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OBJECTIVE: The authors aimed to examine how certified community behavioral health clinics (CCBHCs) fulfill crisis service requirements and whether clinics added crisis services after becoming a CCBHC. METHODS: National survey data on CCBHC crisis services were paired with data on clinic features and the demographic and socioeconomic characteristics of the counties within a CCBHC service area. The dependent variables were whether CCBHCs provided the three categories of CCBHC crisis services (i.e., crisis call lines, mobile crisis response, and crisis stabilization) directly or through another organization and whether these services were added after becoming a CCBHC. Descriptive statistics and multivariable logistic regression analyses were performed with data about clinics and the counties they served. In total, 449 CCBHCs were surveyed in the summer of 2022, with a response rate of 56%. The final sample comprised 247 clinics. RESULTS: The number of CCBHC employees per 1,000 people within a CCBHC service area was significantly and positively associated with clinics providing some crisis services directly (mobile crisis response: adjusted OR [AOR]=1.46, 95% CI=1.08-1.98; crisis stabilization services: AOR=1.60, 95% CI=1.17-2.19). Compared with clinics that did not receive a CCBHC Medicaid bundled payment, clinics that received this payment had higher odds of adding mobile crisis response (AOR=2.52, 95% CI=1.28-4.97) and crisis stabilization services (AOR=3.19, 95% CI=1.51-6.72) after becoming a CCBHC. CONCLUSIONS: CCBHC initiatives, particularly CCBHC Medicaid bundled payments, may provide opportunities to increase the availability of behavioral health crisis services, but the sufficiency of this increase for meeting crisis care needs remains unknown.
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BACKGROUND: Prosecutorial discretion to pursue or decline criminal charges is a powerful mechanism determining criminal justice outcomes among people who use drugs (PWUD). In the US, prosecutors are increasingly employing this tool to prevent arrest, incarceration, and subsequent health and social harms among PWUD. Many cite harm reduction as a basis for these reforms; however, the extent of prosecutors' knowledge and understanding of harm reduction principles, and how they are operationalized in the policy process, remains unclear. METHODS: We assess references to and application of harm reduction in the policy design and implementation process of prosecutorial drug policy reform in 14 US jurisdictions. In-depth-interviews (N = 16) were conducted with elected prosecutors and their policy staff from November 2021-April 2022. Through initial structured analysis, policymakers' understanding and utilization of the term 'harm reduction' emerged as a salient theme which we conducted secondary thematic analysis to further explore. RESULTS: While all participants identified as progressive, there was wide variation in their ideologies, policy provisions, and engagement with harm reduction principles. Eleven participants explicitly referred to 'reducing harms of drug use' or 'harm reduction' as guiding their policy approach; the remainder did not invoke 'harm reduction' by name but highlighted relevant concepts like racial equity and 'public health approaches' as core policy tenets. While some prosecutors demonstrated familiarity with traditional harm reduction principles (meeting PWUD where they are, reducing harms to them), others focused on harm to the wider community (the 'public,' businesses, etc). Invocation of harm reduction was not always consistent with specific policy provisions: prosecutors implemented policies ranging from unconditional non-prosecution of drug possession to diversion, some of which were odds with core harm reduction principles of dignity and justice (i.e., involving coercive treatment incentives/requirements). CONCLUSIONS: As prosecutors shift their approach to redress the harms caused by drug criminalization, clarity is needed on what a harm reduction approach to using discretionary powers entails. Targeting reform-minded prosecutors with messaging on the principles, evidence base, and best practices of harm reduction is merited.
