the Beck Anxiety Inventory (BAI), with BAI ≥ 16 indicating moderate-to-severe anxiety. The primary outcomes were retention in assigned and any OAT at week 24. In addition, the impact of anxiety severity on retention was examined, and assigned OAT was considered an effect modifier. RESULTS: Of the participants, 176 (65%) reported moderate-to-severe baseline anxiety. In adjusted analyses, there was no significant difference in retention between those with BAI ≥ 16 and those with BAI < 16 assigned (29% vs. 28%; odds ratio (OR) = 2.03, 95% confidence interval (CI) = 0.94-4.40; P = 0.07) or any OAT (35% vs. 34%; OR = 1.57, 95% CI = 0.77-3.21; P = 0.21). In addition, there was no significant effect modification by OAT type for retention in assigned (P = 0.41) or any OAT (P = 0.71). In adjusted analyses, greater retention in treatment was associated with BNX (vs. MMT), male gender identity (vs. female, transgender, or other), enrolment in the Quebec study site (vs. other sites), and absence of a positive urine drug screen for stimulants at baseline. CONCLUSIONS: Baseline anxiety severity did not significantly impact retention in OAT for adults with POUD, and there was no significant effect modification by OAT type. However, the overall retention rates were low, highlighting the need to develop new strategies to minimize the risk of attrition from treatment. CLINICAL TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT03033732).

Does This Patient Have Alcohol Use Disorder?: The Rational Clinical Examination Systematic Review.

Importance: The accuracy of screening tests for alcohol use disorder (defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress) requires reassessment to align with the latest definition in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5). Objective: To assess the diagnostic accuracy of screening tools in identifying individuals with alcohol use disorder as defined in the DSM-5. Data Sources and Study Selection: The databases of MEDLINE and Embase were searched (January 2013-February 2023) for original studies on the diagnostic accuracy of brief screening tools to identify alcohol use disorder according to the DSM-5 definition. Because diagnosis of alcohol use disorder does not include excessive alcohol use as a criterion, studies of screening tools that identify excessive or high-risk drinking among younger (aged 9-18 years), older (aged ≥65 years), and pregnant persons also were retained. Data Extraction and Synthesis: Sensitivity, specificity, and likelihood ratios (LRs) were calculated. When appropriate, a meta-analysis was performed to calculate a summary LR. Results: Of 4303 identified studies, 35 were retained (N = 79 633). There were 11 691 individuals with alcohol use disorder or a history of excessive drinking. Across all age categories, a score of 8 or greater on the Alcohol Use Disorders Identification Test (AUDIT) increased the likelihood of alcohol use disorder (LR, 6.5 [95% CI, 3.9-11]). A positive screening result using AUDIT identified alcohol use disorder better among females (LR, 6.9 [95% CI, 3.9-12]) than among males (LR, 3.8 [95% CI, 2.6-5.5]) (P = .003). An AUDIT score of less than 8 reduced the likelihood of alcohol use disorder similarly for both males and females (LR, 0.33 [95% CI, 0.20-0.52]). The abbreviated AUDIT-Consumption (AUDIT-C) has sex-specific cutoff scores of 4 or greater for males and 3 or greater for females, but was less useful for identifying alcohol use disorder (males: LR, 1.8 [95% CI, 1.5-2.2]; females: LR, 2.0 [95% CI, 1.8-2.3]). The AUDIT-C appeared useful for identifying measures of excessive alcohol use in younger people (aged 9-18 years) and in those older than 60 years of age. For those younger than 18 years of age, the National Institute on Alcohol Abuse and Alcoholism age-specific drinking thresholds were helpful for assessing the likelihood of alcohol use disorder at the lowest risk threshold (LR, 0.15 [95% CI, 0.11-0.21]), at the moderate risk threshold (LR, 3.4 [95% CI, 2.8-4.1]), and at the highest risk threshold (LR, 15 [95% CI, 12-19]). Among persons who were pregnant and screened within 48 hours after delivery, an AUDIT score of 4 or greater identified those more likely to have alcohol use disorder (LR, 6.4 [95% CI, 5.1-8.0]), whereas scores of less than 2 for the Tolerance, Worried, Eye-Opener, Amnesia and Cut-Down screening tool and the Tolerance, Annoyed, Cut-Down and Eye-Opener screening tool identified alcohol use disorder similarly (LR, 0.05 [95% CI, 0.01-0.20]). Conclusions and Relevance: The AUDIT screening tool is useful to identify alcohol use disorder in adults and in individuals within 48 hours postpartum. The National Institute on Alcohol Abuse and Alcoholism youth screening tool is helpful to identify children and adolescents with alcohol use disorder. The AUDIT-C appears useful for identifying various measures of excessive alcohol use in young people and in older adults.

