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Background People who use drugs (PWUD) have a higher incidence of infectious complications that require medical interventions only available in hospital settings. Hospitalizations for PWUD are also more likely to result in patient directed discharge (PDD) before completing medical treatment. Stigma directed at PWUD pressurizes and shapes clinical encounters, leading to poor communication between patient and provider. We explore how the relational philosophy of harm reduction – the premise that building relationships rooted in compassion and respect, as opposed to a transactional encounter – can redress the harms and communication barriers between PWUD and healthcare providers in the hospital setting. Methods We recruited sixteen patients (achieving thematic saturation) with substance use disorder during their hospital stay at a large academic medical center with an urban, suburban, and rural referral base. Interviews were semi-structured, and focused on assessing patient knowledge and experiences of accessing harm reduction services and medical care. Interviews were transcribed verbatim and analyzed using content and thematic analysis. Findings When discussing patient experiences accessing medical care, three key themes emerged from our interviews about their hospital experiences: 1) providers disregard for social contexts of PWUD, 2) providers withholding care because of patient’s substance use, 3) patients viewed in negative or pejorative ways because of their addiction. All participants reported experienced or anticipated stigma related to drug use. Our participants described avoiding seeking medical care and developing strategies to deal with anticipated and experienced stigma; some reported their minimization of physical complaints due to providers’ focus on their substance use as well as medical care being withheld because of their substance use. Three themes emerged around experiences of care that conferred dignity and autonomy: 1) experience dignity in and through use and access of harm reduction services, 2) peer support as a tool to model for relational harm reduction 3) harm reduction as community care (leveraging a responsibility to look out for others). Participants identified these social supports as giving them hope and motivation around their own health goals. Conclusion Our findings emphasize that healthcare settings remain challenging for PWUD. Patients describe how stigmatizing beliefs impact clinical reasoning and bleed into negative healthcare experiences and lower quality of care. The foundational principles of harm reduction – appreciating the social contexts in which individuals use drugs and the dignity in survival strategies – offer pathways for therapeutic communication between patients and providers.

Background In Pittsburgh, PA, legal changes in recent decades have set the stage for an expanded role for community pharmacists to provide harm reduction services, including distributing naloxone and non-prescription syringes (NPS). In the wake of the syndemics of the COVID-19 pandemic and worsening overdose deaths from synthetic opioids, we examine knowledge, attitudes, and practices of harm reduction services among community pharmacists in Pittsburgh and identify potential barriers of expanded pharmacy-based harm reduction services. Methods We provided flyers to 83 community pharmacies within a 5-mile radius of the University of Pittsburgh Medical Center to recruit practicing community pharmacists to participate in an anonymous electronic survey. We used a 53-question Qualtrics survey consisting of multiple-choice, 5 or 6 point-Likert scale, and open-ended questions adapted from 5 existing survey instruments. Survey measures included demographics, knowledge, attitudes, and practices of harm reduction services (specifically naloxone and NPS provision), and explored self-reported barriers to future implementation. Data was collected July–August 2022. We conducted descriptive analysis using frequencies and proportions reported for categorical variables as well as means and standard deviations (SD) for continuous variables. We analyzed open-ended responses using inductive content analysis. Results Eighty-eight community pharmacists responded to the survey. 90% of participants agreed pharmacists had a role in overdose prevention efforts, and 92% of participants had previously distributed naloxone. Although no pharmacists reported ever refusing to distribute naloxone, only 29% always provided overdose prevention counseling with each naloxone distributed. In contrast, while 87% of participants had positive attitudes toward the usefulness of NPS for reducing disease, only 73% of participants ever distributed NPS, and 54% had refused NPS to a customer. Participants endorsed a lack of time and concerns over clientele who used drugs as the most significant barriers to offering more comprehensive harm reduction services. Conclusions Our findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of NPS. Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly.

