Using the BBraun BSmartTM Pressure Manometer to Prevent Unsafe Injection Pressures During Simulated Peripheral Nerve Blockade: A Pilot Study

Background: Peripheral nerve injury during regional anaesthesia may result from accidental intraneural placement of the needle, or forceful needle nerve contact. Intraneural injections are associated with increased resistance to injection, typically >15 psi. The BBraun BSmart™ is an inline mechanical manometer, offering a visual display of injection pressures. Objective: The primary objective of this study was to determine if using the BBraun BSmartTM manometer successfully prevents 90% of anaesthetists and anaesthetic assistants from injecting at pressures > 15 psi during simulated nerve block. Methods: This was a prospective observational study involving anaesthetists and anaesthetic assistants. Two 20 ml injections were performed by each participant, once when the BBraun BSmartTM manometer was obscured from view, and once with the manometer visible. A PendoTech PressureMATTMS recorded injection pressures. Results: 39 participants completed the study, with a total of 78 injections recorded. During the study, 32 peak pressures during the 78 procedures were recorded above the recommended upper limit of 15 psi, 41% of the total injections. The peak pressure rose above 15 psi in 24/39 (62%) injections when the BBraun Bsmart™ manometer was obscured, but only in 8/39 (21%) injections when the manometer was visible. Conclusion: The BBraun Bsmart™ manometer did not successfully prevent 90% of anaesthetists or anaesthetic assistants from injecting at unsafe pressures. However, using the BBraun BSmart™ did reduce the number of unsafe injection pressures generated by participants. When utilised in conjunction with PNS and ultrasound guidance, this may offer additional safety during peripheral nerve blockade.

Anabolic-Androgenic Steroid Misuse: Mechanisms, Patterns of Misuse, User Typology, and Adverse Effects

Anabolic-androgenic steroids (AAS) encompass a broad group of natural and synthetic androgens. AAS misuse is highly prevalent on a global scale, with the lifetime prevalence of AAS misuse in males being estimated to be around 6%, with 15 to 25% of male gym attendees using it at any one time. AAS are associated with sudden cardiac death, neuropsychiatric manifestations, and infertility. The average AAS user is unlikely to voluntarily declare their usage to a physician, with around 1 in 10 actively engaging in unsafe injection techniques. The aim of this paper is to review the current evidence base on AAS with emphasis on mechanisms of action, adverse effects, and user profiles that are most likely to engage in AAS misuse. This paper also reviews terminologies and uses methods specific to the AAS user community.

Unsafe Injection Is Associated with Higher HIV Testing after Bayesian Adjustment for Unmeasured Confounding

Background: To apply a novel method to adjust for HIV knowledge as an unmeasured confounder for the effect of unsafe injection on future HIV testing. Methods: The data were collected from 601 HIV-negative persons who inject drugs (PWID) from a cohort in San Francisco. The panel-data generalized estimating equations (GEE) technique was used to estimate the adjusted risk ratio (RR) for the effect of unsafe injection on not being tested (NBT) for HIV. Expert opinion quantified the bias parameters to adjust for insufficient knowledge about HIV transmission as an unmeasured confounder using Bayesian bias analysis. Results: Expert opinion estimated that 2.5%–40.0% of PWID with unsafe injection had insufficient HIV knowledge; whereas 1.0%–20.0% who practiced safe injection had insufficient knowledge. Experts also estimated the RR for the association between insufficient knowledge and NBT for HIV as 1.1-5.0. The RR estimate for the association between unsafe injection and NBT for HIV, adjusted for measured confounders, was 0.96 (95% confidence interval: 0.89,1.03). However, the RR estimate decreased to 0.82 (95% credible interval: 0.64, 0.99) after adjusting for insufficient knowledge as an unmeasured confounder. Conclusion: Our Bayesian approach that uses expert opinion to adjust for unmeasured confounders revealed that PWID who practice unsafe injection are more likely to be tested for HIV – an association that was not seen by conventional analysis.

Predictors of skin and soft tissue infections among sample of rural residents who inject drugs

Introduction Skin and soft tissue infections (SSTIs) are among the leading causes of morbidity and mortality for people who inject drugs (PWID). Studies demonstrate that certain injection practices correlate with SSTI incidence among PWID. The opioid epidemic in the USA has particularly affected rural communities, where access to prevention and treatment presents unique challenges. This study aims to estimate unsafe injection practices among rural-dwelling PWID; assess treatments utilized for injection related SSTIs; and gather data to help reduce the overall risk of injection-related SSTIs. Methods Thirteen questions specific to SSTIs and injection practices were added to a larger study assessing unmet health care needs among PWID and were administered at six syringe exchange programs in rural Wisconsin between May and July 2019. SSTI history prevalence was estimated based on infections reported within one-year prior of response and was compared to self-reported demographics and injection practices. Results Eighty responses were collected and analyzed. Respondents were white (77.5%), males (60%), between the ages 30 and 39 (42.5%), and have a high school diploma or GED (38.75%). The majority of respondents (77.5%) reported no history of SSTI within the year prior to survey response. Females were over three times more likely to report SSTI history (OR = 3.07, p = 0.038) compared to males. Water sources for drug dilution (p = 0.093) and frequency of injecting on first attempt (p = 0.037), but not proper skin cleaning method (p = 0.378), were significantly associated with a history of SSTI. Injecting into skin (p = 0.038) or muscle (p = 0.001) was significantly associated with a history of SSTI. Injection into veins was not significantly associated with SSTI (p = 0.333). Conclusion Higher-risk injection practices were common among participants reporting a history of SSTIs in this rural sample. Studies exploring socio-demographic factors influencing risky injection practices and general barriers to safer injection practices to prevent SSTIs are warranted. Dissemination of education materials targeting SSTI prevention and intervention among PWID not in treatment is warranted.

