Evaluation of Two Videos that Apply Evidence-Based Strategies to Increase Self-Efficacy and Reduce Opioid-Related Stigma Among Medical Students.

OBJECTIVE: This study evaluated the video-based application of evidence-based stigma reduction strategies to increase medical students' screening-diagnostic self-efficacy for opioid use disorder (OUD) and reduce stigma toward opioid use. METHODS: Formative qualitative research informed development of two videos for medical students. One uses an education strategy by including education regarding non-stigmatizing language use and OUD screening and diagnosis (Video A); the other uses an interpersonal contact strategy by presenting narratives regarding opioid use from three people who have a history of opioid use and three physicians (Video B). Both videos were administered to all respondents, with video order randomized. Effects on outcomes were evaluated using a pre-/post-test design with a 1-month follow-up. Participants also provided feedback on video content and design. RESULTS: Medical students (N = 103) watched the videos and completed the pre-/post-test, with 99% (N = 102) completing follow-up 1 month after viewing both videos. Self-efficacy increased directly following viewing Video A, and this increase was sustained at 1-month follow-up. Stigma toward opioid use decreased directly following viewing Video B, and this decrease was sustained at 1-month follow-up for participants who watched Video B first. Statistically significant improvements were observed in most secondary outcomes (e.g., harm reduction acceptability) directly following watching each video and most were sustained at 1-month follow-up. Feedback about the videos suggested the delivery of evidence-based strategies in each video was appropriate. CONCLUSIONS: Video-based applications of these evidence-based strategies were found acceptable by medical students and have potential to elicit sustained improvement in their screening-diagnostic self-efficacy and opioid-related stigma.

Experiences Administering Naloxone Among People in Different Social Roles: People Who Use Opioids and Family Members and Friends.

Unintentional drug overdose deaths continue to be a critical public health issue. Naloxone, a nonscheduled, safe, and effective drug that reverses opioid-involved overdoses is available to non-medically trained individuals ("lay people"), but there is scant information about how people in different social roles experience naloxone administration. We conducted 24 in-depth interviews with people who use opioids (PWUO; n = 15) and family members and friends of people who use opioids (FF; n = 9) who had administered naloxone in response to an opioid overdose. Compared with PWUO, members of the FF group were less reticent to administer naloxone in response to an overdose. PWUO and FF had different perspectives of law enforcement and demonstrated varied knowledge of the Good Samaritan Law. While PWUO found that having and administering naloxone was empowering, FF took a more pragmatic approach, reporting the need for naloxone as an unfortunate reality of their loved one's drug use.

The Nation's First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City.

In November of 2021, multiple factors converged to create a window of opportunity to open overdose prevention centers (OPCs) at two existing syringe service programs (SSPs) in New York City (NYC). Political will exists in NYC, particularly toward the end of the de Blasio administration's term, and the NYC Health Department worked to garner additional support from local and state elected officials given the dire need to address the overdose crisis. This coincided with readiness on the part of one of the NYC SSP providers, OnPoint NYC, to open and operate OPC services. Legal risks were assessed by both the city and the provider. This case study outlines the sequence of events that resulted in NYC supporting OnPoint to open the first two publicly recognized OPCs in the nation, including lessons learned to inform other jurisdictions considering offering such services.

A mixed-methods analysis of risk-reduction strategies adopted by syringe services program participants and non-syringe services program participants in New York City.

BACKGROUND: Since the emergence of fentanyl in the drug market, syringe services programs (SSPs) have been at the forefront of providing life-saving tools such as naloxone and fentanyl test strips to people who use drugs (PWUD). It is still unclear, however, how the adoption of risk-reduction practices has differed among PWUD in the context of increasing presence of non-pharmaceutical fentanyl in the drug supply. This study aims to assess the adoption of risk-reduction tools (e.g., naloxone) among those engaged with SSP services and those not engaged with SSP services. METHODS: We conducted a mixed-methods study following a convergent parallel design integrating both quantitative and qualitative data. Interviews were conducted with 80 people who used street opioids (i.e., heroin or opioid pills not prescribed), 32 of whom were not engaged in SSP services. Quantitative differences between those engaged and those not engaged in SSPs were assessed using independent samples t tests and Fisher's exact tests. A thematic analytic approach was employed to compare qualitative responses between the two groups. RESULTS: Three main themes emerged in our analysis: (1) Both groups expressed an interest in fentanyl test strips (FTS), but those engaged in SSP services found them to be more accessible; (2) there was greater adoption of and enthusiasm for naloxone among SSP participants; and (3) SSP participants were more likely to have or be interested in having someone check in on them when using alone, but stigma and perceived personal risk of overdose prevented widespread adoption of this practice among all participants. CONCLUSION: SSPs provide a vital function by facilitating naloxone and FTS distribution to participants who often have little control over their exposure to fentanyl. However, stigma and misconceptions regarding drug use are barriers to people adopting risk-reduction practices, particularly among those not engaged with SSPs.