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OBJECTIVE: People who use opioids are vulnerable to sleep disturbances due to a range of factors, including the substances they use and the various structural vulnerabilities they face. We aimed to understand the burden of sleep-related impairment and problems pertaining to sleep context and schedule among people who use opioids. METHODS: We explored sleep quality and problems among a suburban sample of people who use opioids experiencing extensive structural vulnerabilities (N = 170). Participants reported their most urgent concern in the past week (e.g., sleep, drug use, housing), their sleep context, sleep problems, sleep schedules, and scores on the PROMIS Sleep-Related Impairment measure. We then quantified associations between Sleep-Related Impairment scores and sociodemographics and substance use. RESULTS: Participants were primarily men (66%) and non-Hispanic Black (67%) with a mean age of 42 (SD: 12.1). Many experienced hunger (44%) and literal homelessness (40%). One-quarter (28%) reported that sleep was their most urgent concern in the past week. The most common problems when falling or staying asleep were mental health-related symptoms (81%) and pain/discomfort (32%). Literal homelessness (ß = 2.2, 95% CI: 0.6, 3.7), hunger (ß = 2.3, 95% CI: 1.0, 3.6), and frequent alcohol use (ß = 1.5, 95% CI: 0.2, 2.7) were significantly associated with Sleep-Related Impairment scores. CONCLUSIONS: Homelessness and hunger are associated with sleep-related impairment in people who use opioids. Poor sleep quality, substance use, structural vulnerability, and mental health problems are all interrelated sources of functional impairment in this population. Interventions that address poverty as an underlying cause of sleep-related impairment and provide safe sleeping environments are needed.
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OBJECTIVE: Following changes to drug criminalization policies, we re-examine the epidemiology of drug arrests among people who use drugs (PWUD) in the U.S. METHODS: Serial cross-sectional data from the National Survey on Drug Use and Health (2015-2019) were utilized. Past-year illicit drug use (excluding cannabis) and drug arrests were described by year, area of residence, drug use characteristics and participant demographics. Adjusted associations between race and drug arrest were estimated using multivariable logistic regression. RESULTS: Past-year illicit drug use remained consistent over time and was highest among non-Hispanic (NH) white respondents. Of those reporting past-year illicit drug use (n = 25,429), prevalence of drug arrests remained stable over time overall and in metro areas while increasing in non-metro areas. Arrests were elevated among NH Black participants and those with lower income, unemployment, housing transience, non-metro area residence, polysubstance use, history of drug injection, substance use dependence and past-year drug selling. Adjusted odds of drug arrest remained significantly higher among NH Black individuals [aOR 1.92, 95% CI 1.30, 2.84]. CONCLUSION: Despite recent shifts away from punitive drug policies, we detected no reduction in drug arrests nationally and increasing prevalence in non-metro areas. Despite reporting the lowest level of illicit substance use and drug selling, NH Black individuals had significantly increased odds of arrest across years. Findings highlight the need for further examination of policy implementation and policing practices in different settings, with more research focused non-metro areas, to address enduring structural racism in drug enforcement and its consequences for health.
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Trastornos Relacionados con Sustancias , Humanos , Estados Unidos/epidemiología , Masculino , Femenino , Estudios Transversales , Adulto , Trastornos Relacionados con Sustancias/epidemiología , Persona de Mediana Edad , Prevalencia , Drogas Ilícitas , Adolescente , Adulto Joven , Encuestas Epidemiológicas , Aplicación de la Ley , Consumidores de Drogas/estadística & datos numéricosRESUMEN
BACKGROUND: Health and human rights organizations have endorsed drug decriminalization to promote public health-oriented approaches to substance use. In the US, policymakers have begun to pursue this via prosecutorial discretion-or the decision by a prosecutor to decline criminal charges for drug possession in their jurisdiction. This study characterizes drivers of adoption, policy design and implementation processes, and barriers to impact and sustainability of this approach to inform evolving policy efforts promoting the health of people who use drugs (PWUD). METHODS: We conducted n=22 key informant interviews with policymakers and national policy experts representing 13 jurisdictions implementing de facto drug policy reforms. Analyses were informed by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and analyzed using a hybrid inductive-deductive approach. RESULTS: Drivers of policy adoption included racial inequities, perceived failures of criminalization, and desires to prioritize violent crime given resource constraints. Three distinct policy typologies are described with varying conditions for eligibility, linkage to services, and policy transparency and dissemination. Public misinformation, police resistance and political opposition were seen as threats to sustainability. CONCLUSIONS: Given evidence that criminalization amplifies drug-related harms, many policymakers are adopting de facto drug policy reforms in the absence of formal legislation. This is the first study to systematically describe relevant implementation processes and emerging policy models. Findings have implications for designing rigorous evaluations on health outcomes and informing sustainable evidence-based policies to promote health and racial equity of PWUD in the US.
