Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency.

BACKGROUND: West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state's drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston's needle and syringe program was forced to close. This paper considers the risk environment in which the state's drug-related loss of life, and those attempting to prevent it, exist. METHODS: This rapid ethnographic study involved semi-structured interviews (n = 21), observation and video recordings of injection sequences (n = 5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n = 2) with individuals involved in service provision were also carried out. RESULTS: PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH. CONCLUSIONS: Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

Co-use of methamphetamine and opioids among people in treatment in Oregon: A qualitative examination of interrelated structural, community, and individual-level factors.

BACKGROUND: Rates of methamphetamine use and methamphetamine-related deaths have increased steadily in the United States in recent years. Methamphetamine is increasingly present in opioid-related deaths. An initial study of de-identified urine specimens (n = 102) collected at a drug treatment program between 2017 and 2018 indicated that 61% of specimens contained methamphetamine; of the specimens containing methamphetamine, people were, on average, five years younger than those who tested negative for methamphetamine; and non-fentanyl opioids were more than three times as common in methamphetamine positive specimens. The National Drug Early Warning System (NDEWS) Coordinating Center initiated a HotSpot Study to assess whether there was an emerging dynamic in the area, or if enhanced data collection could give insights into the co-use of methamphetamine and opioids. METHODS: A qualitative study, grounded in principles of rapid ethnographic assessment and a social science/anthropological framework was conducted and used methodological complementarity to contextualize results from the initial urinalysis study. Targeted sampling was conducted at two treatment sites. Program staff and patients were recruited to participate in focus groups and semi-structured interviews to assess structural, community, and individual-level factors impacting methamphetamine and opioid co-use. RESULTS: Within our broader framework of structural, community, and individual-level factors intersecting co-use, our data yielded three sub-themes: 1) the circulation of stigma regarding methamphetamine use was consistently described by both patients and staff and this intersected structural changes in treatment policy and suggested compounded stigma; 2) community-level factors and temporality were important for understanding patterns of methamphetamine use and for further interpreting the initial urinalysis; 3) patient rationales regarding the co-use of methamphetamine and opioids included strategies to mitigate the harms of heroin, as well as to detox or titrate the effects of heroin. CONCLUSION AND IMPLICATIONS: Using an ethnographically-oriented and social science/anthropological approach and methodological complementarity to contextualize the prior urinalysis study demonstrates how behavioral variables cannot be abstracted from larger socio-structural and community contexts which impact people's decision-making process regarding co-use of methamphetamine and opioids. Further, by grounding our analysis in the meaning-centered and experiential narratives of people who use drugs, our research demonstrates the importance of considering the expertise of people who co-use opioids and methamphetamine as central for informing future sustainable program planning to address co-use that also accounts for the interrelationship between structural, community, and individual-level factors.

Beyond NIMBYism: understanding community antipathy toward needle distribution services.

In late 2007 the Homeless Youth Alliance (HYA), a small non-profit serving homeless youth in the Haight-Ashbury neighbourhood of San Francisco, USA, attempted to move its needle exchange service from a site on the Haight street commercial strip to a community centre approximately 150m away. The reaction of the housed community in the area was vocal and organized, and attracted considerable regional media attention. Ultimately, the plan to move the service had to be cancelled. The authors were, respectively, board chair and executive director of HYA at the time, and collected extensive field notes and media records as events unfolded. In this paper, we re-examine these events through literatures on contested spaces and on 'Not In My Backyard' (NIMBY) resistance to social services. We found that opposition to the service relocation had little to do with opposition to needle exchange itself, but rather was symptomatic of broader contestation over the identity and character of the neighbourhood. On the one hand, the neighbourhood had experienced skyrocketing housing prices over the past 40 years, making home ownership almost exclusively the province of the wealthy. On the other, the neighbourhood retains historic connections to the 1968 'Summer of Love', and the main commercial strip forms the centre of an active injecting drug use scene. As a consequence, many home owners who felt they had made considerable sacrifices to afford to live in the area expressed a sense of being "under siege" from drug users, and also believed that the City government pursues a deliberate policy of "keeping the Haight weird" by supporting ongoing service provision to drug users in the area. Housed residents responded to this situation in a variety of ways. One response was to engage in what we term 'defensive place making', in which a small part of a broader neighbourhood is reimagined as "a different neighbourhood". HYA's attempt to move from its current location to this 'different neighbourhood' was thus perceived as an "invasion" which threatened to break down a tentatively established separate identity. We conclude with a discussion of the relevance of these events for understanding and mitigating community opposition to services for drug users elsewhere.

A GIS-based methodology for improving needle exchange service delivery.

BACKGROUND: A variety of legal, social and logistical factors can prevent individuals from accessing formal needle exchange programmes. One common solution to this problem is satellite exchange, which involves collaborating with people who already use an exchange to deliver needles and other supplies to those unable to access the exchange. While this approach can be very successful, one potential problem is that those most willing to deliver needles to their peers are often members of social networks that are already well connected with the needle exchange, leading to duplication of effort. In this paper we describe a simple and novel method for identifying groups of people who are demonstrably in need of improved access to needles, and for re-targeting efforts to meet the needs of those people. The method described was piloted at the Homeless Youth Alliance, San Francisco, USA, and further refined at Clean Needles Now, Los Angeles, USA. METHODS: People accessing needle exchange sites were asked to participate in a survey with two questions: "where were you and what time was it last time someone borrowed a needle from you?" and "where were you and what time was it last time you had to borrow a needle from someone else?" Responses were geocoded, and maps produced showing 'hotspots' where people were frequently finding themselves without needles. RESULTS: Satellite needle exchange was refined from an ad-hoc activity into one which focused on delivering needles to those with empirically demonstrable need. Maps produced in the process also proved valuable in discussions with local officials and other agencies about funding, as well as needle provision policy and practices. CONCLUSION: We describe a method for rapidly assessing, describing, and responding to unmet and under-met need among injecting drug users. The method is particularly well-suited to organizations with extremely limited resources.