Interventions to Reduce Drug Use Among Methamphetamine Users at Risk for HIV.

PURPOSE OF REVIEW: This paper reports on the results of a study comparing two behavioral treatments for methamphetamine users. The outcome was the effectiveness of the interventions in reducing meth use. The interventions were contingency management (CM) and contingency management plus strengths-based case management (CM/SBCM). RECENT FINDINGS: CM/SBCM was found to be associated with attending more sessions for people who reported being in a couple. Also, participants who earned more money in the first part of the study were more likely to have more clean urinalysis in the second part of the study. Latent class analysis identified a class of participants who were in a couple, without sexual abuse history, and less meth use at baseline. This class tended to have more clean urinalysis in the CM/SBCM intervention. These results indicate that incentive-based interventions with case management may be useful for helping meth users reduce their drug use.

A Hazard Analysis of Risk Factors of Mortality in Individuals Who Inject Drugs in Denver CO.

Despite multiple risk factors for mortality among People Who Inject Drugs (PWID), more research is warranted that examines sub-populations within PWID. Mortality data from PWID participating in longitudinal HIV prevention research in Denver were obtained from The Colorado Department of Public Health and Environment. Risk factors for both all-cause and acute-toxicity related mortality were analyzed using Cox proportional hazards regression. Two-thousand seven individuals were interviewed at baseline. Eighty-six individuals died during the time frame of the study, 58 of which were due to acute-toxicity. Disabled (HR = 3.3, p < 0.001), gay/lesbian-identified (HR = 2.6, p = 0.03), white race/ethnicity (HR = 2.4, p = 0.003), and use of a shared cooker (HR = 2.1, p = 0.01) were important adjusted risk factors. These suggest that drug and HIV interventions should utilize techniques that can address the needs of marginalized populations in addition to HIV drug risk behaviors.

Gender and risk behaviors for HIV and sexually transmitted infections among recently released inmates: A prospective cohort study.

Women in prison have a higher prevalence of HIV than men. After release from prison, former inmates have the opportunity to engage in risk behaviors for HIV and other sexually transmitted infections (STIs). We sought to assess change in risk behaviors over time and the association of gender with risk behavior in the postrelease period. In this prospective cohort study, we interviewed 200 former inmates (51 women) approximately two weeks (baseline) and three months (follow-up) after release and tested them for HIV infection at follow-up. We examined the association of gender with unprotected vaginal or anal sex in the last seven days using chi-square and Fisher's exact tests and multivariable logistic regression. At baseline, 22% of men and 41% of women reported unprotected vaginal sex (p < 0.01) and 5% of men and 8% of women reported unprotected anal sex (p = 0.51). Being younger (OR for each decade increase 0.48, 95% CI = 0.29-0.80), being gay/lesbian or being bisexual (compared with being heterosexual, OR = 4.74, 95% CI = 1.01-22.17 and OR = 3.98, 95% CI = 1.41-11.26, respectively), or reporting a drug of choice of heroin/speedballs or cocaine/crack (compared with marijuana/no drug of choice, OR = 24.00, 95% CI = 5.15-111.81 and OR = 3.49, 95% CI = 1.20-10.18, respectively) was associated with unprotected vaginal or anal sex after adjusting for race, homelessness, and hazardous drinking. At follow-up, 21% of men and 44% of women reported unprotected sex (p = 0.005), and female gender (OR = 4.42, 95% CI = 1.79-10.94) and hazardous drinking (compared with not meeting criteria for hazardous drinking, OR = 3.64, 95% CI = 1.34-9.86) were associated with unprotected sex, adjusting for race and homelessness. In this population with a high prevalence of HIV, we demonstrated persistent engagement in sexual risk behavior during the postrelease period. Enhanced efforts to promote sexual health and reduced risk behavior among both male and female current and former prison inmates are needed, including improved access to preventive care and HIV and STI screening, testing, and treatment.

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.

Law enforcement practices associated with HIV infection among injection drug users in Odessa, Ukraine.