Understanding Vaccine Perceptions and Willingness to Receive COVID-19 Vaccination: Opportunities to Strengthen Public Health Responses and COVID-19 Services for People Who Use Drugs.

Background: People who use drugs (PWUD) are at high risk for COVID-19 infection, morbidity, and mortality. COVID-19 vaccines are safe and effective at reducing serious illness and death from COVID-19. There are sparse data on the perceptions and willingness of PWUD to receive COVID-19 vaccination. Materials and Methods: In order to assess the perceptions of, and willingness to receive, COVID-19 vaccination among PWUD, we conducted a rapid survey-based assessment of 100 PWUD in NYC (Spring 2021) who reported not having received COVID-19 vaccination and who reported past 30-day illicit drug use. Results: More than 80% of respondents agreed that personally receiving a COVID-19 vaccine was important for the health of others in the community, and endorsing this belief was significantly associated with COVID-19 vaccine willingness reflecting a high prevalence of altruistic beliefs (p-value: 0.01). Other reported perceptions that were significantly associated with COVID-19 vaccine willingness were believing that COVID-19 vaccines are safe for PWUD and trusting COVID-19 information from their healthcare providers (p-values < 0.05). That said, 62% reported being unwilling to receive a COVID-19 vaccine, and 70−83% had concerns about general vaccine safety/efficacy. Examining pairs of questions to explore potential ambivalence between vaccine endorsement and vaccine concerns identified that 56−65% simultaneously reported vaccine safety/efficacy concerns and beliefs that vaccination was an important intervention. Of the 75 respondents who reported past 30-day use of harm reduction and/or substance use disorder (SUD) programs, nearly 90% reported these programs as trusted sources of COVID-19 information. Conclusion: Most participants reported altruistic beliefs about the role of vaccines for community health, including COVID-19 vaccines, and this altruism was associated with willingness to be vaccinated against COVID-19. These findings suggest a complex relationship between beliefs about the role of vaccination in community health and the safety/efficacy of vaccines; this ambivalence suggests that COVID-19 vaccine willingness may not be firmly fixed, indicating potential opportunities to address questions and build vaccine confidence. Harm reduction and SUD programs could be leveraged to further engage PWUD in receipt of COVID-19 information and/or vaccination. Recognizing vaccine ambivalence, emphasizing collective and individual benefits of vaccination, and messaging from trusted sources may be promising approaches to increase vaccination in this population.

Implementation of buprenorphine services in NYC syringe services programs: a qualitative process evaluation.

BACKGROUND: Syringe services programs (SSPs) hold promise for providing buprenorphine treatment access to people with opioid use disorder (OUD) who are reluctant to seek care elsewhere. In 2017, the New York City Department of Health and Mental Hygiene (DOHMH) provided funding and technical assistance to nine SSPs to develop "low-threshold" buprenorphine services as part of a multipronged initiative to lower opioid-related overdose rates. The aim of this study was to identify barriers to and facilitators of implementing SSP-based buprenorphine services. METHODS: We conducted 26 semi-structured qualitative interviews from April 2019 to November 2019 at eight SSPs in NYC that received funding and technical assistance from DOHMH. Interviews were conducted with three categories of staff: leadership (i.e., buprenorphine program management or leadership, eight interviews), staff (i.e., buprenorphine coordinators or other staff, eleven interviews), and buprenorphine providers (six interviews). We identified themes related to barriers and facilitators to program implementation using thematic analysis. We make recommendations for implementation based on our findings. RESULTS: Programs differed in their stage of development, location of services provided, and provider type, availability, and practices. Barriers to providing buprenorphine services at SSPs included gaps in staff knowledge and comfort communicating with participants about buprenorphine, difficulty hiring buprenorphine providers, managing tension between harm reduction and traditional OUD treatment philosophies, and financial constraints. Challenges also arose from serving a population with unmet psychosocial needs. Implementation facilitators included technical assistance from DOHMH, designated buprenorphine coordinators, offering other supportive services to participants, and telehealth to bridge gaps in provider availability. Key recommendations include: (1) health departments should provide support for SSPs in training staff, building health service infrastructure and developing policies and procedures, (2) SSPs should designate a buprenorphine coordinator and ensure regular training on buprenorphine for frontline staff, and (3) buprenorphine providers should be selected or supported to use a harm reduction approach to buprenorphine treatment. CONCLUSIONS: Despite encountering challenges, SSPs implemented buprenorphine services outside of conventional OUD treatment settings. Our findings have implications for health departments, SSPs, and other community organizations implementing buprenorphine services. Expansion of low-threshold buprenorphine services is a promising strategy to address the opioid overdose epidemic.