Predictors of Skin and Soft Tissue Infections Among Sample of Rural Residents Who Inject Drugs

Introduction: Skin and soft tissue infections (SSTIs) are among the leading causes of morbidity and mortality for people who inject drugs (PWID). Studies demonstrate that certain injection practices correlate with SSTI incidence among PWID. The opioid epidemic in the United States has particularly affected rural communities, where access to prevention and treatment presents unique challenges. This study aims to estimate unsafe injection practices among rural-dwelling PWID; assess treatments utilized for injection related SSTIs; and gather data to help reduce the overall risk of injection-related SSTIs. Methods: Thirteen questions specific to SSTIs and injection practices were added to a larger study assessing unmet health care needs among PWID and were administered at six syringe exchange programs in rural Wisconsin between May and July 2019. SSTI history prevalence was estimated based on infections reported within one-year prior of response and was compared to self-reported demographics and injection practices. Results: Eighty responses were collected and analyzed. Respondents were white (77.5%), males (60%), between the ages 30-39 (42.5%), and have a high school diploma or GED (38.75%). The majority of respondents (77.5%) reported no history of SSTI within the year prior to survey response. Females were over three times more likely to report SSTI history (OR=3.07, p=0.038) compared to males. Water sources for drug dilution (p=0.093) and frequency of injecting on first attempt (p=0.037), but not proper skin cleaning method (p = 0.378), were significantly associated with a history of SSTI. Injecting into skin (p=0.038) or muscle (p=0.001) were significantly associated with a history of SSTI. Injection into veins was not significantly associated with SSTI (p=0.333).Conclusion: Higher-risk injection practices were common among participants reporting a history of SSTIs in this rural sample. Studies exploring socio-demographic factors influencing risky injection practices and general barriers to safer injection practices to prevent SSTIs are warranted. Dissemination of education materials targeting SSTI prevention and intervention among PWID not in treatment are warranted.

French People’s positions on supervised injection facilities for drug users

Background Supervised injection facilities have been set-up in many countries to curb the health risks associated with unsafe injection practices. These facilities have, however, been met with vocal opposition, notably in France. As harm reduction policies can only succeed to the extent that people agree with them, this study mapped French people’s opinions regarding the setting-up of these facilities. Method A sample of 318 adults--among them health professionals--were presented with 48 vignettes depicting plans to create a supervised injection facility in their town. Each vignette contained three pieces of information: (a) the type of substance that would be injected in the facility (amphetamines only, amphetamines and cocaine only, or amphetamines, cocaine and heroin), (b) the type of staff who would be working in the facility (physicians and nurses, specially trained former drug users, specially trained current drug users, or trained volunteers recruited by the municipality), and (c) the staff members’ mission (to be present and observe only, technical counselling about safe injection, counselling about safe injection and hygiene, or counselling and encouragement to follow a detoxification program). Results Through cluster analysis, three qualitatively different positions were found: Not very acceptable (20%), Depends on staff and mission (49%), and Always acceptable (31%). These positions were associated with demographic characteristics--namely gender, age and political orientation. Conclusion French people’s positions regarding supervised injection facilities were extremely diverse. One type of facility would, however, be accepted by a large majority of people: supervised injection facilities run by health professionals whose mission would be, in addition to technical and hygienic counselling, to encourage patrons to enter detoxification or rehabilitation programs.

