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Painkiller (mis)use in sport presents a range of potential health risks to athletes (e.g., injury exacerbation). There is a lack of qualitative data examining the sociological genesis of variations in attitudes toward painkiller use. Focusing on the concept of physical capital, this article explores how attitudes toward painkiller use among professional cricket players in England are socialized by their workplace. Attitudes toward painkiller (mis)use stem from field-level structures that foster employment vulnerability, ensuring physical capital is precarious and legitimating painkiller (mis)use as a method of protecting economic opportunities with the added benefit of accruing symbolic capital by demonstrating toughness. Based on the findings, this article advocates for a sociologically informed harm-reduction approach to pain management in elite sport. [ABSTRACT FROM AUTHOR]

Background: In the United States, community overdose education and naloxone distribution (OEND) programs have demonstrated efficacy in reducing opioid-related mortality. OEND programs have expanded across San Diego County, California, but differential naloxone accessibility among people who use drugs (PWUD) has not been assessed. We examined factors that shape individual naloxone accessibility in San Diego.Methods: We employed a convergent parallel mixed methods design using surveys (n=194) and qualitative interviews (n=20). Ordinal logistic regression examined factors associated with personal naloxone accessibility (i.e., the frequency with which participants could access naloxone within five minutes, categorized as never, sometimes, or always). Qualitative interviews explored participant perceptions of naloxone accessibility and whether and how they maintained naloxone. We organized multilevel findings into a modified social-ecological model.Results: In quantitative and qualitative samples, participants were majority male (72% and 70% respectively), non-White race/ethnicity (55% and 75%), with an average age around 42 years. In the quantitative sample, 24% never had personally accessible naloxone, 52% sometimes did, and 24% always did. Factors independently associated with greater personal naloxone accessibility were female gender (Adjusted Odds Ratio [AdjOR]: 2.51, 95% Confidence Interval [CI]: 1.31–4.85), monthly income

BACKGROUND: Prisons often serve as high-risk environments for drug use, and incarcerated people are at a high risk for substance use-related mental and physical harms. This study aimed to determine the prevalence of non-injection drug use inside the prison and its related factors among incarcerated people in Iran. METHODS: We utilized data from three national bio-behavioral surveillance surveys conducted among incarcerated people in Iran in 2009, 2013, and 2017. Eligibility criteria were being ≥ 18 years old, providing informed consent, and being incarcerated for over a week. Overall, 17,228 participants across all surveys were recruited through a multi-stage random sampling approach. Each participant underwent a face-to-face interview and HIV test. The primary objective of the study was to assess self-reported non-injection drug use within the prison environment within the last month. A multivariable logistic regression model was built to determine associated covariates with drug use inside prison and an adjusted odds ratio (aOR) with 95% confidence intervals (CI) were reported. RESULT: The prevalence of non-injection drug use inside the prison was 24.1% (95% CI 23.5, 24.7) with a significant decreasing trend (39.7% in 2009, 17.8% in 2013, 14.0% in 2017; p-value

Injection drug use is the primary driver of the human immunodeficiency virus HIV epidemic in Iran. We characterized people who inject drugs (PWID) living in Iran who had never received opioid agonist therapy (OAT) and examined barriers to OAT uptake. We recruited 2,684 PWID with a history of drug injection in the previous 12 months using a respondent-driven sampling approach from 11 geographically dispersed cities in Iran. The primary outcome was no lifetime uptake history of OAT medications. The lifetime prevalence of no history of OAT uptake among PWID was 31.3%, with significant heterogeneities across different cities. In the multivariable analysis, younger age, high school education or above, no prior incarceration history, and shorter length of injecting career was significantly and positively associated with no history of OAT uptake. Individual-level barriers, financial barriers, and system-level barriers were the main barriers to receiving OAT. PWID continue to face preventable barriers to accessing OAT, which calls for revisiting the OAT provision in Iran.

Introduction: Medical and nonmedical ketamine use is increasing in the United States. This will likely lead to an increase in emergency department (ED) visits in individuals experiencing associated side effects. Physicians will need to be able to effectively recognize and manage ketamine-related complications.Case Report: A 31-year-old male with a three-year history of inhalational, intramuscular, and intravenous nonmedical ketamine use presented to the ED twice within a week with symptoms of severe atraumatic back pain, abdominal pain, and dyspepsia. A comprehensive workup, including advanced imaging, was unrevealing for identifiable causes, and the patient was discharged with instructions for primary care follow-up for further evaluation. The patient used information shared on Reddit, an online forum and social network, to identify that the cause of his pain was related to chronic ketamine use. Subsequently, upon discontinuation of ketamine, the pain improved in 24 hours. The patient self-navigated to addiction treatment.Conclusion: Emergency physicians should consider sequelae of chronic ketamine use as a possible cause for gastrointestinal and urologic symptoms in the ED. In addition to thorough examination and assessment for other acute medical problems, patients should be offered education, symptomatic treatment, and linkage to harm reduction and substance use disorder treatment services.

People who nonmedically use drugs (PWUD) face intricate social issues that suppress self-actualization, communal integration, and overall health and wellness. Strengths-based approaches, an under-used pedagogy and practice in addiction medicine, underscore the significance of identifying and recognizing the inherent and acquired skills, attributes, and capacities of PWUD. A strengths-based approach engenders client affirmation and improves their capacity to reduce drug use-related harms by leveraging existing capabilities. Exploring this paradigm, we conducted and analyzed interviews with 46 PWUD who were clients at syringe services programs in New York City and rural southern Illinois, two areas with elevated rates of opioid-related morbidity and mortality, to assess respondents perceived strengths. We located two primary thematic modalities in which strengths-based ethos is expressed: individuals (1) being and advocate and resource for harm reduction knowledge and practices and (2) engaging in acts of continuous self-actualization. These dynamics demonstrate PWUD strengths populating and manifesting in complex ways that both affirm and challenge humanist and biomedical notions of individual agency, as PWUD refract enacted, anticipated, and perceived stigmas. In conclusion, programs that blend evidence-based, systems-level interventions on drug use stigma and disenfranchisement with meso and micro-level strengths-based interventions that affirm and leverage personal identity, decision-making capacity, and endemic knowledge may help disrupt health promotion cleavages among PWUD.

BACKGROUND: The overdose crisis driven by synthetic opioids continues to escalate in the USA. We evaluated the efficacy of multiple manufacturing lots of a fentanyl test strip (FTS) to detect fentanyl and fentanyl analogs and assessed cross-reactivity with possible interferences. METHODS: Drug standards were dissolved in water in a laboratory setting and serially diluted. Drug dilutions were tested using five different manufacturing lots of BTNX Rapid Response (20 ng/mL cutoff) lateral flow chromatographic immunoassay strips to assess lot-to-lot variability for FTS sensitivity and cross-reactivity for the analytes of interest. RESULTS: All five manufacturing lots cross-reacted with fentanyl and eleven fentanyl analogs. Diphenhydramine, lidocaine, MDMA, and methamphetamine were found to cause false positives with the strips. There was notable lot-to-lot variability in the sensitivity of the strips for fentanyl, fentanyl analogs, and known interferences. DISCUSSION: FTS remains an important overdose prevention tool, but lot-to-lot variability in performance complicates robust instructions that balance the prevention of false positives and false negatives. Continued lot-to-lot performance assessment is recommended to ensure health education for FTS remains accurate. More sophisticated drug checking technologies and services are needed in the community landscape to augment personal FTS use to facilitate informed consumption and overdose risk mitigation.

BackgroundXylazine is an increasingly common adulterant in the North American unregulated drug supply that is associated with adverse health outcomes (e.g., skin infections, overdose). However, there are significant knowledge gaps regarding how xylazine was initially identified and how syringe services program (SSP) staff and clients (people who use drugs) responded to its emergence.MethodsFrom June-July 2023, we conducted qualitative interviews with medical (e.g., clinicians) and frontline SSP staff (e.g., outreach workers) and adult clients with a history of injection drug use at a Miami-based SSP. Inductive memos identified emergent codes; thematic analysis involving team consensus established final themes.ResultsFrom interviews with SSP staff (n = 8) and clients (n = 17), xylazine emergence was identified at different times, in various ways. Initially, during summer 2022, clients identified a "tranquilizer-like substance" that worsened sedation and withdrawal and caused wounds. SSP medical staff later identified this adulterant as xylazine by treating new medical cases and through diverse information-sharing networks that included professional societies and news sources; however, frontline SSP staff and clients needed additional educational resources about xylazine and its side effects. With limited guidance on how to reduce harm from xylazine, SSP clients altered their drug consumption routes, reduced drug use, and relied on peers' experiences with the drug supply to protect themselves. Some individuals also reported preferring xylazine-adulterated opioids and increasing their drug use, including the use of stimulants to avoid over sedation.ConclusionsXylazine's emergence characterizes the current era of unprecedented shifts in the unregulated drug supply. We found that xylazine spurred important behavioral changes among people who use drugs (e.g., transitioning from injecting to smoking). Incorporating these experiences into early drug warning surveillance systems and scaling up drug-checking services and safer smoking supply distribution could help mitigate significant health harms caused by xylazine and other emergent adulterants.