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Trastornos Relacionados con Sustancias , Humanos , Estados Unidos , Política de Salud , Política Pública , Formulación de PolíticasRESUMEN
BACKGROUND: The legal enforcement of drug possession is associated with a host of negative consequences for people who use drugs (PWUD), has demonstrated little effectiveness at curbing drug use, and has contributed to lasting financial, social, and health-related racial disparities in Black and Brown communities in the United States (U.S.). One policy alternative is reinvesting resources typically used for enforcing drug possession into health-promoting services such as drug treatment or harm reduction that can better serve the needs of PWUD than the criminal legal system. We sought to characterize the prevalence and correlates of national public support for this reinvestment in the U.S. METHODS: A nationally representative sample of U.S. adults (N = 1,212) completed the Johns Hopkins COVID-19 Civic Life and Public Health Survey (wave three, fielded November 11-30, 2020). The outcome is support for reinvestment of resources spent on enforcing drug possession into health-promoting alternatives (i.e., drug treatment, harm reduction, housing support, or community-based resources). We measured potential correlates including socio-demographics and social/political attitudes, including political ideology (conservative, moderate, liberal) and racial resentment toward the Black community. Analyses accounted for complex survey weights. RESULTS: Weighted prevalence of support for reinvestment of resources was 80 %. Multivariable logistic regression (controlling for confounders) showed that white respondents were more likely than Black (OR = 2.51, 95% CI = 1.08, 5.87) to favor reinvestment. Respondents with moderate (OR = 0.34, 95 % CI = 0.15-0.79) or conservative (OR = 0.21, 95 % CI = 0.09-0.50) political ideology (compared to liberal) and medium (OR = 0.26, 95 % CI = 0.09-0.74) or high (OR = 0.12, 95 % CI = 0.04-0.35) levels of racial resentment (compared to low) were less likely to support reinvestment. CONCLUSION: There is substantial national support for reinvesting resources into health-promoting alternatives, though political ideology and racial resentment temper support. Results can inform targeted messaging to increase support for moving drug policy from the criminal legal sphere toward public health.
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Reducción del Daño , Humanos , Adulto , Masculino , Femenino , Estados Unidos , Persona de Mediana Edad , Trastornos Relacionados con Sustancias , Opinión Pública , Promoción de la Salud , Adulto Joven , COVID-19 , Aplicación de la Ley , Adolescente , Consumidores de Drogas/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
INTRODUCTION: Allostatic load (AL) is a significant marker of aging, associated with disease and mortality. Research has elucidated the impact of education and income on AL. However, the roles of wealth and discrimination in contributing to AL and shaping AL disparities remain underexplored. This study aimed to investigate the association between wealth and AL, while also examining the independent contributions of education, income, wealth, and everyday discrimination in shaping AL disparities. METHODS: Using 2016 data from the nationally representative Health and Retirement Study (N=3,866), this study employed multilinear regression analysis to quantify the association between education and income, wealth (calculated as assets minus debts), and everyday discrimination with AL. Oaxaca-Blinder decomposition analysis was conducted to determine the proportion of AL disparities between Black and White participants attributed to education and income, wealth, and everyday discrimination. Analyses were performed in 2023. RESULTS: Having a college degree or more (b = -0.32; 95% CI: -0.46, -0.17), higher income (b = -0.06; 95% CI: -0.11, -0.01), and greater wealth (b = -0.11; 95% CI: -0.16, -0.07) were linked to reduced AL. Conversely, increased experiences of everyday discrimination were associated with heightened AL (b = 0.07; 95% CI: 0.01, 0.16). Collectively, differences in possessing a college degree or more, wealth, and exposure to discrimination accounted for about 18% of the observed Black-White AL disparities. CONCLUSIONS: Education, income, wealth, and experiences of discrimination may independently contribute to AL and partially explain Black-White disparities in AL. There is a need to elucidate the underlying mechanisms governing these relationships, particularly wealth, and extend the research to additional social determinants of racial health disparities.