Impact of Depressive Symptom Severity on Buprenorphine/Naloxone and Methadone Outcomes in People With Prescription-Type Opioid Use Disorder: Results From a Pragmatic Randomized Controlled Trial.

OBJECTIVE: To evaluate the impact of depressive symptom severity on opioid use and treatment retention in individuals with prescription-type opioid use disorder (POUD). METHOD: We analyzed data from a multi-centric, pragmatic, open-label, randomized controlled trial comparing buprenorphine/naloxone to methadone models of care in 272 individuals with POUD. Opioid use was self-reported every two weeks for 24 weeks using the Timeline Followback. Depressive symptom severity was self-reported with the Beck Depression Inventory at baseline, week 12 and week 24. RESULTS: Baseline depressive symptom severity was not associated with opioid use nor treatment retention. At week 12, moderate depressive symptoms were associated with greater opioid use while mild to severe depressive symptoms were associated with lowered treatment retention. At week 24, moderate depressive symptoms were associated with greater opioid use. CONCLUSIONS: Ongoing depressive symptoms lead to poorer outcomes in POUD. Clinicians are encouraged to use integrative approaches to optimize treatment outcomes. This study was registered in ClinicalTrials.gov (NCT03033732) on January 27th, 2017, prior to participants enrollment.

Sensitivity to change of generic preference-based instruments (EQ-5D-3L, EQ-5D-5L, and HUI3) in the context of treatment for people with prescription-type opioid use disorder in Canada.

PURPOSE: Using data from a randomized controlled trial for treatment of prescription-type opioid use disorder in Canada, this study examines sensitivity to change in three preference-based instruments [EQ-5D-3L, EQ-5D-5L, and the Health Utilities Index Mark 3 (HUI3)] and explores an oft-overlooked consideration when working with contemporaneous responses for similar questions-data quality. METHODS: Analyses focused on the relative abilities of three instruments to capture change in health status. Distributional methods were used to categorize individuals as 'improved' or 'not improved' for eight anchors (seven clinical, one generic). Sensitivity to change was assessed using area under the ROC (receiver operating characteristics) curve (AUC) analysis and comparisons of mean change scores for three time periods. A 'strict' data quality criteria, defined a priori, was applied. Analyses were replicated using 'soft' and 'no' criteria. RESULTS: Data from 160 individuals were used in the analysis; 30% had at least one data quality violation at baseline. Despite mean index scores being significantly lower for the HUI3 compared with EQ-5D instruments at each time point, the magnitudes of change scores were similar. No instrument demonstrated superior sensitivity to change. While six of the 10 highest AUC estimates were for the HUI3, 'moderate' classifications of discriminative ability were identified in 12 (of 22) analyses for each EQ-5D instrument, compared with eight for the HUI3. CONCLUSION: Negligible differences were observed between the EQ-5D-3L, EQ-5D-5L, and HUI3 regarding the ability to measure change. The prevalence of data quality violations-which differed by ethnicity-requires further investigation.