BackgroundDelivering methadone treatment in community health facilities by primary care providers is a task-shifting strategy to expand access to drug use treatment, especially in rural mountainous areas. This study aims to investigate factors related to confidence in providing methadone treatment among primary care providers in Vietnam to inform good practice development.MethodsWe conducted a cross-sectional survey with 276 primary care providers who were physicians, physician assistants, nurses, pharmacists or dispensing staff from 67 communes in a mountainous province in Northern Vietnam. Using self-report scales, we measured providers' confidence in providing methadone treatment, beliefs in harm reduction, perceived work-related support, perceived stigma and risk in working with drug-using patients, and empathy towards this population. We used multiple linear regression analyses to explore factors associated with providers' confidence in providing methadone treatment in the whole sample and to compare two groups of providers who did and did not have experience providing methadone. Potential associated factors were measured at facility and provider levels.Result114 (41.3%) participants had previously experience in providing methadone treatment. Providers with methadone treatment experiences had higher confidence in and more accurate knowledge of methadone treatment, perceived less stigma of working with drug-using patients, and reported more work-related support than those without experiences. Higher medical education is associated with lower confidence in providing methadone treatment among providers without methadone experiences, but higher confidence among providers with methadone experiences. Better methadone knowledge was associated with greater confidence in providing methadone treatment among inexperienced providers but not among those with experiences. Receiving work-related support was associated with greater confidence in providing treatment in both groups, regardless of their past methadone experiences.ConclusionIn rural provinces where methadone treatment has been expanded to primary care clinics, interventions to improve primary care providers' confidence should benefit professionals with diverse experiences in providing methadone treatment. Continued training and support at work for providers is essential to ensuring quality in decentralized methadone treatment.

BackgroundMortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered.MethodsWe conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis.ResultsWe found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels.ConclusionThis study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

BackgroundCannabis use before the COVID-19 pandemic for many involved sharing prepared cannabis for inhalation, practices that were less prevalent during the pandemic. State-level COVID-19 containment policies may have influenced this decrease. This study examined the extent to which the intensity of state-level COVID-19 policies were associated with individual-level cannabis sharing. Findings have the potential to guide harm reduction policies for future respiratory pandemics and seasonal respiratory virus waves.MethodsThis study used cross-sectional individual-level data from the COVID-19 Cannabis Study, an anonymous U.S.-based web survey on cannabis use disseminated during the early phase of the pandemic (Full sample N = 1,883). We combined individual-level data with state-level policy data from Kaiser Family Foundation's State COVID-19 Data and Policy Actions for three time-points from June to August 2020 that overlapped with the survey period. Cannabis sharing was dichotomized as any versus no sharing. We adapted a previously published coding framework to score the intensity of COVID-19 policies implemented in each U.S. state and averaged the policy score across the time period. We then used Poisson regression models to quantify the associations of the average state-level COVID-19 policy score with cannabis sharing during the pandemic.ResultsParticipants (n = 925) reporting using inhalation as a mode for cannabis use were included in this analysis. Most respondents were male (64.1%), non-Hispanic White (54.3%), with a mean age of 33.7 years (SD 8.8). A large proportion (74.9%) reported sharing cannabis during the pandemic. Those who shared cannabis more commonly lived in states with a lower average policy score (16.7, IQR 12.3-21.5) compared to those who did not share (18.6, IQR 15.3-25.3). In adjusted models, the prevalence ratio of any cannabis sharing per every 5-unit increase in the average COVID-19 policy score was 0.97 (95% CI 0.93, 1.01).ConclusionsFewer individuals shared cannabis in states with more intense COVID-19 containment policies compared to those in states with less intense policies. Individuals who use cannabis may be willing to make changes to their behavior and may further benefit from specific and directed public health messaging to avoid sharing during respiratory infection outbreaks.

BackgroundAgainst the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis.Harm reduction and overdose prevention in housingIn response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts.ConclusionEmerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings.

BackgroundPeople who use drugs (PWUD) experience elevated HIV risk and numerous barriers to facility-based HIV testing. HIV self-testing (HIVST) could circumvent many of those barriers and is acceptable among PWUD, yet HIVST implementation for PWUD is limited. Service providers' perspectives on specific HIVST delivery strategies could help increase availability for PWUD.MethodsFrom April-November 2021, we interviewed 16 health, harm reduction, and social service providers working with PWUD in San Diego, CA. Interviews and rapid thematic analysis explored perspectives on HIVST's utility and appropriateness, as well as the feasibility of and anticipated challenges with specific HIVST delivery strategies, including peer or secondary distribution.ResultsParticipants viewed HIV as a significant threat to PWUD health and confirmed the presence of numerous barriers to local facility-based HIV testing. Participants viewed HIVST as a promising and potentially empowering solution. Based on community familiarity with secondary distribution of harm reduction supplies (i.e., naloxone) and information, participants viewed secondary distribution of HIVST kits as an appropriate and feasible strategy for increasing the reach of HIVST, but also described potential barriers (e.g., engaging socially disconnected individuals, ensuring linkages to services following HIVST) and provided suggestions for alternative HIVST kit delivery models (e.g., harm reduction vending machines).ConclusionsService providers viewed secondary distribution of HIVST kits among PWUD as promising, appropriate, and feasible, yet specialized efforts may be needed to reach the most marginalized individuals and ensure consistent provision of educational information and referral supports that maximize the impact of this approach.

Background: With the advent of direct acting antivirals (DAAs) the World Health Organisation (WHO) adopted global strategy to eliminate hepatitis C virus (HCV) infection by 2030. In Europe, people who inject drugs (PWID) account for the majority of new cases, however testing and treatment remain suboptimal. The aim was to monitor progress in HCV policy and cascade-of-care for PWID, led by the civil society organisations (CSO) that provide harm reduction services for PWID across Europe. Methods: In period 2020–2023, CSOs representing focal points of Correlation-European Harm Reduction Network were annually invited to complete online questionnaire on use/impact of HCV test-and-treat guidelines for PWID, availability/functioning of continuum-of-care, and role/limitations of harm reduction services for PWID. A retrospective longitudinal analysis of responses to questions answered each year by the same respondents was performed, and a comparison among the studied years was made. Results: Twenty-five CSOs from cities in 25 European countries were included and responded to 25 questions. Between 2020 and 2023, there was positive trend in number of HCV treatment guidelines, separate guidelines for PWID, and their positive impact on acess to testing/treatment (24/25, 5/25, and 16/25 in 2023, respectively). DAAs were available in all countries, predominantly prescribed by specialist physicians only (slight increase at primary care), with restrictions including active drug use, stage of liver fibrosis or/and reimbursement policies (2/25, 4/25, and 3/25 in 2023, respectively). A decrease in HCV testing sites was noted. Treatment was consistently most common at clinical settings, however an increase outside the specialist settings was detected, particularly in prisons (12/25 and 15/25 in 2020–2021, respectively). Comparing 2022–2023, number of HCV-testing services increased in many cities with positive dynamic in nearly all the settings; increase in treatment at harm reduction services/community centres was noted (6/25 to 8/25, respectively). Between 2020 and 2023 the frequency of various limitations to CSOs addressing HCV was oscillating, presenting an increase between 2022 and 2023 (9/25 to 14/25, respectively). Conclusion: The overall progress towards WHO HCV elimination goals across Europe remains insufficient, most probably also due to the influence of Covid-19 pandemic. Further improvements are needed, also by including CSOs for PWID in continuum-of-care services, and in monitoring progress. [ABSTRACT FROM AUTHOR]