Despite HIV prevention efforts over the past 10 years in Odessa, Ukraine, HIV rates among injection drug users (IDUs) remain high. We explored whether IDUs' experiences with the police and court system in Odessa were associated with HIV serostatus, after controlling for other factors. Qualitative methods, including semi-structured interviews with the police and members of court (N = 19), and focus groups with IDUs (N = 42), were employed to aid in developing a survey instrument for a larger quantitative phase and to assist in interpreting the findings from the quantitative phase, which included 200 participants who were interviewed and tested for HIV. Overall, 55 % tested positive for HIV. Negative experiences with the police were noted by 86 % and included having preloaded syringes taken (66 %), rushed injections due to fear of the police (57 %), police planting drugs (18 %), paying police to avoid arrest (61 %) and threatened by the police to inform on other IDUs (23 %). HIV positive participants were more likely than those who were negative to report these experiences. In a multiple logistic regression, the most significant correlate of HIV infection was rushed injections due to fear of the police. Police actions in Odessa may be contributing to the continued escalation of HIV among IDUs, underscoring the need for structural interventions.

Development of a risk reduction intervention to reduce bacterial and viral infections for injection drug users.

Bacterial infections are widespread problems among drug injectors, requiring novel preventive intervention. As part of a NIDA-funded study, we developed an intervention based on the Information-Motivation-Behavioral Skills model, past research, injection hygiene protocols, and data collected from focus groups with 32 injectors in Denver in 2009. Qualitative responses from focus groups indicated that most participants had experienced skin abscesses and believed that bacterial infections were commonly a result of drug cut, injecting intramuscularly, and reusing needles. Access to injection supplies and experiencing withdrawal were the most frequently reported barriers to utilizing risk reduction. Implications for intervention development are discussed.

Reasons for Marijuana Use and Its Perceived Effectiveness in Therapeutic and Recreational Marijuana Users Among People Living with HIV in Florida.

Therapeutic and recreational marijuana use are common among people living with HIV (PLWH). However, the distinction between perceived "therapeutic" and "recreational" use is blurred, with little information about the specific reasons for use and perceived marijuana effectiveness in adults with chronic conditions. We aimed to compare reasons for use and reason-specific perceived marijuana effectiveness between therapeutic and recreational users among PLWH. In 2018-2019, 213 PLWH currently using marijuana (mean age 48 years, 59% male, 69% African American) completed a questionnaire assessing their specific reasons for using marijuana, including the "main reason." Participants were categorized into one of three motivation groups: therapeutic, recreational, or both equally. For each specific reason, participants rated marijuana effectiveness as 0-10, with 10 being the most effective. The mean effectiveness scores were compared across the three motivation groups via ANOVA, with p <0.05 considered statistically significant. The most frequent main reasons for marijuana use in the therapeutic (n=63, 37%), recreational (n=48, 28%), and both equally (n=59, 35%) categories were "Pain" (21%), "To get high" (32%), and "To relax" (20%), respectively. Compared to recreational users, therapeutic and both equally users provided significantly higher mean effectiveness scores for "Pain," and "To reduce anger." The "Both equally" group also provided significantly higher mean effectiveness scores for "To feel better in general," "To get high," and "To relax" compared to the other two categories. There is a significant overlap in self-reported reasons for marijuana use in primarily therapeutic or recreational users. Perceived marijuana effectiveness was lowest among recreational users.

Predictors of methamphetamine injection in out-of-treatment IDUs.

From 2004-2006, 439 injection drug users were recruited in Denver, Colorado, to participate in a study of drug use and HCV risk. Over two-thirds were male, more than half were white, and 28% were methamphetamine injectors. The Risk Behavior Assessment, which assesses demographics, drug use, and HIV risk behaviors, was used. Variables were assessed for association with methamphetamine (MA) injection. A logistic regression model was built using forward stepwise method to determine independent associations between variables of interest and MA injection. The study's limitations are noted, and implications are described.

Predictors of risky needle use following interventions with injection drug users in Ukraine.

