Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction

Gomes T., Ledlie S., Tadrous M., Mamdani M., Paterson J.M., Juurlink D.N.

ImportanceOpioid-related harms constitute a major public health crisis in the US, and this crisis has worsened during the COVID-19 pandemic.ObjectivesTo characterize the societal burden of unintentional opioid-related deaths in the US and describe changing mortality patterns during the COVID-19 pandemic.Design, Setting, and ParticipantsA serial cross-sectional study examined all unintentional opioid-related deaths in the US, evaluated annually from calendar years 2011 to 2021.Main Outcomes and MeasuresThe public health burden of opioid toxicity–related deaths was estimated in 2 ways. First, the proportion of all deaths that were attributable to unintentional opioid toxicity by year (2011, 2013, 2015, 2017, 2019, and 2021) and age group (15-19, 20-29, 30-39, 40-49, 50-59, and 60-74 years) were calculated, using age-specific estimates of all-cause mortality as the denominator. Second, the total years of life lost (YLL) due to unintentional opioid toxicity was estimated, overall and by sex and age group, for each year studied.ResultsAmong the 422 605 unintentional deaths due to opioid toxicity between 2011 and 2021, the median age of the individuals was 39 (IQR, 30-51) years, and 69.7% were male. The number of unintentional deaths due to opioid toxicity increased 289% over the study period, from 19 395 (2011) to 75 477 (2021). Similarly, the percentage of all deaths that were attributed to opioid toxicity increased from 1.8% in 2011 to 4.5% in 2021. By 2021, opioid toxicity was responsible for 10.2% of all deaths among those aged 15 to 19 years, 21.7% of deaths among those aged 20 to 29 years, and 21.0% of deaths among those aged 30 to 39 years. The YLL due to opioid toxicity increased 276% over the study period, from 777 597 in 2011 to 2 922 497 in 2021. While YLL plateaued between 2017 (7.0 YLL per 1000) and 2019 (7.2 YLL per 1000), it increased by 62.9% between 2019 and 2021 coincident with the COVID-19 pandemic, reaching 11.7 YLL per 1000 population. This relative increase was similar across all age groups and sexes with the exception of those aged 15 to 19 years, in whom the YLL nearly tripled, from 1.5 to 3.9 YLL per 1000 population.Conclusions and RelevanceIn this cross-sectional study, deaths due to opioid toxicity increased substantially during the COVID-19 pandemic. By 2021, 1 of every 22 deaths in the US was attributable to unintentional opioid toxicity, underscoring the urgent need to support people at risk of substance-related harm, particularly men, younger adults, and adolescents.

Jawa R., Tin Y., Nall S., Calcaterra S.L., Savinkina A., Marks L.R., Kimmel S.D., Linas B.P., Barocas J.A.

ImportanceUS primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.ObjectiveTo estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.Design, Setting, and ParticipantsIn this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.Main Outcomes and MeasuresLife-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs).ResultsThe simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.Conclusions and RelevanceThis modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Khan M.R., Hoff L., Elliott L., Scheidell J.D., Pamplin J.R., Townsend T.N., Irvine N.M., Bennett A.S.

Abstract Background Drug overdose mortality is rising precipitously among Black people who use drugs. In NYC, the overdose mortality rate is now highest in Black (38.2 per 100,000) followed by the Latinx (33.6 per 100,000) and white (32.7 per 100,000) residents. Improved understanding of access to harm reduction including naloxone across racial/ethnic groups is warranted. Methods Using data from an ongoing study of people who use illicit opioids in NYC (N = 575), we quantified racial/ethnic differences in the naloxone care cascade. Results We observed gaps across the cascade overall in the cohort, including in naloxone training (66%), current possession (53%) daily access during using and non-using days (21%), 100% access during opioid use (20%), and complete protection (having naloxone and someone who could administer it present during 100% of opioid use events; 12%). Naloxone coverage was greater in white (training: 79%, possession: 62%, daily access: 33%, access during use: 27%, and complete protection: 13%, respectively) and Latinx (training: 67%, possession: 54%, daily access: 22%, access during use: 24%, and complete protection: 16%, respectively) versus Black (training: 59%, possession: 48%, daily access:13%, access during use: 12%, and complete protection: 8%, respectively) participants. Black participants, versus white participants, had disproportionately low odds of naloxone training (OR 0.40, 95% CI 0.22–0.72). Among participants aged 51 years or older, Black race (versus white, the referent) was strongly associated with lower levels of being trained in naloxone use (OR 0.20, 95% CI 0.07–0.63) and having 100% naloxone access during use (OR 0.34, 95% CI 0.13–0.91). Compared to white women, Black women had 0.27 times the odds of being trained in naloxone use (95% CI 0.10–0.72). Conclusions There is insufficient protection by naloxone during opioid use, with disproportionately low access among Black people who use drugs, and a heightened disparity among older Black people and Black women.

