Remote harm reduction services are key solutions to reduce the impact of COVID-19-like crises on people who use drugs: evidence from two independent structures in France and in the USA.

BACKGROUND: Harm Reduction (HR) policies for People Who Use Drugs (PWUD) have a significant positive impact on their health. Such approaches limit the spread of infections and reduce opioid overdose mortality. These policies have led to the opening of specialized structures located mainly in big cities and urbanized zones. The COVID-19 pandemic reduced access to HR structures in locations undergoing lockdown. Before the pandemic, HR services in France and in the USA were complemented by the development of remote HR programs: HaRePo (Harm Reduction by Post) for France, implemented in 2011, and NEXT Distro for the USA founded in 2017. These programs are free and specifically designed for people who have difficulties accessing HR tools and counseling in-person. PWUD can access HaRePo program by phone and/or email. NEXT Distro users can access the program through its dedicated website. The aim of the study is to test if and possibly how COVID-19 pandemic and the associated lockdowns have impacted the HR services in both countries. METHODS: By using t-test comparing the year 2019 with the year 2020, we analyzed how lockdowns impacted the number of new users entering the programs, as well as the numbers of parcels sent and naloxone distributed, by using records of both structures. RESULTS: We showed that the activity of both programs was significantly impacted by the pandemic. Both show an increase in the number of new users joining the programs (+ 77.6% for HaRePo and + 247.7% for NEXT Distro) as well as for the number of parcels sent per month (+ 42.7% for HaRePo and + 211.3% for NEXT Distro). It shows that remote HR was able to partially compensate for the reduced HR activities due to COVID-19. We also observed that the distribution of naloxone per parcel tends to increase for both structures. CONCLUSION: With the ability to reach PWUD remotely, HaRePo and NEXT Distro were particularly effective at maintaining service continuity and scaling up services to meet the needs of PWUD during the COVID-19 pandemic. By studying two independent structures in France and in the USA sharing similar objectives (remote HR), we showed that this approach can be a key solution to crises that impact classical HR structures despite various differences in operating procedures between countries.

[Which psychoactives substances are found in used syringes?] / Analyse des seringues usagées : un reflet de la consommation de substances psychoactives par les usagers de drogues par voie intraveineuse ?

OBJECTIVE: The aim of this study is to analyze the residual content of used syringes. METHODS: Used syringes were collected in March 2014 at 9 sites in Marseille (automatic injection kit dispensers, streets, drug-user risk reduction centers [Centres d'accueil et d'accompagnement à la réduction de risques pour usagers de drogues [CAARUD]). Several substances (n=28) were investigated using liquid chromatography and mass spectrometry method. RESULTS: On average, 2±1 substances in each syringe were found among 254 syringes analyzed. The most detected substances were cocaine, buprenorphine, methylphenidate and cathinones (in 57 %, 56 %, 39 % and 19 % of the syringes respectively). Heroin and morphine were found in 10 % of the syringes. DISCUSSION-CONCLUSION: This study helps define the main substances consumed by injection drugs users. It highlighted differencies in used substances according to neighborhood and site of collection and thus help to adjust prevention and harm reduction strategies.

Substances detected in used syringes of injecting drug users across 7 cities in Europe in 2017 and 2018: The European Syringe Collection and Analysis Project Enterprise (ESCAPE).

BACKGROUND AND AIMS: Injecting drug use is a matter of public health concern, associated with risks of overdoses, addiction and increased risk of bloodborne viral transmissions. Self-reported data on substances injected can be inaccurate or subject to bias or drug users might be oblivious to their injected substances or adulterations. Gathering of robust analytical information on the actual composition of substances injected might provide better information about the drugs that are being used. Therefore, this study aimed to analyse the residual content of discarded syringes collected across 7 European cities, collectively called the European Syringe Collection and Analysis Project Enterprise (ESCAPE). METHODS: Used syringes were collected at street automatic injection kit dispensers or at harm-reduction services in Amsterdam, Budapest, Cologne, Glasgow, Helsinki, Lausanne and Paris. Two sampling periods were executed thus far, in 2017 and 2018. Qualitative chemical analysis of the content of used syringes was performed combining gas chromatographic (GC) and ultra(high)performance liquid chromatographic ((U)HPLC) analytical techniques with detection by mass spectrometry (MS). RESULTS: Substances detected most frequently across both campaigns were cocaine, heroin, buprenorphine, amphetamines and synthetic cathinones. In Amsterdam, Cologne, Lausanne and Glasgow heroin and cocaine were the psychoactive substances most often detected, often in conjunction with each other. Helsinki showed a high presence of buprenorphine and amphetamines. In Budapest and Paris, synthetic cathinones were frequently detected. Less synthetic cathinones and cocaine was detected in 2018, whereas buprenorphine was detected almost twice as much. Inner-city variations were found, probably reflecting the types of people who inject drugs (PWID) in different areas of the city. CONCLUSION: Overall, laboratory-confirmed local data on injected substances showed resemblance to national surveys done among PWID. However, the ESCAPE data also showed some interesting differences, showing it can be used for local interventions and complementing existing monitoring data.