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Alostasis , Negro o Afroamericano , Escolaridad , Disparidades en el Estado de Salud , Renta , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Alostasis/fisiología , Negro o Afroamericano/estadística & datos numéricos , Renta/estadística & datos numéricos , Racismo/estadística & datos numéricos , Factores Socioeconómicos , Estados Unidos , Blanco/estadística & datos numéricosRESUMEN
BACKGROUND: Upon reintegration into society, formerly incarcerated individuals (FIIs) experience chronic financial stress due to prolonged unemployment, strained social relationships, and financial obligations. This study examined whether marriage and perceived social status can mitigate financial stress, which is deleterious to the well-being of FIIs. We also assessed whether sociodemographic factors influenced financial stress across marital status. We used cross-sectional data from 588 FIIs, collected in the 2023 Survey of Racism and Public Health. The financial stress outcome (Cronbach's [Formula: see text] = 0.86) comprised of five constructs: psychological distress, financial anxiety, job insecurity, life satisfaction, and financial well-being. Independent variables included marital and social status, age, race/ethnicity, gender identity, educational attainment, employment status, and number of dependents. Multivariable models tested whether financial stress levels differed by marital and perceived social status (individual and interaction effects). Stratified multivariable models assessed whether social status and sociodemographic associations varied by marital status. RESULTS: We found that being married/living with a partner (M/LWP, b = -5.2) or having higher social status (b = -2.4) were protective against financial stress. Additionally, the social status effect was more protective among divorced, separated, or widowed participants (b = -2.5) compared to never married (NM, b = -2.2) and M/LWP (b = -1.7) participants. Lower financial stress correlated with Black race and older age, with the age effect being more pronounced among M/LWP participants (b = -9.7) compared to NM participants (b = -7.3). Higher financial stress was associated with woman gender identity (overall sample b = 2.9, NM sample b = 5.1), higher education (M/LWP sample b = 4.4), and having two or more dependents (overall sample b = 2.3, M/LWP sample b = 3.4). CONCLUSIONS: We provide novel insights into the interrelationship between marriage, perceived social status, and financial stress among FIIs. Our findings indicate the need for policies and programs which may target the family unit, and not only the individual, to help alleviate the financial burden of FIIs. Finally, programs that offer legal aid to assist in expungement or sealing of criminal records or those offering opportunities for community volunteer work in exchange for vouchers specific to legal debt among FIIs could serve to reduce financial stress and improve social standing.
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BACKGROUND: Co-use of benzodiazepines and opioids significantly increases fatal overdose risk, yet few studies have examined co-use of these drugs when obtained both with and without a prescription. We examined associations of daily co-use of prescribed benzodiazepines/tranquilizers (BZD/TRQ) and prescribed and nonprescribed opioids among people who use street opioids (PWUO). METHODS: PWUO (N = 417) were recruited from Baltimore City and neighboring Anne Arundel County, Maryland, and surveyed on sociodemographic characteristics, structural vulnerabilities, healthcare access and utilization, substance use, and overdose experiences. Multivariable logistic regression was used to identify factors associated with self-reported co-use. RESULTS: Participants were 46 years old on average, and predominantly Black (74%) males (62%). Daily co-use was reported by 22%. In multivariable analyses, odds of co-use were significantly higher among participants who did not have a high school degree/GED (adjusted odds ratio [aOR]: 1.71, 95% confidence interval [CI]: 1.02-2.88), endorsed receiving mental health treatment in the past 6 months (aOR: 2.13, 95% CI: 1.28-3.56), reported daily use of powdered cocaine (aOR: 3.57, 95% CI: 1.98-6.45), and synthetic cannabinoids (aOR: 3.11, 95% CI: 1.40-6.93). Odds of co-use were significantly lower among Black participants compared to white participants (aOR: 0.39, 95% CI: 0.19-0.82). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Clinicians working with PWUO or who prescribe BZDs or opioids should screen patients who use cocaine or synthetic cannabinoids, have low level of educational attainment, or recently accessed mental health services, as these patients may be at higher risk for daily co-use of BZD/TRQ and opioids, and therefore lethal overdose.
