Sleep Health among Community-Recruited Opioid-Using People Who Inject Drugs in Los Angeles, CA and Denver, CO.

Chronic insufficient and poor-quality sleep are linked to hypertension, diabetes, depression, heart attack, and stroke. While studies on substance use and sleep typically focus on people in or entering treatment, there is a lack of research on sleep health among community-recruited people who inject drugs (PWID). To address this literature gap, we examined factors associated with insufficient and poor-quality sleep among community-recruited PWID. We recruited and interviewed 472 active opioid-using PWID (injected within the last 30 days) in Los Angeles, CA and Denver, CO between 2021 and 2022. Participants completed computer-assisted interviews covering demographics, subsistence measures, drug use patterns, injection-related behaviors, health risks, and sleep duration and quality in the last 3 months. Descriptive statistics were used to analyze all variables for subjects with complete responses to sleep items (n = 464). Bivariate analyses determined factors associated with sleep measures using chi-square and t-tests. Collinear variables were removed, and binomial linear multivariable regression calculated risk ratios (RR) for insufficient and poor-quality sleep in the last 3 months. Participants exhibited low sleep duration (mean = 4.99, standard deviation (SD) = 2.70), with 76% reporting insufficient sleep and 62% poor-quality sleep. Bivariate analyses associated both sleep measures with drug use, high subsistence scores, violent victimization, and poor health outcomes. Multivariable analyses showed a high subsistence score predicting insufficient (RR = 1.31) and poor-quality sleep (RR = 1.69) compared to low subsistence. Poor sleep health is common among structurally vulnerable community-recruited PWID, as measured by subsistence index associated with adverse sleep outcomes. Further research on structural interventions to address sleep and subsequent health outcomes among PWID is imperative.

"I don't need my kid to be high": prioritizing harm reduction when using cannabis during pregnancy.

BACKGROUND: Cannabis is the most common illicit substance used in pregnancy. As use continues to increase, understanding peoples' behaviors surrounding cannabis use during pregnancy is needed to improve maternal and child health outcomes. The aim of this study was to better understand pregnant individuals' perceptions and knowledge of cannabis use and use patterns as well as the social and environmental factors that may influence their use. METHODS: We conducted interviews with 19 participants between December 2022 and March 2023. Individuals self-identified as BIPOC (Black, Indigenous, People of Color), were over 21 years of age, spoke English or Spanish, resided in California, and had used cannabis during pregnancy in the last 0-2 years. Using qualitative, constructivist grounded theory methods, we analyzed the contexts that contributed to participants' lived experiences surrounding cannabis use behaviors during pregnancy. RESULTS: Participants reported making conscious decisions to responsibly manage their cannabis use during pregnancy to minimize potential harm to the fetus. Participants prioritized making what they perceived to be safer adjustments to their use of cannabis: (1) changing the amount of cannabis used, (2) changing the types of cannabis products used, and (3) changing sources of cannabis procurement. DISCUSSION: Our findings show that pregnant individuals are seeking information about safe cannabis use beyond medical supervision and are open to altering their cannabis consumption patterns. However, they are unable to find trustworthy and evidence-based harm reduction practices which can be implemented to mitigate harm to their unborn children. A harm reduction approach is needed in the field of maternal cannabis use to promote positive maternal and fetal health outcomes. CONCLUSIONS: More data is needed on comprehensive harm reduction approaches to cannabis use during pregnancy. This requires implementation of education on these topics in healthcare settings presented by prenatal care clinicians.

Housing and Displacement as Risk Factors for Negative Health Outcomes Among People Who Inject Drugs in Los Angeles, CA, and Denver, CO, USA.

Background The United States is currently experiencing a housing and homelessness crisis. In response, many cities have adopted policies of displacement that move unhoused people from place to place. Recent research indicates that these policies may have negative health impacts on unhoused people who use drugs. We sought to examine health risks associated with government-enforced displacement among unhoused people who inject drugs (PWID). Methods We interviewed a community-recruited sample of opioid-using PWID in Los Angeles, CA and Denver, CO between April 2021 and November 2022 (N = 472) about their demographic/socioeconomic characteristics, drug use patterns, housing status, government-enforced displacement including items discarded during displacements, and health risks. We constructed binomial generalized linear regression to examine the risk ratio of non-fatal overdose, and syringe and cooker/cotton sharing between four groups of participants: housed, unhoused and not displaced, unhoused and relocated voluntarily, and unhoused and displaced in the last three months. Results In the last 3 months, 52% of participants were unhoused and displaced by the government. Among those who were displaced, median number of government-enforced displacements was 3 with 69% reporting loss of syringes, 56% loss of naloxone, and 22% loss of buprenorphine medicine. In multivariate models, risk ratios for unhoused and displaced participants were higher for nonfatal overdose and cooker/cotton sharing as compared to housed participants. Risk ratios for syringe sharing amongst unhoused participants did not differ significantly. Conclusions Unhoused and displaced PWID experience elevated health risks. Ending the use of government-enforced displacement of unhoused PWID is essential to reducing health risk in this population.

The fentanyl made me feel like I needed more methadone": changes in the role and use of medication for opioid use disorder (MOUD) due to fentanyl.