This study was designed to assess factors associated with change in needle-related risk behaviors as well as predictors of continued high-risk behavior following intervention efforts among injection drug users (IDUs) in Ukraine. In each of three locations--Kiev, Odessa, and Makeevka/Donesk--100 IDUs were recruited using modified targeted sampling methods. Following a baseline interview, participants were offered free HIV testing and, over the course of the next 5 months, individualized interventions focusing on reducing HIV-related risk behaviors. Former IDUs conducted interventions through street outreach. The intervention model was based on the Indigenous Leader Outreach Model (ILOM) and stressed assessing an individual's unique risks and developing strategies by which to minimize those risks. Follow-up assessments showed significant reductions in every risk behavior measured. Following the intervention, however, approximately one of four participants reported front- or backloading, using drugs obtained from a common container or injecting with a used needle/syringe. Although the sample as a whole averaged only 28 years of age, those who were younger were significantly more likely to engage in each of these behaviors than those who were older. In light of the overall young age of the Ukrainian IDUs observed in this study, the consistent finding that younger IDUs were at highest risk foreshadows a worsening HIV epidemic in Ukraine.

Public Health Effects of Medical Marijuana Legalization in Colorado.

INTRODUCTION: The public health consequences of the legalization of marijuana, whether for medical or recreational purposes, are little understood. Despite this, numerous states are considering medical or recreational legalization. In the context of abrupt changes in marijuana policy in 2009 in Colorado, the authors sought to investigate corresponding changes in marijuana-related public health indicators. METHODS: This observational, ecologic study used an interrupted time-series analysis to identify changes in public health indicators potentially related to broad policy changes that occurred in 2009. This was records-based research from the state of Colorado and Denver metropolitan area. Data were collected to examine frequency and trends of marijuana-related outcomes in hospital discharges and poison center calls between time periods before and after 2009 and adjusted for population. Analyses were conducted in 2014. RESULTS: Hospital discharges coded as marijuana-dependent increased 1% per month (95% CI=0.8, 1.1, p<0.001) from 2007 to 2013. A change in trend was detected in poison center calls mentioning marijuana (p<0.01). After 2009, poison center calls increased 0.8% per month (95% CI=0.2, 1.4, p<0.01). Poison center calls also increased 56% (95% CI=49%, 63%, p<0.001) in the period following the policy change. Further, there was one hospital discharge coded as dependent for every 3,159 (95% CI=2465, 3853, p<0.001) medical marijuana registrant applications. CONCLUSIONS: The abrupt nature of these changes suggests public health effects related to broad policy changes associated with marijuana. This report may be used to assist in policy decisions regarding the short-term public health effects of marijuana legalization.

Is cannabis use associated with less opioid use among people who inject drugs?

BACKGROUND: Clinical, experimental, and ethnographic research suggests that cannabis may be used to help manage pain. Ethnographic research has revealed that some people are using cannabis to temper their illicit opioid use. We seek to learn if there is an association between cannabis use and the frequency of nonmedical opioid use among people who inject drugs (PWID). METHODS: PWID were recruited using targeted sampling methods in Los Angeles and San Francisco, California, 2011-2013. We limited analysis to people who used opioids in past 30 days (N=653). OUTCOME VARIABLE: number of times used any opioids non-medically in past 30 days. Explanatory variable: any cannabis use past 30 days. STATISTICS: multivariable linear regression with a log-transformed outcome variable. RESULTS: About half reported cannabis use in the past 30 days. The mean and median number of times using opioids in past 30 days were significantly lower for people who used cannabis than those who did not use cannabis (mean: 58.3 vs. 76.4 times; median: 30 vs 60 times, respectively; p<0.003). In multivariable analysis, people who used cannabis used opioids less often than those who did not use cannabis (Beta: -0.346; 95% confidence interval: -0.575, -0.116; p<0.003). CONCLUSIONS: There is a statistical association between recent cannabis use and lower frequency of nonmedical opioid use among PWID. This may suggest that PWID use cannabis to reduce their pain and/or nonmedical use of opioids. However, more research, including prospective longitudinal studies, is needed to determine the validity of these findings.

Factors associated with methadone maintenance treatment retention among street-recruited injection drug users.

