Public support for reinvesting resources from enforcing drug possession to health-promoting alternatives: A nationally representative poll of adults in the United States.

BACKGROUND: The legal enforcement of drug possession is associated with a host of negative consequences for people who use drugs (PWUD), has demonstrated little effectiveness at curbing drug use, and has contributed to lasting financial, social, and health-related racial disparities in Black and Brown communities in the United States (U.S.). One policy alternative is reinvesting resources typically used for enforcing drug possession into health-promoting services such as drug treatment or harm reduction that can better serve the needs of PWUD than the criminal legal system. We sought to characterize the prevalence and correlates of national public support for this reinvestment in the U.S. METHODS: A nationally representative sample of U.S. adults (N = 1,212) completed the Johns Hopkins COVID-19 Civic Life and Public Health Survey (wave three, fielded November 11-30, 2020). The outcome is support for reinvestment of resources spent on enforcing drug possession into health-promoting alternatives (i.e., drug treatment, harm reduction, housing support, or community-based resources). We measured potential correlates including socio-demographics and social/political attitudes, including political ideology (conservative, moderate, liberal) and racial resentment toward the Black community. Analyses accounted for complex survey weights. RESULTS: Weighted prevalence of support for reinvestment of resources was 80 %. Multivariable logistic regression (controlling for confounders) showed that white respondents were more likely than Black (OR = 2.51, 95% CI = 1.08, 5.87) to favor reinvestment. Respondents with moderate (OR = 0.34, 95 % CI = 0.15-0.79) or conservative (OR = 0.21, 95 % CI = 0.09-0.50) political ideology (compared to liberal) and medium (OR = 0.26, 95 % CI = 0.09-0.74) or high (OR = 0.12, 95 % CI = 0.04-0.35) levels of racial resentment (compared to low) were less likely to support reinvestment. CONCLUSION: There is substantial national support for reinvesting resources into health-promoting alternatives, though political ideology and racial resentment temper support. Results can inform targeted messaging to increase support for moving drug policy from the criminal legal sphere toward public health.

Strategies and Interventions Used to Prevent Violence Against Sex Workers in the United States: A Scoping Review Using the Social-Ecological Model.

Structural factors in the United States, such as criminalization, contribute to disproportionate rates of violence against sex workers and subsequent risk of adverse health outcomes. There is a clear need for systemic interventions and risk reduction strategies to reduce violence in this population. To inform next steps in prevention, this scoping review provides an overview of the literature on violence prevention efforts targeting sex workers in the United States, mapped out according to the social-ecological model (SEM). A comprehensive search of peer-reviewed literature across five databases with no limit on publication date yielded 2,372 documents. Studies were eligible for inclusion if they focused on the U.S. population of sex workers and had a clearly defined aim or purpose of exploring, describing, or evaluating sex work violence prevention interventions or risk reduction strategies. Twelve studies met all eligibility criteria and were selected. Only two of the studies evaluated sexual violence prevention interventions, while the remaining 10 explored strategies sex workers use to minimize the risk of violence. Most research focused on female sex workers, violence from paying clients, and prevention at the individual level of the SEM. Our findings suggest a need for additional violence prevention interventions tailored for diverse groups of sex workers and cognizant of the overlapping forms of violence they face. This scoping review contributes to the limited body of research on the prevention of violence against sex workers in the United States by providing future directions for research and program development that span across the SEM.

Implementation of Overdose Prevention in Maryland: Implications for Resource Allocation, Program Scale-Up, and Evaluation.

Overdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland's Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state's response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p = .04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States.

Exploring trauma and wellbeing of people who use drugs after witnessing overdose: A qualitative study.

BACKGROUND: The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior. METHODS: We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti. RESULTS: A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices. CONCLUSION: Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.

A Longitudinal Analysis of Residential Mobility and Experience of Client Violence Among Women Who Exchange Sex in Baltimore.

Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants were at least at 18 years of age, were cisgender women, reported having engaged in transactional sex three or more times within the last 3 months, and were willing to be contacted for 6-, 12-, and 18-month follow-up visits. Analyses of responses from 370 women who exchange sex participating in at least one study visit were conducted. Unadjusted and adjusted Poisson regression models of the association over time between residential mobility and recent experience of physical or sexual violence were fit. Generalized estimating equations with an exchangeable correlation structure and robust variance estimation were used to account for clustering of participants' responses over time. Findings demonstrated that those who had lived in at least four places in the past 6 months had a 39% increased risk of client-perpetrated physical violence (aRR: 1.39; 95% CI: 1.07-1.80; p < .05) and a 63% increased risk of sexual violence (aRR: 1.63; 95% CI: 1.14-2.32; p < .01) compared to their less-mobile counterparts. These findings provide necessary evidence of correlations over time between residential mobility and experience of client-perpetrated violence among women who exchange sex. Strengthening our understanding of how residential mobility intersects with violence is critical for the development of public health interventions that are relevant to women's lives and needs. Future interventions should explore including residential mobility, a critical pillar of housing instability, with efforts to address client-perpetrated violence.

Disruptions to naloxone training among lay and occupational responders in Maryland during the emergence of COVID-19: early impacts, recovery, and lessons learned.

Background: : Opioid overdose death rates increased during the COVID-19 pandemic. Disruptions in community-based naloxone trainings could have reduced the likelihood of overdose reversal and increased the chances of a fatal overdose. We investigated changes in the number of people trained in naloxone administration and distribution in Maryland before, during, and after COVID-related stay-at-home orders. Methods: : Data on naloxone training are from the Maryland Department of Health. We used interrupted time series models to estimate changes in average monthly number of people trained: [1] pre-interruption (4/2019-3/2020), [2] 1-month post-interruption (4/2020-5/2020), and [3] 12-months post-interruption (4/2020-3/2021). Trainees were classified as lay (e.g., people who use drugs) or occupational (e.g., law enforcement officers and harm reduction workers) responders. Results: : There were 101,332 trainees; 54.1% lay, 21.5% occupational, and 23.4% unknown responder status. We observed a decrease in the average monthly number of trainees in the pre-interruption period (-235, p<0.001), a larger decrease of 93.2% during the 1-month post-interruption (-846, p=0.013), and an increase 12-months post-interruption (+217, p<0.001). There was a significant decrease among occupational responders 1-month post-interruption, and a significant increase among lay responders in the 12-month post-interruption period. Conclusions: : Findings suggest a marked decrease in naloxone trainees immediately after stay-at-home order, followed by a moderate rebound in the 12-months after stay-at-home order. The decrease in occupational responders trained may have limited access to naloxone, but would likely have been offset by increases in number of lay responders trained. Strengthening lay and occupational responder connections could maintain naloxone distribution during public health crises.

Racial Disparities in Drug Arrest Before and After De Facto Decriminalization in Baltimore.

INTRODUCTION: To mitigate the harms of arrest and incarceration on health and racial equity, jurisdictions are increasingly enacting reforms to decriminalize drug possession through prosecutorial discretion (de facto). Impacts on health outcomes rely on whether this policy can reduce exposure to the carceral system among people who use drugs; however, data evaluating effects on arrest are lacking. This study explores the possible impacts of Baltimore City's enactment of de facto decriminalization on arrests by race. METHODS: Police and court records were used to explore the possible impacts of Baltimore City's de facto decriminalization on street arrests and (processed) arrests advancing through the courts among people who use drugs. Interrupted time series models were used to compare pre-policy (January 2018-March 2020) trends with post-policy (April 2020-December 2021) trends in arrests for possession of drugs/paraphernalia and estimate racial disparities in street arrests (Black versus other races). Analyses were performed in February-May 2022. RESULTS: The policy was associated with a significant and immediate decline in street and processed arrests for possession, which was not seen for other crime categories. Although declines were concentrated in the Black community, disparities in arresting persisted after the policy. CONCLUSIONS: De facto decriminalization may be a promising strategy to reduce exposure to the carceral system, an established risk factor for overdose and other drug-related sequelae and a driver of racial disparities in the U.S. Further research is needed to elucidate the drivers of persisting racial disparities and disentangle policy effects from pandemic-related closures.

