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1.  Law enforcement attitudes toward overdose prevention and response 
Drug and alcohol dependence  2013;133(2):677-684.
Law enforcement is often the first to respond to medical emergencies in the community, including overdose. Due to the nature of their job, officers have also witnessed first-hand the changing demographic of drug users and devastating effects on their community associated with the epidemic of nonmedical prescription opioid use in the United States. Despite this seminal role, little data exist on law enforcement attitudes toward overdose prevention and response.
We conducted key informant interviews as part of a 12-week Rapid Assessment and Response (RAR) process that aimed to better understand and prevent nonmedical prescription opioid use and overdose deaths in locations in Connecticut and Rhode Island experiencing overdose “outbreaks.” Interviews with 13 law enforcement officials across three study sites were analyzed to uncover themes on overdose prevention and naloxone.
Findings indicated support for law enforcement involvement in overdose prevention. Hesitancy around naloxone administration by laypersons was evident. Interview themes highlighted officers’ feelings of futility and frustration with their current overdose response options, the lack of accessible local drug treatment, the cycle of addiction, and the pervasiveness of easily accessible prescription opioid medications in their communities. Overdose prevention and response, which for some officers included law enforcement-administered naloxone, were viewed as components of community policing and good police-community relations.
Emerging trends, such as existing law enforcement medical interventions and Good Samaritan Laws, suggest the need for broader law enforcement engagement around this pressing public health crisis, even in suburban and small town locations, to promote public safety.
PMCID: PMC3947507  PMID: 24051061
law enforcement; police; overdose; prescription opioid abuse; naloxone
2.  Moderate/heavy alcohol use and HCV infection among injection drug users in two Russian cities 
Drug and alcohol dependence  2013;132(3):571-579.
In Russia, injection drug use and transmission of blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are inextricably linked, however the burden of alcohol use remains unexplored among injection drug users (IDUs).
Individuals who were 18 years of age and older and had injected drugs in the previous 30 days were recruited in the cities of Novosibirsk and Ivanovo by respondent driven sampling. Consenting individuals were administered a quantitative survey instrument and provided blood samples for serological testing.
In Novosibirsk and Ivanovo, 29% and 35% of respondents were categorized as moderate/heavy drinkers respectively. Individuals reported problems related to alcohol use that affected their physical health (23%), family (55%), and induced financial hardships (43%). In the multivariate analysis, we found that methamphetamine injection in the past 12 months was a strong and significant correlate of moderate/heavy drinking in Novosibirsk (aOR = 5.63 95% CI: [1.01–31.47]) and Ivanovo (aOR = 3.81 95% CI [2.20–6.62]). There was poor agreement between self-reported HCV status and HCV test results (kappa = −0.05 and 0.26 in Novosibirsk and Ivanovo respectively). IDUs who correctly knew their HCV seropositive status in Novosibirsk and IDUs who correctly knew their HCV seronegative status in Ivanovo were significantly more likely to be moderate/heavy drinkers.
Alcohol use is problematic among IDUs who are at high risk for HCV. Future interventions should target IDUs who are moderate/heavy drinkers in order to prevent liver complications resulting from HCV infection.
PMCID: PMC3770791  PMID: 23642314
Russia; Hepatitis C; Alcohol; injection drug use; methamphetamine
3.  Seroprevalence of HIV, Hepatitis B Virus, and Hepatitis C Virus among Injection Drug Users in Connecticut: Understanding Infection and Coinfection Risks in a Nonurban Population 
American journal of public health  2013;104(9):1713-1721.
We examined HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) seroprevalence in an interim analysis and the potential risk factors associated with these infections among injection drug users (IDUs) residing in nonurban communities of southwestern Connecticut.
We recruited and interviewed active adult IDUs about their injection-associated risk and conducted serological tests for HIV, HBV, and HCV. Regression analyses were performed to identify risk factors for infection and coinfection.
Among 446 participants, 51.6% carried at least 1 infection, and 16.3% were coinfected. Infection risk was associated with longer duration of injection use, overdose, substance abuse treatment, depression, and involvement with the criminal justice system. Coinfection was associated with longer injection drug use, lower education, overdose, and criminal justice involvement. Multivariate models identified injection drug use duration, substance abuse treatment, and criminal justice involvement as the most significant predictors of infection; injection drug use duration and education were the most significant predictors of coinfection.