Applewhite D., Regan S., Donelan K., Macias-Konstantopoulos W.L., Williamson D., Kehoe L.G., Shaw C., Wakeman S.E.

Rife-Pennington T., Dinges E., Ho M.Q.

Syringe services programs are community-based prevention programs that provide evidence-based, lifesaving services for people who use illicit drugs, including access to syringes, naloxone, fentanyl test strips, infection screening, and linkage to treatment. Historically, syringe services programs did not exist within the Veterans Health Administration owing to many factors, including lack of clarity regarding legality for federal agency-purchased syringes. Three champions at Veterans Affairs facilities in Danville, IL, Orlando, FL, and San Francisco, CA, worked to clarify legal considerations, address barriers, and implement syringe services programs that are integrated in the health care systems. Since 2017, these 3 programs have engaged approximately 400 Veterans and distributed nearly 10,000 syringes, 2500 fentanyl test strips, 50 wound care kits, and 45 safer sex kits. These programs, both led by and in collaboration with clinical pharmacist practitioners, paved the way for nationwide implementation within the Veterans Health Administration. This commentary describes successes, challenges, and proposed next steps to increase Veteran access to syringe services programs, written from the perspective of 3 facility-based champions.

Gupta R., Levine R.L., Cepeda J.A., Holtgrave D.R.

Kariisa M., Davis N.L., Kumar S., Seth P., Mattson C.L., Chowdhury F., Jones C.M.

Drug overdose deaths increased approximately 30% from 2019 to 2020 in the United States. Examining rates by demographic and social determinants of health characteristics can identify disproportionately affected populations and inform strategies to reduce drug overdose deaths.Data from the State Unintentional Drug Overdose Reporting System (SUDORS) were used to analyze overdose death rates from 2019 to 2020 in 25 states and the District of Columbia. Rates were examined by race and ethnicity and county-level social determinants of health (e.g., income inequality and treatment provider availability).From 2019 to 2020, drug overdose death rates increased by 44% and 39% among non-Hispanic Black (Black) and non-Hispanic American Indian or Alaska Native (AI/AN) persons, respectively. Significant disparities were found across sex, age, and racial and ethnic subgroups. In particular, the rate in 2020 among Black males aged ≥65 years (52.6 per 100,000) was nearly seven times that of non-Hispanic White males aged ≥65 years (7.7). A history of substance use was frequently reported. Evidence of previous substance use treatment was lowest for Black persons (8.3%). Disparities in overdose deaths, particularly among Black persons, were larger in counties with greater income inequality. Opioid overdose rates in 2020 were higher in areas with more opioid treatment program availability compared with areas with lower opioid treatment availability, particularly among Black (34.3 versus 16.6) and AI/AN (33.4 versus 16.2) persons.Health disparities in overdose rates continue to worsen, particularly among Black and AI/AN persons; social determinants of health, such as income inequality, exacerbate these inequities. Implementation of available, evidence-based, culturally responsive overdose prevention and response efforts that address health disparities impacting disproportionately affected populations are urgently needed.

Hoover K., Lockhart S., Callister C., Holtrop J.S., Calcaterra S.L.

