Addressing Mental Health Barriers in HIV Care Coordination Is Crucial to Providing Optimal HIV/AIDS Care.

For people with HIV (PWH) who have psychological comorbidities, effective management of mental health issues is crucial to achieving and maintaining viral suppression. Care coordination programs (CCPs) have been shown to improve outcomes across the HIV care continuum, but little research has focused on the role of care coordination in supporting the mental health of PWH. This study reports qualitative findings from the Program Refinements to Optimize Model Impact and Scalability based on Evidence (PROMISE) study, which evaluated a revised version of an HIV CCP for Ryan White Part A clients in New York City. Semistructured interviews were conducted with 30 providers and 27 clients from 6 CCP-implementing agencies to elucidate barriers and facilitators of program engagement. Transcripts were analyzed for key themes related to clients' mental health needs and providers' successes and challenges in meeting these needs. Providers and clients agreed that insufficiently managed mental health issues are a common barrier to achieving and maintaining viral suppression. Although the CCP model calls for providers to address clients' unmet mental health needs primarily through screening and referrals to psychiatric and/or psychological care, both clients and providers reported that the routine provision of emotional support is a major part of providers' role that is highly valued by clients. Some concerns raised by providers included insufficient training to address clients' mental health needs and an inability to document the provision of emotional support as a delivered service. These findings suggest the potential value of formally integrating mental health services into HIV care coordination provision. ClinicalTrials.gov protocol number: NCT03628287.

Syndemic factors associated with non-fatal overdose among young opioid users in New York City.

Introduction: Rates of illicit opioid use are particularly high among young adults, yet research on overdose experience and factors associated with overdose in this population remains limited. This study examines the experiences and correlates of non-fatal overdose among young adults using illicit opioids in New York City (NYC). Methods: 539 participants were recruited via Respondent-Driven Sampling in 2014-2016. Eligibility criteria included: aged 18-29 years old; current residence in NYC; and nonmedical prescription opioid (PO) use and/or heroin use in the past 30 days. Participants completed structured interviews to assess their socio-demographics, drug use trajectories, current substance use and lifetime and most recent overdose experiences, and were tested on-site for hepatitis C virus (HCV) antibodies. Results: 43.9% of participants reported lifetime overdose experience; of these, 58.8% had experienced two or more overdose events. The majority of participants' most recent overdoses (63.5%) were due to polysubstance use. In bivariable analyses, after RDS adjustment, having ever overdosed was correlated with: household income of >$100,00 growing up (vs. $51,000-100,000); lifetime homelessness; HCV antibody-positive status; lifetime engagement in regular nonmedical benzodiazepine use, regular heroin injection and regular PO injection; and using a non-sterile syringe in the past 12 months. Multivariable logistic regression identified childhood household income >$100,00 (AOR=1.88), HCV-positive status (AOR=2.64), benzodiazepine use (AOR=2.15), PO injection (AOR=1.96) and non-sterile syringe use (AOR=1.70) as significant independent correlates of lifetime overdose. A multivariable model with multiple overdoses (vs. one) found only lifetime regular heroin use and PO injection to be strong correlates. Discussion: Results indicate a high prevalence of lifetime and repeated overdose among opioid-using young adults in NYC, highlighting a need for intensified overdose prevention efforts for this population. The strong associations of HCV and indices of polydrug use with overdose suggest that prevention efforts should address the complex risk environment in which overdose occurs, attending to the overlapping nature of disease-related risk behavior and overdose risk behavior among young people who inject opioids. Overdose prevention efforts tailored for this group may find it useful to adopt a syndemic conception of overdose that understands such events as resulting from multiple, and often interrelated, risk factors.

Why Young Women Who Use Opioids Are at Risk for Rape: The Impact of Social Vulnerabilities and Sexually Coercive Drug Using Contexts.

This study tests a theoretically informed model to understand why women who use opioids (WWUO) are at risk of rape while using drugs. Structured interviews were conducted with 168 WWUO. Three domains were hypothesized to increase risk: the sexually coercive context of drug use, women's social vulnerability, and drug use severity. Logistic regression examined the odds of being raped by domain. One-third of WWUO had been raped while using drugs. The sexually coercive context and social vulnerability domains significantly increased women's odds of being raped. Prevention efforts should target social and contextual factors.