Suburban IDUs are at significant risk for acquiring single and multiple viral infections. Effective harm reduction strategies are needed to reach users early. There might be roles for interventions in the treatment and justice systems in which IDUs interact.
PMCID: PMC3990658  PMID: 24134382
Drugs; Epidemiology; Hepatitis; HIV/AIDS; Prevention; Surveillance
4.  Hepatitis C virus seroprevalence among people who inject drugs and factors associated with infection in eight Russian cities 
BMC Infectious Diseases  2014;14(Suppl 6):S12.
Behavioural surveillance among people who inject drugs (PWID) and testing for hepatitis C virus (HCV) and HIV is needed to understand the scope of both epidemics in at-risk populations and to suggest steps to improve their health.
PWID were recruited using respondent-driven sampling (RDS) in eight Russian cities. A standardized survey was administered to collect sociodemographic and behavioral information. Blood specimens were obtained for serological testing for HCV and HIV-1. Data across the eight sites were pooled to identify individual-, network-, and city-level factors associated with positive HCV serostatus.
Among 2,596 PWID participating in the study, 1,837 tested positive for HCV (71%). The sample was 73% male and the mean age was 28. Very few PWID reported regular contact with harm reduction programs. Factors associated with testing positive for HCV were longer duration of injection drug use, testing positive for HIV-1, sharing non-syringe injection paraphernalia and water for rinsing syringes, and larger social network size. Factors negatively associated with HCV-positive serostatus were injecting with a used syringe and two city-level factors: longer mean RDS recruitment chain in a city and higher levels of injecting stimulants.
HCV prevalence in all eight Russian cities is at the higher end of the range of HCV prevalence among PWID in Europe, which provides evidence that more resources, better prevention programs, and accelerated treatment targeting PWID are needed to control the HCV epidemic.
PMCID: PMC4178532  PMID: 25253447
5.  Factors associated with hepatitis B vaccine series completion in a randomized trial for injection drug users reached through syringe exchange programs in three US cities 
BMC Public Health  2014;14(1):820.
Hepatitis B virus (HBV) is a vaccine preventable infection yet vaccination rates are low among injection drug users (IDUs) despite the high risk of infection and longstanding recommendations to promote vaccination. We sought to improve vaccination rates by reaching IDUs through syringe exchange programs (SEPs) in three U.S. cities.
IDUs were randomized in a trial comparing the standard HBV vaccination schedule (0, 1, and 6 months) to an accelerated schedule (0, 1, and 2 months) and participation data were analyzed to identify determinants of completion of the three-dose vaccine series. Independent variables explored included sociodemographics, injection and syringe access behaviors, assessment of health beliefs, HBV-associated knowledge, and personal health status.
Covariates associated with completion of the three-dose vaccine series were accelerated vaccine schedule (aOR 1.92, 95% CI 1.34, 2.58, p = <0.001), older age (aOR 1.05, 95% CI 1.03, 1.07, p = <0.001), and poorer self-rated health score (aOR 1.26, 95% CI 1.05, 1.5, p = 0.02). Completion was less likely for those getting syringes from SEP customers than for SEP customers (OR 0.33, 95% CI 0.19, 0.58, p = <0.001).
SEPs should offer hepatitis vaccination in a manner that minimizes time between first and last visits by accelerating the dosing schedule. Public health interventions should target younger, less healthy, and non-SEP customer participants. Other health interventions at SEPs may benefit from similar approaches that reach out beyond regular SEP customers.
PMCID: PMC4138371  PMID: 25107530
Hepatitis B; Vaccination; Syringe exchange programs; Injection drug users
6.  Collaboration or Coercion? Partnering to Divert Prescription Opioid Medications 
Diversion of prescription opioids is a widespread problem in the USA. While “doctor shopping” and pill brokering are well-described types of medication diversion, we sought to understand the social dynamic of diversion of prescription opioids and identify other diversion methods. Using qualitative data collected as part of a 12-week Rapid Assessment and Response study of prescription opioid overdose and abuse (the RARx Study) conducted in three communities in two New England states, we reviewed and thematically coded 195 interviews. Diversion took many forms: doctor shopping, pill brokering, and, most commonly, siphoning from the family medicine chest. Partnering—of patients with other “patients,” of patients with “caregivers”— to obtain prescription opioids was also described. Motivations for partnering indicated doing so out of fear of violence, for financial benefit, or in exchange for transportation or other services. Partnering for prescription opioids exhibited a range of power differentials, from collaboration to coercion, and tended to involve vulnerable populations such as the elderly, disabled, or destitute. Increased awareness among health providers of the ease of access and diversion of prescription opioids is needed to promote patient safety and prevent interpersonal violence.