AbstractBackground Addiction consultation services (ACS) provide evidence-based treatment to hospitalized patients with substance use disorders (SUD). Expansion of hospital-based addiction care may help to counteract the stigma that patients with SUD experience within the health care system. Stigma is among the most impactful barriers to seeking care and adhering to medical advice among people with SUD. We aimed to understand how the presence of an ACS affected patients' and hospital-based providers' experiences with stigma in the hospital setting. Methods We conducted a qualitative study utilizing focus groups and key informant interviews with hospital-based providers (hospitalists and hospital-based nurses, social workers, pharmacists). We also conducted key informant interviews with patients who received care from an ACS during their hospitalization. An interprofessional team coded and analyzed transcripts using a thematic analysis approach to identify emergent themes. Results Sixty-two hospital-based providers participated in six focus groups or eight interviews. Twenty patients participated in interviews. Four themes emerged relating to the experiences of stigma reported by hospital-based providers and hospitalized patients with SUD: (1) past experiences in the health care system propagate a cycle of stigmatization between hospital-based providers and patients; (2) documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among hospital-based providers resulting in anticipated stigma among patients; (3) the presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative; (4) ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among patients with SUD. Conclusions An ACS can facilitate destigmatization of hospitalized patients with SUD by incorporating evidence-based SUD treatment into routine hospital care, by providing and modeling compassionate care, and by reframing addiction as a chronic condition to be treated alongside other medical conditions. Future reductions of stigma in hospital settings may result from promoting greater use of evidence-based treatment for SUD and expanded education for health care providers on the use of non-stigmatizing language and medical terminology when documenting SUD in the medical chart.

Khan G.K., Harvey L., Johnson S., Long P., Kimmel S., Pierre C., Drainoni M.

Community-based harm reduction programs reduce morbidity and mortality associated with drug use. While hospital-based inpatient addiction consult services can also improve outcomes for patients using drugs, inpatient clinical care is often focused on acute withdrawal and the medical management of substance use disorders. There has been limited exploration of the integration of community-based harm reduction programs into the hospital setting. We conducted a qualitative study to describe provider perspectives on the implementation of a harm reduction in-reach program. We conducted 24 semi-structured interviews with providers from three different primary work sites within a safety net hospital in Boston, MA, in 2021. Interviews explored perceived facilitators and barriers to the implementation of the harm reduction in-reach program in the hospital setting and solicited recommendations for potential improvements to the harm reduction in-reach program. Interviews were analyzed using an inductive approach that incorporated principles of grounded theory methodology to identify prevailing themes. Twenty-four participants were interviewed from the harm reduction in-reach program, inpatient addiction consult service, and the hospital observation unit. Thematic analysis revealed seven major themes and multiple facilitators and barriers to the implementation of the harm reduction in-reach program. Participants highlighted the impact of power differences within the medical hierarchy on inter-team communication and clinical care, the persistence of addiction-related stigma, the importance of coordination and role delineation between care team members, and the benefits of a streamlined referral process. Harm reduction programs offer accessible, patient-centered, low-barrier care to patients using drugs. The integration of community-based harm reduction programs into the inpatient setting is a unique opportunity to bridge inpatient and outpatient care and expand the provision of harm reduction services. Trial registration: Not applicable.

Perera R., Stephan L., Appa A., Giuliano R., Hoffman R., Lum P., Martin M.

Hospital-based addiction care focuses on assessing and diagnosing substance use disorders, managing withdrawal, and initiating medications for addiction treatment. Hospital harm reduction is generally limited to prescribing naloxone. Hospitals can better serve individuals with substance use disorders by incorporating harm reduction education and equipment provision as essential addiction care. We describe the implementation of a hospital intervention that provides harm reduction education and equipment (e.g., syringes, pipes, and fentanyl test strips) to patients via an addiction consult team in an urban, safety-net hospital. We performed a needs assessment to determine patient harm reduction needs. We partnered with a community-based organization who provided us harm reduction equipment and training. We engaged executive, regulatory, and nursing leadership to obtain support. After ensuring regulatory compliance, training our team, and developing a workflow, we implemented this harm reduction program that provides education and equipment to individuals whose substance use goals do not include abstinence. During a 12-month period we provided 195 individuals harm reduction kits. This intervention allowed us to advance hospital-based addiction care, better educate and engage patients, staff, and clinicians, and reduce stigma. By establishing a community harm reduction partner, obtaining support from hospital leadership, and incorporating feedback from staff, clinicians, and patients, we successfully implemented harm reduction education and equipment provision in a hospital setting as part of evidence-based addiction care. Trial registration: Commentary, none.