Impact of a Community Empowerment Intervention on Sexually Transmitted Infections Among Female Sex Workers in Baltimore, Maryland.

BACKGROUND: Female sex workers ( FSWs) are vulnerable to a number of health issues, but often delay seeking health care due to structural barriers. Multiservice drop-in centers have been shown to increase FSW access to health services globally, but their impact on FSW in the United States is lacking. This study seeks to evaluate the effect of a community-level empowerment intervention (the multiservice drop-in SPARC center) on cumulative sexually transmitted infections (STIs) among FSW in a city in the United States. METHODS: Between September 2017 and January 2019, 385 FSWs were recruited in Baltimore. Participants from areas served by SPARC were recruited to the intervention; other areas of Baltimore were the control. Follow-up occurred at 6, 12, and 18 months. The primary outcome is cumulative STI (ie, positive gonorrhea or chlamydia test at any follow-up). We tested effect modification by condomless sex with paying clients reported at baseline. Logistic regressions with propensity score weighting were used to estimate intervention effect, accounting for loss to follow-up, with bootstrap confidence intervals. RESULTS: Participants completed 713 follow-up study visits (73%, 70%, 64% retention at 6, 12, and 18 months, respectively). Baseline STI prevalence was 28% and cumulative STI prevalence across follow-ups was 26%; these both did not differ between control and intervention communities in bivariate analyses. After adjusting for covariates, FSW in the intervention had a borderline-significant decrease in odds of cumulative STI compared with control (odds ratio, 0.61, P = 0.09 ) . There was evidence of effect modification by baseline condomless sex, such that FSW in the intervention who reported condomless sex had lower odds of cumulative STI compared with FSW in the control community who also reported baseline condomless sex (odds ratio, 0.29; P = 0.04). CONCLUSIONS: Results demonstrate the value of a low-barrier, multiservice model on reducing STIs among the highest-risk FSW.Clinical Trial Number: NCT04413591.

Criminalization and coercion: sexual encounters with police among a longitudinal cohort of women who exchange sex in Baltimore, Maryland.

BACKGROUND: The criminalization of sex work and drug use creates unequal power dynamics easily exploited by police. Women who exchange sex (WES) in settings around the globe have reported coerced sex and sexual assault by police, and some have reported police as paying clients. Little research has examined nuances underlying WES's sexual interactions with police. METHODS: A cohort of cisgender WES (N = 308) was recruited through targeted sampling in Baltimore, Maryland and completed a structured survey every 6 months for 18 months. Follow-up surveys included detailed questions about recent sexual encounters with police. In bivariate and multivariate models using generalized estimating equations to account for intra-person correlation, we examined correlates of reporting recent sex with police over time. RESULTS: One-third reported recent sex with police at any study visit. At each time point, about 90% of women who reported sex with police reported any uniformed or non-uniformed police had paid for sex. Between 72 and 85% had been solicited for paid sex by uniformed police. Between 41 and 50% of women who reported recent sex with police indicated they had done so because they feared arrest otherwise; one-third were directly pressured for sex by police to avoid arrest or trouble. In the final adjusted model, severe food insecurity [adjusted odds ratio (aOR) = 2.05; 95% confidence interval (CI) 1.13-3.71], Black race (vs. white, non-Hispanic; aOR = 1.90; 95% CI 1.13-3.17), recent arrest (aOR = 1.51; 95% CI 1.01-2.27), nonfatal overdose (aOR = 1.94; 95% CI 1.24-3.01), and client- or non-paying intimate partner-perpetrated violence (aOR = 2.46; 95% CI 1.63-3.71) were significantly independently associated with recent sex with police. CONCLUSIONS: Sexual encounters between WES and police in Baltimore are common and often coerced to avoid arrest in a setting where both drug use and sex work are criminalized. Recent sex with police was more prevalent among WES who were racially marginalized, highly structurally vulnerable, and/or at high risk for drug overdose-and therefore subject to the dual-criminalization of sex work and drug use. This indicates deep power imbalances and their exploitation by police as the root of such sexual encounters and adds to the evidence regarding the need for decriminalization to support the health and wellbeing of WES.