This study examined factors associated with methadone maintenance retention, defined as remaining in treatment for a minimum of 90 days, among street recruited injection drug users (IDUs). Targeted sampling methods were used to establish recruitment quotas in Denver census tracks. A total of 577 IDUs were randomly assigned to either a risk reduction intervention, focusing on safer injection and sex behaviors, or motivational interviewing, addressing more sweeping lifestyle changes including drug treatment. All subjects who wanted treatment were provided transportation, rapid intake and a waiver of the intake fee. In addition, 50% were randomly assigned a coupon for 90 days of free treatment. Overall, 33% entered treatment and of these, 60% remained for at least 90 days. Factors associated with retention included higher methadone dose, free treatment, greater contacts with the clinic and counselor rating of patient cooperation. Although desire for treatment, or motivation, was associated in univariate analyses with greater retention, there were no differences observed between the motivational interviewing and risk reduction interventions.

Improving entry to methadone maintenance among out-of-treatment injection drug users.

This study of 577 out-of-treatment drug injectors was designed to assess predictors of methadone maintenance treatment entry, including offering free treatment coupons. Using targeted sampling methods, participants were recruited through street outreach; randomly, they were either assigned a coupon for 90 days of free treatment or required to pay for their treatment. Regardless of assignment, all subjects who desired treatment were provided transportation, rapid intake, and a waiver of the treatment entry fee. Overall, 33% entered treatment, including 66% of those who received a free coupon. Other factors associated with treatment entry included desire for treatment, heroin use, prior treatment experience, associating with fewer drug-using friends, and injecting with a previously used unsterile needle/syringe. Injecting cocaine and smoking crack reduced the probability of treatment entry. Findings lend support to street outreach efforts designed to increase rates of treatment entry among chronic out-of-treatment drug injectors. Additional treatment options are required for those abusing cocaine.

Medical Marijuana Use and Parenting: A Qualitative Study.

BACKGROUND: The number of medical marijuana patients is increasing. This increase raises important concerns about how medical marijuana use may affect parenting. METHODS: Thirty-two adult medical marijuana patients participated in focus groups. The focus groups were audio-recorded and transcribed. The transcriptions were coded by a team that met regularly to resolve coding differences. Codes related to parenting were used to develop a conceptual model for this manuscript. RESULTS: Six of 11 participants who identified being parents reported that using marijuana helped them to be calmer with their children and to manage difficult emotions related to parenting. At the same time, most medical marijuana patients did not want their children to use marijuana. Their concerns about their children led to different strategies related to storing medical marijuana securely and how to communicate with children about medical marijuana use. CONCLUSIONS: These findings show that many medical marijuana patients are concerned about their children using marijuana and may be open to strategies to addressing this issue with their children. These findings also show that some medical marijuana patients may benefit from alternative strategies for managing difficult emotions related to parenting.

Skin and needle hygiene intervention for injection drug users: results from a randomized, controlled Stage I pilot trial.

A new skin and needle hygiene intervention, designed to reduce high-risk injection practices associated with bacterial and viral infections, was tested in a pilot, randomized controlled trial. Participants included 48 active heroin injectors recruited through street outreach and randomized to either a 2-session intervention or an assessment-only condition (AO) and followed up for 6 months. The primary outcome was skin- and needle-cleaning behavioral skills measured by videotaped demonstration. Secondary outcomes were high-risk injection practices, intramuscular injection, and bacterial infections. Intervention participants had greater improvements on the skin (d = 1.00) and needle-cleaning demonstrations (d = .52) and larger reductions in high-risk injection practices (d = .32) and intramuscular injection (d = .29), with a lower incidence rate of bacterial infections (hazard ratio = .80), at 6 months compared with AO. The new intervention appears feasible and promising as a brief intervention to reduce bacterial and viral risks associated with drug injection.

Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors.

BACKGROUND: Former inmates are at high risk for death from drug overdose, especially in the immediate post-release period. The purpose of the study is to understand the drug use experiences, perceptions of overdose risk, and experiences with overdose among former prisoners. METHODS: This qualitative study included former prison inmates (N=29) who were recruited within two months after their release. Interviewers conducted in-person, semi-structured interviews which explored participants' experiences and perceptions. Transcripts were analyzed utilizing a team-based method of inductive analysis. RESULTS: The following themes emerged: 1) Relapse to drugs and alcohol occurred in a context of poor social support, medical co-morbidity and inadequate economic resources; 2) former inmates experienced ubiquitous exposure to drugs in their living environments; 3) intentional overdose was considered "a way out" given situational stressors, and accidental overdose was perceived as related to decreased tolerance; and 4) protective factors included structured drug treatment programs, spirituality/religion, community-based resources (including self-help groups), and family. CONCLUSIONS: Former inmates return to environments that strongly trigger relapse to drug use and put them at risk for overdose. Interventions to prevent overdose after release from prison may benefit from including structured treatment with gradual transition to the community, enhanced protective factors, and reductions of environmental triggers to use drugs.