Since the 1990s, Vietnam has begun prioritising preventing and combating drug-related crimes (supply reduction) and rehabilitating drug users (demand reduction). In the 2000s, harm reduction approaches in relation to drug control began to be recognised as one of Vietnam's opiate substitution therapy methods before embarking on greater drug policy reform in the early 2010s. In implementing the ideology of the Communist Party of Vietnam, the anti-narcotic police forces often apply a zero-tolerance approach to drug traffickers and identify drug users as a priority applies a zero-tolerance approach to drug traffickers and identifies drug users as a priority to send them to prison or compulsory detention centres rather than apply harm reduction as the international standard model to promote health conditions for them without detention. This study conducted a qualitative content analysis of documents by collecting and analysing grey literature on drug policy resources, combined with qualitative interviews with experts and drug policy professionals. Although Vietnam (re)states its commitment to balance the three pillars of harm minimisation in its drug policy reform, my research demonstrates that unclear provisions and blurred policies remain, and the challenges associated with scaling these approaches equally may not be feasible in reality. To do this, this study briefly explains (1) why Vietnam dominates the use of supply reduction-driven measures with 'hard strikes' for drug-related crimes, including the death penalty; (2) why Vietnam continues to use compulsory detention facilities for drug users as the main component of its demand reduction policy; and (3) why Vietnam still struggles to apply harm reduction, including in relation to policing practices. Some specific recommendations are called for further consideration to support harm reduction in policing. [ABSTRACT FROM AUTHOR]

Background: People who use drugs (PWUD) are at increased risk for blood-borne viruses, including hepatitis B (HBV) and delta (HDV). Despite the public health threats both viruses present, awareness remains low among at-risk communities and providers who serve them. This study assessed barriers to HBV and HDV prevention, diagnosis, and linkage to care, evaluated existing levels of knowledge, and identified educational needs and preferences among both PWUD and service providers. Methods: For this mixed-methods study, data were collected through an anonymous online provider-focused survey, and interviews with PWUD, non-medical staff, and healthcare providers at a harm reduction organization in Philadelphia, PA, USA. Convenience sampling was used for recruitment of both key informants and survey respondents. Survey respondents were categorized according to their type of practice. For the interviews, a codebook was created for qualitative analysis. Data were subsequently organized into thematic categories. Results: The top provider-related barriers limiting HBV screening were identified as confusion about insurance coverage (48%) and competing priorities (45%). Barriers to vaccination included patient hesitancy (52%) and challenges with administering multiple doses (39%). Respondents indicated low knowledge of HDV tests (62%) and cited guideline complexity (31%) as barriers to HDV testing. HBV and HDV awareness within the community and among staff was poor. Findings demonstrated that stigma related to drug use and harm reduction posed a significant barrier to care. Participants recommended awareness campaigns tailored for the PWUD community that are non-stigmatizing and non-judgmental, clear, factual, digestible, and interactive, with empowering steps to protect health. Conclusion: This study identified major gaps in HBV and HDV service delivery for PWUD, including poor basic knowledge, the need to address this through culturally appropriate, non-stigmatizing and tailored educational programming, and challenges with access to vaccination and testing. Continued initiatives are needed to close disparities, and to continue to provide financial and political support for harm reduction organizations, a frequently cited facilitator of healthcare access for PWUD. Significant efforts are essential to address lack of vaccination, testing, and linkage to care, and to improve health outcomes among PWUD. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsConclusionThe Médecins Sans Frontières (MSF) Kiambu People Who Use Drugs (PWUD) project, which started in September 2019, had enrolled 590 PWUD in its Medically Assisted Therapy (MAT) program by April 2022. This project provides a one-stop-shop model, offering a comprehensive range of medical and psychosocial services. This study aimed to explore how PWUD navigate from heroin use to MAT enrolment.The study involved individual, paired and group interviews conducted between August and October 2022. Purposive sampling was applied. Interviews were recorded, transcribed, coded with NVivo and analysed using reflexive thematic analysis. Methodological triangulation enhanced interpretation.PWUD faced various challenges to engage in the MAT program. Replacing heroin with MAT, the ‘medicine,’ was insufficient to ensure meaningful recovery. Engaging in MAT required personal motivation to exit the hotspots that their lives revolve around. Main barriers were coping with changed lifestyles and behavioural patterns, and the need to develop new perspectives on dealing with ‘idleness.’The study revealed the complex realities PWUD are confronted with when trying to engage in MAT. MAT programs need to address medical, psychosocial, employment and other structural factors while supporting people to restore their broken social conditions. [ABSTRACT FROM AUTHOR]

AbstractThis paper examines the evolution and current challenges of the Brazilian Psychosocial Care Centers for Alcohol and other Drugs (CAPS-ADs), central to Brazil’s mental health reform. Established within the broader Psychosocial Care Network (RAPS) in 2002, CAPS-AD represents a shift from hospital-centric to community-based care for mental health and substance dependency. Synthesizing 39 peer-reviewed articles, the study explores CAPS-AD’s operational characteristics, effectiveness and limitations. The model is distinguished by its interdisciplinary approach, open-door policy, and focus on social reintegration, providing continuous access to specialized care. Key features include singular therapeutic plans, harm reduction strategies and integration with primary care. The CAPS-AD III modality, offering 24-hour care, highlights the model’s adaptability. Despite its strengths, the CAPS-ADs face challenges such as user dissatisfaction with rigid therapeutic activities, limited autonomy and inadequate participation in care planning. Structural deficiencies, particularly in resource-limited regions and the persistence of traditional biomedical approaches further hinder quality care. Additional barriers include insufficient attention to gender-specific needs, age-appropriate care and the stigmatization of substance users and professionals. Addressing these challenges through structural reforms, enhanced training, and a more integrated, personalized, and stigma-free approach is essential to fully realize the potential of CAPS-AD and advance equitable mental health care in Brazil. [ABSTRACT FROM AUTHOR]

Background: Different countries, including Iran, have implemented various policies to address substance use disorder. This study aims to describe the policies related to substance use disorder treatment and identify challenges related to these policies in Iran since the beginning of the Iranian Revolution in 1979. Methods: This qualitative study utilized document analysis and interviews with policymakers and implementers. We reviewed a total of 22 documents related to substance use disorder treatment and harm reduction. The results from document analysis complemented and validated the interview data. The research population comprised policymakers and implementers, including individuals directly involved in formulating and implementing substance use disorder treatment policies. Purposive sampling was employed, with a snowball strategy utilized to maximize diversity. Data saturation was achieved after conducting 32 semi-structured interviews. Conventional content analysis was used for data analysis. Results: In general, the policy landscape for substance use disorder treatment in the Islamic Republic of Iran can be divided into two periods: the "Moral Model" era (1979–1993) and the "Disease Model" era (1993–present). Challenges within the content of substance use disorder treatment policies in Iran encompass the lack of law revisions, existence of contradictions in laws and nature of disease, the absence of evidence-based policymaking, and an inadequate comprehensive perspective on the phenomenon of substance use disorder. Conclusions: The presence of multiple authorities with different perspectives on substance use disorder and its treatment, coupled with the application of personal preferences in policymaking and the absence of evidence-based policymaking, have contributed to weaknesses in decision-making and policy formulation. The true philosophy of Disease Model appears not to have been fully grasped by health policymakers in Iran, as all Disease Model policies have been pursued with an emphasis on abstinence and quitting. Iran and other nations facing similar challenges should place more reliance on evidence-based approaches and shift away from the "Moral Model" paradigm to develop more effective substance use disorder treatment policies. [ABSTRACT FROM AUTHOR]

Background: In Pakistan, tobacco smoking and indoor smoke from cooking fires pose significant health risks. Lady Health Workers (LHWs) play a crucial role in improving healthcare access, particularly in rural areas. This study aimed to explore the practicality of training LHWs to deliver health education aimed at reducing household exposure to tobacco smoke and indoor biomass smoke, while also documenting baseline exposure levels and assessing the immediate impact on household awareness and intentions to reduce exposure. The Program: Over 170 LHWs were trained and equipped with health education resources to raise awareness about the risks of tobacco and biomass smoke exposure. The training was designed to be integrated into their routine duties. Results: Over 24 weeks, the program was delivered to 25,760 households in Gujranwala district. Approximately half of these households had at least one person who smoked, with 90% smoking indoors. Many (85%) households used indoor cooking fires. Only 24% of household head-women were aware of the health risks associated with indoor smoke exposure. Awareness of less harmful alternatives to smoking was low. Most households had someone who wanted to stop smoking and 51 women and 146 men agreed to try a tobacco harm reduction (THR) product. Primary health units' staff appreciated the project, especially the training provided. They believed the program could be sustainable, and LHWs expressed interest in continuing it. Conclusion: The study demonstrated the practicality of training LHWs to deliver health education on reducing tobacco and biomass smoke exposure in rural settings. The program effectively raised awareness and showed potential for sustainable integration into existing healthcare structures, highlighting the value of community-centric approaches in low-resource settings. [ABSTRACT FROM AUTHOR]