Who Asks About HIV/STI Status?: An Analysis of Women Who Sell Sex and Inject Drugs.

Communication about HIV and sexually transmitted infections (STI) is a cornerstone of risk reduction, yet there is a dearth of research that examines communication patterns among persons with dual risks for HIV/STI acquisition, such as women who sell sex and inject drugs (WSSID). We used logistic regression to identify factors associated with WSSID (N = 211) in Baltimore, Maryland always asking new clients about their HIV/STI status. Most WSSID were non-Hispanic White (73%) and 74% reported current homelessness. 50% of WSSID reported always asking new clients about their HIV/STI status. Experiencing depressive symptoms (adjusted odds ratio [aOR]: 0.53; 95% confidence interval [CI]: 0.29, 0.96) and having condomless sex with clients (aOR 0.31; 95% CI: 0.17, 0.57) were inversely associated with WSSID always asking new clients about their HIV/STI status. Recent entry into sex work (aOR 2.99; 95% CI: 1.30, 6.87) was positively associated with always asking new clients about their HIV/STI status. Enhancing HIV/STI communication in combination with engagement in other risk mitigation strategies may decrease disease incidence among WSSID.

Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex.

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

A study protocol to explore and implement community-based point-of-care COVID-19 testing for women who use drugs in Baltimore, Maryland: The CARE study.

Women who use drugs (WWUD) experience structural vulnerabilities (e.g., housing, food insecurities) and comorbidities that elevate their susceptibility to more severe COVID-19 symptoms or fatality compared to similarly-aged women who do not use illicit drugs. Testing is a cornerstone of effective COVID prevention, however, entrenched barriers to healthcare utilization means that WWUD may have diminished accessing to COVID testing. The CARE (COVID Action Research Engagement) study first examines predisposing and enabling factors that predict COVID testing uptake over six months (baseline, 3-, and 6-month follow-up) among a cohort of WWUD (N = 250) in Baltimore, Maryland, providing a nuanced and holistic understanding of how to meaningfully engage WWUD in COVID testing. Then, point-of-care COVID testing will be implemented on a mobile outreach van affiliated with a local community-based organization primarily serving WWUD; anonymous surveys of mobile outreach guests (N = 100) will assess feasibility and acceptability of this integrated testing. The study is grounded in the Behavioral Model for Vulnerable Populations and the Theoretical Framework of Acceptability. We hypothesize that point-of-care COVID testing integrated into a low-barrier harm reduction service, such as a mobile outreach program, will be an enabling environment for COVID testing uptake in part by reducing structural impediments to testing and will be highly feasible and acceptable to participants. Strengths, limitations, and plans for results dissemination are discussed.

Law enforcement and syringe services program implementation in rural counties in Kentucky: a qualitative exploration.

BACKGROUND: Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality. OBJECTIVE: This study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties. METHODS: From August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement. RESULTS: Participants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries. CONCLUSIONS: The results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity.

Understanding the longitudinal relationship between substance use and violent victimization among street-based women who exchange sex in Baltimore, Maryland.

BACKGROUND: Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES. METHODS: We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time. RESULTS: Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)). CONCLUSIONS: Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population.

External resilience in the context of drug use and socio-structural vulnerabilities: a qualitative exploration among women who use drugs and sell sex in Baltimore, Maryland.