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Cannabinoides , Cocaína , Sobredosis de Droga , Trastornos Relacionados con Sustancias , Masculino , Humanos , Persona de Mediana Edad , Femenino , Analgésicos Opioides/uso terapéutico , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Sobredosis de Droga/tratamiento farmacológico , Benzodiazepinas/efectos adversosRESUMEN
The continued prevalence of xylazine in the illicit drug market has necessitated development of quick and simple methods for identification, including lateral flow immunoassays (also known as "test strips"), like those frequently used to detect fentanyl. This study explored the drug checking applicability of the first publicly available xylazine test strips (XTS) using four sub-studies: reproducibility (i.e., consistency of positive results in a highly-concentrated xylazine solution); limit of detection on a calibration curve of xylazine concentrations; cross-reactivity against 77 commonly encountered drugs, cutting agents, and other structurally similar compounds; and applicability for analyzing community-acquired samples-where 100 drug residue samples were analyzed using XTS, direct analysis in real time mass spectrometry (DART-MS), and gas chromatography tandem mass spectrometry (GC-MS/MS). XTS consistently detected xylazine at concentrations ≥2.5 µg/ml, and XTS results were reproducible. Sensitivity and specificity of XTS were calculated by comparing expected versus obtained results based on xylazine concentration of community-acquired samples measured by GC-MS/MS. XTS consistently detected xylazine in samples with concentration >2 µg/ml and yielded a sensitivity of 0.974, specificity of 1.00, and overall accuracy of 0.986. Cross-reactivity with lidocaine, a common cutting agent, and lack of XTS reactivity with other α2 -agonists found in the illicit drug supply highlight the need to offer consumers comprehensive drug checking services that identify a range of substances and better inform them about drug contents.
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Overdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland's Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state's response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p = .04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States.
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INTRODUCTION: Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD) via non-injection routes of administration in suburban areas are lacking. METHODS: We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs' likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS. FINDINGS: Participants' median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS. CONCLUSION: Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts.
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Sobredosis de Droga , Masculino , Humanos , Femenino , Adulto , Estudios Transversales , Sobredosis de Droga/prevención & control , Fentanilo , Heroína , Aplicación de la LeyRESUMEN
Background: : Opioid overdose death rates increased during the COVID-19 pandemic. Disruptions in community-based naloxone trainings could have reduced the likelihood of overdose reversal and increased the chances of a fatal overdose. We investigated changes in the number of people trained in naloxone administration and distribution in Maryland before, during, and after COVID-related stay-at-home orders. Methods: : Data on naloxone training are from the Maryland Department of Health. We used interrupted time series models to estimate changes in average monthly number of people trained: [1] pre-interruption (4/2019-3/2020), [2] 1-month post-interruption (4/2020-5/2020), and [3] 12-months post-interruption (4/2020-3/2021). Trainees were classified as lay (e.g., people who use drugs) or occupational (e.g., law enforcement officers and harm reduction workers) responders. Results: : There were 101,332 trainees; 54.1% lay, 21.5% occupational, and 23.4% unknown responder status. We observed a decrease in the average monthly number of trainees in the pre-interruption period (-235, p<0.001), a larger decrease of 93.2% during the 1-month post-interruption (-846, p=0.013), and an increase 12-months post-interruption (+217, p<0.001). There was a significant decrease among occupational responders 1-month post-interruption, and a significant increase among lay responders in the 12-month post-interruption period. Conclusions: : Findings suggest a marked decrease in naloxone trainees immediately after stay-at-home order, followed by a moderate rebound in the 12-months after stay-at-home order. The decrease in occupational responders trained may have limited access to naloxone, but would likely have been offset by increases in number of lay responders trained. Strengthening lay and occupational responder connections could maintain naloxone distribution during public health crises.