Fentanyl preference among people who use opioids in New York City.

BACKGROUND: Several studies have pointed to a sub-sample of people who use drugs (PWUD) who prefer the use of non-pharmaceutical fentanyl (NPF) and, as such, pose a unique challenge for public health initiatives amidst the continued rise in overdose mortality. However, matters of drug preference and autonomy of choice remain under-studied and often misunderstood. This paper examined the experiences of PWUD reporting a preference for NPF or an NPF-heroin mixture, specifically how they navigate the perceived benefits of NPF and its established risks. METHODS: 22 in-depth interviews were conducted in New York City between March 2018 and August 2019 with PWUD who self-reported a preference for NPF or an NPF-heroin mix. Interviews were audio-recorded, and the resulting transcripts analyzed using a thematic approach. RESULTS: Participants highlighted various factors that contributed to expressed preference for NPF or an NPF-heroin mix, including a desire to feel good, financial resources, drug availability, decreased consumer autonomy, and physiological demand. Participants reported practicing several risk reduction strategies; however, they highlighted that many, particularly carrying naloxone and always using with someone else, were difficult to implement in the context of illicit drug use. CONCLUSIONS: Our results demonstrate participants' decreased consumer agency and greater exposure to systemic factors in the illicit markets, highlighting the need for expansion of various services, including drug checking resources and systems of outreach for PWUD who do not use intravenously. To promote tailored interventions, continued efforts in overdose prevention ought to more thoughtfully consider the context, perceptions, preferences, and behaviors of PWUD.

Collecting Data During the COVID-19 Pandemic: Lessons From an In-Person Survey of People Who Use Opioids.

OBJECTIVES: In response to the COVID-19 pandemic, much in-person data collection has been suspended or become tele-remote. However, tele-remote methods often exclude marginalized groups, including people who use drugs, many of whom lack the technology to participate. To inform future surveillance and research during the pandemic and other public health disasters, we report methods and lessons learned from an in-person survey of people who use opioids conducted by the New York City Department of Health and Mental Hygiene (DOHMH) during the COVID-19 pandemic. MATERIALS AND METHODS: This public health surveillance was a component of the Centers for Disease Control and Prevention Overdose Data to Action initiative and aimed to inform overdose prevention efforts. Survey domains inquired about participants' drug use patterns, risk behaviors, overdose history, and service use. RESULTS: From June 16 through September 9, 2020, DOHMH staff members conducted 329 surveys with participants from 4 syringe service programs (n = 148, 44.9%) and via street intercept (n = 81, 55.1%). To survey participants safely and effectively, it was important to build rapport upfront so that requests to maintain distance were not perceived as stigmatizing. DOHMH staff members offered all participants, regardless of survey eligibility, Narcan and hygiene products, including face masks and soap. PRACTICE IMPLICATIONS: Surveys administered outdoors during the COVID-19 pandemic should be limited to 30 minutes. Although conducting in-person surveys poses unique challenges, this method should be considered so marginalized populations are included in data collection and public health responses.

"I didn't feel like a number": The impact of nurse care managers on the provision of buprenorphine treatment in primary care settings.