Lennox R., Martin L., Brimner C., O'Shea T.

Hospitals are a critical touchpoint for people who use drugs (PWUD). However, hospital policies, both formal and informal, can have a detrimental impact on PWUD in acute care settings. Introducing new policies, or revising existing policies that inadvertently harm or stigmatize PWUD while hospitalized, could be an effective harm reduction intervention for this high-risk population. This paper explores seven areas where institutional policy change could improve the hospital experience of PWUD: (1) use of nonprescribed substances in hospital, (2) supporting inpatient addiction consultation services (3) in-hospital supervised consumption spaces (4) supply and distribution of safe drug use equipment and naloxone, (5) role of security services and personal searches, (6) use of hospital restrictions, and (7) involvement of PWUD in policy development.

Kariisa M., Seth P., Scholl L., Wilson N., Davis N.L.

Drug overdose deaths involving stimulants, including cocaine and psychostimulants with abuse potential (e.g., methamphetamine), have been increasing, partly because of co-involvement with opioids. Stimulant-involved overdose deaths have disproportionately increased among non-Hispanic Black (Black) and non-Hispanic American Indian/Alaskan Native (AI/AN) persons; however, the role of opioids in exacerbating disproportionate stimulant-involved death rates is unclear.Analysis of National Vital Statistics System multiple cause-of-death mortality files examined age-adjusted cocaine- and psychostimulant-involved death rates. Analyses of death rates stratified by racial and ethnic group and opioid co-involvement included: 1) Joinpoint regression of 2004-2019 trends, 2) changes in rates from 2018 to 2019, and 3) demographic and geographic characteristics of 2019 deaths.From 2004 to 2019, cocaine and psychostimulant-involved death rates were higher for Black and AI/AN persons, respectively. Among all groups, increases in cocaine-involved overdose rates were largely driven by opioid co-involvement, particularly after 2013. From 2004 to 2019, rates for psychostimulant-involved deaths increased with and without opioid co-involvement. Rates for overdoses co-involving cocaine and synthetic opioids increased from 2018 to 2019 for Hispanic, non-Hispanic White (White), and Black persons. Psychostimulant-involved overdose rates with and without synthetic opioid co-involvement increased among Hispanic, White, and Black persons. In 2019, Black and AI/AN persons continued to experience higher cocaine- and psychostimulant-involved death rates, respectively.Stimulant-involved deaths continue to increase, and the role of opioids in driving these deaths varies by race and ethnicity. Ensuring equitable access to proven prevention and treatment interventions and incorporating social determinants of health into future research around effective pharmacotherapies may help reduce stimulant-involved overdose deaths.

Suen L.W., Makam A.N., Snyder H.R., Repplinger D., Kushel M.B., Martin M., Nguyen O.K.