Associations of methadone and buprenorphine-naloxone doses with unregulated opioid use, treatment retention, and adverse events in prescription-type opioid use disorders: Exploratory analyses of the OPTIMA study.

BACKGROUND AND OBJECTIVES: Buprenorphine/naloxone (BUP-NX) and methadone are used to treat opioid use disorder (OUD), yet there is insufficient evidence on the impact of doses on interventions' effectiveness and safety when treating OUD attributable to other opioids than heroin. METHODS: We explored associations between methadone and BUP-NX doses and treatment outcomes using data from OPTIMA, a 24-week, pragmatic, open-label, multicenter, pan-Canadian, randomized controlled, two-arm parallel trial with participants (N = 272) with OUD who primarily use opioids other than heroin. Participants were randomized to receive flexible take-home BUP-NX (n = 138) or standard supervised methadone treatment (n = 134). We examined associations between highest BUP-NX and methadone doses, and (1) percentage of opioid-positive urine drug screens (UDS); (2) retention in the assigned treatment; and (3) adverse events (AEs). RESULTS: The mean (SD) highest BUP-NX and methadone dose were 17.31 mg/day (8.59) and 67.70 mg/day (34.70). BUP-NX and methadone doses were not associated with opioid-positive UDS percentages or AEs. Methadone dose was associated with higher retention in treatment (odds ratio [OR]: 1.025; 95% confidence interval [CI]: 1.010; 1.041), while BUP-NX dose was not (OR: 1.055; 95% CI: 0.990; 1.124). Higher methadone doses (70-110 mg/day) offered higher odds of treatment retention. DISCUSSION AND CONCLUSION: Methadone dose was associated with higher retention, which may be related to its full µ-opioid receptor agonism. Future research should notably ascertain the effect of pace of titration on a wide range of outcomes. SCIENTIFIC SIGNIFICANCE: Our results extend previous findings of high doses of methadone increasing retention to be applied in our population using opioids other than heroin, including highly potent opioids.

Effects of Buprenorphine/Naloxone and Methadone on Depressive Symptoms in People with Prescription Opioid Use Disorder: A Pragmatic Randomised Controlled Trial.

OBJECTIVE: This study aimed to evaluate the effectiveness of flexible take-home dosing of buprenorphine/naloxone (BUP/NX) and methadone standard model of care in reducing depressive symptoms in people with prescription-type opioid use disorder (POUD). This trial also evaluated whether improvements in depressive symptoms were mediated by opioid use. METHODS: Analyzed data came from the OPTIMA study (clinicaltrials.gov identifier: NCT03033732), a pragmatic randomised controlled trial comparing flexible take-home dosing of BUP/NX and methadone standard model of care for reducing opioid use in people with POUD. A total of 272 participants were recruited in four Canadian provinces. Participants were randomised 1:1 to BUP/NX or methadone. After treatment induction, past two-week opioid use was measured using the Timeline Followback every two weeks for a total of 24 weeks. Depressive symptoms were measured with the Beck Depression Inventory at baseline, weeks 12 and 24. RESULTS: Both BUP/NX and methadone significantly reduced depressive symptoms at week 12 (aß ± SE = -3.167 ± 1.233; P < 0.001) and week 24 (aß ± SE = -7.280 ± 1.285; P < 0.001), with no interaction between type of treatment and time (P = 0.284). Improvements in depressive symptoms were only partially mediated by a reduction in opioid use (proportion mediated = 36.8%; 95% confidence interval = -1.158 to -0.070; P = 0.015). CONCLUSIONS: BUP/NX and methadone showed similar effectiveness in decreasing comorbid depressive symptoms in people with POUD. This effect was partially explained by a reduction in opioid use. As both treatments seem equally effective, clinicians are encouraged to tailor the selection of OAT to patients' needs and characteristics.

Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids.

