Abolition and harm reduction in the struggle for "Care, Not Cages".

Care that is organized around the principles of harm reduction and the movement for police and prison abolition has the potential to uproot and transform structural causes of harm and violence, in the interconnected crises of drug-related harm, policing, and punishment. The United States' crisis of overdose and drug-related harm and its system of policing and punishment are historically and empirically linked phenomena. The abandonment of people whose use of drugs leads to their premature death, in the form of an overdose, is directly and indirectly connected to wider systems of criminalization and incarceration that also produce premature suffering and death. Organizations advocating for harm reduction for people who use drugs (PWUD) and organizations seeking the abolition of police and prisons have developed in parallel albeit with different genealogies. We examine the historical origins, principles, and practical applications of the two movements to identify points of overlap and lessons to be learned for the public health goals of addressing and preventing premature suffering and death in the United States. A case study of Los Angeles (LA) County, where elected officials have promised a new paradigm of care, not punishment, frames our analysis. We show how the principles and strategies of harm reduction and abolition are both necessary to practically realizing a paradigm of care, not punishment, and achieving system transformation.

Rethinking urban-rural designations in public health surveillance of the overdose crisis and crafting an agenda for future monitoring.

Rurality has served as a key concept in popular and scientific understandings of the US overdose crisis, with White, rural, and low-income areas thought to be most heavily affected. However, we observe that overdose trends have risen nearly uniformly across the urban-rural designations employed in most research, implying that their importance has likely been overstated or incorrectly conceptualized. Nevertheless, urbanicity/rurality does serve as a key axis to understand inequalities in overdose mortality when assessed with more nuanced modalities-employing a more granular analysis of geography at the sub-county level, and intersecting rurality sociodemographic indices such as race/ethnicity. Using national overdose data from 1999-2021, we illustrate the intersectional importance of rurality for overdose surveillance. Finally, we offer recommendations for integrating these insights into drug overdose surveillance moving forward.

'Red Flags' and 'Red Tape': Telehealth and pharmacy-level barriers to buprenorphine in the United States.

BACKGROUND: Structural vulnerabilities for people who use drugs (PWUD) were exacerbated by the COVID-19 pandemic. In this context, federal lawmakers in the United States (U.S.) invoked an exemption to the 2008 Ryan Haight Act requiring in-person evaluation to prescribe buprenorphine for treatment of opioid use disorder (OUD), which allowed for the initiation and maintenance of buprenorphine via telehealth. Despite the potential for telehealth to address some of the geographic disparities in OUD treatment access, recent research has suggested that significant barriers to buprenorphine also exist at the pharmacy level. The purpose of this study was to qualitatively assess how efforts to increase access to buprenorphine via telehealth are implemented by prescribers and pharmacists and experienced by patients. METHODS: Participant observation and semi-structured interviews focused on telehealth for OUD treatment and buprenorphine prescribing and dispensing were conducted with patients (n = 19), prescribers and clinic staff (n = 24), and pharmacists (n = 10) in Pennsylvania and California between May 2020 - May 2021. FINDINGS: While participants stated that telehealth for OUD treatment was a welcome option, pharmacy-level barriers to buprenorphine persisted. Geographical distance from patient to provider or pharmacist continued to serve as "red flags" for pharmacists, leading to pharmacy-level "red tape:" gatekeeping measures including geographic restrictions, telephone prescription "confirmations," prescription cancellations and refusals. Patients' unmet expectations of buprenorphine access in some cases led to unanticipated risks including a return to injection drug use. CONCLUSION: Challenges to increasing buprenorphine access persist in the U.S. even in settings where telehealth is implemented, and telehealth may inadvertently produce new barriers for some patients. Despite national support for policies aimed at increasing access to treatment for substance use disorders rather than punishment, policy shifts from punishment to treatment have not permeated evenly across all geographic areas and populations. Perceived threats of Drug Enforcement Administration (DEA) enforcement, and self-defensive institutional practices in pharmacies, reinforce ideologies of drug law enforcement, leading to poor patient outcomes including lack of buprenorphine access.

Substance use policy and practice in the COVID-19 pandemic: Learning from early pandemic responses through internationally comparative field data.