Acute healthcare utilization attributed to alcohol use disorders (AUD) and other substance use disorders (SUD) is rising. To describe the prevalence and characteristics of emergency department (ED) visits and hospitalizations made by adults with AUD or SUD. Observational study with retrospective analysis of the National Hospital Ambulatory Medical Care Survey (2014 to 2018), a nationally representative survey of acute care visits with information on the presence of AUD or SUD abstracted from the medical chart. Outcome measured as the presence of AUD or SUD. From 2014 to 2018, the annual average prevalence of AUD or SUD was 9.4% of ED visits (9.3 million visits) and 11.9% hospitalizations (1.4 million hospitalizations). Both estimates increased over time (30% and 57% relative increase for ED visits and hospitalizations, respectively, from 2014 to 2018). ED visits and hospitalizations from individuals with AUD or SUD, compared to individuals with neither AUD nor SUD, had higher percentages of Medicaid insurance (ED visits: AUD: 33.1%, SUD: 35.0%, neither: 24.4%; hospitalizations: AUD: 30.7%, SUD: 36.3%, neither: 14.8%); homelessness (ED visits: AUD: 6.2%, SUD 4.4%, neither 0.4%; hospitalizations: AUD: 5.9%, SUD 7.3%, neither: 0.4%); coexisting depression (ED visits: AUD: 26.3%, SUD 24.7%, neither 10.5%; hospitalizations: AUD: 33.5%, SUD 35.3%, neither: 13.9%); and injury/trauma (ED visits: AUD: 51.3%, SUD 36.3%, neither: 26.4%; hospitalizations: AUD: 31.8%, SUD: 23.8%, neither: 15.0%). In this nationally representative study, 1 in 11 ED visits and 1 in 9 hospitalizations were made by adults with AUD or SUD, and both increased over time. These estimates are higher or similar than previous national estimates using claims data. This highlights the importance of identifying opportunities to address AUD and SUD in acute care settings in tandem with other medical concerns, particularly among visits presenting with injury, trauma, or coexisting depression.

Razaghizad A., Windle S.B., Filion K.B., Gore G., Kudrina I., Paraskevopoulos E., Kimmelman J., Martel M.O., Eisenberg M.J.

Background. Opioids contribute to more than 60 000 deaths annually in North America. While the expansion of overdose education and naloxone distribution (OEND) programs has been recommended in response to the opioid crisis, their effectiveness remains unclear. Objectives. To conduct an umbrella review of systematic reviews to provide a broad-based conceptual scheme of the effect and feasibility of OEND and to identify areas for possible optimization. Search Methods. We conducted the umbrella review of systematic reviews by searching PubMed, Embase, PsycINFO, Epistemonikos, the Cochrane Database of Systematic Reviews, and the reference lists of relevant articles. Briefly, an academic librarian used a 2-concept search, which included opioid subject headings and relevant keywords with a modified PubMed systematic review filter. Selection Criteria. Eligible systematic reviews described comprehensive search strategies and inclusion and exclusion criteria, evaluated the quality or risk of bias of included studies, were published in English or French, and reported data relevant to either the safety or effectiveness of OEND programs, or optimal strategies for the management of opioid overdose with naloxone in out-of-hospital settings. Data Collection and Analysis. Two reviewers independently extracted study characteristics and the quality of included reviews was assessed in duplicate with AMSTAR-2, a critical appraisal tool for systematic reviews. Review quality was rated critically low, low, moderate, or high based on 7 domains: protocol registration, literature search adequacy, exclusion criteria, risk of bias assessment, meta-analytical methods, result interpretation, and presence of publication bias. Summary tables were constructed, and confidence ratings were provided for each outcome by using a previously modified version of the Royal College of General Practitioners’ clinical guidelines. Main Results. Six systematic reviews containing 87 unique studies were included. We found that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants’ attitudes toward naloxone, provide sufficient training for participants to safely and effectively manage overdoses, and effectively reduce opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective. Evidence was limited for other naloxone formulations, as well as the need for hospital transport after overdose reversal. The preponderance of evidence pertained persons who use heroin. Author’s Conclusions. Evidence suggests that OEND programs are effective for reducing opioid-related mortality; however, additional high-quality research is required to optimize program delivery. Public Health Implications. Community-based OEND programs should be implemented widely in high-risk populations.

Peterson C., Li M., Xu L., Mikosz C.A., Luo F.