BACKGROUND AND OBJECTIVE: To promote increased access to and retention in buprenorphine treatment for opioid use disorder, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) implemented the Buprenorphine Nurse Care Manager Initiative (BNCMI) in 2016, in which nurse care managers (NCMs) coordinate buprenorphine treatment in safety-net primary care clinics. To explore how patients experienced the care they received from NCMs, DOHMH staff conducted in-person, in-depth interviews with patients who had, or were currently receiving, buprenorphine treatment at BNCMI clinics. Participants were patients who were receiving, or had received, buprenorphine treatment through BNCMI at one of the participating safety-net primary care practices. METHODS: The study team used a thematic analytic and framework analysis approach to capture concepts related to patient experiences of care received from NCMs, and to explore differences between those who were in treatment for at least six consecutive months and those who left treatment within the first six months. RESULTS: Themes common to both groups were that NCMs showed care and concern for patients' overall well-being in a nonjudgmental manner. In addition, NCMs provided critical clinical and logistical support. Among out-of-treatment participants, interactions with the NCM were rarely the catalyst for disengaging with treatment. Moreover, in-treatment participants perceived the NCM as part of a larger clinical team that collectively offered support, and the care provided by NCMs was often a motivating factor for them to remain engaged in treatment. CONCLUSION: Findings suggest that by providing emotional, clinical, and logistical support, as well as intensive engagement (e.g., frequent phone calls), the care that NCMs provide could encourage retention of patients in buprenorphine treatment.

Primary Care Implementation of a Mandatory Prescription Drug Monitoring Program in New York City.

The ways in which prescription drug monitoring programs (PDMPs) have been integrated into clinical practice remain understudied, and research into PDMP implementation in states where PDMP use by providers is mandated remains scant. This qualitative study describes how use of a state-mandated PDMP influenced clinical practice and opioid analgesic prescribing. We conducted face-to-face, in-depth interviews with 53 New York State-licensed primary care physicians who reported that they currently prescribed opioid analgesic medication, including those providers who reported consistent use of the PDMP (n = 38) in this sample. We used a thematic analytic approach to identify patterns of PDMP implementation into practice following enactment of the New York State legislative usage mandate. Among physicians who consistently used the PDMP, we found two distinct groups: (1) physicians who reported no change in their clinical practice and (2) physicians who acknowledged changes to both clinical practice and administrative management. In the latter group, most physicians felt the PDMP had benefited their patient relationships by fostering dialogue around patient substance use; however, some used the PDMP to dismiss patients from care. Findings suggest that increased education for providers relating to judicious prescribing, opioid use disorder, and best practice for PDMP utilization are needed.

Primary care provider perspectives on and utilization of a mandatory prescription drug monitoring program in New York City.

BACKGROUND: The ways in which prescription drug monitoring programs (PDMPs) have been integrated into primary care practice remain understudied, and research into physician utilization of PDMPs in states where PDMP use is mandated remains scant. OBJECTIVES: To characterize primary care physician perspectives on and utilization of a mandatory PDMP in New York City. METHODS: We conducted face-to-face, in-depth interviews with primary care physicians who reported that they currently prescribed opioid analgesic medication. We used a thematic analytic approach to characterize physician perspectives on the PDMP mandate and physician integration of mandatory PDMP use into primary care practice. RESULTS: Primary care providers demonstrated a continuum of PDMP utilization, ranging from consistent use to the specifications of the mandate to inconsistent use to no use. Providers reported a range of perspectives on the purpose and function of the PDMP mandate, as well as a lack of clarity about the mandate and its enforcement. CONCLUSION: Findings suggest a need for increased clinical and public health education about the use of PDMPs as clinical tools to identify and treat patients with potential substance use disorders in primary care.

Implementing a Methadone Delivery System in New York City in Response to COVID-19.

Opioid agonist medication, including methadone, is considered the first-line treatment for opioid use disorder. Methadone, when taken daily, reduces the risk of fatal overdose; however, overdose risk increases following medication cessation. Amid an overdose epidemic accelerated by the proliferation of fentanyl, ensuring continuity of methadone treatment during the COVID-19 pandemic is a vital public health priority. (Am J Public Health. 2021;111(12):2115-2117. https://doi.org/10.2105/AJPH.2021.306523).

Racial disparities in criminal legal system involvement among New York City overdose decedents: Implications for diversion programs.