Background Syringe service programs (SSPs) provide essential harm reduction and prevention services for people who inject drugs in the USA, where SSP coverage is expanding. During the COVID-19 pandemic, US SSPs underwent unprecedented shifts in operational procedures (e.g., closures of physical sites, staff redeployment into pandemic response efforts). Given the critical role of US SSP workers in the pandemic, we sought to explore the occupational experiences and well-being of SSP staff to inform future emergency response efforts. Methods From July–October 2020, we conducted semi-structured interviews with staff members of four SSPs in diverse regions of Massachusetts. Trained interviewers administered qualitative interviews virtually. Interviews were coded in NVivo v12 and thematic analysis identified common occupational experiences and related impacts on staff well-being in the context of the COVID-19 pandemic. Results Among 18 participants, 12 (67%) had client-facing roles such as harm reduction specialists and six (33%) worked in program management or leadership. We found that staff were frequently anxious about SARS-CoV-2 transmission, which contributed to staff turnover. SSPs rapidly adapted and expanded their services to meet increasing client needs during the pandemic (e.g., food distribution, COVID-19 testing), leading to staff overexertion. Simultaneously, public health measures such as physical distancing led to staff concerns about reduced social connections with clients and coworkers. Through these challenges, SSPs worked to protect staff well-being by implementing flexible and tangible COVID-19-related policies (e.g., paid sick leave), mental health resources, and frequent communication regarding pandemic-related operational changes. Conclusion SSPs in the USA adapted to the COVID-19 pandemic out of necessity, resulting in operational changes that threatened staff well-being. Despite the protective factors revealed in some narratives, our findings suggest that during prolonged, complex public health emergencies, SSPs may benefit from enhanced occupational supports to prevent burnout and promote wellness for this essential public health workforce.

Background The rising rates of drug use-related complications call for a paradigm shift in the care for people who use drugs. While addiction treatment and harm reduction have historically been siloed in the US, co-location of these services in office-based addiction treatment (OBAT) settings offers a more realistic and patient-centered approach. We describe a quality improvement program on integrating harm reduction kits into an urban OBAT clinic. Methods After engaging appropriate stakeholders and delivering clinician and staff trainings on safer use best practices, we developed a clinical workflow for universal offering and distribution of pre-packaged kits coupled with patient-facing educational handouts. We assessed: (1) kit uptake with kit number and types distributed; and (2) implementation outcomes of feasibility, acceptability, appropriateness, and patient perceptions. Results One-month post-implementation, 28% (40/141) of completed in-person visits had at least one kit request, and a total of 121 kits were distributed. Staff and clinicians found the program to be highly feasible, acceptable, and appropriate, and patient perceptions were positive. Conclusions Incorporating kits in OBAT settings is an important step toward increasing patient access and utilization of life-saving services. Our program uncovered a significant unmet need among our patients, suggesting that kit integration within addiction treatment can improve the standard of care for people who use drugs.

The treatment of frostbite injuries has undergone a radical change over the past decade with a shift from supportive therapy and observation towards early and aggressive medical intervention with thrombolytics and vasodilators. Institutions that have implemented evidence-based protocols have significantly decreased their amputation rates (Bruen et al., 2007; Lindford et al., 2017a; Twomey et al., 2005). We present the case of a middle-aged male treated for frostbite of multiple fingers on both hands. Because there was no treatment protocol at our institution, there were multiple delays in the patient's care including imaging and initiation of intravenous (IV) prostanoids. This case illustrates the deleterious effects of delays in treatment and strongly suggests that all facilities located in areas of cold exposure should have protocols in place for such an occurrence.