Importance A persistently high US drug overdose death toll and increasing health care use associated with substance use disorder (SUD) create urgency for comprehensive estimates of attributable direct costs, which can assist in identifying cost-effective ways to prevent SUD and help people to receive effective treatment. Objective To estimate the annual attributable medical cost of SUD in US hospitals from the health care payer perspective. Design, Setting, and Participants This economic evaluation of observational data used multivariable regression analysis and mathematical modeling of hospital encounter costs, controlling for patient demographic, clinical, and insurance characteristics, and compared encounters with and without secondary SUD diagnosis to statistically identify the total attributable cost of SUD. Nationally representative hospital emergency department (ED) and inpatient encounters from the 2017 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and National Inpatient Sample were studied. Statistical analysis was performed from March to June 2020. Exposures International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)principal or secondary SUD diagnosis on the hospital discharge record according to the Clinical Classifications Software categories (disorders related to alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, and other substances). Main Outcomes and Measures Annual attributable SUD medical cost in hospitals overall and by substance type (eg, alcohol). The number of encounters (ED and inpatient) with SUD diagnosis (principal or secondary) and the mean cost attributable to SUD per encounter by substance type are also reported. Results This study examined a total of 124 573 175 hospital ED encounters and 33 648 910 hospital inpatient encounters from the 2017 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and National Inpatient Sample. Total annual estimated attributable SUD medical cost in hospitals was $13.2 billion. By substance type, the cost ranged from $4 million for inhalant-related disorders to $7.6 billion for alcohol-related disorders. Conclusions and Relevance This study’s results suggest that the cost of effective prevention and treatment may be substantially offset by a reduction in the high direct medical cost of SUD hospital care. The findings of this study may inform the treatment of patients with SUD during hospitalization, which presents a critical opportunity to engage patients who are at high risk for overdose. Aligning incentives such that prevention cost savings accrue to payers and practitioners that are otherwise responsible for SUD-related medical costs in hospitals and other health care settings may encourage prevention investment.

Knudsen H.K., Back-Haddix S., Andrews-Higgins S., Goetz M., Davis O.A., Oyler D.R., Walsh S.L., Freeman P.R.

Abstract Background Efforts to scale up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, was a major focus of the HEALing Communities Study (HCS). The aim of this analysis is to describe the qualitative perspectives of partner organizations regarding the impacts of implementing OEND in a state that used a naloxone “hub with many spokes” model for scaling up this strategy. Methods Small group (n = 20) and individual (n = 24) qualitative interviews were conducted with staff from 44 agencies in eight Kentucky counties that implemented OEND from April 2020 to June 2022. Interviews were conducted between 6 and 8 months after the end of the intervention. Initial deductive coding used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework, and then additional inductive sub-coding focused on passages within the OEND Effectiveness code. Thematic analysis was then utilized to identify themes regarding the impacts of implementing OEND. Results Participants identified multi-level impacts of implementing OEND. At the individual-level, participants described lives being saved, greater access to naloxone for individuals served by the agency, reduced stigma toward OEND by clients, and greater client-level self-efficacy to respond to overdoses. Organizational impacts included improved staff readiness for overdose response, enhanced clinical relationships between staff and clients, and reduced staff stigma. Participants described positive impacts on their organizational networks and clients’ social networks. Community-level impacts included greater overall access and reduced stigma toward OEND. Conclusions These qualitative data revealed that staff from agencies involved in a community-wide effort to scale up OEND perceived multi-level benefits, including saving lives, reducing stigma, improving naloxone access, and enhancing staff and client readiness, while strengthening organizational and community networks. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939

Assaf R.D., Morris M.D., Straus E.R., Martinez P., Philbin M.M., Kushel M.