Background: An exemption to existing U.S. regulation of methadone maintenance therapy after the onset of the COVID-19 pandemic permitted increased take-home doses beginning March 2020.Objectives: We assessed the impact of this exemption on opioid use.Methods: A pre/post study of 187 clients recruited from an OTP who completed a survey and consented to share their urine drug testing (UDT) data. Use of fentanyl, morphine, hydromorphone, codeine, and heroin was assessed via UDT. Receipt of take-home methadone doses was assessed from clinic records for 142 working days pre- and post-COVID exemption. Analysis was conducted using a linear regression model to assess the association between increased take-home doses and use of illicit opioids.Results: In the pre- vs. post-COVID-19 SAMHSA exemption periods, 26.2% vs. 36.3% of UDTs were positive for 6-acetylmorphine respectively, 32.6% vs. 40.6% positive for codeine, 34.2% vs 44.2% positive for hydromorphone, 39.5% vs. 48.1% positive for morphine, 8.0% vs. 14.4% positive for fentanyl (p-value < .001). However, in the unadjusted descriptive data, when grouped by change in substance use, those clients who experienced a decrease in the use of morphine, codeine, and heroin post-COVID-19 were given significantly more take-home doses than the groups that had no change or an increase in the use of these substances. In the adjusted model, there was no significant relationship between change in opioid use and increased receipt of take-home methadone doses.Conclusions: Although take-home doses post-COVID-19 nearly doubled, this increase was not associated with a significant change in use of illicit opioids.

Periods of Homelessness Linked to Higher VACS Index Among HIV-Positive People Who Use Drugs.

We sought to evaluate the impact of homelessness on HIV disease progression among people who use unregulated drugs (PWUD) living with HIV and test if this association was mediated by adherence to antiretroviral therapy (ART). We applied general linear mixed-effects modeling to estimate the longitudinal relationship between homelessness and the Veterans Aging Cohort Study (VACS) Index, a validated measure of HIV disease progression that predicts all-cause mortality, among a prospective cohort of PWUD. In a longitudinal model adjusted for ART adherence, homelessness was significantly associated with increased VACS Index scores and 16% of the association was mediated by ART adherence. These findings indicate that homelessness was a significant risk factor for HIV disease progression and this association was marginally mediated by ART adherence. Future studies are needed to quantify the other mechanisms (e.g., food insecurity, mental health) by which homelessness increases mortality risk among PWUD living with HIV.

Crack cocaine use frequency is associated with HIV disease severity independent of antiretroviral therapy exposure: a prospective cohort study.

We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. In multivariable adjusted models, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (ß = 0.8, 95% confidence interval: 0.1, 1.5) as compared to none. Our finding suggests that daily or greater frequency of crack cocaine use exacerbates HIV disease severity independent of ART exposure. The observed effect may reflect an underlying biological mechanism or other factors linked with crack cocaine use; further investigation is warranted.

Opioid use disorder Cascade of care framework design: A roadmap.

Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.

The Veterans Aging Cohort Study (VACS) Index Predicts Mortality in a Community-recruited Cohort of People With Human Immunodeficiency Virus (HIV) Who Use Illicit Drugs.

The Veterans Aging Cohort Study (VACS) index combines commonly collected clinical biomarkers to estimate human immunodeficiency virus (HIV) disease severity. Among a prospective cohort of people living with HIV who use illicit drugs (PWUD) (n = 948), we found that the VACS index was significantly associated with mortality over a 20-year study period.

Use of Cannabis for Harm Reduction Among People at High Risk for Overdose in Vancouver, Canada (2016-2018).

Objectives. To characterize the prevalence and reasons for the use of cannabis as a strategy to reduce the harms arising from other substances.Methods. We drew data about recent cannabis use and intentions from 3 prospective cohort studies of marginalized people who use drugs based in Vancouver, Canada, from June 2016 to May 2018. The primary outcome was "use of cannabis for harm reduction," defined as using cannabis for substitution for licit or illicit substances such as heroin or other opioids, cocaine, methamphetamine, or alcohol; treating withdrawal; or coming down off other drugs.Results. Approximately 1 in 4 participants reported using cannabis for harm reduction at least once during the study period. The most frequent reasons included substituting for stimulants (50%) and substituting for illicit opioids (31%).Conclusions. The use of cannabis for harm reduction is a common strategy among people who use drugs in our setting. Further research into the factors associated with this strategy is needed. Better characterization of the risks and benefits of substitution strategies, including for opioids and stimulants, may prompt new treatment options for PWUD.

