Factors associated with daily use of benzodiazepines/tranquilizers and opioids among people who use drugs.

BACKGROUND: Co-use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co-use of these drugs when obtained both with and without a prescription. We examined associations of daily co-use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who use street opioids (PWUO). METHODS: PWUO (N = 417) were recruited from Baltimore City and neighboring Anne Arundel County, Maryland, and surveyed on sociodemographic characteristics, structural vulnerabilities, healthcare access and utilization, substance use, and overdose experiences. Multivariable logistic regression was used to identify factors associated with self-reported co-use. RESULTS: Participants were 46 years old on average, and predominantly Black (74%) males (62%). Daily co-use was reported by 22%. In multivariable analyses, odds of co-use were significantly higher among participants who did not have a high school degree/GED (adjusted odds ratio [aOR]: 1.71, 95% confidence interval [CI]: 1.02-2.88), endorsed receiving mental health treatment in the past 6 months (aOR: 2.13, 95% CI: 1.28-3.56), reported daily use of powdered cocaine (aOR: 3.57, 95% CI: 1.98-6.45), and synthetic cannabinoids (aOR: 3.11, 95% CI: 1.40-6.93). Odds of co-use were significantly lower among Black participants compared to white participants (aOR: 0.39, 95% CI: 0.19-0.82). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Clinicians working with PWUO or who prescribe BZDs or opioids should screen patients who use cocaine or synthetic cannabinoids, have low level of educational attainment, or recently accessed mental health services, as these patients may be at higher risk for daily co-use of BZD/TRQ and opioids, and therefore lethal overdose.

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.

Factors Associated with HIV Testing Among People Who Inject Drugs: Findings from a Multistate Study at the Start of the COVID-19 Pandemic.

Few studies have examined HIV testing among people who inject drugs (PWID) during the COVID-19 pandemic. This study examines factors associated with PWID who have been recently (past six months) tested for HIV during the COVID-19 pandemic. PWID were recruited between August 2020 and January 2021 from 22 drug treatment and harm reduction programs in nine states and the District of Columbia. We used logistic regression to identify correlates of recent HIV testing among PWID (n = 289). Most (52.9%) PWID reported having been recently tested for HIV. Factors associated with recent HIV testing included: having attended college [adjusted odds ratio (aOR) 2.32, 95% confidence interval (95% CI) 1.32-4.10], weekly hunger (aOR 2.08, 95% CI 1.20-3.60), crystal methamphetamine injection (aOR 2.04, 95% CI 1.05-3.97), and non-metropolitan residence (aOR 0.33, 95% CI 0.13, 0.88). Findings suggest HIV testing initiatives should be expanded during times of crisis, such as global pandemics.

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.

High willingness to use overdose prevention sites among suburban people who use drugs who do not inject.

INTRODUCTION: Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD) via non-injection routes of administration in suburban areas are lacking. METHODS: We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs' likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS. FINDINGS: Participants' median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS. CONCLUSION: Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic.

BACKGROUND: Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises. OBJECTIVE: This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19. METHODS: From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing. RESULTS: One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing. CONCLUSIONS: Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia.

BACKGROUND: The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia. METHODS: From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data. RESULTS: Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff. CONCLUSIONS: Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Overdose Experiences among People Who Inject Drugs in West Virginia: Personal Loss, Psychological Distress, Naloxone, and Fentanyl.

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results: Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions: Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia.

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Exploring the impact of the COVID-19 pandemic on syringe services programs in rural Kentucky.

BACKGROUND: The coronavirus pandemic (COVID-19) exacerbated risks for adverse health consequences among people who inject drugs by reducing access to sterile injection equipment, HIV testing, and syringe services programs (SSPs). Several decades of research demonstrate the public health benefits of SSP implementation; however, existing evidence primarily reflects studies conducted in metropolitan areas and before the COVID-19 pandemic. OBJECTIVES: We aim to explore how the COVID-19 pandemic affected SSP operations in rural Kentucky counties. METHODS: In late 2020, we conducted eighteen in-depth, semi-structured interviews with persons (10 women, 8 men) involved in SSP implementation in rural Kentucky counties. The interview guide broadly explored the barriers and facilitators to SSP implementation in rural communities; participants were also asked to describe how COVID-19 affected SSP operations. RESULTS: Participants emphasized the need to continue providing SSP-related services throughout the pandemic. COVID-19 mitigation strategies (e.g., masking, social distancing, pre-packing sterile injection equipment) limited relationship building between staff and clients and, more broadly, the pandemic adversely affected overall program expansion, momentum building, and coalition building. However, participants offered multiple examples of innovative solutions to the myriad of obstacles the pandemic presented. CONCLUSION: The COVID-19 pandemic impacted SSP operations throughout rural Kentucky. Despite challenges, participants reported that providing SSP services remained paramount. Diverse adaptative strategies were employed to ensure continuation of essential SSP services, demonstrating the commitment and ingenuity of program staff. Given that SSPs are essential for preventing adverse injection drug use-associated health consequences, further resources should be invested in SSP operations to ensure service delivery is not negatively affected by co-occurring crises.

Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in Maryland.

BACKGROUND: Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men's selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland. METHODS: Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors. RESULTS: Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97-0.99, p < 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81-7.37, p < 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05-3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02-3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex. CONCLUSIONS: Synergistic sources of social and structural marginalization-from sexuality to hunger, homelessness, and injection drug use-are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO.

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.

Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs.

BACKGROUND: Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic. METHODS: We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs. RESULTS: We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services. CONCLUSIONS: In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.

Alternative use of buprenorphine among people who use opioids in three U.S. Cities.

Background: Buprenorphine is an effective treatment for opioid use disorder, yet some persons are concerned with its "alternative use" (i.e., any use unintended by the prescriber). There is limited evidence on the factors associated with alternative use of buprenorphine (AUB); in this study, we examined correlates of recent (past 6 months) AUB. Methods: Multivariable logistic regression was used to analyze survey data from a multi-site, cross-sectional study of people who use drugs (PWUD) (N = 334) in Baltimore, Maryland; Boston, Massachusetts; and Providence, Rhode Island. Results: One-fifth (20%) of the sample reported recent AUB. In adjusted analyses, significant negative correlates of AUB were female gender (adjusted odds ratio [aOR] 0.48, 95% confidence intervals [CI] 0.24-0.95), recent emergency room visit (aOR 0.45, 95% CI 0.23-0.89), and recent injection drug use (aOR 0.41, 95% CI 0.19-0.88). Significant positive correlates were alternative use of other prescription opioids (aOR 8.32, 95% CI 4.22-16.38), three or more overdoses in the past year (aOR 3.74, 95% CI 1.53-9.17), recent buprenorphine use as prescribed (aOR 2.50, 95% CI 1.12-5.55), and recent residential rehabilitation treatment (aOR 3.71, 95% CI 1.50-9.16). Conclusions: Structural and behavioral correlates of AUB may help identify PWUD at high risk of overdose with unmet treatment needs.

Characterising HIV and STIs among transgender female sex workers: a longitudinal analysis.

OBJECTIVES: Though highly vulnerable to HIV and STIs, transgender female sex workers (TFSWs) are understudied in the US HIV and STI response. This study examined the correlates of laboratory-confirmed STIs among a cohort of 62 TFSWs followed over the course of 1 year and explored associations between specimen site and self-reported engagement in insertive and receptive anal intercourse. METHODS: Participants completed an interviewer-administered computer-assisted personal interview at baseline, 3-, 6-, 9- and 12-month visits where self-administered anal swabs and urine samples for gonorrhea, chlamydia and trichomoniasis were also collected. HIV testing was conducted at baseline, 6-month and 12-month visits. RESULTS: Baseline HIV prevalence was 40.3% with no HIV seroconversions over follow-up. Baseline prevalence of gonorrhea, chlamydia and trichomoniasis was 9.7%, 17.7% and 14.5%, respectively. In the multivariable regression modelling, recent arrest was significantly associated with testing positive for any STI (adjusted risk ratio (RR) 1.77; 95% CI: 1.10 to 2.84). Insertive anal sex with clients was associated with increased risk of testing positive for an STI via urine specimen (RR 3.48; 95% CI: 1.14 to 10.62), while receptive anal sex was not significantly associated with specimen site. CONCLUSION: Our findings confirm a high prevalence of STIs among TFSWs and highlight the importance of addressing structural drivers such as criminal justice involvement as well as the need to ensure screening for STIs at all anatomical sites regardless of self-reported sites of potential exposure. More research is needed to better understand HIV and STI vulnerabilities and appropriate interventions for TFSWs in the USA.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA.

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Awareness of and interest in oral pre-exposure prophylaxis (PrEP) for HIV prevention and interest in hypothetical forms of PrEP among people who inject drugs in rural West Virginia.

Injection drug use-associated HIV outbreaks have occurred in rural communities throughout the United States, which often have limited HIV prevention services for people who inject drugs (PWID). Pre-exposure prophylaxis (PrEP) is one tool that may help fill gaps in HIV prevention programing in rural settings. Oral PrEP has been approved for use, and new PrEP formulations are under development. Research is needed to better understand interest in oral and possible forthcoming PrEP formulations among PWID. We used survey data from 407 PWID in rural West Virginia. We asked if participants had heard of, taken, and were interested in taking PrEP, and about interest in several hypothetical forms of PrEP (arm injections, abdomen injections, implants, intravenous infusions). We estimated the prevalence of interest in each formulation and assessed correlates using Chi-squared tests. A minority had heard of oral PrEP (32.6%), and few had used it (3.7%). Many were interested in using oral PrEP (58.3%). Half were interested in arm injections (55.7%). Common correlates of interest across PrEP formulations were sexual minority status, comfort talking to a doctor about sex, sex work, and sharing injection equipment. Oral and injectable PrEP have the potential to fill HIV prevention gaps for rural PWID.

