Attitudes Toward Injection Practices Among People Who Inject Drugs Utilizing Medical Services: Opportunities for Harm Reduction Counseling in Health Care Settings.

Hospitals are an important setting to provide harm reduction services to people who inject drugs (PWID). This study aimed to characterize PWID's injection practices, the perceived risk and benefits of those practices, and the immediate IDU risk environment among individuals seeking medical care. Surveys were administered to 120 PWID seeking medical services at an urban hospital. Poisson regression was used to examine the effect of perceived risk or importance of injection practices on the rate of engaging in those practices. The mean participant reported "often" reusing syringes and "occasionally" cleaning their hands or skin prior to injection. 78% of participants reported that syringes were extremely risky to share, which was associated with lower likelihood of sharing them (ARR: 0.59; 95% CI: 0.36-0.95). 38% of participants reported it was extremely important to use a new syringe for each injection, and these participants were more likely to report never reusing syringes >5 times (ARR: 1.62, 95% CI: 1.11-2.35). Other factors that may influence injection practices-including fear of arrest, withdrawal, lack of access to supplies, and injecting outdoors-were common among participants. In conclusion, practices that place PWID at risk of injury and infection are common, and risk-benefit perception is associated with some, but not all, injection practices. Injecting in challenging environments and conditions is common. Therefore, harm reduction counseling in medical settings must be accompanied by other strategies to reduce risk, including facilitating access to supplies. Ultimately, structural interventions, such as affordable housing, are needed to address the risk environment.

Substance use disorder bridge clinics: models, evidence, and future directions.

BACKGROUND: The opioid overdose and polysubstance use crises have led to the development of low-barrier, transitional substance use disorder (SUD) treatment models, including bridge clinics. Bridge clinics offer immediate access to medications for opioid use disorder (MOUD) and other SUD treatment and are increasingly numerous. However, given relatively recent implementation, the clinical impact of bridge clinics is not well described. METHODS: In this narrative review, we describe existing bridge clinic models, services provided, and unique characteristics, highlighting how bridge clinics fill critical gaps in the SUD care continuum. We discuss available evidence for bridge clinic effectiveness in care delivery, including retention in SUD care. We also highlight gaps in available data. RESULTS: The first era of bridge clinic implementation has yielded diverse models united in the mission to lower barriers to SUD treatment entry, and preliminary data indicate success in patient-centered program design, MOUD initiation, MOUD retention, and SUD care innovation. However, data on effectiveness in linking to long-term care are limited. CONCLUSIONS: Bridge clinics represent a critical innovation, offering on-demand access to MOUD and other services. Evaluating the effectiveness of bridge clinics in linking patients to long-term care settings remains an important research priority; however, available data show promising rates of treatment initiation and retention, potentially the most important metric amidst an increasingly dangerous drug supply.

Subcutaneous Extended-release Buprenorphine Depot Misdiagnosed as an Abscess Resulting in Incision and Drainage and Disruption of Opioid Use Disorder Treatment.

Monthly extended-release buprenorphine subcutaneous injection (BUP-XR) is a newer treatment formulation for use in moderate to severe opioid use disorder. After injection into the subcutaneous tissue of the abdomen, the medication forms a depot to allow for slow release of buprenorphine. As such, a small yet visible and palpable nodule is normal and is expected to decrease in size over the following weeks to months. Given the newness of this medication, it is possible that not all healthcare providers are familiar with this formulation, nor will they interpret the BUP-XR depot as normal findings. Herein, we provide a case report where a patient's BUP-XR depot was misdiagnosed as an abscess, resulting in incision and drainage and disruption of life-saving opioid use disorder treatment. To prevent cases like this in the future, it is important that providers administering BUP-XR properly educate patients on what to expect during treatment with BUP-XR and when to seek care for potential abnormalities. In addition, it is critical that healthcare providers working in other treatment settings are aware of how to properly evaluate BUP-XR injection sites.

Real-world outcomes with extended-release buprenorphine (XR-BUP) in a low threshold bridge clinic: A retrospective case series.

BACKGROUND: In clinical trial settings, extended-release buprenorphine (XR-BUP) is noninferior to sublingual buprenorphine and may offer some advantages. However, real-world experiences of XR-BUP are limited and outcomes are unknown for low-threshold clinics with high-risk populations. Practical guidance is lacking on overcoming treatment challenges, such as inability for some to stabilize on sublingual (SL) BUP for seven days prior to XR-BUP and ongoing craving/withdrawal symptoms during treatment. METHODS: Retrospective case series of a convenience sample of 40 serial adults with opioid use disorder (OUD) treated with XR-BUP from Massachusetts General Hospital bridge clinic from February 1, 2019, to July 31, 2019. RESULTS: Patients were mostly male (67.5%), non-Hispanic white (97.5%), unstably housed (77.5%), and average age of 32.1 years old. The average SL BUP dose prior to XR-BUP was 18.6 mg (standard deviation [SD] = 5; range 8-32) for an average treatment duration of 105 days (SD = 191; range 1-810). Ten (25%) patients received SL BUP for fewer than the seven recommended days (mean = 3.7, SD = 1.4, range = 1-6). Standard induction dosing was administered to 30%, empiric high-dose XR-BUP (300 mg monthly) was administered to 25%, and 55% were treated with supplemental SL BUP ranging from 4 to24mg, daily or as needed, for varying time periods. At the end of data collection, 65% remained on XR-BUP, 30% discontinued XR-BUP, and one patient was lost to follow-up. Acute care utilization rates were similar between patients who continued XR-BUP versus discontinued at 18.5% and 16.6%, respectively (χ2 = 0.02, p-value = 0.89). Toxicology was negative for other opioids in 65% of patients throughout treatment. There were no reports of overdose, withdrawal after use of opioids, or precipitated withdrawal after subsequent XR-BUP. Patients' most cited reason for discontinuing XR-BUP was a preference for SL BUP. CONCLUSION: This real-world evaluation of XR-BUP in a low-threshold clinic found that treatment was feasible, well tolerated, and outcomes were good, with most individuals choosing to continue treatment and a majority with no evidence of ongoing opioid use or precipitated withdrawal.