The Feasibility of Interventions to Reduce HIV Risk and Drug Use among Heterosexual Methamphetamine Users.

This paper reports on a feasibility study that examined contingency management among out-of-treatment, heterosexual methamphetamine users and the reduction of drug use and HIV risk. Fifty-eight meth users were recruited through street outreach in Denver from November 2006 through March 2007. The low sample size reflects that this was a pilot study to see if CM is feasible in an out-of-treatment, street-recruited population of meth users. Secondary aims were to examine if reductions and drug use and risk behavior could be found. Subjects were randomly assigned to contingency management (CM) or CM plus strengths-based case management (CM/SBCM), with follow-up at 4 and 8 months. Participants were primarily White (90%), 52% male and averaged 38 years old. Eighty-three percent attended at least one CM session, with 29% attending at least fifteen. All participants reduced meth use significantly at follow-up. Those who attended more sessions submitted more stimulant-free urines than those who attended fewer sessions. Participants assigned to CM/SBCM attended more sessions and earned more vouchers than clients in CM. Similarly, participants reported reduced needle-sharing and sex risk. Findings demonstrate that CM and SBCM may help meth users reduce drug use and HIV risk.

"From the prison door right to the sidewalk, everything went downhill," a qualitative study of the health experiences of recently released inmates.

In many states, budget constraints are prompting earlier release of prison inmates. Prior studies have demonstrated elevated mortality rates in the post-release period but little is known about the health experiences of former inmates in the transition from prison to the community. The objective of this study was to understand the health-seeking experiences, perceptions of risk, and medical and mental health needs of former prisoners in the first two months after release from prison. Participants consisted of 29 former inmates within the first two months after their release from prison to the Denver, Colorado area. Using qualitative methods, trained interviewers conducted individual, in-person, semi-structured interviews exploring participants' experiences with health, mental health, and health care since release. Interview transcripts were coded and analyzed utilizing a team-based approach to inductive analysis. We found that health-related behavior occurred in the context of a complex life experience, with logistical problems exacerbated by emotional distress. Major themes included 1) transitional challenges; 2) cognitive responses including perceptions about personal risk, knowledge and priorities; 3) emotional responses including pronounced stress, fear, anxiety, disappointment; and 4) health behaviors. Former inmates reported multiple challenges, poor transitional preparation preceding release, and inadequate or absent continuity of mental and physical health care in the context of significant emotional distress and anxiety. Improved release planning, coordination between the medical, mental health and criminal justice systems may reduce the risk of poor health outcomes for this population.

Case management outcomes for women who use crack.

Women who use crack are at risk for HIV in addition to problems surrounding their drug use. In this study, 149 crack using women participated in a case management intervention. The sample was predominantly African-American and Hispanic and averaged 42 years old. At follow-up, significant improvements were reported on drug and alcohol use, mental and emotional health, and employment. The results indicate that case management services are useful to help crack-using women improve their lives.

The effect of methadone maintenance on positive outcomes for opiate injection drug users.

This study examined outcome variables for 160 opiate injection drug users (IDUs) who entered methadone maintenance between baseline and 6-month follow-up. Outcome variables of interest included drug use, productivity, and HIV risk behaviors. Participants were recruited through street outreach in Denver, CO, from 2000 through 2004 using targeted sampling. The sample was primarily men, White (48%), averaged 39 years of age, and had been injecting drugs for an average of nearly 20 years. Significant improvements were found in univariate tests. Logistic regression revealed that spending more time in treatment was a significant predictor of positive outcomes on drug use and HIV risk behaviors. The results underscore the importance of retaining IDUs in methadone maintenance to maximize their treatment success. Results from this study show that time in treatment can affect many aspects of the participant's life in a positive way, including reduction of HIV risk.