Since March 2020, the US federal government has invested tremendous public health effort in COVID-19 responses by expediting the availability of vaccines and have therapeutics. Meanwhile, addiction care providers, public health workers, and people who use drugs have been sounding alarms about the pandemic's collateral damage, which has contributed to the ongoing surge of unintentional fatal overdoses. Reduced access to addiction treatment and services combined with fentanyl infiltrating drug supplies resulted in an estimated 100000 fatal overdoses in 2020 alone.1 Although the Centers for Disease Control and Prevention iCDC; has released official health advisories2 and the US Department of Health and Human Services (HHS) has supported widespread implementation of expanded distribution and use of naloxone in high-risk populations, there is not enou ugh naloxone in the hands of those who need it most. Only one naloxone prescription is dispensed for every 70 high-dose opioid prescriptions nationwide.3 In communities that experience disproportionate rates of overdose from illicit opioids, a recent study suggests that nonurban areas have lower naloxone distribution relative to overdose deaths than urban areas do.4 Given the pervasiveness of this national crisis, it is critical to saturate our communities now with naloxone. The 2021 Model Expanded Access to Emergency Opioid Antagonists Act is a first step in aiming for uniform naloxone access because it provides a legislative template that states could eventually choose to implement.5 We call on federal policymakers and regulators to take one step further to increase naloxone availability by (1) making naloxone available over the counter (OTC), (2) increasing funding for community-based programs focusing on harm reduction, (3) permanently eliminating insurance oope.iyments and prior-authorization requirements, and (a) mandating coprescribed and codispensed naloxone with all higher-risk opioid prescriptions and medications for opioid use disorder.

Abstract Background Infectious complications of substance use are increasingly encountered in infectious diseases (ID) clinical care. In this study, we surveyed ID fellows in the United States to assess training experiences, clinical practices, and perspectives in caring for people who use drugs (PWUD). Methods An 18-item survey was distributed to ID fellows via email and social media platforms. Four focus groups were conducted with a subset of participants to elucidate themes in fellowship experiences and training needs. Results Among 196 survey respondents (estimated 24% response rate), all reported caring for PWUD in ID fellowship. Forty-nine percent received some formal fellowship-based didactics around care of PWUD, and 64% worked with faculty seen as advocates for PWUD. Integrated care practices for PWUD were infrequently employed: 50% offered risk reduction counseling, and 33% discussed medications for opioid use disorders, naloxone, or HIV preexposure prophylaxis. Risk reduction counseling was felt to be “extremely” within scope of ID practice (69%), although comfort level with this skill was low; fellows’ likelihood of offering counseling was significantly associated with their comfort (P ≤ .0001). Common themes in caring for PWUD included an expanded role for ID consultants, a lack of formalized training, and benefits of developing dedicated opportunities in this field. Conclusions ID fellows frequently care for PWUD but may have gaps in knowledge or comfort that affect care practices. Increased fellowship training in the care of PWUD has potential to improve clinical practices and support growing interest in this field among current and prospective ID fellows. US infectious diseases fellows often care for people who use drugs, but they report limited experience in integrated infectious diseases/addiction care as well as a lack of comfort in these skills. Increased fellowship-based training would be beneficial in meeting fellows’ interests and improving clinical care.

We investigated the association of 90-day opioid and stimulant co-use and HIV risk behaviors in a cross-sectional analysis of hospitalized HIV-negative people who inject drugs (PWID). We compared those injecting opioids alone to two sub-groups who co-used opioids with (1) cocaine, (2) amphetamine-type stimulants (ATS), on sex and injection drug risk behaviors assessed via the Risk Assessment Battery (RAB), where a higher score indicates a higher risk. Of 197 participants who injected opioids, 53% co-used cocaine only, 5% co-used ATS only, 18% co-used both cocaine and ATS, 24% co-used neither stimulant. PWID who injected opioids alone had a mean RAB drug risk score of 5.98 points and sex risk score of 2.16 points. Compared to PWID who injected opioids alone, PWID who co-used stimulants had higher mean drug risk RAB scores: cocaine, b = 2.84 points [95% confidence interval (CI) 1.01; 4.67]; ATS, b = 3.43 points (95% CI 1.29; 5.57). Compared to PWID who injected opioids alone, cocaine co-use was associated with higher sex RAB scores b = 1.06 points (95% CI 0.32; 1.79). Overall, we found a significant association between stimulant co-use and higher HIV sex and drug risk scores.