Hepatitis C virus risk among young people who inject drugs.

Background: Injection drug use (IDU) is the leading risk factor for hepatitis C virus (HCV) transmission in the U.S. While the general risk factors for HCV transmission are known, there is limited work on how these factors interact and impact young people who inject drugs (YPWID). Methods: Project data were drawn from a study of 539 New York City (NYC) residents ages 18-29 who were recruited via Respondent-Driven Sampling and, reported past-month non-medical use of prescription opioids and/or heroin. Analyses are based on a subsample of 337 (62%) who reported injecting any drug in the past 12 months. All variables were assessed via self-report, except HCV status, which was established via rapid antibody testing. Integrating the observed statistical associations with extant literature on HCV risk, we also developed a qualitative system dynamics (SD) model to use as a supplemental data visualization tool to explore plausible pathways and interactions among key risk and protective factors for HCV. Results: Results showed a 31% HCV antibody prevalence with an overall incidence of 10 per 100 person-years. HCV status was independently correlated with having shared cookers with two or more people (AOR = 2.17); injected drugs 4-6 years (AOR = 2.49) and 7 or more years (AOR = 4.95); lifetime homelessness (AOR = 2.52); and having been incarcerated two or more times (AOR = 1.99). These outcomes along with the extant literature on HCV risk were used to develop the qualitative SD model, which describes a causal hypothesis around non-linearities and feedback loop structures underlying the spread of HCV among YPWID. Conclusions: Despite ongoing harm reduction efforts, close to a third of YPWID in the community sample have been exposed to HCV, have risks for injection drug use, and face challenges with structural factors that may be preventing adequate intervention. The qualitative SD model explores these issues and contributes to a better understanding of how these various risk factors interact and what policies could potentially be effective in reducing HCV infections.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts.

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Lessons from the First Wave of COVID-19 for Improved Medications for Opioid Use Disorder (MOUD) Treatment: Benefits of Easier Access, Extended Take Homes, and New Delivery Modalities.

Background Medications for Opioid Use Disorder (MOUD) are associated with important public health benefits. Program changes implemented in response to COVID-19 hold promise as ongoing strategies to improve MOUD treatment. Methods: MOUD patients on buprenorphine or methadone, providers, government regulators, and persons who use drugs not in MOUD were recruited in the Northeast region of the United States between June and October of 2020 via advertisements, fliers, and word of mouth. Semi-structured qualitative interviews were conducted. Interviews were professionally transcribed and thematically coded by two independent coders. Results: We conducted interviews with 13 people currently on buprenorphine, 11 currently on methadone, 3 previously on buprenorphine, 4 previously on methadone, and 6 who used drugs but had never been on MOUD. In addition, we interviewed MOUD providers, clinic staff, and government officials at agencies that regulate MOUD. Most participants found increased take-home doses, home medication delivery, and telehealth implemented during COVID-19 to be favorable, reporting that these program changes reduced travel time to clinics, facilitated retention in care, and reduced stigma associated with clinic attendance. However, some participants reported negative consequences of COVID-19, most notably, decreased access to basic resources, such as food, clothing, and harm reduction materials that had previously been distributed at some MOUD clinics. Conclusion: Access to and retention in MOUD can be lifesaving for persons using drugs. COVID-19-impelled program changes, including increased take-home doses, home medication delivery, and telehealth generally improved participants' experiences with MOUD. Making these permanent could improve retention in care.

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health.

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

"It's like 'liquid handcuffs": The effects of take-home dosing policies on Methadone Maintenance Treatment (MMT) patients' lives.