Recent years have marked a shift in selling and buying illicit psychoactive drugs from darknet cryptomarkets to publicly accessible social media and messaging platforms. As more users turn to procuring drugs this way, the role of digital harm reduction has become particularly urgent. However, one of the main obstacles complicating the implementation of digital harm reduction is the increasingly automated content moderation by the social media platforms. While some platforms are less restrictive about harm reduction content (e.g., TikTok), others implement higher degrees of moderation, including the removal of individual content and banning of entire profile pages (e.g., Instagram). This article discusses community guidelines of five popular social media and messaging platforms and their content moderation tools. It aims to highlight how these guidelines may be inadvertently curbing the dissemination of harm reduction and health promotion materials, and erroneously interpreting it as a promotion of drug use and sales. The discussion concludes that digital harm reduction requires transdisciplinary collaboration of professional organizations, researchers, and social media platforms to ensure reliable implementation of digital harm reduction, and help build safer digital communities. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsDiscussionConclusionsVolatile nitrites, such as amyl nitrite, are used recreationally to enhance sexual experience and provide a feeling of euphoria. They are associated with severe adverse reactions including methaemoglobinaemia and maculopathy. The aim of this study was to explore the epidemiology and clinical effects of volatile nitrite exposures reported to the Victorian Poisons Information Centre in Australia over a 10-year period.This was a retrospective, observational study of poison centre call records. Data were extracted for all exposures to volatile nitrites reported from 2013 to 2022.There were 132 calls about volatile nitrites, representing 122 exposures, with a more than five-fold increase in the annual number of exposures (from five in 2013 to 26 in 2022). Ingestion (49.2%) and inhalation (27.9%) were the most common routes of exposure. Seventy-six (62.3%) patients reported one or more symptoms related to volatile nitrite exposure. The most common symptoms were light-headedness/dizziness (20.5%), oro-mucosal irritation (15.6%), ocular irritation (14.8%), nasal irritation (12.3%), and nausea/vomiting (9.8%). Less common, but potentially serious, adverse effects included methaemoglobinaemia (4.1%), hypoxia (1.6%) and hypotension (0.8%). Symptom severity was usually classified as minor (70/76, 92.1%) at the time of the poisons centre call. Fifty-four (44.3%) patients were either in the hospital when the poisons centre was contacted or were referred to the hospital by the poisons centre.The increase in reported volatile nitrite exposures observed in this study aligns with epidemiological data showing an increase in volatile nitrite usage in Australia. The findings about the nature of exposures and symptoms experienced can be used to inform harm reduction and education efforts for community members and health professionals.Exposures to volatile nitrites reported to an Australian poisons centre increased between 2013 and 2022. More than 40% of exposures resulted in a hospital presentation. Methaemoglobinaemia was reported in 4.1% of cases. [ABSTRACT FROM AUTHOR]

Evidence suggests that people experiencing inequities and who are highly marginalized (e.g., people impacted by racism, sexism, discrimination, stigma, mental illness, substance use issues, disability, and the effects of homelessness; also referred to as structurally vulnerable individuals) often die alone, in pain, and not receiving the care they need. Some research even points to highly marginalized people not feeling worthy of care. The need to consider equity in the context of palliative care has recently emerged but little attention has been paid to how ethical decision-making generally, and relational ethics, specifically, could provide guidance in the care of highly marginalized people who are on a palliative trajectory. Relational ethics offers a model of care and decision-making framework that emphasizes how clients, healthcare providers, and larger social structures are interwoven and acknowledge that structural conditions can position people to have less choice than others. Relational approaches in the context of palliative care for highly marginalized people have the potential to provide a lens to better support the delivery of equitable palliative care. This critical essay explores relational ethics as a way to approach equity in palliative care to support clients facing structural vulnerabilities. We discuss relational ethical considerations to approach collaborative partnerships between clients, healthcare providers, and the larger community with the goal of aligning care with clients' values. An ethical case for how a relational ethics approach might be used to promote equitable access to palliative care will be explored, highlighting how such approaches have the potential to better align client wishes with their needs and to ensure decision-making and care delivery is trauma-informed, harm reduction focused, and culturally respectful. Relational ethics can support social change in equity and palliative care by contributing ethically informed ways of caring for/with/about highly marginalized people. [ABSTRACT FROM AUTHOR]

Background: Canada has one of the highest prevalence of cannabis use globally, particularly among young adults aged 20–24 (50%) and youth aged 16–19 (37%). In 2018, Canada legalized recreational cannabis with the aim of protecting youth by restricting their access and raising public awareness of health risks. However, there has been limited qualitative research on the perceptions of harms associated with youth cannabis use since legalization, which is crucial for developing effective harm reduction strategies. This qualitative study examined perceptions of cannabis use among youth from the perspectives of youth, parents, and service providers. We explored how participants described the perceived risks or harms associated with youth cannabis use, as well as how they described their own and others' approaches to reducing cannabis-related risks and harms. Methods: This qualitative study used a community-based participatory research approach in partnership with Families for Addiction Recovery (FAR), a national charity founded by parents of youth and young adults with addiction issues. Virtual semi-structured interviews were conducted, and the data were analyzed using thematic analysis. Results: The study included 88 participants from three key groups (n = 31 youth, n = 26 parents, n = 31 service providers). Two main themes emerged regarding perceived risks or harms associated with cannabis use: (1) concerns about cannabis-related risks and harms, including addiction, brain development, impact on family, and various adverse effects on areas such as motivation, concentration, finances, employment, education, physical and mental health; and (2) minimization of risks and harms, featuring conflicting messages, normalization, and perceptions of cannabis being less harmful than other substances. Additionally, two themes related to harm reduction approaches were identified: (1) implementation of harm reduction, and (2) challenges in implementing a harm reduction approach. Specific challenges for each participant group were noted, along with structural barriers such as unavailable and inaccessible services, easy access to cannabis, inadequate public education, and insufficient information on lower-risk cannabis use guidelines. Conclusions: Youth cannabis use is a significant public health concern that requires a multi-pronged approach. Developing youth-centered harm reduction strategies that recognize the developmental needs and vulnerabilities of youth, as well as the important role of families, is imperative. [ABSTRACT FROM AUTHOR]