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina.

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

Frequent Cannabis Use and Cessation of Injection of Opioids, Vancouver, Canada, 2005-2018.

Objectives. To evaluate the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID).Methods. Three prospective cohorts of PWID from Vancouver, Canada, provided the data for these analyses. We used extended Cox regression analysis with time-updated covariates to analyze the association between cannabis use and injection cessation and injection relapse.Results. Between 2005 and 2018, at-least-daily cannabis use was associated with swifter rates of injection cessation (adjusted hazard ratio [AHR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). A subanalysis revealed that this association was only significant for opioid injection cessation (AHR = 1.26; 95% CI = 1.12, 1.41). At-least-daily cannabis use was not significantly associated with injection relapse (AHR = 1.08; 95% CI = 0.95, 1.23).Conclusions. We observed that at-least-daily cannabis use was associated with a 16% increase in the hazard rate of injection cessation, and this effect was restricted to the cessation of injection opioids. This finding is encouraging given the uncertainty surrounding the impact of cannabis policies on PWID during the ongoing opioid overdose crisis in many settings in the United States and Canada.

Longitudinal Factors Associated with Used Syringe Lending Among HIV-Positive Antiretroviral Therapy-Naïve People Who Inject Drugs in a Canadian Setting.

Sharing used syringes is an important route of HIV transmission, however, factors shaping used syringe-lending among antiretroviral therapy (ART)-naïve HIV-positive people who inject drugs (PWID) are not well-characterized. Multivariable logistic regression analyses using generalized estimating equations (GEE) were employed to investigate correlates of used syringe lending among ART-naïve PWID. Data was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive illicit drug users in Vancouver, Canada, from 1996 to 2015. The analysis included 482 ART-naïve PWID, of which 116 (24.1%) reported ≥ 1 periods of used syringe lending. In longitudinal analyses, incarceration (Adjusted Odds Ratio [AOR] = 2.18, 95% Confidence Interval [CI] 1.48-3.20), daily cocaine injection (AOR= 1.97, 95% CI 1.33-2.90), and sex work (AOR = 1.61, 95% CI 1.02-2.55) during the 180-day observation period were positively associated with used syringe lending, while having a high school diploma (AOR = 0.63, 95% CI 0.43-0.93) and holding formal employment (AOR = 0.20, 95% CI 0.05-0.82) were negatively associated. We found a high prevalence of used syringe lending among ART-naïve HIV-positive PWID, particularly among those recently incarcerated, involved in sex work or who injected cocaine frequently. Conversely, markers of higher socio-economic status were negatively associated with used syringe lending. These findings highlight the critical need for policies and interventions to decrease socio-economic marginalization and criminalization among PWID living with HIV alongside the scale up of access to harm reduction services.

Disparities in uptake of direct-acting antiviral therapy for hepatitis C among people who inject drugs in a Canadian setting.