ImportanceThe lack of representative research on homelessness risks mischaracterizing and misrepresenting the prevalence of illicit substance use.ObjectiveTo estimate the population prevalence and patterns of illicit substance use, treatment, nonfatal overdose, and naloxone possession among people experiencing homelessness in 1 US state.Design, Setting, and ParticipantsThis representative survey study of adults experiencing homelessness from October 2021 to November 2022 in 8 California counties used multistaged probability-based sampling and respondent-driven sampling. Eligible individuals were 18 years or older and met the federal definition of homelessness.Main Outcomes and MeasuresThe primary outcome measures included lifetime and past–6-month illicit substance use and substance type (methamphetamine, nonprescription opioids, or cocaine). Lifetime and current substance use treatment, unmet treatment need, types of treatments received, nonfatal overdose (lifetime and current episode of homelessness), and current possession of naloxone were measured. Population prevalence estimates with 95% Wald CIs were calculated using survey replicate weights.ResultsOf 3865 individuals approached, 3042 (79%) participated and an additional 158 participants were recruited through respondent-driven sampling. Among 3200 participants, the mean age was 46.1 (95% CI, 45.3-46.9) years, 67.3% (95% CI, 65.2%-69.3%) were cisgender male, and there were similar proportions of Black and African American, Hispanic and Latine, and White participants. Overall, an estimated 65.3% (95% CI, 62.2%-68.4%) of participants used illicit drugs regularly (≥3 times per week) in their lifetime; 41.6% (95% CI, 39.4%-43.8%) began using regularly before their first episode of homelessness and 23.2% (95% CI, 20.5%-25.9%) began using regularly after. In the past 6 months, an estimated 37.1% (95% CI, 32.9%-41.3%) of participants reported regular use of any drug; 33.1% (95% CI, 29.4%-36.7%) reported use of methamphetamines, 10.4% (95% CI, 7.9%-12.9%) reported use of opioids, and 3.2% (95% CI, 1.8%-4.6%) reported use of cocaine. In their lifetime, an estimated 25.6% (95% CI, 22.8%-28.3%) injected drugs and 11.8% (95% CI, 9.8%-13.8%) injected drugs in the past 6 months. Among those with any regular lifetime use, an estimated 6.7% (95% CI, 3.8%-9.5%) of participants were currently receiving treatment. Of those with any regular use in the last 6 months, an estimated 21.2% (95% CI, 17.9%-24.5%) reported currently wanting but not receiving treatment. An estimated 19.6% (95% CI, 17.4%-21.8%) of participants had a nonfatal overdose in their lifetime and 24.9% (95% CI, 21.3%-28.5%) currently possessed naloxone.Conclusion and RelevanceIn a representative study of adults experiencing homelessness in California, there was a high proportion of current drug use, history of overdose, and unmet need for treatment. Improving access to treatment tailored to the needs of people experiencing homelessness could improve outcomes.

Shaw L.C., Brown E.A., Creegan E., Bertrand T.E., Ogundare S., Park C.J., Berk J., Chan P.A., Marshall B.D.

Objective: Improved harm reduction approaches are needed to address the ongoing opioid epidemic in the United States. The study aimed to evaluate the statewide implementation of harm reduction vending machines (HRVMs) and existing in-person harm reduction services. Design: We analyzed 2 years of data from in-person harm reduction encounters and an HRVM pilot program between January 1, 2022, and December 31, 2023. Setting: Rhode Island. Participants: This analysis compared unique persons served, total encounters, types of products dispensed, and time and day of transaction (weekday vs weekend) for in-person services provided by state-funded community organizations and the HRVMs in operation during the pilot program. Main Outcome Measures: At each encounter, the date, location, sociodemographic information, and product(s) dispensed were recorded, among other information for both in-person and HRVM services. Results: Over 15 000 people accessed in-person and HRVM services during the 2-year study period (N = 15 267 in-person; N = 485 HRVM or both). Overall, 38% were female, and 64% were white and non-Hispanic. People who frequented the HRVMs tended to be an average of 5 years younger (P< .001). Twenty-eight percent of HRVM encounters happened over the weekend, while only 2% of in-person encounters occurred during this time. Notably, 29% of HRVM encounters occurred overnight or during the early morning hours. Safer injection kits, safer smoking kits, and naloxone kits were the 3 most common products dispensed during in-person encounters, with 68% of encounters also supplying basic needs like water, snacks, and clothing. Safer injection kits represented 89% of products dispensed by the HRVMs. Conclusions: HRVMs are a feasible method of distributing harm reduction supplies as a complement to in-person services. HRVMs could complement other services already offered in many communities. Around-the-clock access is a key component of effective HRVMs.

Medellin T., Moczygemba L.R., Thurman W.