Background: The increasing diversity of psychoactive substances on the unregulated drug market poses significant health, psychological, and social risks to people who use drugs (PWUD). To address these risks, various harm reduction (HR) policies have been implemented, including drug checking services (DCS). Many analytical methods are used for DCS. While qualitative methods (e.g., thin layer chromatography, spectroscopy) are easier to implement, they are not as accurate as quantitative methods (e.g., LC-UV, LC-MS). Some HR programmes have implemented high-performance liquid chromatography coupled with UV detection (LC-UV). This article presents the cross-validation of this quantitative method with a reference liquid chromatography coupled with high resolution mass spectrometry (LC-HRMS) method. Methods: Drug samples were provided by PWUD to a DCS called DrugLab in Marseille, France. The samples were weighed and prepared through dissolution in methanol, followed by ultrasonic bathing. Samples were analysed onsite using LC-UV analysis. They were then subsequently analysed with the reference LC-HRMS method. The LC-UV instrument in DrugLab was calibrated after being purchased; analysis of standard solutions was routinely performed once a month and after maintenance operations. For the LC-HRMS instrument, calibration and quality control procedures followed European Medicines Agency (EMA) guidelines. Statistical analyses were conducted including Spearman correlation tests using IBM® SPSS® Statistics version 20. Results: A total of 102 samples representing different product classes and cutting agents were cross-validated. Differences between both analyses methods for each molecule analysed were ≤ 20%, with significant correlations between both methods' results for most substances. Notably, LC-HRMS provided lower concentration values for cocaine and acetaminophen, whereas it provided higher values for other substances. Correlations were significant for cocaine, ketamine, MDMA, heroin, amphetamine, caffeine, acetaminophen, and levamisole. Conclusions: This study demonstrates that the results provided by DrugLab were accurate and reliable, making LC-UV an adaptable, stable, and suitable analytical method for simple matrices like drugs in a DCS context. However, this cross validation does not guarantee accuracy over time. A proficiency test project in HR laboratories across France is currently under development in order to address potential drifts in LC-UV accuracy. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic generated or accelerated healthcare changes, some of which persist thereafter (e.g., healthcare reorganisation, remote consultation). Such changes entail novel risks for patient safety. Methods: Aim To compare the characteristics of patient safety incidents with harm (PSIH) in primary care before the pandemic and at present. Design and setting Cross-sectional, comparative, observational study conducted within the entire Primary Care Service of the Madrid region with observations at two time points (2018 and 2021/2022). Participants Patients > 18 years of age with at least one consultation in the previous year. The necessary sample size was established at N1 = 2,000 for the first time point and N2 = 2,700 for the second. Sampling was performed by simple randomisation for the first group and by clusters followed by simple randomisation for the second. Main measurements Age, gender, presence of PSIH in the medical record, and characteristics of the PSIH, specifically avoidability, severity, place of occurrence, nature, and contributory factors. Triggers validated in primary care were employed to screen the patients' medical records and those containing any trigger were reviewed by three nurse-physician teams who underwent previous training. Analysis Comparative analysis using Fisher's exact test. Results: A total of 63 PSIHs and 25 PSIHs were found for the first and second samples, respectively. The comparison of the characteristics of PSIH before the pandemic and currently was: avoidable 62% vs. 52% (p = 0.47), mild 51% vs. 48% (p = 0.57), in the primary care setting 73% vs. 64% (p = 0.47), respectively. Although no statistically significant differences were observed globally in the nature of the incidents (p = 0.13), statistically significant differences were found for diagnostic errors, with pre-pandemic rates of 6% vs. 20% at present (p < 0.05). Finally, no significant differences were found in the contributory factors. Conclusions: No differences were found in the avoidability, severity, place of occurrence, or contributory factors of PSIHs before the pandemic and currently. In terms of the nature of these incidents, the outcomes revealed an increase in diagnostic errors (excluding diagnostic tests), which could be attributed to a greater frequency of remote consultations and a decrease in the longitudinality of care resulting from the shortage of professionals. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsConclusionsDrug policy is prone to build on rationales based on different moralities rather than evidence. Less is known about how moralities influence drug policy implementation in practice. The aim was to analyze expressions of moralities among local policy-makers, professionals, and drug users in the context of the Stockholm needle and syringe exchange program (NSP).Using political documentation from Stockholm (2003–2016), focus group (12 NSP staff), and 32 drug user interviews, moralities concerning drug policy and harm reduction were analyzed based on moral foundations theory and boundary work.Three main moral dilemmas were identified concerning the subjects, aims, and orientation of drug policy: whether drug users are worthy of inclusion to society; if the general public should be prioritized or the health of drug users, and the orientation of practices as based on control or autonomy. Policy debate was driven by virtues such as purity and authority, whereas staff and drug users valued care, fairness and liberty.The prohibitionist and abstinence-oriented Swedish drug policy has created social boundaries on the practice-level. Hence, users’ perspectives, and those who care about them, should be extensively involved in political discussions to foster a more moral and humane drug policy. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsConclusionThis study explores how cannabis has been accommodated over the last 18 years in the social world of an online forum in Poland. It considers users who operate in the context of unhurried normalization and restrictive policy that has barely changed over the last two decades. Simultaneously, these users refer to global cannabis cultures and follow progressive policy developments worldwide.Cannabis-related threads were scrapped from the biggest Polish forum, posted in the years 2006–2023, and divided into three periods marked by minor relaxation of the punitive law in 2011 and the introduction of medical cannabis in 2019. The threads were thematically analyzed to track changes in the perceived access to cannabis and shifts in the reasons users praise it.The shifts indicate the interaction of the normalization processes on both sides of the cannabis social world in Poland: among users and in society. The praise becomes less unconditional, and nuanced goals, or reflexivity of use emerges.We have recognized a consensus among forum users that there are problems associated with use. Instead of harm being neutralized as it used to be when stigmatization mattered more, it is now discussed among users who are becoming better informed, reflexive, and likely to engage with bottom-up harm reduction efforts. [ABSTRACT FROM AUTHOR]

Background: The substitution of cannabis for alcohol and other drugs has been conceptualised in a harm reduction framework as where cannabis is used to reduce the negative side-effects, addiction potential, and social stigma of other drugs. There is currently mixed evidence with recent reviews suggesting cannabis co-use patterns may vary by age and ethnicity. Yet few studies have had large enough samples to examine this demographic variation in detail. Aims: To explore the co-use of cannabis with alcohol and other drugs within demographic subgroups of a large sample of people who use cannabis. Specifically: (1) whether cannabis is being substituted for other drugs, and (2), whether cannabis use leads to more, less or the same level of other drug use. Method: Online convenience survey promoted via Facebook™ completed by 23,500 New Zealand respondents. Those who had used cannabis and any of eight other substances in the same six-month period were asked if their use of cannabis had any impact on their use of each other substance ("a lot more", "little more", "no impact/same", "little less", "a lot less"). Frequency and quantity used of each other drug was compared by co-use group. Generalised logistic regression models were developed to predict co-use categories. Results: Significant proportions reported cannabis use led to "less" alcohol (60%), synthetic cannabinoid (60%), morphine (44%) and methamphetamine (40%) use. Those who reported using "less" had lower frequency and amount used of other drugs. Approximately seven-out-ten reported cannabis use had "no impact" on LSD, MDMA, and cocaine use. One-in-five reported using cannabis led to "more" tobacco use. Young adults (21–35-years) were more likely to report cannabis use led to "less" drinking and methamphetamine use. Adolescent co-users (16–20 years) reported mixed impacts. Māori were more likely to report cannabis use resulted in "less" alcohol, tobacco, methamphetamine, and LSD use. Students and those living in cities were less likely to report cannabis use lowering use of other substances. Conclusion: Cannabis and other drug co-use patterns are moderated by life stages, lifestyles, cultural perspectives, and urbanicity. Harm reduction initiatives and policy reforms should take account of these moderating factors. [ABSTRACT FROM AUTHOR]

Background: Under a housing affordability crisis, Montreal, Canada, is host to a growing homeless population. While people who use drugs or alcohol make up a large part of this group, homeless resources in the city continue to exclude them through sobriety rules or by not adapting programming to their specific needs. This systematic exclusion, and the conditions of these resources, can often be retraumatizing for individuals seeking help. Applying a trauma‐informed spaces of care framework, this research asks what are the needs of homeless individuals who use substances to exit homelessness? What are the current limits within homeless resources in Montreal to actualize these needs? How can they change to meet these needs? Methods: In 2023, 30 semistructured interviews were conducted, with follow‐up at 3 months, with individuals who use drugs or alcohol currently experiencing homelessness. Transcribed interviews were analyzed in Nvivo. Results: Findings called for serious reforms to homeless service provision, with an emphasis on more forms of harm reduction‐based programming, integrated occupational activities, improved psychosocial accompaniment, better division of service users, and alternative and adapted housing interventions for substance users. Most participants disclosed potentially traumatic life experiences, highlighting the need for trauma‐informed programming. Conclusion: Allowing individuals to articulate their needs and desires for programming demonstrates that this group recognizes the inadequacy of services and identifies the homeless resource as a site of potential traumatization. While the recommendations of people with living experience of homelessness and substance use articulate promising practices in substance use recovery, as well as homelessness service provision, homeless service providers are slow to adapt their programming accordingly. [ABSTRACT FROM AUTHOR]

