Associations of hepatitis C virus (HCV) antibody positivity with opioid, stimulant, and polysubstance injection among people who inject drugs (PWID) in rural U.S. communities.

BACKGROUND: People who inject drugs (PWID) in the rural U.S. often inject stimulants, alone or with opioids. The impact of these substance use patterns may influence HCV risk behaviors. This analysis examines the associations of HCV antibody positivity with injecting only opioids, only stimulants (methamphetamine/cocaine), and opioids and stimulants together among rural PWID. METHODS: The Rural Opioid Initiative (ROI) consists of eight research sites that enrolled people who use drugs in rural communities in ten U.S. states from 2018 to 2020. This cross-sectional analysis included adult participants who resided in a study area and injected any drug in the past 30 days. The primary outcome was HCV antibody positivity. The exposure of interest was injection drug use classified as only opioids, only stimulants, separate injections of opioids and stimulants, and same-syringe injection of both in the past 30 days. We used multivariable log-binomial regression with generalized linear mixed models to generate prevalence ratios (P.R.) adjusted for demographics, injection history, health insurance, and substance use treatment. RESULTS: Among 3,084 participants enrolled in the ROI, 1,982 met inclusion criteria. Most participants injected opioids and stimulants in the same syringe (34%) or separately (21%), followed by injecting only stimulants (26%), and injecting only opioids (19%). Half (51%) were HCV antibody positive. Compared to people who injected only stimulants, HCV antibody positivity was more prevalent among people who injected opioids alone (aPR=1.62, 95% CI:(1.29-2.03)), injected both opioids and stimulants separately (aPR=1.61, 95% CI:(1.32-1.95)), and in the same syringe (aPR=1.54, 95% CI:(1.28-1.85)). CONCLUSION: HCV antibody positivity, indicating prior exposure, was highest among those who had recently injected opioids, alone or with stimulants. Additional nucleic acid testing is necessary to confirm active infection. More research is needed to determine the underlying causes of HCV antibody positivity by injection use.

Opioid Use Disorder from Poppy Seed Tea Use: A Case Report.

BACKGROUND Unwashed or unprocessed poppy seeds may be an underrecognized substance that can lead to dependence, abuse, and an opioid use disorder. Poppy seeds can be purchased in an unwashed or unprocessed form, and these seeds can be contaminated with the opium alkaloids morphine, codeine, and thebaine on their surfaces. Poppy seeds that are commercially available, such as those used for baking and in other food products, are legal to purchase, as they do not contain the opium alkaloids on their seed coats. Purchase and possession of the unwashed or unprocessed seeds are not legal in the United States. These contaminated poppy seeds can then be put through a process in which they are washed, and the supernatant (tea) is collected and consumed to experience its intoxicating effect or for the treatment of pain or opioid withdrawal. CASE REPORT A 65-year-old man with a history of alcohol use disorder, cannabis use, and chronic pain began using this poppy seed tea for treatment of chronic pain after his provider had stopped prescribing opioid pain medications for him. He developed a dependence on the tea. He had reached out for assistance as it was his desire to stop using the poppy seed tea. The diagnosis of an opioid use disorder was made using the DSM-V criteria. He was successfully induced and maintained on a buprenorphine/naloxone product. CONCLUSIONS Poppy seeds in their unwashed and unprocessed form can be misused and could lead to an opioid use disorder. This disorder can be treated with buprenorphine/naloxone products.

Violence and Emergency Department Use among Community-Recruited Women Who Experience Homelessness and Housing Instability.

Women who experience housing instability are at high risk for violence and have disproportionately high rates of emergency department (ED) use. However, little has been done to characterize the violence they experience, or to understand how it may be related to ED use. We recruited homeless and unstably housed women from San Francisco shelters, free meal programs, and single room occupancy (SRO) hotels. We used generalized estimating equations to examine associations between violence and any ED use (i.e., an ED visit for any stated reason) every 6 months for 3 years. Among 300 participants, 44% were African-American, and the mean age was 48 years. The prevalence of violence experienced in the prior 6 months included psychological violence (87%), physical violence without a weapon (48%), physical violence with a weapon (18%), and sexual violence (18%). While most participants (85%) who experienced physical violence with a weapon or sexual violence in the prior 6 months had not visited an ED, these were the only two violence types significantly associated with ED use when all violence types were included in the same model (ORphysical/weapon = 1.83, 95% CI 1.02-3.28; ORsexual = 2.15, 95% CI 1.30-3.53). Only violence perpetrated by someone who was not a primary intimate partner was significantly associated with ED use when violence was categorized by perpetrator. The need to reduce violence in this population is urgent. In the context of health care delivery, policies to facilitate trauma-informed ED care and strategies that increase access to non-ED care, such as street-based medicine, could have substantial impact on the health of women who experience homelessness and housing instability.

HCV treatment barriers among HIV/HCV co-infected patients in the US: a qualitative study to understand low uptake among marginalized populations in the DAA era.

BACKGROUND: Well-tolerated, highly effective HCV treatment, known as direct-acting antivirals (DAAs), is now recommended for all people living with HCV, providing the tools for HCV elimination. We sought to understand treatment barriers among low-income HIV/HCV coinfected patients and providers with the goal of increasing uptake. METHODS: In 2014, we conducted 26 interviews with HIV/HCV co-infected patients and providers from a San Francisco clinic serving underinsured and publically-insured persons to explore barriers impacting treatment engagement and completion. Interview transcripts were coded, and a thematic analysis was conducted to identify emerging patterns. RESULTS: Conditions of poverty-specifically, meeting basic needs for food, shelter, and safety-undermined patient perceptions of self-efficacy to successfully complete HCV treatment programs. While patient participants expressed interest in HCV treatment, the perceived burden of taking daily medications without strong social support was an added challenge. This need for support contradicted provider assumptions that, due to the shorter-course regimens, support is unnecessary in the DAA era. CONCLUSIONS: Interferon-free treatments alone are not sufficient to overcome social-structural barriers to HCV treatment and care among low-income HIV/HCV co-infected patients. Support for patients with unmet social needs may facilitate treatment initiation and completion, particularly among those in challenging socioeconomic situations.