BACKGROUND: Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing risk of overdose, arrest, and transmission of blood-borne viruses like HIV and HCV among people that use opioids. Yet, MMT's use of restrictive take-home dose policies that force most patients to attend their clinic on a daily, or near-daily, basis may be unpopular with many patients and lead to low rates of treatment uptake and retention. In response, this article examines how clinics' take-home dosing policies have affected patients' experiences of treatment and lives in general. METHODS: This article is based on semi-structured, qualitative interviews with a variety of stakeholders in MMT. Interviews explored: reasons for engaging with, or not engaging with MMT; how MMT is conceptualized by patients and treatment providers (e.g., as harm reduction or route to abstinence and/or recovery); experiences with MMT; perception of barriers to MMT (e.g., organizational/regulatory, social) and how MMT might be improved to support peoples' substance use treatment needs and goals. RESULTS: Nearly all of the patients with past or present MMT use were highly critical of the limited access to take-home doses and consequent need for daily or near daily clinic attendance. Participants described how the use of restrictive take-home dose policies negatively impacted their ability to meet day-to-day responsibilities and also cited the need for daily attendance as a reason for quitting or avoiding OAT. Responses also demonstrate how such policies contribute to an environment of cruelty and stigma within many clinics that exposes this already-stigmatized population to additional trauma. CONCLUSIONS: Take-home dose policies in MMT are not working for a substantial number of patients and are reasonably seen by participants as degrading and dehumanizing. Revision of MMT regulations and policies regarding take home doses are essential to improve patient satisfaction and the quality and effectiveness of MMT as a key evidence-based treatment and harm reduction strategy.

Adverse Childhood Experiences Predict Early Initiation of Opioid Use Behaviors.

Introduction: Although a substantial body of research documents a relationship between traumatic stress in childhood and the initiation of substance use later in the life course, only limited research has examined potential linkages between adverse childhood experiences (ACEs) and the initiation of non-medical prescription opioid use and other opioid use behaviors. The present study contributes to this growing body of work by investigating the association of childhood trauma with early initiation of a series of opioid use behaviors. Methods: New York City young adults (n = 539) ages 18-29 who reported non-medical use of prescription opioids or heroin use in the past 30 days were recruited using Respondent-Driven Sampling in 2014-16. Ten ACEs were assessed via self-report with the ACE Questionnaire. Associations between number of ACEs and self-reported ages of initiating seven opioid use behaviors (e.g., non-medical prescription opioid use, heroin use, heroin injection) were estimated with multivariable logistic regression. Results: Eighty nine percent of participants reported at least one ACE, and 46% reported four or more ACEs, a well-supported threshold indicating elevated risk for negative health consequences. Every increase of one trauma was associated with a 12-23% increase in odds of early initiation across the seven opioid use behaviors. Findings also document that the mean age at initiation increased with increasing risk severity across the behaviors, contributing to evidence of a trajectory from opioid pill misuse to opioid injection. Discussion: Increasing number of childhood traumas was associated with increased odds of earlier initiation of multiple opioid misuse behaviors. In light of prior research linking earlier initiation of substance use with increased substance use severity, present findings suggest the importance of ACEs as individual-level determinants of increased opioid use severity. Efforts to prevent onset and escalation of opioid use among at-risk youth may benefit from trauma prevention programs and trauma-focused screening and treatment, as well as increased attention to ameliorating upstream socio-structural drivers of childhood trauma.

Web-based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: How did it work and for whom?

This study explored mediating pathways, moderating factors, and moderated mediation effects of a web-based, cognitive behavioral therapy (CBT) intervention for chronic pain patients with aberrant drug-related behavior (ADRB). In a 2-arm RCT, patients with chronic pain who screened positive for ADRB received treatment-as-usual (TAU, n = 55) or TAU plus a 12-week, web-based CBT intervention (n = 55). Assessments were conducted at weeks 4, 8, and 12, and at 1- and 3-months post intervention. Web-CBT significantly reduced pain catastrophizing, which, in turn, reduced pain interference and pain severity via a pathway of pain catastrophizing. Web-CBT also significantly reduced ADRB both directly and indirectly by reducing pain catastrophizing. For pain interference and pain severity, web-CBT was more effective than TAU for younger patients (≤ age 50). For pain severity, web-CBT was more effective for both younger patients (≤ age 50), and those with a lifetime substance use disorder. Findings suggest that web-CBT's positive impact on pain outcomes and ADRB are mediated by its effect on pain catastrophizing, and its treatment effects may be most robust for younger patients and those with histories of substance dependence.

Hepatitis C testing and treatment uptake among young people who use opioids in New York City: A cross-sectional study.