BACKGROUND: Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one's environment). Further, substance use is often viewed as antithetical to resilience despite populations like women who use drugs and sell sex (WWUD-SS) surviving significant hardships. This study aims to fill a gap in the literature by characterizing external resilience among WWUD-SS and understanding the ways that socio-structural vulnerabilities (e.g., poverty, stigma) and substance use shape external resilience. METHODS: WWUD-SS (N = 18) enrolled in an ongoing cohort study were purposively sampled for age, race, and recruitment location and participated in semi-structured, in-depth interviews aimed to elucidate external resilience (i.e., social support and resource utilization). WWUD-SS were queried about recent difficult experiences with a focus on how they did or did not use social support or formal resources (e.g., clinic, crisis hotline) in response. RESULTS: Participants were a median age of 37 years, 50% identified as Black, and 50% reported currently injecting drugs. Participants described reluctance to ask for support and often felt resigned to address problems alone. Participants also distinguished between transactional relationships (help is contingent upon receiving something in return) versus genuine (non-transactional or altruistic) support, including the role of family members who do and do not use drugs. Resource utilization was rare, and "self-medication" through substance use was common absent other perceived options for help. CONCLUSIONS: External resilience appears limited among WWUD-SS and shaped by the social and economic contexts of a street-involved life. WWUD-SS' ability to exercise external resilience may be undercut by experiencing structural vulnerabilities and competition for material resources that create transactional relationships and diminish the perceived value of social support. Internalized stigma, reflecting the larger society's stigmatized views of drug use, sex work, and poverty, left WWUD-SS eschewing help from outside sources. Focus on internal resilience alone offers an incomplete picture of the construct in drug-using populations. Improving connections to community resources may be a targeted way to strengthen external resilience, as are policies addressing structural vulnerabilities for marginalized communities.

Self and professional treatment of skin and soft tissue infections among women who inject drugs: Implications for wound care provision to prevent endocarditis.

Background: Skin and soft tissue infections (SSTI) are common among people who inject drugs and can result in severe health consequences, including infective endocarditis. Numerous barriers to accessing care often prevent people who inject drugs from seeking healthcare including past negative healthcare experiences, transportation, and shame around drug use. These barriers can lead some people who inject drugs to self-care instead of seeking formal treatment. Methods: We explored the prevalence of SSTIs and associated treatment behaviors among women who inject drugs and sell sex (N = 114). Women reported their drug use and SSTI histories. Those who experienced an SSTI reported if they self-treated their SSTIs and/or sought formal treatment. Results: Half (50.0%) experienced at least one SSTI in the past 6 months. SSTIs were more common among those who injected painkillers (24.6% vs 8.8%, p = 0.02) and who had ever been treated for endocarditis (28.1% vs 10.5%, p = 0.02). SSTIs were less common among those who injected multiple times per day (17.9% vs 38.6%, p = 0.01) and always injected with a sterile syringe (19.3% vs 42.1%, p = 0.01). Among those who experienced an SSTI, most (85.7%) reported self-treating, and half (52.6%) sought formal care. The emergency room was the most common source of care (73.3%). Conclusions: When experiencing SSTIs, women often opted to self-treat rather than seek formal healthcare. A lack of formal care can lead to infections progressing to serious conditions, like endocarditis. Self-treatment with non-prescribed antibiotics may further result in antibiotic-resistant infections. Low threshold, stigma free, community-based wound care programs are warranted.

Co-occurring Threats to Agency Among Female Sex Workers in Baltimore, Maryland.

Driven largely by the unequal distribution of power, female sex workers (FSW) globally bear a disproportionately high burden of HIV, sexually transmitted infections, and interpersonal violence. Prior literature has identified a number of multi-level factors that may serve to constrain FSWs' agency, or their ability to define and take action to realize goals. Among these are work-based violence and substance use, which are potentiated by the criminalization of sex work and structural vulnerability. Quantitative research related to U.S.-based FSWs' own sense of agency, as well as the barriers that may impede it, is sparse. We sought to identify patterns of various threats to agency and explore to what extent they were associated with perceived agency among a cohort of 381 FSW in Baltimore, Maryland, United States, using latent class analysis. Latent class indictors were past-six-month experience of client-perpetrated sexual violence, client-perpetrated physical violence, homelessness, food insecurity, arrest, daily crack-cocaine use, and daily heroin use. Perceived agency was measured using the short form of the Pearlin Mastery Scale. We identified three typologies of threatened agency among women in our sample: a "threatened by structural factors, drug use, and violence" class, a "threatened by structural factors and drug use" class, and a "less threatened" class. Mean perceived agency score was significantly lower for the class characterized by client-perpetrated violence than for either of the other classes. This suggests violence, in the context of deeper, structural power imbalances embedded in hunger, homelessness, and drug use, may dramatically reduce one's sense of agency and operate as a critical barrier to empowerment. Our study adds important insights to the broader FSW community empowerment literature and supports the need for interventions to bolster both individual and collective agency among U.S.-based FSW, including interventions to prevent sex work-related violence.