The increasing legalization of Cannabis sativa plant products has sparked growing interest in their therapeutic applications. Prohibition laws established in 1937 hindered formal research on cannabis, a plant with cultural and medicinal roots dating back to 2700 BC in Chinese history. Despite regulatory hurdles, published research on cannabis has emerged; yet elite athletes remain an underrepresented population in these studies. Athletes, known for exploring diverse substances to optimize performance, are drawn to the potential benefits of cannabinoid therapy, with anecdotal reports suggesting positive effects on issues ranging from anxiety to brain injuries. This review aims to evaluate empirical published cannabis research with a specific focus on its potential applications in athletics. The changing legal landscape, especially the removal of cannabis from drug testing programs in leagues such as the National Basketball Association (NBA), and endorsements by Major League Baseball (MLB) for cannabinoid products and the National Football League (NFL) for cannabis research, reflects a shift in the acceptability of such substances in sports. However, stigma, confusion, and a lack of education persist, hindering a cohesive understanding among sports organizations, including business professionals, policymakers, coaches, and medical/training staff, in addition to athletes themselves. Adding to the confusion is the lack of consistency with cannabinoid regulations from sport to sport, within or out of competition, and with cannabis bioactive compounds. The need for this review is underscored by the evolving attitudes toward cannabinoids in professional sports and the potential therapeutic benefits or harms they may offer. By synthesizing current cannabis research, this review aims to provide a comprehensive understanding of the applications and implications of cannabinoid use in the realm of athletics. [ABSTRACT FROM AUTHOR]

Approximately one in three older adults (aged 65 years and over) experience pain, negatively impacting their quality of life. Opioid analgesics are commonly prescribed to manage pain; however, balancing the benefits and harms of these high-risk analgesics can be challenging for both healthcare professionals and patients. This is particularly true for older adults, as factors such as polypharmacy, age-related physiological changes and cognitive decline may impact upon opioid safety and efficacy. Deprescribing is the patient-centred process of reducing or discontinuing a medication that is no longer appropriate, or where the risks of continuation are deemed to outweigh the anticipated benefits. Opioid deprescribing has been proposed as a mechanism to reduce individual and societal opioid-related harm; however, to date, research has predominantly focused on the general adult population, rather than older adults. This current opinion aims to summarise the existing opioid deprescribing literature, discussing its applicability for older adults. Drawing on a non-systematic review of the literature, it identifies unique challenges and considerations for this population, highlights international initiatives to enhance opioid deprescribing in clinical practice and proposes future directions to advance the field. [ABSTRACT FROM AUTHOR]

Background: Mobile health (mHealth) technology use may reduce alcohol use and related negative consequences; however, little is known about its efficacy without prompting from researchers or pay‐per‐use. This exploratory analysis assessed relationships between mHealth technology use frequency and alcohol‐use outcomes. Methods: Young adults who drink heavily (N = 97, Mage = 23, 51% male, 64% non‐Hispanic White, Mdrinks/week = 21) had the option to use three mHealth technologies (breathalyzer device/app, blood alcohol content estimator app, drink counting via text message) while drinking for 2 weeks. Relationships between alcohol‐related outcomes and any, multiple, and specific mHealth technology use across study days and drinking days were evaluated via bivariate correlations and multiple regressions. Results: Participants used one or more mHealth technologies on approximately 68% of drinking days (33% of field days), with multiple technologies used on 34% of drinking days. Bivariate correlations revealed that a higher percentage of study days with any mHealth technology use was related to higher mean weekly drinks. However, a higher percentage of drinking days with any mHealth technology use was related to lower mean weekly drinks, percent of heavy and high‐intensity drinking days, and negative consequences. There were several significant, inverse correlations between alcohol variables and using the mHealth technologies that provided personalized feedback. Multiple regression analyses (holding sex and baseline alcohol variables constant) indicated that a higher percentage of drinking days with any mHealth technology use was related to lower mean weekly drinks and lower percentage of heavy drinking days. Conclusions: Using mHealth technologies to moderate drinking without direct prompting from the research team or per‐use incentives was related to less overall alcohol use and heavy drinking. This indicates potential real‐world engagement with mHealth apps to assist with in‐the‐moment drinking. Normalizing mHealth technology use during drinking could help curb the public health crisis around harmful alcohol use in young adult populations. [ABSTRACT FROM AUTHOR]

Introduction: Harm reduction strategies at music festivals seek to create a safer environment for patrons. The Emerging Drugs Network of Australia–Victoria (EDNAV) project is a state‐wide toxicosurveillance network that derives drug intelligence from a sample of patients presenting to hospital with illicit drug‐related toxicity. This publication describes the preliminary outcomes of conducting toxicosurveillance for critically unwell festival patrons within on‐site medical facilities. Methods: Blood samples were collected from patrons who presented with severe illicit drug‐related toxicity across three festivals (2022/2023). Blood samples were analysed via liquid chromatography–tandem mass spectrometry for over 700 pharmaceutical and illicit drugs. Results: There were 1603 individual medical encounters across the festivals, 228 of which were illicit drug related. A blood sample was collected for 24 patients, with a median age of 22 years (range 18–39 years). A median of two drugs (range 1–5 drugs) were reported and four drugs (range 0–8 drugs) were analytically confirmed per patient. The most frequently reported exposures were congruent with analytical results, 3,4‐methylenedioxymethamphetamine (reported n = 17, detected n = 20), ketamine (reported n = 9, detected n = 13) and cocaine (reported n = 9, detected n = 12). An unreported illicit drug and/or new psychoactive substance (NPS) was detected in 18 patients, including methylamphetamine (n = 10), a cathinone (n = 7), benzodiazepine‐type NPS (n = 6), N‐ethylamphetamine (n = 1), 3‐hydroxyphencyclidine (n = 1) and/or 4‐hydroxy‐N‐methyl‐N‐isopropyltryptamine (n = 1). Discussion and Conclusions: EDNAV toxicosurveillance serves as an additional tool within a multi‐faceted approach to harm reduction at festivals. Continued data collection will allow for the characterisation of high‐risk drug use patterns to provide evidence‐based messaging to festival patrons and key stakeholders. [ABSTRACT FROM AUTHOR]

Introduction: Given structural barriers, access to services is key for preventing drug‐related harms and managing chronic disease among people who inject drugs (PWID). The Patient Activation Measure (PAM), a validated scale to assess self‐efficacy in navigating one's own health care, was operationalised to improve service utilisation and outcomes but has not been assessed among PWID. We characterised PAM and its association with healthcare and harm reduction utilisation among PWID in the AIDS Linked to IntraVenous Experience cohort in Baltimore. Methods: From 2019 to 2020, participants completed surveys on PAM, service utilisation and drug use. We used log‐binomial regression to identify correlates of "Lower" PAM and modelled the association between lower PAM and service utilisation, stratified by recent IDU. Results: Participants (n = 351) were primarily male (67%), Black (85%) and 24% reported recent IDU. Lower PAM was significantly more common in those reporting IDU (aPR 1.45; 95% CI 1.03, 2.04), heavy alcohol (aPR 1.77; 95% CI 1.24, 2.51) and marijuana (aPR: 1.70; 95% CI 1.23, 2.36) but less common among women (aPR 0.57; 95% CI 0.38, 0.84) and those living with HIV (APR 0.52; 95% CI 0.35, 0.78). In modelling service utilisation, lower PAM was associated with a lower prevalence of methadone utilisation (aPR 0.27; 95% CI 0.09, 0.84) among those reporting IDU, but a higher prevalence of methadone utilisation (aPR 2.72; 95% CI 1.46, 5.08) among those not reporting IDU, after controlling for correlates of PAM. Discussion and Conclusion: PAM‐tailored interventions targeting methadone utilisation warrant consideration but should account for socio‐structural barriers to utilisation and correlates of PAM among PWID. [ABSTRACT FROM AUTHOR]

Introduction: The negative attitudes people hold towards those who use alcohol or other drugs (AOD) can also affect the people who work with this community, leading to lowered productivity and wellbeing. The impact of this stigma by association in the AOD and harm reduction sector is particularly significant because workers may have lived experience of AOD use and identify strongly with their client group. This study aimed to examine how stigma by association among health workers in the AOD/harm reduction sector relates to workplace outcomes. A secondary aim was to explore how lived experience influences experiences of stigma by association. Methods: The research used a cross‐sectional survey design and data collection occurred in 2023. Australian AOD/harm reduction workers (n = 228) completed an online survey assessing stigma by association as well as various workplace outcomes measures. Results: Participants who reported experiencing more stigma by association experienced poorer workplace wellbeing, higher burnout and greater intentions to leave the AOD/harm reduction field. Experiences of stigma by association were unrelated to job satisfaction. Additional analyses revealed that participants with lived experience reported higher levels of job satisfaction and lowered intentions to leave the sector, but findings of stigma by association and its impacts on workplace outcomes did not differ from those without lived experience. Discussion and Conclusions: Identifying staff experiences of stigma by association and developing support and advocacy mechanisms to address this is likely to be key to reducing these experiences and ultimately to increasing positive workplace outcomes for AOD and harm reduction staff. [ABSTRACT FROM AUTHOR]