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BACKGROUND: Drug overdose deaths continue to rise, and considerable racial inequities have emerged. Overdose Good Samaritan laws (GSLs) are intended to encourage overdose witnesses to seek emergency assistance. However, evidence of their effectiveness is mixed, and little is known regarding racial disparities in their implementation. This study examined GSL impact by assessing racial differences in awareness of and trust in New York state's GSL. METHODS: Using a sequential mixed methods design, Black and white participants were recruited from an existing longitudinal cohort study of people who use illicit opioids in New York City to participate in a quantitative survey and qualitative interviews. Racially stratified survey responses were analyzed using chi-squared tests, Fisher exact tests, or t-tests. Qualitative interviews were analyzed using a hybrid inductive-deductive approach. RESULTS: Participants (n=128) were 56% male and predominantly aged 50 years or older. Most met criteria for severe opioid use disorder (81%). Fifty-seven percent reported that the New York GSL makes them more likely to call 911 even though 42% reported not trusting law enforcement to abide by the GSL; neither differed by race. Black people were less likely to have heard of the GSL (36.1% vs 60%) and were less likely to have accurate information regarding its protections (40.4% vs 49.6%). CONCLUSIONS: Though GSLs may reduce negative impacts of the criminalization of people who use drugs, their implementation may exacerbate existing racial disparities. Resources should be directed towards harm reduction strategies that do not rely on trust in law enforcement.
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Sobredosis de Droga , Humanos , Masculino , Femenino , Proyectos Piloto , Estudios Longitudinales , Sobredosis de Droga/tratamiento farmacológico , Analgésicos Opioides/uso terapéutico , Ciudad de Nueva YorkRESUMEN
INTRODUCTION: To mitigate the harms of arrest and incarceration on health and racial equity, jurisdictions are increasingly enacting reforms to decriminalize drug possession through prosecutorial discretion (de facto). Impacts on health outcomes rely on whether this policy can reduce exposure to the carceral system among people who use drugs; however, data evaluating effects on arrest are lacking. This study explores the possible impacts of Baltimore City's enactment of de facto decriminalization on arrests by race. METHODS: Police and court records were used to explore the possible impacts of Baltimore City's de facto decriminalization on street arrests and (processed) arrests advancing through the courts among people who use drugs. Interrupted time series models were used to compare pre-policy (January 2018-March 2020) trends with post-policy (April 2020-December 2021) trends in arrests for possession of drugs/paraphernalia and estimate racial disparities in street arrests (Black versus other races). Analyses were performed in February-May 2022. RESULTS: The policy was associated with a significant and immediate decline in street and processed arrests for possession, which was not seen for other crime categories. Although declines were concentrated in the Black community, disparities in arresting persisted after the policy. CONCLUSIONS: De facto decriminalization may be a promising strategy to reduce exposure to the carceral system, an established risk factor for overdose and other drug-related sequelae and a driver of racial disparities in the U.S. Further research is needed to elucidate the drivers of persisting racial disparities and disentangle policy effects from pandemic-related closures.