Young people who use drugs have a rising hepatitis C (HCV) incidence in the United States, but they may face barriers to testing and treatment adoption due to stigma. We conducted a cross-sectional study of New York City residents aged 18-29 years who reported non-medical prescription opioid and/or heroin use in the past 30 days. Participants were recruited from the community between 2014-2016 via respondent-driven sampling. Participants completed an in-person structured survey that included questions about HCV testing and treatment and received HCV antibody testing. There were 539 respondents: 353 people who inject drugs (PWID) and 186 non-PWID. For PWID, median age was 25 years, 65% were male and 73% non-Hispanic White. For non-PWID, median age was 23 years, 73% were male and 39% non-Hispanic White. 20% of PWID and 54% of non-PWID had never been tested for HCV (P < .001). Years since first injection (aOR 1.16, CI: 1.02-1.32, P = .02) and history of substance use treatment (aOR 3.17, CI: 1.53-6.61, P = .02) were associated with prior testing among PWID. The seroprevalence of HCV among PWID was 25%, adjusted for sampling weights. Of the 75 who were aware of their HCV-positive status, 53% had received HCV-related medical care, and 28% had initiated treatment. HCV prevalence among young PWID is high, and many have never been tested. Injection experience and treatment engagement is associated with testing. Interventions to increase testing earlier in injection careers, and to improve linkage to HCV treatment, will be critical for young PWID.

The Opioid/Overdose Crisis as a Dialectics of Pain, Despair, and One-Sided Struggle.

The opioid/overdose crisis in the United States and Canada has claimed hundreds of thousands of lives and has become a major field for research and interventions. It has embroiled pharmaceutical companies in lawsuits and possible bankruptcy filings. Effective interventions and policies toward this and future drug-related outbreaks may be improved by understanding the sociostructural roots of this outbreak. Much of the literature on roots of the opioid/overdose outbreak focuses on (1) the actions of pharmaceutical companies in inappropriately promoting the use of prescription opioids; (2) "deaths of despair" based on the deindustrialization of much of rural and urban Canada and the United States, and on the related marginalization and demoralization of those facing lifetimes of joblessness or precarious employment in poorly paid, often dangerous work; and (3) increase in occupationally-induced pain and injuries in the population. All three of these roots of the crisis-pharmaceutical misconduct and unethical marketing practices, despair based on deindustrialization and increased occupational pain-can be traced back, in part, to what has been called the "one-sided class war" that became prominent in the 1970s, became institutionalized as neo-liberalism in and since the 1980s, and may now be beginning to be challenged. We describe this one-sided class war, and how processes it sparked enabled pharmaceutical corporations in their misconduct, nurtured individualistic ideologies that fed into despair and drug use, weakened institutions that created social support in communities, and reduced barriers against injuries and other occupational pain at workplaces by reducing unionization, weakening surviving unions, and weakening the enforcement of rules about workplace safety and health. We then briefly discuss the implications of this analysis for programs and policies to mitigate or reverse the opioid/overdose outbreak.

Prescription opioid injection among young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose.

AIM: Evidence is emerging that prescription opioid (PO) injection is associated with increased health risks. This mixed-methods study compares the mechanics of PO and heroin injection and examines the demographic and drug-related correlates of lifetime PO injection in a sample of young people who inject drugs (PWID) in New York City (NYC). METHODS: Qualitative analysis of 46 semi-structured interviews with young adult opioid users ages 18-32. Interview segments describing PO injection were analyzed for common themes. Quantitative analysis of structured interviews with 539 young adult opioid users ages 18-29 recruited via respondent-driven sampling (RDS). Analyses are based on the subsample of 353 participants (65%) who reported having ever injected drugs. All variables were assessed via self-report, except hepatitis C virus status, which was established via rapid antibody testing. RESULTS: Participants described injecting POs and reported that preparing abuse-deterrent pills for injection is especially cumbersome, requiring extended manipulation and large amounts of water. Injecting POs, in contrast to injecting heroin, requires repeated injections per injection episode. Among RDS-recruited participants, the majority of injectors reported injecting POs, sporadically (33%) or regularly (26%), but often infrequently (≤ 7 days/month). In separate multivariable analyses controlling for syringe- and cooker-sharing, ever injecting POs was a significant predictor of testing HCV antibody-positive (AOR = 2.97) and lifetime experience of non-fatal overdose (AOR = 2.51). Ever injecting POs was independently associated with lifetime homelessness (AOR = 2.93) and having grown up in a middle-income ($51,000-100,000/year vs. ≤ $50,000/year; AOR = 1.86) or a high-income household (> $100,000/year vs. ≤ $50,000/year; AOR = 2.54). CONCLUSIONS: Even in an urban environment like NYC with widespread heroin access, most young PWID have injected POs, although less frequently than heroin. PO injection involves practices that are known to increase risk for blood-borne viral infection (e.g., repeated injections) and predicted testing HCV-positive, as well as overdose. PO injection may also serve as a marker for a subgroup of PWID at elevated risk for multiple drug use-related comorbidities. Programs that provide prevention services to PWID need to tailor harm reduction measures and messaging to the specific practices and harms associated with the injection of POs.

