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Background: Illicitly manufactured fentanyls and stimulants are implicated in the escalating US mortality from drug overdose. San Francisco, California (SF) has seen declining fentanyl injection while smoking has increased. Beliefs and behaviors surrounding this development are not well understood. Methods: The study used rapid ethnography to explore fentanyl and methamphetamine use in SF. The team conducted semi-structured interviews (n = 34) with participants recruited from syringe service programs. Video-recorded smoking sequences (n = 12), photography and daily field notes supplemented interview data. Results: Difficulty injecting and fear of overdose motivated transitions from injecting to smoking. Fentanyl was extremely cheap—$10/gram—with variability in quality. Foil was the most commonly used smoking material but glass bubbles, bongs and dabbing devices were also popular. No reliable visible methods for determining fentanyl quality existed, however, participants could gauge potency upon inhalation, and developed techniques to regulate dosage. Several participants reported at least hourly use, some reporting one or more grams of daily fentanyl consumption. Smoking was also very social, with people sharing equipment, drugs and information. Participants raised concerns about hygiene and overdose risk to others arising from shared equipment. Reportedly potent fentanyl 'residue' accumulated on smoking materials and was commonly shared/traded/stolen or consumed accidentally with diverse preferences for its use. Conclusion: Our data highlight fentanyl residue as a new overdose risk with potential mismatch between the potency of the residual drug and the recipient's tolerance. Further, large doses of fentanyl are being consumed (estimated at approximately 50 mg of pure fentanyl/day). Smoking fentanyl has potential health benefits over injecting and may be protective against overdose, but substantial uncertainty exists. However, SF overdose mortality hit a record high in 2023. Recommendations to reduce fentanyl smoking overdose risks through pacing, greater awareness of dosages consumed and checking tolerance of residue recipients are potentially viable interventions deserving further exploration. [ABSTRACT FROM AUTHOR]

The article discusses the ongoing issue of overdose deaths in the United States, particularly due to the use of fentanyl in combination with other substances. Despite efforts to reduce the number of deaths, there has only been a slight reduction in the past 8 months. The Healing Communities Study, which aimed to reduce overdose deaths, was unsuccessful in bringing down the death rate. The authors suggest that the Covid-19 pandemic and differences in politics and social norms among communities may have contributed to the lack of success. The article also highlights the need to address the underlying structural causes of the opioid crisis and mentions the potential decline in overdose numbers in some eastern U.S. states. [Extracted from the article]

Background: Fentanyl-related deaths continue to increase in the United States; however, most national studies focus on fatal overdose. More research, including data on nonfatal overdose, is needed. Objective: We examined trends in characteristics of fatal and nonfatal fentanyl-related poisonings ("exposures") in the US. Methods: National Poison Control data were examined to estimate trends in characteristics of reported exposures between 2015 and 2021 (N = 15,391; 38.7% female). We also delineated correlates of experiencing a major adverse effect or death. Results: The proportion of exposures increased among all age groups between ages 13 and 39 (ps <.05) with the largest increase among those age 13–19 (a 127.8% increase). With respect to reasons for use, the proportion of cases involving fentanyl "abuse" increased by 63.8% (p <.001). The proportion involving fentanyl inhalation increased 427.6% from 5.7% to 29.9% and injection increased from 6.7% to 9.6%, a 42.3% increase (ps <.01). The proportion also increased for co-use of methamphetamine (by 669.0%), cocaine (by 374.0%), and heroin (by 159.5%). The proportion of major adverse effects increased from 15.5% to 39.6% (p <.001). In the multivariable model, "abuse", suspected suicide attempts, and use via inhalation were risk factors for experiencing a major effect or death, and misuse, ingestion, dermal use, and co-use of methamphetamine were associated with lower risk. Conclusion: Poison Control data suggest that characteristics of individuals exposed to fentanyl continue to shift, with use via inhalation increasing and medical outcomes of nonfatal poisonings becoming more severe. These results complement mortality data and inform prevention and harm reduction efforts. [ABSTRACT FROM AUTHOR]

Federal HIV prevention strategy seeks to increase efforts by health care providers to identify and reduce their HIV-positive patients' transmission-related behaviors. Implementation of these recommendations will be hindered if providers perceive these efforts have the potential to harm their relationships with patients. Because transmission-related behaviors (unsafe sex and sharing needles) and the related issues of drug and alcohol use also jeopardize the health of HIV-positive patients, providers can use patient-centered counseling when addressing those behaviors. We suggest efforts to increase provider-delivered transmission-prevention counseling be reframed so that 'prevention with positives' includes the goal of protecting HIV-positive patients' health. We review the specific consequences of these risky behaviors on HIV-positive patients' health and review brief counseling strategies appropriate for HIV care providers.

Objectives. We estimated the proportion of HIV-positive adults who have any sexual contact without disclosure and the proportion of their sexual partnerships that involve unprotected sex without disclosure. Methods. We drew participants from the HIV Cost and Services Utilization Study (n = 1421). Interviews assessed disclosure and sexual activities with up to 5 recent partners. Results. Overall, 42% of the gay or bisexual men, 19% of the heterosexual men, and 17% of all the women reported any sex without disclosure, predominately within nonexclusive partnerships (P< .001). Across all groups, 13% of serodiscordant partnerships involved unprotected anal or vaginal sex without disclosure, with no significant difference between groups. Conclusions. Risky sex without disclosure of serostatus is not uncommon among people with HIV.