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Drogas Ilícitas , Aplicación de la Ley , Racismo Sistemático , Humanos , Baltimore , Crimen , Policia , Negro o AfroamericanoRESUMEN
INTRODUCTION: Treatment for opioid use disorder (OUD) with diacetylmorphine is an evidence-based form of drug treatment, but it is not available in the United States (US). Better understanding acceptability of treatment with injectable diacetylmorphine among people who use opioids (PWUO) in the US may expedite future initiatives designed to engage persons in this form of treatment should it become available. The purpose of this research is to examine factors associated with interest in treatment with injectable diacetylmorphine among a sample of PWUO in the US. METHODS: Data are from a cross-sectional study of PWUO in Baltimore City, Maryland. Participants were given a brief description of treatment with injectable diacetylmorphine and then asked to rate their level of interest. We used Poisson regression with robust variance to assess factors associated with interest in treatment with injectable diacetylmorphine. RESULTS: The average age of participants was 48 years, 41% were women, and most (76%) identified as non-Hispanic, Black. The most commonly used substances were non-injection heroin (76%), opioid pain relievers (73%), and non-injection crack/cocaine (73%). Two-thirds of participants (68%) indicated interest in treatment with injectable diacetylmorphine. Factors significantly associated with interest in injectable diacetylmorphine treatment included: having at least a high school education (adjusted prevalence ratio [aPR]: 1.23; 95% confidence interval [CI]: 1.04-1.45), not having health insurance (aPR: 1.23; 95% CI: 1.06-1.44), having ever overdosed (aPR: 1.20; 95% CI: 1.01-1.42), and past utilization of medications for opioid use disorder (aPR: 1.22; 95% CI: 1.01-1.47). Recent non-injection cocaine use was inversely associated with interest in treatment with injectable diacetylmorphine (aPR 0.80; 95% CI: 0.68-0.94). CONCLUSION: The majority of participants reported interest in treatment with injectable diacetylmorphine. Given worsening trends in the addiction and overdose crisis in the US, treatment with injectable diacetylmorphine should be considered as another evidence-based option for treating OUD.KEY MESSAGESInterest in treatment with injectable diacetylmorphine was high among a sample of people who use opioids in the United States.Factors associated with increased interest in treatment with injectable diacetylmorphine included having at least a high school education, having ever overdosed, and not having health insurance.Past utilization of medications for opioid use disorder was associated with interest in treatment with injectable diacetylmorphine.
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Cocaína , Sobredosis de Droga , Trastornos Relacionados con Opioides , Femenino , Humanos , Estados Unidos/epidemiología , Persona de Mediana Edad , Masculino , Analgésicos Opioides/uso terapéutico , Heroína/efectos adversos , Baltimore/epidemiología , Estudios Transversales , Trastornos Relacionados con Opioides/tratamiento farmacológico , Trastornos Relacionados con Opioides/epidemiología , Sobredosis de Droga/tratamiento farmacológico , Cocaína/uso terapéuticoRESUMEN
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.
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COVID-19 , Consumidores de Drogas , Infecciones por VIH , Abuso de Sustancias por Vía Intravenosa , Humanos , Compartición de Agujas , Abuso de Sustancias por Vía Intravenosa/epidemiología , Pandemias , Infecciones por VIH/epidemiología , Asunción de RiesgosRESUMEN
The US overdose crisis continues to worsen and is disproportionately harming Black and Hispanic/Latino people. Although the "War on Drugs" continues to shape drug policy-at the disproportionate expense of Black and Hispanic/Latino people-states have taken some steps to reduce War on Drugs-related harms and adopt a public health-centered approach. However, the rhetoric regarding these changes has, in many cases, outstripped reality. Using overdose Good Samaritan Laws (GSLs) as a case study, we argue that public health-oriented policy changes made in some states are undercut by the broader enduring environment of a structurally racist drug criminalization agenda that continues to permeate and constrict most attempts at change. Drawing from our collective experiences in public health research and practice, we describe 3 key barriers to GSL effectiveness: the narrow parameters within which they apply, the fact that they are subject to police discretion, and the passage of competing laws that further criminalize people who use illicit drugs. All reveal a persisting climate of drug criminalization that may reduce policy effectiveness and explain why current reforms may be destined for failure and further disadvantage Black and Hispanic/Latino people who use drugs. (Am J Public Health. 2023;113(S1):S43-S48. https://doi.org/10.2105/AJPH.2022.307037).
Asunto(s)
Sobredosis de Droga , Drogas Ilícitas , Humanos , Racismo Sistemático , Sobredosis de Droga/prevención & control , Sobredosis de Droga/tratamiento farmacológico , Policia , Política PúblicaRESUMEN
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, MD, 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: WWID appear to engage frequently in SDU 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.