“It’s called overamping”: experiences of overdose among people who use methamphetamine

Background The USA is experiencing increases in methamphetamine use and methamphetamine-related or attributed deaths. In the current study, we explore qualitative narratives of methamphetamine overdose and strategies used by people who use drugs to reduce the undesirable effects associated with methamphetamine use. Methods We conducted 21 qualitative interviews with people over the age of 18 who reported using methamphetamine in the previous 3 months in Nevada and New Mexico. Interviews were recorded, transcribed, and analyzed using qualitative thematic analysis. Results Respondents described a constellation of psychological and physical symptoms that they characterized as “overamping,” experienced on a continuum from less to more severe. Reports of acute, fatal methamphetamine overdose were rare. Few reported seeking medical attention for undesirable effects (usually related to psychological effects). General self-care strategies such as sleeping and staying hydrated were discussed. Conclusions When asked directly, our respondents claimed that acute, fatal methamphetamine overdose is rare or even impossible. However, they described a number of undesirable symptoms associated with overconsumption of methamphetamine and had few clinical or harm reduction strategies at their disposal. Addressing this current wave of drug-related deaths will require attention to the multiple factors that structure experiences of methamphetamine “overdose,” and a collaborative effort with PWUDs to devise effective harm reduction and treatment strategies.

Reducing the harms of unsafe abortion: a systematic review of the safety, effectiveness and acceptability of harm reduction counselling for pregnant persons seeking induced abortion

BackgroundGlobally, access to safe abortion is limited. We aimed to assess the safety, effectiveness and acceptability of harm reduction counselling for abortion, which we define as the provision of information about safe abortion methods to pregnant persons seeking abortion.MethodsWe searched PubMed, EMBASE, ClinicalTrials.gov, Cochrane, Global Index Medicus and the grey literature up to October 2021. We included studies in which healthcare providers gave pregnant persons information on safe use of abortifacient medications without providing the actual medications. We conducted a descriptive summary of results and a risk of bias assessment using the ROBINS-I tool. Our primary outcome was the proportion of pregnant persons who used misoprostol to induce abortion rather than other methods among those who received harm reduction counselling.ResultsWe included four observational studies with a total of 4002 participants. Most pregnant persons who received harm reduction counselling induced abortion using misoprostol (79%–100%). Serious complication rates were low (0%–1%). Uterine aspiration rates were not always reported but were in the range of 6%–22%. Patient satisfaction with the harm reduction intervention was high (85%–98%) where reported. We rated the risk of bias for all studies as high due to a lack of comparison groups and high lost to follow-up rates.DiscussionBased on a synthesis of four studies with serious methodological limitations, most recipients of harm reduction counselling use misoprostol for abortion, have low complication rates, and are satisfied with the intervention. More research is needed to determine abortion success outcomes from the harm reduction approach.FundingThis work did not receive any funding.PROSPERO registration numberWe registered the review in the PROSPERO database of systematic reviews (ID number: CRD42020200849).

Evaluation of a novel therapeutic education programme for people with alcohol use disorder in France: a mixed-methods intervention study protocol (ETHER)

Background ETHER (“Education THEérapeutique pour la Réduction des dommages en alcoologie” or Therapeutic education for alcohol-related harm reduction) is a multicentre community-based mixed-methods study, which aims to evaluate the effectiveness of the innovative therapeutic patient education (TPE) programme ‘Choizitaconso’ in a sample of French people with alcohol use disorder (people with AUD). Choizitaconso teaches people with AUD psychosocial skills to help them (re)establish controlled drinking and reduce alcohol-related harms. Recruitment started in October 2019. We present here the protocol of the ETHER study. Methods ETHER’s quantitative component involves a 6-month controlled intervention study which evaluates Choizitaconso’s effectiveness by comparing 30 people with AUD following the programme with a control group of 60 people with AUD not enrolled in it, using a questionnaire co-constructed by the research team and members of the people with AUD community. Thirty-four alcohol-related harms are assessed and summed to provide an individual measure of the ‘harm burden’ from consuming alcohol (primary outcome). Secondary outcomes are anticipated and internalized stigma, alcohol consumption measures, craving for alcohol, coping strategies, health-related quality of life, self-confidence to control or abstain from drinking, treatment self-regulation, anxiety and depressive symptoms, alcohol-related neuropsychological impairments, and capabilities (a measure of wellbeing in adults). Data will be collected in face-to-face and phone-based interviews at enrolment and 6 months later. Linear regression models will be used to assess the impact of the TPE programme on changes in the primary and secondary outcomes, while adjusting for other correlates and confounders. The study’s qualitative component comprises semi-structured interviews with 16 people with AUD who have already completed the TPE programme at least 6 months before the interview. Qualitative interviews will be analysed using thematic analysis. Results and conclusions ETHER is the first evaluation study of an innovative TPE programme specifically designed to reduce alcohol-related harms and reach controlled drinking in France. The involvement of the people with AUD community in selecting which experienced and perceived alcohol-related harms to measure ensures that ETHER will provide healthcare staff and researchers with a relevant set of harm reduction criteria for use in future research. Finally, ETHER will provide scientific justification for implementing novel alcohol-related harm reduction approaches and champion controlled drinking as a therapeutic goal. Trial registration ClinicalTrials.gov, NCT03954054. Registered 17 May 2019—Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03954054?cond=alcohol&cntry=FR&city=Marseille&draw=1&rank=1.

Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians

Background Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions. Methods The “Six Moments of Harm Reduction” provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool’s effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction. Results N=75 respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling patients who inject drugs (PWID). 60 respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP) and, of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (p<0.0001), 65 respondents (86.6%) reported they planned to use the “Six Moments” model in their own practice, and 100% said they would consider referring patients to a SSP in the future. Conclusions The “Six Moments” model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.

Electronic cigarettes as a harm reduction strategy among patients with COPD: protocol for an open-label two arm randomized controlled pilot trial

Background Smoking cessation is the most effective means of slowing the decline of lung function associated with chronic obstructive pulmonary disease (COPD). While effective smoking cessation treatments are available, they are underutilized and nearly half of people with COPD continue to smoke. By addressing both nicotine and behavioral dependence, electronic cigarettes (EC) could help people with COPD reduce the harm of combustible cigarettes (CC) through reductions in number of Cigarettes per Day (CPD) or quitting CC completely. The purpose of this pilot study is to identify barriers and facilitators to the use of and assess the preliminary effectiveness of EC as a harm reduction strategy among people with COPD. Methods In an open-label two-arm randomized controlled trial pilot study, 60 patients identified as smokers with a COPD diagnosis via electronic health records from a large urban health center are randomized in a 1:1 ratio to either standard care [counseling + nicotine replacement therapy (NRT)] or counseling + EC. The NRT arm will receive nicotine patches and nicotine lozenges for 12 weeks. The EC arm will receive EC for 12 weeks. Both cohorts will receive counseling from a licensed mental health counselor. Using ecological momentary assessment, participants will report their use of CC in both arms and EC use in the EC arm daily via text message. Primary outcomes will be feasibility and acceptability of intervention, and secondary outcomes will be reduction in CPD and change in COPD symptoms as measured by COPD Assessment Tool (CAT) score at 12-weeks. EC displacement of CC. To explore attitudes towards the use of EC as a harm-reduction strategy for patients with COPD, interviews will be performed with a sample of participants from both study arms. Discussion Despite decades of availability of smoking cessation medications, nearly half of people with COPD still smoke. This study aims to address the unmet need for feasible and effective strategies for reducing CC use among those with COPD, which has the potential to significantly improve the health of people with COPD who smoke. Trial Registration ClinicalTrials.gov Identifier: NCT04465318.

Assessment of Policies and Harm Reduction Services for Young People Who Use Drugs in Kathmandu Valley of Nepal: Identifying Gaps and Opportunities

Background: Young people under 30 represent the majority of people who use drugs in the Kathmandu Valley, Nepal. Young people who use drugs (YPWUD) may have particular needs and require different service and policy responses when compared to their older peers. This research examines the strengths and limitations of currently available policies and services; their effectiveness in meeting the needs of YPWUD and identifies gaps and opportunities for their improvement.Methodology: Semi-structured interviews (n=9) with key stakeholders and one focus group (n=5) discussion with YPWUD were conducted. Results were analyzed using the Rhodes Risk Environment framework which considers the ‘physical’, ‘social’, ‘economic’ and ‘policy’ level factors shaping risk at ‘micro’, ‘meso’ and ‘macro’ levels.Results: Drug use patterns among YPWUD in the Kathmandu Valley, Nepal are changing. Several trends have been identified including increased use of methamphetamine, diverted pharmaceuticals and ‘Southasian-Cocktail’ (a mixture of buprenorphine, benzodiazepine and antihistamines); use at the border regions and a move away from drug dealing ‘hotspots’ to online drug purchasing. YPWUD and service providers report a range of barriers to accessing services including stigma and discrimination; a lack of local services; a lack of knowledge of existing services; age of consent legislation and opening hours which may conflict with commitments such as school and college. YPWUD report a range of human rights violations including involuntary treatment, arbitrary detention, forced labour and public body searches. Service providers and policymakers report precarious international donor funding of services through HIV prevention programs with little to no youth-specific services for YPWUD.Conclusion: The findings of this study highlight the importance of youth-friendly harm reduction services that are relevant and responsive to the unique needs and experiences of YPWUD. These services should address current trends including the use of new substances (for example, methamphetamine and ‘Southasian Cocktail’) in diverse environments (including at the border regions and online). The perspectives of YPWUD are vital while developing and implementing harm reduction programs to ensure that the programs are effective, efficient and based on the diverse needs of YPWUD.