BACKGROUND & AIMS: Despite the high burden of hepatitis C virus (HCV) infection among people who inject drugs (PWID), uptake of interferon-based therapies has been extremely low. Increasing availability of direct-acting antiviral (DAA)-based therapies offers the possibility of rapid treatment expansion with the goal of controlling the HCV epidemic. We evaluated DAA-based treatment uptake among HCV-positive PWID in Vancouver after introduction of DAAs in the government drug formulary. METHODS: Using data from three cohorts of PWID in Vancouver, Canada, we investigated factors associated with DAA-therapies uptake among participants with HCV between April 2015 and November 2017. RESULTS: Of the 915 HCV-positive PWID, 611 (66.8%) were recent PWID and 369 (40.3%) had HIV coinfection. During the study period, 146 (16.0%) initiated DAA-therapies, a rate of 6.0 per 100 person-year, with higher initiation rates among non-recent PWID and an increasing trend over time. In multivariable analysis, HIV coinfection (Adjusted Odds Ratio [AOR] = 2.29, 95% Confidence Interval [CI]: 1.55-3.40), white race (AOR = 1.56, 95% CI: 1.05-2.35), and engagement in HCV care (AOR = 1.94, 95% CI: 1.31-2.90) were positively associated with DAA-therapies uptake, while high-risk drinking (AOR = 0.47, 95% CI: 0.23-0.88) and daily crack use were negatively associated (AOR = 0.41, 95% CI: 0.17-0.85). Among recent PWID, engagement in opioid agonist therapy emerged as an independent correlate of DAA uptake. CONCLUSIONS: Despite increases in HCV treatment uptake among PWID after the introduction of DAAs in our setting, disparities in access remain. Social-structural and behavioural barriers to HCV care should be addressed for the success of any HCV elimination strategy.

Successful treatment with slow-release oral morphine following afentanyl-related overdose: A case report.

Background: Overdose deaths as a result of untreated opioid use disorder (OUD) pose a major public health concern across North America. Although slow-release oral morphine (SROM) is increasingly used as an alternative option for the treatment of OUD, research on its efficacy among individuals exposed to illicit fentanyl or those with previous unsuccessful attempts with other opioid agonist therapies (OATs) is limited and controversial. Case: We present a case of a 48-year-old male with severe OUD seeking treatment following a near-fatal fentanyl overdose. His previous treatment attempts with methadone and buprenorphine/naloxone-based OAT had been unsuccessful. As per local guidelines, he was started on SROM with subsequent cessation of opioid cravings and illicit drug use. Discussion: This case report describes a patient entering early remission for OUD when treated with SROM following unsuccessful past treatment attempts on first-line oral medications. Future studies should seek to evaluate SROM-based OAT as a potential second-line treatment alternative for OUD.

Patterns of Transmitted Drug Resistance and Virological Response to First-line Antiretroviral Treatment Among Human Immunodeficiency Virus-Infected People Who Use Illicit Drugs in a Canadian Setting.

BACKGROUND: Transmitted drug resistance (TDR) may compromise response to antiretroviral therapy (ART). However, there are limited data on TDR patterns and impacts among people who use illicit drugs (PWUD). METHODS: Data were drawn from 2 prospective cohorts of PWUD in Vancouver, Canada. We characterized patterns of TDR among human immunodeficiency virus (HIV)-infected PWUD, and assessed its impacts on first-line ART virological outcomes. RESULTS: Between 1996 and 2015, among 573 ART-naive PWUD (18% with recent HIV infection), the overall TDR prevalence was 9.8% (95% confidence interval [CI], 7.3%-12.2%), with an increasing trend over time, from 8.5% in 1996-1999 to 21.1% in 2010-2015 (P = .003), mainly driven by resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs). TDR-associated mutations were more common for NNRTIs (5.4%), followed by nucleoside reverse transcriptase inhibitors (3.0%) and protease inhibitors (1.9%). TDR prevalence was lower among recently infected PWUD (adjusted odds ratio, 0.39 [95% CI, .15-.87]). Participants with TDR had higher risk of virological failure than those without TDR (log-rank P = .037) in the first year of ART. CONCLUSIONS: Between 1996 and 2015, TDR prevalence increased significantly among PWUD in Vancouver. Higher risk of virological failure among PWUD with TDR may be explained by some inappropriate ART prescribing, as well as undetected minority resistant variants in participants with chronic HIV infection. Our findings support baseline resistance testing early in the course of HIV infection to guide ART selection among PWUD in our setting.