PMCID: PMC3732688  PMID: 23371052
Diversion; Prescription opioid abuse; Overdose; Elder abuse
7.  HIV transmission from drug injectors to partners who do not inject, and beyond: Modelling the potential for a generalized heterosexual epidemic in St. Petersburg, Russia☆ 
Drug and alcohol dependence  2013;133(1):242-247.
HIV infection is prevalent among drug injectors in St. Petersburg and their non-injecting heterosexual partners (PIDUs). There are fears that sexual transmission of HIV from IDUs to PIDUs may portend a self-sustaining, heterosexual epidemic in Russia.
Our model combines a network model of sexual partnerships of IDUs and non-IDUs to represent sexual transmission of HIV and a deterministic model for parenteral transmission among IDUs. Behavioural parameters were obtained from a survey of St. Petersburg IDUs and their sexual partners. We based our model fits on two scenarios for PIDU prevalence in 2006 (5.6% and 15.1%, calculated excluding and including HCV co-infected PIDUs respectively) and compared predictions for the general population HIV prevalence.
Results indicate that sexual transmission could sustain a non-IDU HIV epidemic. The model indicates that general population prevalence may be greater than current estimates imply. Parenteral transmission drives the epidemic and the PIDU bridge population plays a crucial role transferring infection to non-IDUs. The model indicates that the high PIDU prevalence is improbable because of the high risk behaviour this implies; the lower prevalence is possible.
The model implies that transmission through PIDUs will sustain a heterosexual epidemic, if prevalence among IDUs and PIDUs is as high as survey data suggest. We postulate that current estimates of population prevalence underestimate the extent of the HIV epidemic because they are based on the number of registered cases only. Curtailing transmission among injectors and PIDUs will be vital in controlling heterosexual transmission.
PMCID: PMC4113725  PMID: 23692991
Injecting drug users; Mathematical model; Heterosexual transmission; Surveillance; Russia; Partners of IDUs
8.  Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia 
To assess risk for unintended pregnancy, this study describes the correlates of unprotected sexual intercourse (UPSI) among women who inject illicit drugs or who have sexual partners who inject drugs in St Petersburg, Russia.
Data from a cross-sectional survey and biological test results collected between 2005 and 2008 from 202 Russian women (143 drug injectors and 59 non-drug injectors) were analysed. Multivariate regression was used to investigate the correlates of UPSI occurring at the women’s last sexual act. Independent variables included socio-demographics, age at sexual debut, first sexual encounter perceived as involuntary, number of pregnancies and number of children for which the participant is the primary caretaker, heavy sporadic drinking (i.e. consuming more than five drinks in 2 hours at least twice a month), at-risk drinking per the Alcohol Use Disorder Identification Test (AUDIT-C) score, and sexually transmitted infections (HIV-1, syphilis serology, Chlamydia trachomatis and Neisseria gonorrheae).
Sixty-seven percent of women reported UPSI at last intercourse. UPSI was independently associated with heavy sporadic drinking [odds ratio (OR) 2.8, 95% CI 1.2–6.6] and having been pregnant (OR 2.25, 95% CI 1.1–4.6).
Despite the high risk for HIV acquisition or transmission and unintended pregnancy, condom use among the study population is low. Programmes to investigate and improve contraceptive use, including condom use, among this vulnerable group of women are needed. Such programmes may require identifying and targeting female reproductive health concerns and problem drinking, particularly heavy sporadic drinking, rather than conventional measures of alcohol misuse.
PMCID: PMC4111630  PMID: 23377534
9.  Patterns of new drug emergence: A comment in light of ‘krokodil’ 
PMCID: PMC4108988  PMID: 23827763
10.  Pharmacies as providers of expanded health services for people who inject drugs: a review of laws, policies, and barriers in six countries 
People who inject drugs (PWID) are underserved by health providers but pharmacies may be their most accessible care settings.
Studies in the U.S., Russia, Vietnam, China, Canada and Mexico employed a three-level (macro-, meso-, and micro-) model to assess feasibility of expanded pharmacy services for PWID. Studies employed qualitative and quantitative interviews, review of legal and policy documents, and information on the knowledge, attitudes, and practices of key stakeholders.