Identifying pathways to recent non-fatal overdose among people who use opioids non-medically: How do psychological pain and unmet mental health need contribute to overdose risk?

BACKGROUND: Significant associations exist between psychological pain, unmet mental health need, and frequency and severity of substance use among people who use drugs (PWUD), but no studies have analyzed the relationship of these variables to non-fatal overdose. METHODS: We conducted a cross-sectional survey of people who used opioids non-medically in Baltimore, Maryland (n = 563) as part of a broader harm reduction-focused evaluation (PROMOTE). The outcome was self-reported recent (past 6 months) non-fatal overdose; exposures of interest were recent self-reported unmet mental health need, experiencing daily "long-lasting psychological or mental pain" (vs. < daily), and daily multi-opioid use (vs. none/one opioid used). Path analysis was used to model direct relationships between these variables, personal characteristics (race, gender, experiencing homelessness, drug injection) and overdose. RESULTS: 30% of the sample had experienced a recent non-fatal overdose, 46% reported unmet mental health need, 21% reported daily psychological pain, and 62% used multiple types of opioids daily. After adjusting for covariates, daily multi-opioid use (aOR = 1.78, p = 0.03) and unmet mental health need (aOR = 2.05, p = 0.01) were associated with direct, significant increased risk of recent overdose. Significant pathways associated with increased odds of unmet mental health need included woman gender (aOR = 2.23, p = 0.003) and daily psychological pain (aOR = 4.14, p = 0.002). In turn, unmet mental health need associated was with greater odds of daily multi-opioid use (aOR = 1.57, p = 0.05). DISCUSSION: Unmet mental heath need and daily psychological pain are common experiences in this sample of PWUD. Unmet mental health need appears on several pathways to overdose and associated risk factors; improving access to mental healthcare for PWUD (particularly women) expressing need may be an important harm reduction measure.

Gaps and barriers in drug and alcohol treatment following implementation of the affordable care act.

Background: This study examines changes in the substance use disorder (SUD) treatment gap and barriers to treatment for low-income adults following Affordable Care Act (ACA) implementation. Methods: National Survey on Drug Use and Health (NSDUH) data were pooled to assess pre-ACA (2009-2013) and post-ACA (2015-2019) implementation. The sample (n = 44,622) included respondents 18-64 years old, income <200% federal poverty level, and meeting SUD criteria for abuse or dependence of heroin, powdered cocaine, crack cocaine, marijuana, or alcohol. The primary outcome was NSDUH-defined past-year illicit drug or alcohol treatment gap (needing but not receiving SUD specialty treatment). A secondary analysis assessed barriers to SUD treatment including insurance-related barriers, stigma, barriers to access, priority of treatment, and no interest in stopping substance use. Results: Ninety-three percent of respondents reported a drug or alcohol treatment gap before and after ACA implementation. No interest in stopping use was the greatest barrier (40%), followed by insurance-related barriers (39%) and stigma (20%). After adjusting for covariates, results did not show a significant change in SUD treatment gap post-ACA compared to pre-ACA (adjusted odds ratio [aOR]=1.11, 95% confidence interval [CI]=0.97, 1.28, p = 0.13). Compared to pre-ACA, odds of reporting stigma-related barriers (aOR=1.66, 95% CI=1.17, 2.37, p = 0.01) and access-related barriers (aOR=1.79, 95% CI=1.34, 2.38, p < 0.001) increased post-ACA. Conclusions: There was no significant change in the prevalence of SUD treatment gap after ACA implementation. Increasing access to SUD treatment for low-income individuals will require intervening at multiple socioecological levels beyond reforming treatment financing.