Emergency Room Utilization and Methamphetamine Overdose Symptoms Among Syringe Services Program Participants in Washington State.

BACKGROUND: Methamphetamine overdose can cause severe psychological and physical health issues including psychosis, heart attack, and death. People who use methamphetamine (PWUM) who experience methamphetamine overdose symptoms (MOS) are advised to seek emergency healthcare; however, factors related to seeking care are not well characterized. METHODS: This study used data from the 2021 Washington State Syringe Services Program (SSP) Health Survey, a cross-sectional survey administered to participants at 21 SSPs in Washington (N = 955). Participants answered questions related to substance use including emergency department/room (ER) utilization for methamphetamine use and whether they experienced psychological and physical MOS. Using Poisson regression, we assessed the association between ER utilization for methamphetamine use, non-fatal opioid overdose, and other key covariates among PWUM who experienced MOS. RESULTS: Methamphetamine use in the last three months was reported by 86% of participants. Among PWUM, 31% reported psychological MOS, 19% reported physical MOS, and 37% reported ≥1 MOS in the prior three months. Non-fatal opioid overdose (adjusted prevalence ratio [APR] = 2.04, 95% CI = 1.38-3.03), main drug of goofball (heroin and methamphetamine combined) (APR = 1.98, 95% CI = 1.34-2.92) and recent blood infection/sepsis (APR = 2.07, 95% CI = 1.24-3.46) were associated with ER utilization for MOS. CONCLUSION: Among people who use SSPs in Washington State, methamphetamine use remains high, and MOS are common. Recent non-fatal opioid overdose was positively associated with ER utilization for methamphetamine use among PWUM who experienced MOS. Patients in the ER for MOS should be screened for opioid use disorder and linked with harm reduction supplies like naloxone and medications for opioid use disorder.

Trends and correlates of naloxone possession and use among people who inject drugs in Seattle, Washington.

BACKGROUND: Naloxone distribution has been implemented as an essential opioid overdose prevention measure for people who inject drugs (PWID), and many jurisdictions in the United States have implemented policy change to increase naloxone access. This project describes temporal trends in and correlates of naloxone possession and use among PWID in the Seattle area of Washington State. METHODS: Using a repeat cross-sectional design, we utilized two sets of serial cross-sectional surveys of PWID, which included biennial surveys of Seattle area syringe service program (SSP) clients and community-based National HIV Behavioral Surveillance surveys of PWID (NHBS-PWID) conducted from 2012-2019. Survey participant characteristics were descriptively compared between participants reporting naloxone possession to those not reporting naloxone possession. Multivariable Poisson regression was used to calculate prevalence ratios for naloxone possession comparing later to earlier survey years, adjusting for age, gender, race/ethnicity, primary drug, and experiencing and witnessing an overdose in the past 12 months. RESULTS: Naloxone possession and use increased in both survey populations. The prevalence of possessing naloxone was 2.8 times greater [2019 vs. 2013= 95% CI: 2.40-3.33] among SSP participants and 2.8 times greater [2018 vs. 2012=95% CI: 2.41-3.16] among NHBS-PWID participants for the most recent time period. The prevalence of naloxone use was 1.3 times greater [2019 vs. 2017= 95% CI: 1.13-1.58] and 2.1 times greater [2015 vs. 2012=95% CI:1.62-2.73] among SSP and NHBS-PWID participants, respectively, for the most recent time period. CONCLUSION: Naloxone possession and use increased in PWID in the Seattle area from 2012-2019, and is, at least in part, likely the result of numerous policy and programmatic efforts to facilitate easier naloxone accessibility in the wake of dramatic increases in overdose mortality. Further research on disparities in naloxone possession are needed to ensure equitable access.

Racial disparities in use of syringe service programs in King County, WA: a comparison of two cross-sectional surveys.

BACKGROUND: Syringe service programs (SSPs) provide tools to people who inject drugs (PWID) to prevent overdose, reduce the risk of HIV and HCV infection, and reduce injection frequency. While effective, previous research suggests that SSPs may not adequately reach some marginalized or particularly vulnerable subpopulations of PWID. METHODS: To identify disparities in SSP use, data from two cross-sectional surveys conducted in King County, Washington were compared: a survey of SSP clients and a community survey of PWID in King County. It was hypothesized that Black PWID, women, and gender minorities would be underrepresented in the SSP survey relative to the general population of PWID. RESULTS: SSP clients identified as White at a significantly higher rate than the community sample of PWID (p = 0.030). Black (p < 0.001), American Indian/Alaska Native (p < 0.001), Latinx/Hispanic (p = 0.009), and Native Hawaiian/ Pacific Islander PWID (p = 0.034) were underrepresented in the SSP client survey. The gender of SSP clients was similar to the distribution seen in the community sample of PWID (p = 0.483). CONCLUSIONS: Black PWID are underrepresented in Seattle-area SSPs, consistent with studies in other large US cities. Both nationally and in Seattle, overdose deaths have been increasing among Black PWID, and harm reduction strategies are vital to reversing this trend. SSPs should explore and test ways to be more accessible to minority populations.