Studies produced a mixed assessment of feasibility. Provision of information and referrals by pharmacies is permissible in all study sites and sale and safe disposal of needles/syringes by pharmacies is legal in almost all sites, although needle/syringe sales face challenges related to attitudes and practices of pharmacists, police, and other actors. Pharmacy provision of HIV testing, hepatitis vaccination, opioid substitution treatment, provision of naloxone for drug overdose, and abscess treatment, face more serious legal and policy barriers.
Challenges to expanded services for drug users in pharmacies exist at all three levels, especially the macro-level characterized by legal barriers and persistent stigmatization of PWID. Where deficiencies in laws, policies, and community attitudes block implementation, stakeholders should advocate for needed legal and policy changes and work to address community stigma and resistance. Laws and policies are only as good as their implementation, so attention is also needed to meso- and micro- levels. Policies, attitudes, and practices of police departments and pharmacy chains as well as knowledge, attitudes, and practices of individual PWID, individual pharmacies, and police officers should support rather than undermine positive laws and expanded services. Despite the challenges, pharmacies remain potentially important venues for delivering health services to PWID.
PMCID: PMC4070647  PMID: 24938376
11.  Clients of street-based female sex workers and potential bridging of HIV/STI in Russia: Results of a pilot study 
AIDS care  2012;24(5):665-672.
In Russia, sexual transmission of HIV is increasing and street-based female sex workers (FSW) have a high HIV prevalence, but the role of male clients of FSW in HIV transmission and bridging to the general population has not been studied. Sixty-two male clients completed structured interviews during February-March of 2010 in St. Petersburg Russia. Descriptive analyses focused on condom use with different types of sex partners, substance use, and STI/HIV testing histories. The median lifetime and past 12 month numbers of FSW partners were 10 and 3, respectively. A majority of clients (74%) reported having non-FSW partners during the past 12 months, and nearly half (47%) reported having regular sex partners. Consistent condom use was reported in 61% of relationships with FSW partners and in 43% of relationships with non-FSW partners. A majority of clients (58%) was classified as active or potential bridgers based on having both FSW and non-FSW partners and reporting inconsistent condom use with their non-FSW partners. A majority (61%) also reported concurrent partnerships with FSW and non-FSW partners. Nearly half (48%) of last contacts with FSW partners involved consumption of alcohol by the client. Non-injection and injection drug use in the past 30 days were reported by 15% and 7% of clients, respectively. Twenty-nine percent reported history of an STI and 74% reported a previous HIV test; active/potential bridgers were significantly less likely than unlikely bridgers to have ever been tested for HIV. These data signal the potential for HIV/STI transmission among male clients of street-based FSW in St. Petersburg Russia due to their variety of partner types, sub-optimal condom use, and concurrent partnerships. Larger studies are needed to confirm these findings, further explore the roles of alcohol and drug use, and identify effective strategies and interventions for HIV prevention.
PMCID: PMC4009684  PMID: 22292804
HIV; bridging; female sex workers; clients; Russia
12.  Short Communication: HIV Prevalence and Risk Behavior Among Injection Drug Users and Their Sex Partners in Two Russian Cities 
The HIV epidemic in Russia remains concentrated mostly among injection drug users (IDUs). Little is known about the extent to which sexual partnerships are the bridge between IDUs and the general population and create the potential for generalizing the epidemic. IDUs in two Russian cities, Novosibirsk and Ivanovo (N=593), were recruited via respondent-driven sampling. A modified one-step snowball strategy was used to recruit IDU's sex partners who do not themselves use drugs (PIDU, N=82). Sexual behaviors of all participants were assessed using an interviewer-administered questionnaire. All participants provided blood specimens for HIV and hepatitis C virus (HCV) testing. HIV and HCV prevalence among IDUs was 34.0% and 44.4% in Ivanovo and 3.8% and 54.3% in Novosibirsk. HIV prevalence among PIDUs was 6.8% in Ivanovo and 8.7% in Novosibirsk. In both cities large proportions of IDUs reported sexual partnerships with non-IDUs—49.7% in Ivanovo vs. 62.7% in Novosibirsk (p≤0.001) and fewer than one in four IDUs reported constant condom use in such partnerships. This pilot study shows that two IDU populations with a significantly different HIV prevalence both form sexual partnerships with non-IDUs and practice unsafe sexual behavior within such types of partnerships. However, the proportion of PIDUs who form partnerships with other non-IDUs that therefore could lead to a generalization of the epidemic is very different between the two cities and this difference needs to be considered when estimating the spread of HIV into the general population. Unsafe sexual behavior and HIV testing should be specific targets for prevention activities for IDUs and their sex partners in Russia.