The COVID-19 pandemic has created an unprecedented natural experiment in drug policy, treatment delivery, and harm reduction strategies by exposing wide variation in public health infrastructures and social safety nets around the world. Using qualitative data including ethnographic methods, questionnaires, and semi-structured interviews with people who use drugs (PWUD) and Delphi-method with experts from field sites spanning 13 different countries, this paper compares national responses to substance use during the first wave of the COVID-19 pandemic. Field data was collected by the Substance Use x COVID-19 (SU x COVID) Data Collaborative, an international network of social scientists, public health scientists, and community health practitioners convened to identify and contextualise health service delivery models and social protections that influence the health and wellbeing of PWUD during COVID-19. Findings suggest that countries with stronger social welfare systems pre-COVID introduced durable interventions targeting structural drivers of health. Countries with fragmented social service infrastructures implemented temporary initiatives for PWUD led by non-governmental organisations. The paper summarises the most successful early pandemic responses seen across countries and ends by calling for greater systemic investments in social protections for PWUD, diversion away from criminal-legal systems toward health interventions, and integrated harm reduction, treatment and recovery supports for PWUD.

Treating risk, risking treatment: experiences of iatrogenesis in the HIV/AIDS and opioid epidemics.

This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis.

Commercially sexually exploited youths' health care experiences, barriers, and recommendations: A qualitative analysis.

The current study sought to understand commercially sexually exploited (CSE) youths' health care experiences, barriers to care, and recommendations for improving health care services. We conducted focus groups (N=5) with 18 CSE youth from February 2015 through May 2016 at two group homes serving CSE youth in Southern California. We performed thematic content analysis to identify emergent themes about CSE youths' perspectives on health care. Youth described facilitators to care, including availability of services such as screening for sexually transmitted infections, knowledge about sexual health, and a strong motivation to stay healthy. Barriers included feeling judged, concerns about confidentiality, fear, perceived low quality of services, and self-reliance. Overall, youth emphasized self-reliance and "street smarts" for survival and de-emphasized "victimhood," which shaped their interactions with health care, and recommended that health providers develop increased understanding of CSE youth. Our findings suggest that providers and community agencies can play an essential role in raising awareness of the needs of CSE youth and meet their health needs through creating a non-judgmental environment in health care settings that validates the experiences of these youth.

Enhancing school asthma action plans: qualitative results from southeast Minnesota beacon stakeholder groups.

BACKGROUND: This study explores ways southeast Minnesota schools currently address asthma problems, identifies areas for improvement, and assesses the potential value of asthma action plans (AAPs) in schools. METHODS: Focus groups were used to query stakeholder groups on asthma care in schools. Groups were held separately for elementary school personnel, parents of elementary school children with asthma, and health professionals (N = 103). Transcripts were analyzed by hand and by using NVivo 9 software. RESULTS: Overall 103 stakeholders participated in focus groups. Major themes were (1) Communication; no uniform way of exchanging information between schools and health professionals. (2) Asthma Control Continuum; students require individualized instructions and information related to their asthma care. (3) Policy/Protocol; school staff roles and rules vary and are unclear. (4) Self-Reliance; older children self-manage their asthma and are unknown until they need emergent support. Solution recommended included AAPs used systematically with a method to communicate back from schools to physicians and parents. CONCLUSIONS: The AAP may solve several of the school's concerns regarding their ability to provide asthma support in school. However, the AAP must reach the school, and that is currently not happening. In addition, schools would like tools and systems to assess asthma control and share information back with parents and physicians.

Mexican and Somali immigrant breastfeeding initiation and counseling: a qualitative study of practices.

Breastfeeding is highly beneficial to mothers and children. Yet even among women who intend to breastfeed their babies, it is not always initiated or sustained. We decided to examine whether cultural beliefs affect breastfeeding practices. Specifically, we looked at those of immigrant Mexican and Somali women who gave birth at a community hospital in southeastern Minnesota and those of the nurses and lactation educators who supported them. To study this, we conducted focus groups with health professionals (N=10) and in-person interviews with Somali and Mexican mothers (N=9). Although the mothers in this study stated their intention to breastfeed, our data show they faced significant challenges to early breastfeeding initiation and exclusive breastfeeding, including their belief that they did not initially produce enough milk. We found the nurses' and lactation educators' discomfort with counseling people from another background as well as language differences and lack of cultural understanding were also barriers to early breastfeeding initiation and exclusive breastfeeding. This study highlights how the beliefs of new mothers and the attitudes of nurses and educators can affect breastfeeding outcomes.