HaRePo (harm reduction by post): an innovative and effective harm reduction programme for people who use drugs using email, telephone, and post service.

BACKGROUND: Despite multiple harm reduction (HR) programmes worldwide, there are still an important number of people who use drugs (PWUD) who do not access those services. Their difficulties to obtain HR tools are due to their inability to reach such services (remoteness and/or limited customer service hours), costs, quantitative restrictions, fear of judgement, lack of confidentiality in pharmacy, and unfamiliarity with HR programmes. We tested an innovative approach using the power of remote online communication and the national postal distribution network to improve HR tool access and counselling. METHODS: Based on these observations, SAFE association created HaRePo in 2011, a free and confidential programme designed for people who have difficulties accessing HR tools and counselling. PWUD can access the programme by phone and/or email. An HR professional delivers HR counselling and HR tools and connects PWUD to other HR services, medical, and social workers. HR tools are prepared and sent according to the person's needs through the French postal service to consumers across Metropolitan France and overseas territories. RESULTS: Since 2011, 1920 PWUD have benefited from HaRePo: 10,450 parcels were sent accounting for more than 1.7 million syringes and 6 million HR-related items. HaRePo receives positive feedback from PWUD who have improved their practices through remote but trusted communication. The percentage of people that, after joining the programme, never reuse and/or share HR tools have significantly increased. On average, 71.5% of beneficiaries never reuse syringes and 81% do not reuse needles. And they are 98.5% consumers who never share syringes and 99% needles any longer. Between 44 and 80% HaRePo beneficiaries have reported that their drug-related practices (injection, inhalation, and snorting) are now safer. Finally, between 39 and 53% HaRePo consumers declared that their overall physical state has improved (e.g. venous condition, the appearance of point of injection, swelling of arms, legs, and hands). CONCLUSION: HaRePo is an innovative HR programme efficient for hard-to-reach PWUD. It shows evidence of a positive feedback loop for PWUD in improving their practices. Finally, HaRePo represents a clear benefit for health authorities in France, who decided to expand the programme in 2016.

Age of Initiation and Patterns of Use among People Who Inject Drugs Welcomed in Harm Reduction Facilities in France from 2006 to 2015.

This exploratory analysis of time-series cross-sectional data provides insights on trends in age at first injection among people who inject drugs in France, and on associations with recent risky injecting behaviors. Data were collected from a national survey conducted in harm reduction facilities in five phases between 2006 and 2015. Standardized questionnaires collected information on demographics, substance use, and route of administration, as well as lifetime and past-month injection. Descriptive and multilevel models were applied to account for the hierarchical structure of the data. Prevalence of lifetime and past-month injection remained stable over time, while the prevalence of daily injection increased significantly. Mean age at first injection only appeared to increase for data collected after 2010. Gender differences in mean age at first injection decreased over time, suggesting the development of converging patterns of initiation independent of sex. After controlling for covariates, early initiation of injection was unrelated to daily injection or material sharing, and associated with the number of recently injected substances. Early initiation is likely a predictor of injected polysubstance use. Findings are relevant to the planning, implementation, and evaluation of prevention programs.

Theory versus practice, bacteriological efficiency versus personal habits: A bacteriological and user acceptability evaluation of filtering tools for people who inject drugs.

INTRODUCTION AND AIMS: People who inject drugs (PWID) are exposed to associated viral, bacterial and fungal risks. These risks can be reduced by filtration. Large disparities in the quality of filtration exist between the various available filters. This paper compares both performance and user acceptability of three filters for drug injection (cotton filters, Sterifilt® and wheel filters) by combining epidemiological and bacteriological analyses. DESIGN AND METHODS: A cross-sectional epidemiological study (ANRS-Coquelicot) using time-location sampling combined with the generalised weight sampling method was conducted among 985 PWID in France. Two filtration-based bacteriological studies of 0.20- and 0.45-µm wheel filters, Sterifilt filters and cotton filters were also conducted. RESULTS: The bacteriological study highlighted the value of using wheel filters with a porosity of less than 0.5 µm, as they limit the risk of bacterial and fungal infection. The results of this study clearly highlight a distinction between the efficiency of Sterifilt and wheel filters, the latter being more effective. Our epidemiological study highlighted that the use of cotton filters is widespread and routine, but is the subject of much criticism among PWID. Sterifilt is not widely used, and its adoption is slow. Finally, the wheel filter remains a largely untested tool. DISCUSSION AND CONCLUSIONS: Low product retention and ease of use are the two most important factors for filters for PWID. Bacterial and fungal risk filtration is less important. It is essential to educate PWID about the benefits of wheel filters. [Jauffret-Roustide M, Chollet A, Santos A, Benoit T, Péchiné S, Duplessy C, Bara J-L, Lévi Y, Karolak S, Néfau T. Theory versus practice, bacteriological efficiency versus personal habits: A bacteriological and user acceptability evaluation of filtering tools for people who inject drugs. Drug Alcohol Rev 2018;37:106-115].