Military veterans' overdose risk behavior: Demographic and biopsychosocial influences.

BACKGROUND: U.S. military veterans face many biopsychosocial (BPS) challenges post-service that may elevate risk for opioid-related overdose including physical pain, mental health concerns and social stressors. Some veterans use opioids to manage pain and cope with social readjustment. This study assessed associations between BPS factors and recent engagement in overdose risk behavior in a community sample of post-9/11 veterans who used opioids in New York City. METHODS: Participants (n = 218) were recruited through convenience sampling and completed a baseline assessment including a validated Opioid Risk Behavior Scale (ORBS) that measured past-30-day engagement in 22 opioid-related overdose risk behaviors. Analyses examined associations between ORBS scores and hypothesized demographic, biological/physical, psychological and social predictors. Incident rate ratios estimated the expected relative difference in ORBS score associated with each predictor. RESULTS: Participants reported an average of 4.72 overdose risk behaviors in the past 30 days. Significant independent predictors of higher ORBS score, after adjustment for demographics and current prescription medications, were past-30-day: depression symptoms; unsheltered or living in a homeless shelter (vs. private housing); history of mental health treatment; experiencing stressful life events; average pain severity; and pain interference. CONCLUSION: Veterans face myriad BPS challenges and, while drug-related overdose risks are well understood, findings suggest that other factors-including mental health, pain and stressful life events-may also be associated with overdose risk among opioid-using veterans. The larger challenges veterans face should be considered in the context of BPS forms of pain management when tailoring and delivering overdose prevention interventions.

A comparison of the utility of urine- and hair testing in detecting self-reported drug use among young adult opioid users.

BACKGROUND: Biological testing can be used to validate or detect underreported drug use. Since hair testing is increasingly used in survey research, we examined how the utility of hair testing compares to a more common method-urine testing. METHODS: 532 adults (ages 18-29) reporting past-month heroin use and/or nonmedical prescription opioid use were surveyed about past-month use of various drugs. Participants were urine-tested and the majority (79.3%) provided a hair sample for analysis. We examined the utility of urine vs. hair-testing in detecting past-month use of various drugs. RESULTS: Compared to hair testing, urine testing was able to confirm higher proportions of self-reported use of heroin/opioids (85.5% vs. 80.9%), marijuana (73.9% vs. 22.9%), benzodiazepines (51.3% vs. 15.1%), and methadone (77.0% vs. 48.7%), while hair testing was more likely to detect reported cocaine use (66.3% vs. 48.0%) (Ps<.01). Compared to hair testing, urine testing was more likely to detect unreported use of marijuana (11.3% vs. 0.9%), and benzodiazepines (14.4% vs. 5.4%), and hair testing was more likely to detect unreported use of cocaine (27.0% vs. 5.8%) and oxycodone (19.7% vs. 1.4%) (Ps<.001). When added to urine testing, hair testing increased detection of reported and non-reported use of cocaine and oxycodone ranging from 14 to 22%. CONCLUSIONS: While hair testing is efficacious in detecting drug use in wide window periods (e.g., past-year use), it is less efficacious than urine testing when testing for past-month use of select drugs among opiate/opioid users. However, hair testing is particularly efficacious in detecting unreported use of cocaine and/or oxycodone.

Development, validation, and potential applications of the hepatitis C virus injection-risk knowledge scale (HCV-IRKS) among young opioid users in New York City.