BACKGROUND: Past studies have identified frequent criminal legal system (CLS) involvement among overdose decedents and highlight the need for connecting individuals at risk of overdose with effective interventions during CLS encounters. While some programs divert individuals at risk of overdose to treatment during CLS encounters, eligibility is frequently restricted to those with limited prior CLS involvement. However, differences by race/ethnicity have not been examined. OBJECTIVE: We assessed racial disparities in CLS involvement and eligibility for diversion following arrest for misdemeanor drug possession among New York City (NYC) overdose decedents. METHODS: We matched death certificates for 5018 NYC residents who died of an unintentional drug overdose between 2008 and 2015 with CLS data and compared CLS involvement by race/ethnicity. We compared prior felony involvement at the first misdemeanor drug arrest by race/ethnicity among 2719 decedents with at least one misdemeanor drug arrest. RESULTS: Higher proportions of Black (86 %, 95 % CI: 83.9, 87.9) and Latino (84 %, 95 % CI: 82.2, 86.0) decedents had ever been arrested than White decedents (73 %, 95 % CI: 71.5, 75.2). At the first misdemeanor drug arrest, Black and Latino decedents were twice as likely as White decedents to have a prior felony conviction, adjusted for age at arrest and gender (RR = 2.08, 95 % CI: 1.71, 2.54 and 2.14, 95 % CI: 1.77, 2.59, respectively). CONCLUSIONS: Given racial disparities in CLS involvement among NYC overdose decedents, diversion eligibility is inequitable by race/ethnicity. Diversion programs that restrict eligibility based on prior CLS involvement will have racially disparate effects.

Reformulation of oxycodone 80 mg to prevent misuse: A cohort study assessing the impact of a supply-side intervention.

BACKGROUND: In August 2010, extended-release OxyContin® products, including oxycodone 80 mg, were reformulated and released as abuse-deterrent medications. This paper describes changes in individual prescription filling patterns that followed the reformulation of oxycodone 80 mg. METHODS: Using New York State prescription monitoring program data, we conducted a retrospective analysis of a cohort of New York City residents who had filled at least three consecutive prescriptions for oxycodone 80 mg immediately prior to the reformulation. We classified cohort members into one of three groups (continuers, switchers, and discontinuers) based on prescription filling patterns post-reformulation. Descriptive analyses were conducted to identify prevalence of filling patterns. Differences in median morphine milligram equivalents (MME) pre- and post-reformulation were compared using the Wilcoxon signed-rank sum test. Analyses were completed in 2018. RESULTS: A cohort of 4,098 New York City residents filled continuous prescriptions for oxycodone 80 mg immediately prior to reformulation. Post-reformulation, 14% of the cohort discontinued filling opioid analgesic prescriptions; 46% continued to fill prescriptions for oxycodone 80 mg; and 40% switched to a different opioid analgesic, most commonly oxycodone 30 mg. Post-reformulation, the median MME dose decreased significantly among all three groups: 45 mg among continuers, 150 mg among switchers, and 360 mg among discontinuers. CONCLUSION: Post-reformulation, more than half the cohort changed their filling patterns. Following reformulation, median MME dose decreased significantly among the cohort. We hypothesize that the dramatic decrease in MME dose prompted many to transition to heroin in order to avoid severe withdrawal.

Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program.

Prescription drug monitoring programs (PDMPs) are databases that track controlled substances at the provider, patient, and pharmacy levels. While these databases are widely available at the state level throughout the United States, several jurisdictions in recent years have mandated the use of these systems by health care providers. This study explores the implementation of mandatory PDMP technology in primary care practice and the effects on treatment of people with possible substance use disorders. Findings are based on 53 in-depth interviews with primary care providers in New York City, collected shortly following the passage of legislation mandating use of a PDMP by health care providers in New York State. Findings suggest that use of the PDMP highlighted tensions between provider stigma toward substance use disorders and the clinical care of people who use drugs, challenging their stereotypes and biases. The parallel clinical and law enforcement purposes of PDMP technology placed providers in dual roles as clinicians and enforcers and encouraged the punitive treatment of patients. Finally, PDMP technology standardized the clinical assessment process toward a "diagnosis first" approach, consistent with prior scholarship on the implementation of emerging medical technologies.

The Rikers Island Hot Spotters: Exploring the Needs of the Most Frequently Incarcerated.

A cohort of frequently incarcerated individuals in the New York City jail system was identified through "hot spotting" analysis. This group demonstrated higher levels of substance use, mental illness, and homelessness than the general jail population, and was typically incarcerated on minor criminal charges. To understand this population better, in-depth interviews (n = 20) were conducted at three Rikers Island correctional facilities with people who had entered the jail system at least 18 times in a six-year period. Findings showed that life circumstances, chronic homelessness, mental illness, and substance use resulted in repeated institutionalization across multiple settings. Participants described an "institutional circuit" that promoted a state of permanent instability characterized by rotating involvement with custodial institutions. Exiting the institutional circuit requires the ability to navigate complex bureaucratic systems; however, without structural reorganization in social service delivery and an emphasis on permanent housing, participants in this group are unlikely to break the cycle.

