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

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

Safety in Solitude? Competing Risks and Drivers of Solitary Drug Use among Women who Inject Drugs and Implications for Overdose Detection.

BACKGROUND AND AIMS: Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). DESIGN: A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews. SETTING: Baltimore City, Maryland, USA. PARTICIPANTS: Twenty-seven WWID, (mean age: 39 years, 67% White, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021). MEASUREMENTS: Interviews explored the physical (i.e., indoor/private, outdoor/public) and social (i.e., alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. FINDINGS: Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs, and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ("spotting"), and using drugs in public spaces. CONCLUSIONS: Women who inject drugs appear to engage frequently in solitary drug use due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Increased solitary drug use during COVID-19: An unintended consequence of social distancing.

BACKGROUND: During the COVID-19 pandemic, overdose rates substantially increased in the United States. One possible contributor to this phenomenon may be solitary drug use resulting from social distancing efforts to prevent COVID-19 transmission. METHODS: We surveyed 458 people who use drugs (PWUD) who were recruited from harm reduction and drug treatment providers located in nine states and the District of Columbia. We assessed if solitary drug use had increased since the start of COVID-19. Associations between increased solitary drug use and sociodemographic characteristics, drug use characteristics, and COVID-19 prevention behaviors were examined using multiple logistic regression. RESULTS: Half the sample identified as men (52.7%), White (49.7%), and single (49.3%). The average age was 43.2 (SD:11.8) years. Two-thirds (66.8%) recently injected drugs. 44% reported increased solitary drug use since COVID-19. Significant correlates of increased solitary drug use included being single (adjusted Odds Ratio [aOR]=1.99, 95% Confidence Interval [CI]: 1.33, 2.98), increasing drug use (aOR=2.74, 95% CI: 1.72, 4.37), using more in private locations (aOR=1.91, 95% CI: 1.34, 2.72), and social distancing behaviors (aOR=1.31, 95% CI: 1.11, 1.54). Experiencing homelessness (aOR=0.45, 95% CI: 0.31, 0.65) and identifying as a sexual minority (aOR=0.53, 95% CI: 0.31, 0.93) were associated with being less likely to increase solitary drug use. CONCLUSIONS: Solitary drug use increased during the COVID-19 pandemic. Increases in solitary drug use, in the context of a drug market increasingly permeated by fentanyl, indicates an urgent need for comprehensive harm reduction interventions to reduce overdose mortality.

Racial resentment and support for decriminalization of drug possession in the United States.

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.

Implications of attitudes and beliefs about COVID-19 vaccines for vaccination campaigns in the United States: A latent class analysis.

Unprecedented global efforts in vaccine development have resulted in effective vaccines for COVID-19. The pandemic response in the US has been highly politicized, resulting in significant opposition to public health efforts, including vaccines. We aimed to understand patterns of attitudes and beliefs about the COVID-19 vaccine to inform vaccination campaigns. 583 English speaking United States adults were surveyed November 18-29, 2020. Participants answered 11 questions about their attitudes and beliefs about a COVID-19 vaccine, including perceived vaccine effectiveness, likelihood of getting vaccinated, and concerns that vaccine development was rushed/influenced by politics. We conducted a latent class analysis to identify profiles of attitudes/beliefs about a COVID-19 vaccine. We identified four classes of COVID-19 vaccine beliefs. The pro-vaccine class (28.8%) was willing to get vaccinated and had broadly positive beliefs about the vaccine. The development concerns class (27.8%) was willing to get vaccinated but was concerned about the development process. The third class (22.6%) was largely unsure if they would get vaccinated and if their peer groups would be vaccinated. The forth class (anti-vaccine, 20.8%) was dominated by an unwillingness to get vaccinated, vaccine distrust, vaccine development concerns, and peers groups with negative vaccine intentions. Given the large proportion of individuals who were concerned about the COVID-19 vaccine development process, messaging about rigor and approval processes may be critical to securing this group's commitment to vaccination. Having scientific and cultural leaders endorse vaccination may also be influential.

Implications of Attitudes and Beliefs about COVID-19 vaccines for Vaccination Campaigns in the United States: a Latent Class Analysis

Unprecedented global efforts in vaccine development have resulted in effective vaccines for COVID-19. The pandemic response in the US has been highly politicized, resulting in significant opposition to public health efforts, including vaccines. We aimed to understand patterns of attitudes and beliefs about the COVID-19 vaccine to inform vaccination campaigns. 583 English speaking United States adults were surveyed November 18-29, 2020. Participants answered 11 questions about their attitudes and beliefs about a COVID-19 vaccine, including perceived vaccine effectiveness, likelihood of getting vaccinated, and concerns that vaccine development was rushed/influenced by politics. We conducted a latent class analysis to identify profiles of attitudes/beliefs about a COVID-19 vaccine. We identified four classes of COVID-19 vaccine beliefs. The pro-vaccine class (28.8%) was willing to get vaccinated and had broadly positive beliefs about the vaccine. The development concerns class (27.8%) was willing to get vaccinated but was concerned about the development process. The third class (22.6%) was largely unsure if they would get vaccinated and if their peer groups would be vaccinated. The forth class (anti-vaccine, 20.8%) was dominated by an unwillingness to get vaccinated, vaccine distrust, vaccine development concerns, and peers groups with negative vaccine intentions. Given the large proportion of individuals who were concerned about the COVID-19 vaccine development process, messaging about rigor and approval processes may be critical to securing this group’s commitment to vaccination. Having scientific and cultural leaders endorse vaccination may also be influential.

HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland.

Drug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors among PWID in Baltimore City (BC) and Anne Arundel Country (AAC), Maryland. PWID (N = 283) were recruited to the study through targeted sampling at street-based locations in BC and AAC from July 2018 to March 2020. Receptive syringe sharing (RSS) [adjusted odds ratio (AOR): 2.8, 95% confidence interval (CI): 1.2-6.3] and daily injecting (AOR: 1.9, 95% CI: 1.0-3.6) were associated with injecting fentanyl and cocaine together. Fentanyl availability and COVID-19 bring new HIV prevention challenges, particularly among those who inject fentanyl with cocaine, highlighting the importance to expand and sustain harm reduction, prevention, and treatment services for PWID to reduce HIV and overdose burden.

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

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