BACKGROUND: Fentanyl and fentanyl analogues have disrupted the illicit drug supply through contamination of other substances (i.e., methamphetamine and cocaine) and replacement of heroin in illicit markets. Increasingly, they are contributing to opioid-overdose related deaths. The rapid and growing presence of fentanyl has led to gaps in research on the impact of this illicit market change on people who use drugs (PWUD). We sought to examine how the changing opioid market and growing fentanyl availability influences the role and use of medication for opioid use disorder (MOUD). METHODS: Semi-structured qualitative interviews were conducted with a community recruited sample of PWUD (N = 22) in Los Angeles, California between September 2021 and April 2022. Interviews examined opioid use history, current opioid use behaviors and consumption patterns, and MOUD experiences and perceptions. Thematic analysis was used to systematically code and analyze textual interview data. RESULTS: The following themes related to fentanyl use and MOUD emerged: (1) Use of deviated MOUD to address fentanyl contamination, (2) Changing perception of the effectiveness of MOUD on fentanyl, and (3) Regulatory limitations of MOUD for fentanyl use disorder. CONCLUSIONS: PWUD described several repertoires for adjusting to changes in the illicit market of opioids. Clinicians treating PWUD should ask about recent fentanyl use prior to starting MOUD to account for increased tolerance to opioids. Harm reduction strategies such as naloxone kits, safe supply, and supervised consumption facilities can all prevent overdose deaths due to fentanyl.

"Even Though the System Had Failed Him His Entire Life, We Were Failing Him Yet Again": How Clinical, Welfare, and Penal Medicine Interact to Drive Health Inequities and Medical Moral Injury.

Adam, a justice-involved young man, was brought into the emergency department at the county hospital in cardiogenic shock due to a recurring episode of injection-drug-use-related infective endocarditis (IDU-IE). Adam had initiated injection opioid use in prison. He was surgically treated for the previous episodes of IDU-IE but was unable to fully recover due to limitations in care within penal medicine. This case report explores the prison as a determinant of health, interactions between clinical, welfare, and penal medicine, to produce and maintain health inequities, and structural drivers of physician moral injury through an interview with Adam and reflexive writings from emergency medicine physicians. This case demonstrates the need for three types of structural health interventions: (1) restorative justice, community-based reentry programs, and housing as welfare medicine, (2) increased harm reduction services across healthcare, especially penal medicine, and (3) equitable institutional protocols (contrary to ambiguous guidelines) to treat clinical conditions like IDU-IE that disproportionately impact structurally vulnerable patients.

The unseen patient: competing priorities between patients and providers when cannabis is used in pregnancy, a qualitative study.

Objectives: This study aimed to explore competing priorities when cannabis is used during pregnancy from the perspective of providers and Black and Latina people. Maternal cannabis use is increasingly common, but patients and providers alike struggle to navigate it. Methods: This pilot used qualitative, constructivist ground theory methods to conduct semi-structured, remote interviews between 16 November 2021, and 7 February 2022 with 7 Black and Latina people who used cannabis during pregnancy, and 10 providers between 15 March 2022, and 6 April 2022, all of who were in Southern California, U.S. Results: We identified three main findings: (1) Providers reported barriers to caregiving and relationship building with patients due to maternal cannabis use stigma, (2) Providers prioritized the fetus despite patients' current health system challenges that drove cannabis use, and (3) Both patients and providers engaged in personal research beyond the healthcare system to better understand maternal cannabis use. Discussion: Our findings indicate that challenges exist between people who use cannabis during pregnancy and providers. Both groups need accurate, sociocultural sensitive information about maternal cannabis use via a harm reduction lens.

Transportation Preferences of Patients Discharged from the Emergency Department in the Era of Ridesharing Apps.

INTRODUCTION: Patients discharged from the emergency department (ED) may encounter difficulty finding transportation home, increasing length of stay and ED crowding. We sought to determine the preferences of patients discharged from the ED with regard to their transportation home, and their awareness and past use of ridesharing services such as Lyft and Uber. METHODS: We performed a prospective, survey-based study during a five-month period at a university-associated ED and Level I trauma center serving an urban area. Subjects were adult patients who were about to be discharged from the ED. We excluded patients requiring ambulance transport home. RESULTS: Of 500 surveys distributed, 480 (96%) were completed. Average age was 47 ± 19 years, and 61% were female. There were 33,871 ED visits during the study period, and 67% were discharged home. The highest number of subjects arrived by ambulance (27%) followed by being dropped off (25%). Of the 408 (85%) subjects aware of ridesharing services, only eight (2%) came to the ED by this manner; however, 22 (5%) planned to use these services post-discharge. The survey also indicated that 377 (79%) owned smartphones, and 220 (46%) used ridesharing services. The most common plan to get home was with family/friend (35%), which was also the most preferred (29%). Regarding awareness and past use of ridesharing services, we were unable to detect any gender and/or racial differences from univariate analysis. However, we did detect age, education and income differences regarding awareness, but only age and education differences for past use. Logistic regression showed awareness and past use decreased with increasing patient age, but correlated positively with increasing education and income. Half the subjects felt their medical insurance should pay for their transportation, whereas roughly one-third felt ED staff should pay for it. CONCLUSION: Patients most commonly prefer to be driven home by a family member or friend after discharge from the ED. There is awareness of ridesharing services, but only 5% of patients planned to use these services post-discharge from the ED. Patients who are older, have limited income, and are less educated are less likely to be aware of or have previously used ridesharing services. ED staff may assist these patients by hailing ridesharing services for them at time of discharge.