BACKGROUND: Hepatitis C virus (HCV) incidence has increased dramatically in the United States in recent years and is associated with the opioid epidemic due to high HCV transmission risk among people who inject drugs (PWID). HCV transmission knowledge is difficult to ascertain given the lack of psychometrically-tested measures. We developed and validated an HCV injection-risk knowledge scale. METHODS: Analyses used data from 539 New York City opioid users ages 18-29 recruited via respondent-driven sampling in 2014-16. Blood samples yielded HCV antibody status. Principal components analysis (PCA) of nine knowledge items answered true, false, or don't know identified useful scale items. We evaluated internal consistency with the Cronbach's alpha coefficient and assessed construct validity by comparing knowledge levels with those from a previously validated general HCV knowledge scale and by comparing key sub-group knowledge levels. RESULTS: PCA identified one component with five items that explained 45% of the total variance and had high internal consistency (alpha=0.91). All items referred to transmission through drug-injection equipment and practices: sharing cookers, cottons, diluting water, water containers, and cleaning syringes with water. The mean percent correct was 75%, and as expected, was moderately correlated with general HCV knowledge (Spearman's rho=0.55). As hypothesized, knowledge levels were highest for those previously tested for HCV, those with HCV antibody-positive status, PWID, and those who had received harm reduction information in various settings. CONCLUSIONS: The 5-item, validated HCV Injection-Risk Knowledge Scale (HCV-IRKS) may provide educators, care providers, and researchers with critical information for reducing HCV among PWID.

Network Research Experiences in New York and Eastern Europe: Lessons for the Southern US in Understanding HIV Transmission Dynamics.

PURPOSE: This paper presents an overview of different kinds of risk and social network methods and the kinds of research questions each can address. RECENT FINDINGS: It also reviews what network research has discovered about how network characteristics are associated with HIV and other infections, risk behaviors, preventive behaviors, and care, and discusses some ways in which network-based public health interventions have been conducted. Based on this, risk and social network research and interventions seem both feasible and valuable for addressing the many public health and social problems raised by the widespread use of opioids in the US South.

Young adults' opioid use trajectories: From nonmedical prescription opioid use to heroin, drug injection, drug treatment and overdose.

INTRODUCTION: Recent research has begun to explore the transition from nonmedical use of prescription opioids (POs) to heroin and injection drug use, adding to earlier literature identifying factors that influence the transition from intranasal to injection use of heroin. However, little research has explored how these transitions are embedded within young people's broader opioid use trajectories - individual pathways that may also include experiences of nonfatal overdose and drug treatment. METHODS: Data are from a study of 539 18-29 year-old New York City residents, recruited via Respondent-Driven Sampling, who reported past-month nonmedical use of POs and/or heroin use. Participants completed structured, computer-assisted interviews that included assessment of their ages at a series of "benchmark" events and experiences, including first use of a drug or route of administration, the onset of "regular" use of a drug (i.e., 1 or more times a week for at least 1 month), first overdose and first drug treatment. RESULTS: Results suggest a predictable, ordered pathway by which opioid use tends to progress in this cohort of young adults. Participants initiated nonmedical PO use at age 16.8, on average, and most transitioned to heroin use (83%) and heroin injection (64%), generally within 4 years of first PO misuse. Drug treatment was not typically accessed until after participants had progressed to heroin use. First overdose occurred <1 year after first heroin use, on average. CONCLUSIONS: Findings may help inform the optimal timing for delivery of primary, secondary and tertiary prevention efforts targeting young opioid users.

Heroin Use and Drug Injection among Youth Also Misusing Prescription Drugs.

OBJECTIVES: We identified the prevalence of nonmedical prescription drug use and its relationship to heroin and injection drug use in 4 nationally representative samples of adolescents. METHODS: We used the most recent data (2009-2015) from the Youth Risk Behavior Surveillance System (Ntotal= 61,132). Prevalence rates and 95% confidence intervals for prescription drug misuse, heroin use, and injection drug use were calculated across time points, sex, and race/ethnicity subgroups. Using odds ratios, we determined the likelihood of youth reporting nonmedical prescription drug use also reporting heroin and drug injection. RESULTS: In 2015, one in 6 adolescents reported recent prescription drug misuse. High rates of nonmedical prescription drug use persisted or increased among Hispanic boys, black boys, and "other" youth, while declining among white youth. Youth who used prescription drugs nonmedically at least once were 17.5 times more likely to have used heroin (CI: 13.7, 22.4) and 14.6 times more likely to have injected drugs (CI: 11.2, 19.2) in their lifetime. CONCLUSIONS: Public health programming focused on reducing prescription drug misuse also may reduce youth engagement in heroin and/or injection drug use. Preventive efforts to support communities of color in reducing rates of prescription drug misuse are crucial.