Awareness and Correlates of HIV Pre-Exposure Prophylaxis (PrEP) Among HIV-negative People Who Access Syringe Services in Seattle, Washington.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is safe and effective for use in people who inject drugs (PWID), but PrEP is underutilized in this population. We assessed awareness of PrEP and correlates of interest in PrEP among PWID in Seattle, Washington. METHODS: This study analyzed data from a 2019 survey of PWID at 3 Seattle-area syringe service programs (SSPs). We used descriptive statistics to compare PrEP-aware and unaware PWID and multivariable Poisson regression with robust standard errors to estimate adjusted prevalence ratios (APR) for interest in PrEP. RESULTS: Among 348 HIV-negative PWID, ≤1% were currently taking PrEP, 51% were PrEP aware and 46% were interested in PrEP. Interest in PrEP was inversely associated with prior PrEP awareness (APR 0.58, 95% CI 0.45 - 0.74); however, interest in PrEP was high among PWID meeting pre-specified risk criteria for HIV (APR 1.41, 95% CI 1.06 - 1.88). CONCLUSIONS: Our results suggest increasing awareness of PrEP may not be sufficient to promote PrEP uptake among PWID, and further efforts are needed to understand perceptions of risk for HIV, determinants of PrEP use, and to investigate successful strategies for PrEP implementation and delivery in this marginalized population.Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.2012688 .

Increasing Heroin-Methamphetamine (Goofball) Use and Related Morbidity Among Seattle Area People Who Inject Drugs.

BACKGROUND AND OBJECTIVES: Methamphetamine use is increasing in the United States, potentially including the simultaneous injection of methamphetamine with heroin (goofball). We compared demographic, behavioral, contextual, and health factors among people who inject drugs (PWID) in the Seattle area and who reported that their main drug was goofball, heroin, or methamphetamine. METHODS: We used data from 2017 and 2019 cross-sectional surveys of clients at Public Health-Seattle & King County's syringe services program (N = 792). RESULTS: Among PWID participants, 55.3% reported using goofball in the last 3 months, and the proportion reporting goofball as their main drug doubled between 2017 (10.3%) and 2019 (20.1%, P < .001). The goofball group had the highest proportions of people who were aged less than 30, women, homeless or unstably housed, and recently incarcerated. PWID whose main drug was goofball reported considerable health risks and morbidity. Witnessing an opioid overdose was most commonly reported by participants whose main drug was goofball. This group also reported naloxone possession and use in an overdose situation more than other participants. The majority of participants were interested in reducing or stopping their opioid and stimulant use. DISCUSSION AND CONCLUSIONS: Among PWID, using goofball as a main drug doubled over 2 years and was characterized by contextual and individual factors that increase the risk of morbidity and mortality. SCIENTIFIC SIGNIFICANCE: This is the first study to characterize goofball use as a main drug. Clinical and public health efforts to diminish morbidity associated with opioid use need to integrate interventions that address the co-use of methamphetamine. (Am J Addict 2020;00:00-00).

Increasing methamphetamine injection among non-MSM who inject drugs in King County, Washington.

BACKGROUND: In King County, Washington, the HIV prevalence among men who have sex with men (MSM) who inject methamphetamine is high, while it is low among other people who inject drugs (PWID). Local drug problem indicators suggest that methamphetamine use is increasing. The extent to which this increase affects MSM and non-MSM, and whether MSM and non-MSM networks are connected through injection equipment sharing, is unknown. METHODS: We used data from two serial cross-sectional surveys of PWID including five biannual surveys of Public Health-Seattle and King County Needle and Syringe Exchange Program clients (NSEP, N=2135, 2009-2017) and three National HIV Behavioral Surveillance IDU surveys (NHBS, N=1709, 2009-2015). RESULTS: The proportion of non-MSM PWID reporting any recent methamphetamine injection increased significantly from approximately 20% in 2009 to 65% in 2017. Most of this increase was attributable to injecting methamphetamine in combination with heroin (goofballs). PWID who injected goofballs were more likely to be younger, homeless or unstably housed, report daily injection, and self-report an opioid overdose in the past year than other PWID. The majority of PWID who injected methamphetamine reported sharing any injection equipment. Among these PWID, 43% of MSM had last shared injection equipment with a non-MSM. Eight percent of non-MSM men and 15% of women had last shared equipment with an MSM. CONCLUSIONS: Given non-trivial rates of sharing injection equipment with methamphetamine-using MSM, a population with an HIV prevalence of 40%, non-MSM who inject methamphetamine could be an emerging population at risk for acquiring HIV.

A Decline in HIV Testing Among Persons Who Inject Drugs in the Seattle Area, 2004-2015.

BACKGROUND: Promoting HIV testing is a key component of the public health response to HIV. Assessing HIV testing frequency among persons who inject drugs (PWID) monitors the status of these efforts and can identify unmet needs and opportunities to more effectively promote testing. METHODS: Data were combined from 4 Seattle-area surveys of PWID from the National HIV Behavioral Surveillance (NHBS) program (2005-2015) and 6 surveys of Needle Exchange clients (2004-2015). RESULTS: The proportion of PWID reporting an HIV test in the previous 12 months declined from 64% in 2005% to 47% in 2015 in the NHBS surveys and from 72% to 58% in the Needle Exchange surveys. These declines persisted in multivariate analyses controlling for differences in the study populations in age, race, sex, area of residence, education, current homelessness, drug most frequently injected, daily injection frequency, and combined male-to-male sex and amphetamine injection status. The proportion of NHBS participants reporting not knowing the HIV status of their last injection partner increased from 38% to 45%. The proportion not knowing the HIV status of their last sex partner increased from 27% to 38%. CONCLUSIONS: A decrease in HIV testing was found in 2 independent Seattle-area study populations. This was complemented by increases in the proportions not knowing the HIV status of their last sex and last injection partners. Research is needed to ascertain if such declines are observed elsewhere, the reasons for the decline, and appropriate means to effectively attain optimal HIV testing frequency among PWID.