Introduction: Insulin is an essential treatment within diabetes management; however, it takes on a role of enhancement within image and performance enhancing drug (IPED) communities due to its anabolic effects. This study sought to provide insight into how IPED users perceive and manage the risks linked to insulin. Methods: We conducted semi‐structured interviews with 10 individuals from Australia and United Kingdom who used insulin as part of their IPED protocols. The analysis followed an iterative categorisation approach and applied the lens of situated rationality theory. Results: The decision to incorporate insulin was influenced by peers' experiences and preferences. Participants highlighted the risks and responsibilities associated with insulin use, emphasising the need for precise lifestyle habits. They recognised the potential dangers and called for comprehensive harm reduction strategies within IPED communities to respond to such concerns. Some participants expressed reluctance to discuss insulin openly, underlining the importance of education and awareness to mitigate health risks associated with underground and uninformed use. Discussion and Conclusions: While people who use IPEDs demonstrate awareness of the risks associated with insulin, their practices of routinisation moderate these risks within the context of IPED use. Silence as a risk‐reduction strategy highlights vulnerabilities among certain prospective users, while the hierarchical structure of IPED use establishes expertise and status within the community. Reconsidering insulin risks entails reframing harm reduction messages to better match the social dynamics of IPED communities. Closer ties between IPED communities can enhance support accessibility, particularly through peers, who, with their firsthand knowledge, can offer tailored guidance. [ABSTRACT FROM AUTHOR]

The perinatal transmission of HIV is preventable through a regimen that includes testing of all pregnant individuals, antiretroviral treatment (ART) for the pregnant individual, prophylactic or preventative ART for the infant, and cesarean section delivery for mothers with HIV viremia at the time of delivery. Under this protocol, the United States has seen a significant decline in the perinatal transmission of HIV and achieved a perinatal HIV transmission rate of 0.9% in 2019. However, despite this progress nationally and after zero transmissions in 2021, Maryland recorded 6 cases of perinatal HIV diagnoses in 2022. Each of the 3 major referral centers for pediatric HIV patients in Maryland reported 2 new cases in 2022. A root cause analysis of the cases identified risk factors including delayed entry into perinatal and HIV care, premature birth, maternal adherence challenges in the setting of substance use and other adverse social determinants of health, and failure to diagnose maternal HIV infection in a timely way. All patients were successfully linked to care and initiated on ART. Multiple factors contributed to the 2022 increase in cases of perinatal HIV in Maryland. To achieve and then sustain the elimination of perinatal HIV transmission, the constancy of systems that eliminate barriers for all pregnant people to access testing, prevention, and treatment is critical. [ABSTRACT FROM AUTHOR]

Aim: It is not uncommon to encounter outpatients in the hepatology department with harmful alcohol habits. When treating such chronic liver disease (CLD) patients, an adequate intervention method for harm reduction of alcohol use, such as brief intervention (BI) or BI and nalmefene, should be considered. This study aimed to elucidate the clinical effectiveness of BI for CLD patients affected by harmful alcohol use. Methods: From June 2021 to 2023, 123 Japanese CLD outpatients (hepatitis B virus : hepatitis C virus : alcoholic liver disease : others = 32:18:42:31) with an Alcohol Use Disorders Identification Test (AUDIT) score of ≥8 at the initial interview and a repeat interview with AUDIT 9 months later were enrolled. Clinical features related to patient behavior following the initial AUDIT interview were retrospectively evaluated, and compared between patients without and with BI treatment. Results: For the non‐BI and BI groups, baseline AUDIT score (median 10 [interquartile range (IQR) 9–13] vs. 12 [IQR 10–17], p = 0.016) and relative change in AUDIT score (median 0 [IQR −3 to 2] vs. −3 [IQR −7 to 0], p < 0.01) showed significant differences, whereas there was no significant difference between the groups for AUDIT score at the time of the second interview (p = 0.156). Following BI, significant improvements were observed for items 1, 2, 3, 4, 5, 8, and 10 of AUDIT (each p < 0.05). Conclusion: Patients with an alcohol use disorder as well as those with alcohol dependency who received BI showed a significant decline in AUDIT score, although the score of the follow‐up AUDIT indicated continued alcohol use disorder. In addition to BI, medication with nalmefene should be considered, based on individual factors. [ABSTRACT FROM AUTHOR]

The American Journal of Psychiatry's focus on Substance Use Disorders explores topics such as racial disparities in treatment, harm avoidance strategies, neural circuits, and genetics. Studies reveal racial disparities in alcohol use disorder treatment, with Black and Hispanic individuals less likely to receive treatment compared to White individuals. Reductions in cannabis use are associated with positive functional outcomes, challenging the traditional goal of complete abstinence in substance use disorder treatment. The journal provides new insights into the complex factors related to the pathophysiology and treatment of Substance Use Disorders. [Extracted from the article]

The article discusses lessons from edible packaging policies and child poisonings. Topics include cannabis-related policies that can impact both cannabis business practices and cannabis use-related risks, public health effects of cannabis edible packaging policy, and public health effects as cannabis policies evolve.

Xylazine, a veterinary sedative, has emerged as a concerning element in the landscape of substance use in the United States. This integrative review synthesizes evidence from a systematic examination of 14 selected studies conducted between 2008 and 2023. The primary objective is to comprehensively understand the epidemiology and prevalence of xylazine use, particularly its involvement in drug-related deaths, regional variations, national impact, co-occurrence with opioids, and challenges associated with detection and intervention. The results underscore stark regional disparities in xylazine prevalence. West Virginia and Miami-Dade County have experienced alarming surges in xylazine-involved drug-related deaths. Nationally, its influence extends beyond regional boundaries, predominantly affecting white males in the Northeast. The co-occurrence of xylazine with opioids, especially fentanyl and heroin, significantly amplifies the risks of fatal overdoses. Detecting xylazine presents formidable challenges due to its frequent presence alongside other substances, necessitating enhanced surveillance and more effective detection methods. User perspectives emerge as pivotal, emphasizing the importance of user-informed harm reduction strategies. In conclusion, this review has significant policy implications. Tailored, region-specific strategies are imperative to address the diverse prevalence of xylazine use. A nationwide response is indispensable, prioritizing harm reduction initiatives, enhanced detection methods, and active user engagement. The multifaceted nature of the xylazine issue requires comprehensive approaches to mitigate its profound risks effectively. Policymakers are urged to consider regional disparities and the co-occurrence of xylazine with opioids when crafting targeted interventions. Immediate, user-informed harm reduction is vital to address the evolving landscape of xylazine use in the United States. [ABSTRACT FROM AUTHOR]

This scoping review explored available research focused on ways emergency women's shelters address substance use issues with survivors of intimate partner violence. Twenty-one studies met the inclusion criteria. The articles tended to identify more barriers (e.g., concerns about safety of all residents and staff) and fewer facilitators (e.g., clear policies to guide practice) to implementing harm reduction within women's shelters. Comprehensive training and education about substance use and harm reduction for shelter staff and residents was suggested for successful implementation. More high-quality evidence is needed to understand the viability of implementing harm reduction in emergency women's shelters. Practice Points: An organizational philosophy supporting harm reduction should be accompanied by appropriate and clear guiding policy and procedures. Staff require adequate training in substance use, intimate partner violence, and harm reduction in order to support women who use substances and are accessing emergency women's shelters. Implement flexible harm reduction approaches that support the needs of women who are using but also balance/consider safety for all residents and staff. Staff should interact with residents in a way that allows residents to feel comfortable and safe discussing their substance use. Harm reduction services and supports should be offered to all residents, whether directly by the shelter, or through referrals to other community organizations. [ABSTRACT FROM AUTHOR]