1050. Hepatitis C Infection amongst People who Inject Drugs (PWID): Injection Practices and Risk Factors

Background The rapidly progressing U.S. opioid epidemic has led to an increased prevalence of infections associated with injection drug use (IDU), such as Hepatitis C (HCV). Previous studies have identified a lack of screening, prevention, and treatment of HCV, which has contributed to an increase in HCV-related mortality. Transmission has been linked to unsafe injection practices. Our study aims to characterize risk factors associated with Hepatitis C (HCV) exposure amongst people who inject drugs (PWID) in Maine, a state heavily impacted by the opioid epidemic. Methods Data was obtained from a cross-sectional study of participants hospitalized with an IDU-associated infection at four hospitals in Maine identified as high-risk for HIV/HCV outbreaks. The Audio Computer-Assisted Self-Interview survey and medical record review were used to collect data. The components from the BIRSI 7-item score were used to assess the use of safe injection practices. HCV exposure was defined as HCV antibody positive and/or self-reported exposure. Analysis was performed using descriptive analyses and univariate regression modeling. Results Of the 101 participants enrolled, n=76 (75%) were identified as having exposure to HCV. Out of participants exposed to HCV, 57% reported homelessness (p=< 0.01). Participants exposed to HCV were more likely to have bacteremia during hospitalization (25%, p=.02). All participants unexposed to HCV perceived low likelihood of contracting HCV due to injecting (p=.01). Seventy-one percent of people exposed to HCV reported infrequent use alcohol pads prior to injecting (p=< 0.01) and 67% reported infrequent hand-washing (p=.09). Participants with a higher BIRSI-7 score had higher odds of exposure to HCV (OR=1.48, 95% CI 1.10-2.04). Conclusion The data obtained highlights significant relationships between HCV exposure and certain risk factors. Homelessness was found to be associated with HCV exposure, suggesting an opportunity for more targeted intervention within this subgroup of PWID. Unsafe injection practices as measured by the BIRSI-7 score were related to HCV exposure, indicating educational opportunities about safe injection practices. Overall, targeted harm reduction services could be beneficial in the screening and prevention of HCV exposure amongst PWID. Disclosures All Authors: No reported disclosures

Medical injection and access to sterile injection equipment in low- and middle-income countries: a meta-analysis of Demographic and Health Surveys (2010–2017)

Background Unsafe injection practices contribute to increased risks of blood-borne infections, including human immunodeficiency virus, hepatitis B and hepatitis C viruses. The aim of this study was to estimate the prevalence of medical injections as well as assess the level of access to sterile injection equipment by demographic factors in low- and middle-income countries (LMICs). Methods We carried out a meta-analysis of nationally representative Demographic and Health Surveys (DHSs) conducted between 2010 and 2017 in 39 LMICs. Random effects meta-analysis was used in estimating pooled and disaggregated prevalence. All analyses were conducted using Stata version 14 and Microsoft Excel 2016. Results The pooled 12-month prevalence estimate of medical injection was 32.4% (95% confidence interval 29.3–35.6). Pakistan, Rwanda and Myanmar had the highest prevalence of medical injection: 59.1%, 56.4% and 53.0%, respectively. Regionally, the prevalence of medical injection ranged from 13.5% in west Asia to 42.7% in south and southeast Asia. The pooled prevalence of access to sterile injection equipment was 96.5%, with Pakistan, Comoros and Afghanistan having comparatively less prevalence: 86.0%, 90.3% and 90.9%, respectively. Conclusions Overuse of medical injection and potentially unsafe injection practices remain a considerable challenge in LMICs. To stem the tides of these challenges, national governments of LMICs need to initiate appropriate interventions, including education of stakeholders, and equity in access to quality healthcare services.

316. Hepatitis C and Engagement in Health Care Among Persons Who Inject Drugs and Persons Who Use Non-Injection Drugs, Philadelphia

Background The growing opioid epidemic is driving increasing rates of hepatitis C virus (HCV) infections in the United States. HCV transmission is most frequently attributed to unsafe injection behaviors, but can occur via other unsafe drug use and sexual behaviors. Differences in demographics, HCV rates and associated risk factors in non-injecting PWUD (NIPWUD), compared with people who inject drugs (PWID) must be understood in order to target elimination strategies. Methods Change is Philadelphia’s program to eliminate HCV among PWUD and enrollment includes HCV testing, linkage services, and an interviewer-administered survey including risk behaviors and healthcare engagement. This interim analysis includes the first 835 enrollees that identified as PWUD. For this analysis, PWID are enrollees who indicated ever injecting drugs and those who had not are NIPWUD. Results Among enrollees, 76% (N = 637) reported ever injecting drugs. PWIDs were younger and non-Hispanic (NH) white while NIPWUD were older and NH Black (age: P = 0.003; race/ethnicity: P < 0.0001). NIPWUDs had a high seropositivity rate though significantly lower than PWIDs (24% vs. 85%, respectively; P < 0.0001). Among PWID enrollees, 94% (N = 596) ever snorted. Of enrollees, 63% (N = 124) of NIPWUD and 56% (N = 356) of PWID identified having a PCP (P =0.07). PWIDs are more likely than NIPWUD to have overdosed (OD) (40% vs. 9%; P < 0.0001) though high rates of both groups ever witnessed an OD (84% vs. 67%, respectively). While 80% (N = 105) of NIPWUDs know how to use Narcan, 60% (N = 79) carry it, {94% (N = 503) and 71%(N = 381) in PWID, respectively}. NIPWUDs are more likely to be interested in drug treatment (P < 0.0001) and to have received it in the last 12 months (P = 0.0008). Conclusion Notable HCV infection exists among non-injecting PWUD reinforcing the need for harm reduction counseling and access to drug use equipment used for smoking and snorting. NIPWUD may be able to access drug and HCV treatment through PCPs and fatal ODs may be prevented by ensuring NIPWUDs have access to Narcan. In addition, PWID are likely to snort as well and should be counseled on non-injecting harm reduction methods. To succeed in micro elimination among PWUD, a focus on NIPWUDs as well as PWIDs is necessary to mitigate transmission of HCV. Disclosures All authors: No reported disclosures.