Online test purchased new psychoactive substances in 5 different European countries: A snapshot study of chemical composition and price.

BACKGROUND: New psychoactive substances (NPS) are on offer worldwide online, in order to shed light on the purity and price of these substances in the European Union, a research collaboration was set up involving France, United Kingdom (UK), the Netherlands, Czech Republic and Poland. METHODS: Per country, around 10 different NPS were test purchased from different webshops. Then, chemical analysis of NPS was done with according reference standards to identify and quantify the contents. RESULTS: In contrast to what is generally advertised on the webshops (>99%), purity varied considerably per test purchased NPS. Several NPS were mislabelled, some containing chemical analogues (e.g. 25B/C-NBOMe instead of 25I-NBOMe, pentedrone instead of 3,4-DMMC). But in some cases NPS differed substantially from what was advertised (e.g. pentedrone instead of AMT or 3-FMC instead of 5-MeO-DALT). Per gram, purity-adjusted prices of cathinones differed substantially between three countries of test purchase, with Poland being the least expensive. Synthetic cannabinoids were relatively the most expensive in the Czech Republic and least expensive in the UK. CONCLUSION: The current findings provides a snapshot of the price and chemical contents of NPS products purchased by different countries and in different webshops. There is a potential danger of mislabelling of NPS. The great variety in price and purity of the delivered products might be the result of the market dynamics of supply and demand and the role of law enforcement in different European countries.

The removal of illicit drugs and morphine in two waste water treatment plants (WWTPs) under tropical conditions.

The consumption of drugs of abuse has been recently investigated in Martinique using the back-calculation approach, also called the "sewage epidemiology" method. Results demonstrated a very high consumption considering the international data. Wastewater treatment plants (WWTPs) are located just behind the Martinique island shoreline, and effluents could impact the vulnerable corals and marine seagrass ecosystem. The present article aims to determine a WWTP's efficiency by comparing the influent and effluent of two WWTPs, with different residence times and biological treatments, located either outdoors or indoors. In parallel, a degradation study is conducted using spiked wastewater exposed to tropical and ambient temperatures. Results demonstrate the consistent efficiency of the two processes, especially for the outdoor WWTP which uses the activated sludge process. The positive effect of the tropical temperature is showed by the increase of cocaine degradation at 31 °C. Thus, low illicit drug residue concentrations in effluent would indicate that wastewater treatment is efficient and even enhanced under tropical context. This fact should be confirmed with others molecules. Furthermore, our results highlight the need for subsequent studies of sludge contamination because of their local recycling as compost.

Drug analysis of residual content of used syringes: a new approach for improving knowledge of injected drugs and drug user practices.

BACKGROUND: Since their inception, harm reduction services, including needle exchange programs, have aimed to improve and update knowledge about illicit drug consumption and injection practices in order to assess and regularly revise the effectiveness of preventive strategies. METHODS: In this paper we describe the development of a scientific approach to obtaining this type of information through analysis of the residual content of used syringes. This was done using a validated liquid chromatography method with mass spectrometry detection to identify different molecules. Used syringes were collected from automatic injection kit dispensers at 17 sites in Paris and the surrounding suburbs each month for one year. RESULTS: In total, 3489 syringes were collected. No compounds were detected in 245 syringes. Heroin was the most commonly observed compound (42%), followed by cocaine (41%), buprenorphine (29%) and 4-methylethylcathinone (23%). These analyses also showed the increased appearance of 4-methylethylcathinone between the summer and winter of 2012. CONCLUSIONS: Despite the bias involved in this approach, the method can provide rapid data on patterns of drug consumption for specific time periods and for well-defined locations. This kind of analysis enables the detection of new substances being injected and thus enables harm reduction services to revise and adapt prevention strategies.

Spatial differences and temporal changes in illicit drug use in Europe quantified by wastewater analysis.