North American police responses to the 'drug issue' have long been shaped by a crime control rather than a harm reduction imperative. Consequently, police officers' responses to safe consumption sites (SCSs), where people who use illicit drugs can reduce personal health risks by administering previously obtained drugs in the presence of trained staff, were initially hostile. This paper draws on interview data from police officers in two western Canadian cities to highlight an apparent softening in attitudes, perhaps due to the current fentanyl-driven drug poisoning crisis. While some officers clearly recognized their public health benefits, others accepted SCSs, acknowledging the futility of a continued 'war on drugs'. Some voiced reservations about SCSs, but not because of a generic 'drugs are bad' sentiment. Rather, they worried about specific downstream implications for communities and police work. These findings, reflecting apparent changes in police officers' responses to SCSs, are discussed in the context of contemporary debates about police culture and the possibilities and desirability of pursuing police reform. [ABSTRACT FROM AUTHOR]

Background: England, Australia and the United States have approached the regulation of e‐cigarettes in very different ways, yet all three countries have appealed to the concept of evidence as underpinning policy responses. We compared these policy responses using a combination of the methodologies of historians and policy scientists in order to elucidate the factors that had influenced policy in each country. Argument/Analysis: Each country's evidence and values intersected in different ways, producing very different responses within specific national contexts and histories. Our analysis accordingly emphasized the historical precursors of the policy issues raised by e‐cigarettes and placed the policy debate within the context of regulatory bodies and the networks of researchers and advocates who influenced policy. Issues also of importance were the nature of the state; political context; the pre‐history of nicotine for smoking cessation; the role of activism and its links with government; the influence of harm reduction ideas from drugs and HIV; and finally, whom policy was perceived to benefit. In the United Kingdom, based on this pre‐history of the smoking issue, it was the existing smoker, while in the United States and Australia, protecting children and adolescents has played a central role. Conclusions: Structural and historical factors appear to underpin differences in e‐cigarette policy development in England, Australia and the United States. [ABSTRACT FROM AUTHOR]

Background/Aims: In people with opioid use disorder (OUD), buprenorphine is a vital treatment to decrease opioid use and overdose. The US Food and Drug Administration's prescribing information for buprenorphine advises dosing up to 24 mg/day; however, doses of buprenorphine up to 32 mg have been shown to be safe and effective. We compared outcomes associated increased dosing from 24 to 32 mg/day. Design: Prospective cohort investigation. Setting: Low‐barrier buprenorphine clinic in Washington, District of Columbia, USA. Participants: Participants in the ANCHOR study (people with hepatitis C virus (HCV), OUD, and active opioid misuse who were treated for HCV and offered buprenorphine) who received buprenorphine at doses of 24 and/or 32 mg/day. 72 participants were included in the analysis: 24 (33%) patients stabilized on 24 mg, and 48 (67%) patients stabilized on 32 mg. Patients were predominantly male (78%), Black (96%), unstably housed (57%), and used opioids by injection (93%). Measurements: Patient‐reported drug use, use frequency, triggers for use, and urine drug screens were collected at each visit. For analysis, the cohort was divided into individuals stabilized on 24 mg (24 mg cohort) or 32 mg (32 mg cohort). Drug use outcomes were assessed between cohorts at 24 mg dosing and at respective maximum dosing. Within the 32 mg cohort, outcomes were compared at 24 mg versus 32 mg dosing. Findings Within the 32 mg cohort, increased dosing from 24 to 32 mg was associated with a decline in opioid use (68.5% [5.2%] at 24 mg vs 59.5% [5.6%] at 32 mg; P = 0.02), frequency of use per week (1.58 [0.19] at 24 mg vs. 1.15 [0.16] at 32 mg; P = 0.0002) and physiologic triggers for use (38.2% [6.0%] at 24 mg vs 7.0% [1.9%] at 32 mg; P < 0.0001). At the end of the study period, there were significantly more patients retained in the 32 mg cohort (78.7%) compared with the 24 mg cohort (50.0%, P = 0.02). Conclusion: Higher buprenorphine dosing (32 mg/day) appears to improve outcomes in people with opioid use disorder, even in the absence of abstinence. [ABSTRACT FROM AUTHOR]

Aims: To explore healthcare professionals' perceptions and experiences of take‐home naloxone initiatives in acute care settings to gain an understanding of issues facilitating or impeding dispensing. Design: Systematic literature review. Data Sources: Cochrane, MEDLINE and CINAHL were searched from 15/03/2021 to 18/03/2021, with a follow‐up search performed via PubMed on 22/03/2021. The years 2011 to 2021 were included in the search. Review Methods: A systematic literature review focused on qualitative studies and quantitative survey designs. Synthesis without meta‐analysis was undertaken using a thematic analysis approach. Results: Seven articles from the United States of America (5), Australia (1) and Canada (1) with 750 participants were included in the review. Results indicate ongoing stigma towards people who use drugs with preconceived moral concerns regarding take‐home naloxone. There was confusion regarding roles and responsibilities in take‐home naloxone dispensing and patient education. Similarly, there was a lack of clarity over logistical and financial issues. Conclusion: Take‐home naloxone is a vital harm reduction initiative. However, barriers exist that prevent the optimum implementation of these initiatives. Impact: What is already known:Deaths due to opioid overdose are a global health concern, with take‐home naloxone emerging as a key harm reduction scheme.Globally, less than 10% of people who use drugs have access to treatment initiatives, including take‐home naloxone.An optimum point of distribution of take‐home naloxone is post‐acute hospital care. What this paper adds:There is role confusion regarding responsibility for the provision of take‐home naloxone and patient education. This is exacerbated by inconsistent provision of training and education for healthcare professionals.Logistical or financial concerns are common and moral issues are prevalent with some healthcare professionals questioning the ethics of providing take‐home naloxone.Stigma towards people who use drugs remains evident in some acute care areas which may impact the use of this intervention. Implications for practice/policy:Further primary research should examine what training and education methods are effective in improving the distribution of take‐home naloxone in acute care.Education should focus on reduction of stigma towards people who use drugs to improve the distribution of take‐home naloxone.Standardized care guidelines may ensure interventions are offered equally and take‐home naloxone 'champions' could drive initiatives forward, with support from harm reduction specialists. Reporting Method: This has adhered to the PRISMA reporting guidelines for systematic reviews. Patient or Public Contribution: No patient or public contribution. [ABSTRACT FROM AUTHOR]

This article examines Japan's age of consent law by delving into court judgements, focusing on unravelling the nuances of how the sexual autonomy of children is interpreted. The study reveals a contradictory stance of the court towards child victim's maturity and capacity, indicating that the legal discourse around a child's autonomy is easily manipulated and framed. It further exposes the susceptibility of children's sexual autonomy to the structural moral values associated with patriarchal gender relations and age. By shaping the contours of consent, law draws a line—delineating punishable acts from consensual sexual activity. While the legal reforms aimed at stricter regulations surrounding child sexual abuse, including raising the age of consent, are narrowing the space for recognizing adolescents' sexual autonomy, this article contends that reforming age consent laws must strike a delicate balance between preventing potential harms and avoiding undue interference with adolescents' sexual autonomy. [ABSTRACT FROM AUTHOR]

Background: The influx of patients in the acute care setting with opioid use disorder (OUD) has outpaced many hospitals' ability to educate interprofessional staff. This creates distressing experiences for interprofessional staff and patients, leading to moral distress and burnout in staff and poor patient outcomes. Objective: The purpose of this study was to improve interprofessional staff knowledge, attitudes, and perceptions toward working with patients who have OUD using a blended classroom-simulation-based curriculum. Methods: A preintervention and postintervention design was selected. Interprofessional staff (n=46) participated in a blended classroom-simulation educational intervention focused on the neurobiology of OUD, stigma reduction, pain management, and harm reduction principles, followed by 3 high-fidelity simulation scenarios. Participants completed the Drug and Drug Problems Perceptions Questionnaire to measure staff self-perceived knowledge, skills, and attitudes when working with patients who use drugs before, immediately after, and again 3 and 6months postintervention. Results: Most respondents were nurses with an average of 7.6 (SD, 9.6) years of experience. The majority did not have prior training in substance use disorder before (75.6%). There was a statistically significant decrease in mean Drug and Drug Problems Perceptions Questionnaire scores across the total score mean: 55.2 (95% confidence interval, 52.2-58.3) versus 45.5 (95% confidence interval, 43.9-47.1), P<.001. Decreased score indicates improved attitude and perception. Discussion: A curriculum consisting of a blended classroom-simulation intervention was successful at improving several domains regarding perceptions of caring for patients with OUD. This educational intervention can serve as a model for health care systems with goal of improving patient outcomes and staff well-being. [ABSTRACT FROM AUTHOR]