Street medicine is a health delivery model designed to provide direct patient care to people experiencing unsheltered homelessness where they are physically located, whether that be on the streets or in encampments. The model has developed in response to the barriers people experiencing homelessness (PEH) encounter when accessing care through traditional points of access such as primary care clinics. Street medicine programs are rapidly emerging across the United States (U.S.) in response to the health needs and challenges associated with care access and coordination for unsheltered homeless individuals. Although street medicine is a rapidly growing field, existing street medicine programs have rarely been studied collectively, limiting our understanding of the nature, scope, and range of street medicine programs in the U.S. This study examined 13 programs from across the U.S. to develop a broad characterization of street medicine programs. Results from interviews with representatives from each of the 13 programs show that there is a high degree of variability among the structure, operations, and scope of care of street medicine programs. However, consistent among street medicine programs is the adoption of a patient-centered approach to care and the use of harm-reduction principles. Street medicine programs are also highly engaged with community partners and affiliate organizations that work in their local and regional areas. Because street medicine programs often serve as a bridge between formal healthcare entities and PEH, street medicine offers a strategy for reconnecting individuals to vital healthcare services.

Adebayo O.B., Innis T.

AbstractThe ongoing Canadian opioid crisis has resulted in alarming rates of overdoses and related harms. Harm reduction programs have emerged as a crucial public health strategy to mitigate these risks. The Nēwo-Yōtina Friendship Centre (NYFC) offers harm reduction programs that provide a safe injection site and clean supplies to reduce substance use-associated harm. Researchers have not extensively studied the effectiveness and user experience of this program. Studies have demonstrated the effectiveness of harm reduction programs in mitigating adverse effects of drug use, such as disease transmission and overdose. This in- depth study looked at what program users went through in the NYFC harm reduction program. This was done by looking at the program environment, unexpected outcomes, reasons for seeking services, and obstacles to access. The study used a phenomenological approach, utilising semi-structured interviews with 13 participants and analysing interview data using thematic analysis2 through NVivo. The motivations for seeking services were safety, access to clean supplies, and a non-judgmental environment. Findings revealed that users valued a safe and welcoming atmosphere fostered by friendly, supportive, and non- judgmental staff. The program’s positive outcomes included reduced harm, access to resources, and emotional support. Nevertheless, limited operating hours, stigma, small space, and a lack of awareness were identified as barriers to access. The study recommends improving accessibility, enhancing support systems, and addressing unanticipated outcomes like drug use enablement to optimise the program’s effectiveness. This study provides valuable insights into user experience within the NYFC program. The findings inform program improvements, enhance service delivery, and contribute to a broader understanding of harm reduction strategies for addressing the opioid crisis. It emphasises the importance of user-centred approaches in developing and implementing effective harm reduction programs.

Check D.K., Jones K.F., Osazuwa-Peters O.L., Blalock D.V., Marais A.D., Merlin J.S.

Substance misuse is common among cancer survivors and can negatively impact cancer outcomes. We conducted a cross-sectional study using National Survey on Drug Use and Health data for 2015 to 2020. We included adult respondents with a history of solid tumor cancer. We calculated the weighted prevalence and corresponding SEs (both expressed as percentages) of substance (alcohol, opioid, sedative, stimulant, other) misuse for respondents with any history of solid tumor cancer and, in secondary analyses, respondents diagnosed with cancer in the prior 12 months. The study included 6,101 respondents with any history of cancer, 1,437 diagnosed in the prior 12 months. Alcohol was the most commonly misused substance. The average prevalence of alcohol misuse was 14.4% (SE 0.60%) across cancer types; it was markedly more common among people with a history or cervical (24.2% [3.0%]) or head and neck cancer (27.4% [7.1%]). The next most common form of substance misuse was opioid misuse (average prevalence: 2.7% [0.25%]). As with alcohol misuse, the prevalence of opioid misuse was higher among those with a lifetime history of cervical cancer (5% [1%]) or head and neck cancer (5% [3%]). Results were generally consistent among cancer survivors diagnosed in the prior 12 months. There is a clear opportunity to address substance misuse—particularly alcohol misuse—among cancer survivors. Such efforts should focus on populations with a high prevalence of substance misuse (e.g., cervical and head and neck cancer survivors) and have strong potential to improve cancer-specific and overall health outcomes.

Guta A., Gagnon M., German D., Buchman D.Z., Strike C.J.