Practical implications of naloxone knowledge among suburban people who use opioids.

BACKGROUND: Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available. METHODS: We used data from 173 PWUO from Anne Arundel County, Maryland, which is located between Baltimore City and Washington, DC. We assessed the prevalence of recently (past 6 months) receiving naloxone and currently having naloxone, the type(s) of the naloxone kits received, and the perceived ease/difficultly of accessing naloxone. We also assessed participants knowledge of where naloxone was available in the community. RESULTS: One third (35.7%) of participants had recently received naloxone. Most who had received naloxone received two doses (72.1%), nasal naloxone (86.9%), and education about naloxone use (72.1%). Most currently had naloxone in their possession (either on their person or at home; 78.7%). One third (34.4%) believed naloxone was difficult to obtain in their community. Only half (56.7%) knew of multiple locations where they could get naloxone. The health department was the most commonly identified naloxone source (58.0%). Identifying multiple sources of naloxone was associated with being more likely to perceive that naloxone is easy to access. DISCUSSION: Our results suggest that additional public health efforts are needed to make PWUO aware of the range of sources of naloxone in their communities in order to ensure easy and continued naloxone access to PWUO.

Correlates of recent nonfatal overdose among people who inject drugs in West Virginia.

AIM: Experiencing a nonfatal overdose (NFOD) is a significant risk factor for a subsequent nonfatal or fatal overdose. Overdose mortality rates in rural Appalachian states are some of the highest in the USA, but little is known about correlates of overdose among rural populations of people who inject drugs (PWID). Our study aimed to identify correlates of experiencing a recent (past 6 months) NFOD among rural PWID in Cabell County, West Virginia. METHODS: Using data from a June-July 2018 cross-sectional survey that was designed to estimate the size and characteristics of the PWID population in Cabell County, West Virginia, we used log binomial regression to identify correlates (e.g., structural vulnerabilities and substance use) of NFOD in the past 6 months. RESULTS: The majority of our sample of 420 PWID were male (61.2%), White, non-Hispanic (83.6%), and reported recent heroin injection (81.0%). More than two-fifths (42.6%) experienced a recent NFOD. Independent correlates of NFOD included witnessing an overdose in the past 6 months (adjusted prevalence ratio [aPR] = 2.28; 95% CI 1.48-3.50), attempting to quit using drugs in the past 6 months (aPR = 1.54; 95% CI 1.11-2.14), and the number of drugs injected (aPR = 1.16; 95% CI 1.10-1.23) CONCLUSIONS: A large proportion of rural PWID in Appalachia reported having recently overdosed. The associations between witnessing an overdose, attempting to quit using drugs, and number of drugs injected with recent nonfatal overdose underscore the need for expanded access to overdose prevention resources that are tailored to the needs of this population. Expanding access to evidence-based overdose prevention strategies-such as take-home naloxone programs, treatment with methadone or buprenorphine, and harm reduction services-may decrease overdose morbidity and mortality among rural PWID in Appalachia.

Food access among people who inject drugs in West Virginia.

BACKGROUND: The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food often co-occurs with drug use and contributes to associated sequelae, such as risks for HIV and diabetes. The objective of this study was to examine factors associated with adequate food access among PWID in a rural Appalachian community. METHODS: Cross-sectional surveys were used to collect data among PWID aged 18 and older in Cabell County, West Virginia. Frequency of hunger and sociodemographic, structural and drug use characteristics were measured. Adequate food access was defined as reporting 'never' going to bed hungry at night in the past six months. Pearson's χ2 and t-tests and multivariable logistic regression were used to identify factors associated with food access. RESULTS: Only 71 individuals (17%) reported never going to bed hungry at night in the past six months. Adjusted odds of having adequate food access were higher among PWID who completed high school (aOR 2.94; P = 0.010) and usually used drugs alone (aOR 1.97; P = 0.025), and lower among PWID who were female (aOR 0.51; P = 0.037), experienced homelessness (aOR 0.23, P < 0.001), were recently arrested (aOR 0.50 P = 0.047), and engaged in receptive sharing of injection equipment (aOR 0.52, P = 0.035). CONCLUSIONS: We found extremely low food access in a population of PWID in Appalachia who are vulnerable to overdose and infectious disease transmission. Integrated interventions promoting food access are needed to improve the public health and wellbeing of people who inject drugs in Appalachia.