AIMS: To perform wastewater analyses to assess spatial differences and temporal changes of illicit drug use in a large European population. DESIGN: Analyses of raw wastewater over a 1-week period in 2012 and 2013. SETTING AND PARTICIPANTS: Catchment areas of wastewater treatment plants (WWTPs) across Europe, as follows: 2012: 25 WWTPs in 11 countries (23 cities, total population 11.50 million); 2013: 47 WWTPs in 21 countries (42 cities, total population 24.74 million). MEASUREMENTS: Excretion products of five illicit drugs (cocaine, amphetamine, ecstasy, methamphetamine, cannabis) were quantified in wastewater samples using methods based on liquid chromatography coupled to mass spectrometry. FINDINGS: Spatial differences were assessed and confirmed to vary greatly across European metropolitan areas. In general, results were in agreement with traditional surveillance data, where available. While temporal changes were substantial in individual cities and years (P ranging from insignificant to <10(-3) ), overall means were relatively stable. The overall mean of methamphetamine was an exception (apparent decline in 2012), as it was influenced mainly by four cities. CONCLUSIONS: Wastewater analysis performed across Europe provides complementary evidence on illicit drug consumption and generally concurs with traditional surveillance data. Wastewater analysis can measure total illicit drug use more quickly and regularly than is the current norm for national surveys, and creates estimates where such data does not exist.

Presence of illicit drugs and metabolites in influents and effluents of 25 sewage water treatment plants and map of drug consumption in France.

Consumption of illicit drugs is a new concern for water management that must be considered not only because of the social and public health aspects but also in an environmental context in relation with the contamination of surface waters. Indeed, sewage treatment plant (STP) effluents contain drug residues that have not been eliminated since STP treatments are not completely efficient in their removal. We developed and validated an HPLC-MS/MS analytical method to assess the concentrations of 17 illicit drugs and metabolites in raw urban wastewaters: cocaine and its metabolites, amphetamine and amphetamine-likes (methamphetamine, MDMA, MDEA, MDA), opiates and opiate substitutes (methadone and buprenorphine), and THC-COOH cannabis metabolite. This method has been applied to the analysis of influent and effluent samples from 25 STPs located in France all over the country. The results allowed evaluating the drug consumption in the areas connected to the STPs and the efficiency of the treatment technology implied. We selected STPs according to their volume capacity, their treatment technologies (biofilters, activated sludges, MBR) and their geographical location. In influents, the concentrations varied between 6 ng/L for EDDP (main metabolite of methadone) and 3050 ng/L for benzoylecgonine (cocaine metabolite). Consumption maps were drawn for cocaine, MDMA, opiates, cannabis and amphetamine-like compounds. Geographical significant differences were observed and highlighted the fact that drug consumption inside a country is not homogeneous. In parallel, comparisons between STP technology processes showed differences of efficiency. More, some compounds appear very resistant to STP processes leading to the contamination of receiving water.

Hepatitis C transmission in injection drug users: could swabs be the main culprit?

Prevention programs for intravenous drug users have proven their efficacy in decreasing human immunodeficiency virus transmission but have limited effect on hepatitis C virus (HCV) contamination. A study was conducted to document the presence of HCV genome (HCV RNA) in 620 items of used injecting paraphernalia collected from representative sites. Using sensitive molecular techniques, HCV RNA was not detected on used filters or water vials and was seldom detected on cups (9%). However, HCV RNA was frequently found on syringe pools (38%) and on swabs (82%) at high titers. Our investigation, which was conducted in real injecting settings, highlights swabs as a potential source for HCV transmission.

Estimation of illicit drugs consumption by wastewater analysis in Paris area (France).

Illicit drugs consumption is actually an important public health concern that needs to be well defined to be managed. A new method, expressed as sewage epidemiology has been proposed by Daughton and developed by Zuccato. This method involves estimating the consumption from the measurement of drug residues in sewage. Several studies have been carried out, leading to an assessment of drugs consumption in some European countries. This work, carried out in Paris area (France) brings new data to this assessment and allows a comparison of cocaine and MDMA consumptions with European estimations. Four wastewater treatment plants (WWTPs) have been retained for the study, taking into account biological treatment, volume capacity, geographic location and social environment. Cocaine and its major metabolite benzoylecgonine (BZE), amphetamine, 3,4-methylenedioxymethamphetamine (MDMA) and buprenorphine were measured in raw water and WWTP effluent using HPLC-MS/MS after SPE extraction. Amphetamine was rarely detected. Cocaine and BZE were quantified at levels from 5 to 282 ng L(-1) and 15 to 849 ng L(-1), respectively. MDMA and buprenorphine concentrations remained under 20 ng L(-1). Cocaine consumption was estimated from cocaine or BZE concentrations measured in raw water and the results showed significant difference in drug taking during week or weekend. The estimated doses observed in this study are lower than those reported for others countries, especially Spain and Italy. MDMA consumption was estimated at lower levels than cocaine.