Introduction: People who inject drugs (PWID) are vulnerable to a range of harms, including vascular conditions such as chronic venous insufficiency (CVI), leg ulcers and deep vein thrombosis (DVT). The extent of vascular conditions has rarely been studied, despite contributing to considerable illness and disability among PWID. We assess the prevalence and associations of vascular conditions in PWID in London, UK. Methods: Survey data from the community‐recruited Care and Prevent Study of PWID in London were analysed. Participants were asked about CVI and leg ulcers using pictorial questions, and if they had ever been diagnosed with DVT. Associations between vascular conditions and demographic/drug‐use information were explored using univariate and multivariable logistic regression. Results: Among participants (n = 455), the prevalence of CVI, leg ulcers and DVT was 13% (n = 57), 10% (n = 46) and 23% (n = 105), respectively. CVI and DVT were positively associated with injecting into the groin, while injecting into the leg was positively associated with leg ulcers and DVT. CVI was also associated with not cleaning injection sites and diagnosed hepatitis C virus, and DVT with hepatitis C virus. Discussion and Conclusion: The prevalence of vascular problems among PWID in London is very high in comparison to the general population. These conditions are primarily associated with injection into the femoral vein. Use of these injection sites indicates peripheral venous access problems. There is a need to reinvigorate safe injection information provision in harm reduction services, with attention to reducing risk practices associated with venous damage and transitions to femoral injection. [ABSTRACT FROM AUTHOR]

Doctors should offer to treat intravenous drug addicts with hepatitis C even if the patient is still using illicit drugs. Intravenous drug abuse is one of the ways hepatitis C is transmitted, so treating drug addicts is an important goal. However, the US National Institutes of Health in 1997 recommended withholding treatment from active drug users.

Voluntary HIV testing of hospital patients may not be a cost-effective technique for the prevention of HIV transmission from patients to health care workers (HCWs), but may be a cost-effective HIV screening mechanism. Researchers developed decision analysis models to evaluate the cost-effectiveness of HIV testing of hospital patients. Data for the models were derived from literature reviews, expert opinion, and group consensus. Cost-effectiveness was evaluated in terms of the cost per HCW to prevent patient-to-HCW transmission of HIV infection and the cost per hospital patient for each case of HIV infection detected per year. Results revealed that HIV testing would prevent 3.6 cases of HIV infection in HCWs per year at a cost of $2.7 billion. HIV testing of hospitalized patients would detect 168,874 cases of HIV infection per year at a cost $16,104 per case. This result is based on an estimated HIV infection rate of 1%., Objective. - To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV). Data Sources. - Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors. Data Extraction. - We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force. Data Synthesis. - Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence=l%), testing to detect inpatient HIV infection would cost $16 104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HCW infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive. Conclusions. - This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.

The cost-effectiveness of a mandatory HIV testing program for physicians and dentists depends on the prevalence of HIV infection and the risk of transmission. Data on a number of topics including the prevalence of HIV infection in health care workers, the number of physicians and dentists nationwide and the number of those who have been voluntarily tested were analyzed. The cost-effectiveness of HIV testing was evaluated under a number of conditions. The most cost-effective scenario involved one-time mandatory testing of surgeons and dentists with those who were HIV-positive being forced to restrict their practices to procedures with a low-risk of disease transmission. However, the cost of this scenario varied depending upon the prevalence of HIV infection and risk of transmitting the infection. At a middle level of HIV infection and transmission risk, the cost of preventing one infection would be more than $1 million., Objective.--To evaluate the cost-effectiveness of alternative policies for human immunodeficiency testing (HIV) testing of physicians and dentists. Methods.--Decision analysis and cost-effectiveness analysis from a societal perspective were used. Data were derived from extensive literature review and consultation with experts. We conducted sensitivity analyses and also performed a cost-benefit analysis. Analyses.--We analyzed policies for mandatory or voluntary testing of all physicians, surgeons, and dentists; for those testing positive, we analyzed mandatory or voluntary exclusion from practice, restriction from performance of invasive procedures, or requirements to inform patients of serostatus. Main Outcome Measure.--Cost per patient infection averted. Results.--Although one-time mandatory testing of surgeons and dentists with mandatory restriction of those found to be HIV-positive is more cost-effective than other policies, the cost-effectiveness varies tremendously under different scenarios. Results were highly sensitive to several data inputs, especially HIV seroprevalence of surgeons and dentists and transmission risk. For example, under a medium seroprevalence and transmission risk scenario, mandatory testing of all surgeons might avert 25 infections at a total cost of $27.9 million or $1115 000 per infection averted and an incremental cost of $291 000 compared with current testing; however, the incremental cost-effectiveness per patient infection averted ranges from $29 807 000 under a low-risk scenario to a savings of $81 000 under a high-risk scenario. Conclusion.--Our analysis neither justifies nor precludes a mandatory testing policy. Further research on the key data inputs is needed. Given the ethical, social, and public health implications, mandatory testing policies should not be implemented without greater certainty as to their cost-effectiveness. (JAMA. 1994;271:851-858)

Objective The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). Methods The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. Results The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other prescription drug misuse. The final competencies covered three domains: pain, SUD, and public health issues related to the opioid crisis. Conclusions The authors present a novel set of educational competencies as a response to the opioid crisis. These competencies emphasize the subject areas that are fundamental to the opioid crisis: pain management, the safe use of opioids, and understanding and treating SUD. [ABSTRACT FROM AUTHOR]

Background: Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis. Methods: We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity. Results: We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all. Conclusions: Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications. [ABSTRACT FROM AUTHOR]