Non-Prescribed Buprenorphine in New York City: Motivations for Use, Practices of Diversion, and Experiences of Stigma.

Non-medical use of opioid analgesics (OAs) has increased in the United States over the past decade. Concurrently, access to opioid agonist therapies (OATs) such as buprenorphine has expanded. However, there has been little in-depth qualitative exploration into circumstances surrounding buprenorphine diversion and non-prescribed use. This study reports on qualitative data from in-depth interviews conducted with persons in New York City reporting non-medical OA use in the past 12 months. Participants (n=42) were aged between 18 and 49 years. The majority were male (n=29) and non-Hispanic White (n=35). All participants self-reported physical opioid dependence. Motivations for non-prescribed buprenorphine use included the abatement of withdrawal symptoms or a self-initiated detoxification or treatment plan. Few participants reported buprenorphine use for euphoric effect, and no participants reported using buprenorphine as a primary drug. Buprenorphine diversion primarily occurred as a means of supporting ongoing illicit drug use, and no participants reported selling buprenorphine as a primary source of income. Participants reported misinformation around some key areas of buprenorphine induction and use, as well as stigma within peer networks and from drug treatment providers. As access to buprenorphine treatment continues to expand in the United States, enhancing patient education is a critical step toward minimizing diversion and incidental harms from non-prescribed use.

Circumstances and contexts of heroin initiation following non-medical opioid analgesic use in New York City.

BACKGROUND: As the prevalence of opioid analgesic (OA) misuse and associated harms have increased in the United States, the prevalence of heroin use and rates of unintentional overdose have concurrently risen. Research has begun to identify connections between OA misuse and heroin use, although this relationship remains under explored. The present study explores the context of heroin initiation among persons with histories of OA misuse in New York City. METHODS: In-depth interviews were conducted with 31 individuals with histories of OA misuse who initiated heroin use within the past five years. Data were collected between August 2013 and January 2015. All participants' OA misuse temporally preceded their heroin use. Interviews were coded and analyzed utilizing thematic qualitative methods. RESULTS: Participants ranged in age from 18 to 44 years; 25 identified as male and 30 identified as non-Hispanic white and heterosexual. All participants had stable housing at the time of interview and all were high school graduates. Participants described several key points of transition along their trajectories from OA misuse to heroin initiation: dual- to single-entity OAs; oral to intranasal OA administration; and the development of physical opioid dependence. Participants described the breaking down of heroin-related stigma across social networks as new drug use permeated social groups. CONCLUSION: Several points of transition were identified in participants' trajectories from OA misuse to heroin initiation. In particular the development of physical dependence was a critical factor as existing heroin stigma was rapidly overcome in the face of opioid withdrawal. The relatively short time to heroin initiation documented among new user groups serves as an added challenge to the development of interventions.

Patterns of prescription drug misuse among young injection drug users.

Misuse of prescription drugs and injection drug use has increased among young adults in the USA. Despite these upward trends, few studies have examined prescription drug misuse among young injection drug users (IDUs). A qualitative study was undertaken to describe current patterns of prescription drug misuse among young IDUs. Young IDUs aged 16-25 years who had misused a prescription drug, e.g., opioids, tranquilizers, or stimulants, at least three times in the past 3 months were recruited in 2008 and 2009 in Los Angeles (n = 25) and New York (n = 25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analyzed both quantitatively and qualitatively. Most IDUs sampled were both homeless and transient. Heroin, prescription opioids, and prescription tranquilizers were frequently misused in the past 30 days. Qualitative results indicated that young IDUs used prescription opioids and tranquilizers: as substitutes for heroin when it was unavailable; to boost a heroin high; to self-medicate for health conditions, including untreated pain and heroin withdrawal; to curb heroin use; and to reduce risks associated with injecting heroin. Polydrug use involving heroin and prescription drugs resulted in an overdose in multiple cases. Findings point to contrasting availability of heroin in North American cities while indicating broad availability of prescription opioids among street-based drug users. The results highlight a variety of unmet service needs among this sample of young IDUs, such as overdose prevention, drug treatment programs, primary care clinics, and mental health services.