PMCID: PMC3607905  PMID: 23186172
13.  Drug users in Hanoi, Vietnam: factors associated with membership in community-based drug user groups 
A syndemic conjoins injection drug use, incarceration, and HIV in Vietnam, where there is a need for programs that empower people who use drugs to minimize the harms thereby produced. Here we present a post-hoc evaluation of the organizing efforts of the Centre for Supporting Community Development Initiatives (SCDI) with two community-based drug user groups (CBGs) in Hanoi.
Members (n = 188) of the CBGs were compared to non-member peers (n = 184) on demographic, psychosocial, behavioral and knowledge variables using a face-to-face structured interview that focused on issues of quality of life and harm reduction. Bivariate analyses were conducted, and variables significantly associated with membership at p < 0.10 were included in a multivariate model.
Variables associated with membership in the CBGs in the multivariate model included increased self-efficacy to get drug-related health care (OR 1.59, 1.24-2.04), increased quality of life in the psychological (OR 2.04, 1.07-3.93) and environmental (OR 2.54, 1.31-4.93) domains, and greater history of interactions with police about drugs (OR 3.15, 1.79-5.52). There was little difference between members and non-members on injection-related harms except in the domain of knowledge about opioid overdose. Among the 114 current injectors (30.6% of the sample), low rates of unsafe injection practices were reported, and low statistical power limited the ability to conclusively assess association with membership.
Although the CBG members displayed higher levels of well-being and access to healthcare than non-members, further longitudinal study is required to determine if these are a result of membership. The CBGs should pay more attention towards meeting challenges in responding to specific health issues of those who continue to use drugs including HIV, hepatitis, and drug overdose.
PMCID: PMC4176489  PMID: 24268108
Injection drug use; Harm reduction; Self-efficacy; Vietnam; Drug user groups; HIV; Hepatitis; Overdose; Quality of life
14.  The Feasibility of HIV Vaccine Efficacy Trials among Russian Injection Drug Users 
Vaccine  2007;25(41):7014-7016.
IDU exposure remains a primary driver of the Russian HIV epidemic, and recent incidence data provide little evidence that this epidemic is slowing. While there are multiple important challenges that need to be further explored before starting vaccine trials, most importantly access to evidence-based drug treatment services for trial participants, the current context of high HIV incidence and low genetic diversity of HIV strains, suggests the need for intensified prevention strategies and supports the feasibility of mounting efficacy trials of HIV vaccines among IDUs in the Russian Federation.
PMCID: PMC3747029  PMID: 17707960
HIV; Injection Drug use; St. Petersburg; Molecular Epidemiology; Vaccines
15.  Individual-level, network-level and city-level factors associated with HIV prevalence among people who inject drugs in eight Russian cities: a cross-sectional study 
BMJ Open  2013;3(6):e002645.
To ascertain HIV prevalence among people who inject drug (injection drug users (IDUs)) in the Russian Federation and identify explanations for the disparity in different cities.
Cross-sectional survey with serological testing for HIV and hepatitis C virus prevalent infections.
8 Russian cities—Irkutsk, Omsk, Chelyabinsk, Yekaterinburg, Naberezhnye Chelny, Voronezh, Orel and St Petersburg.
In 2007–2009 active IDUs were recruited by respondent-driven sampling with a target sample size of 300 or more in each city.
Main outcome measures
Participants were administered a questionnaire covering sociodemographics, injection risk and protective behaviours, sexual behaviours, HIV knowledge, experiences with drug treatment and harm reduction programmes and social networks. Participants were tested for HIV and hepatitis C by enzyme immunoassay. Data were analysed to identify individual-level, network-level and city-level characteristics significantly associated with HIV prevalence. Factors significant at p≤0.1 were entered into a hierarchical regression model to control for multicollinearity.
A total of 2596 active IDUs were recruited, interviewed and tested for HIV and hepatitis C virus infection. HIV prevalence ranged from 3% (in Voronezh) to 64% (in Yekaterinburg). Although individual-level and network-level variables explain some of the difference in prevalence across the eight cities, the over-riding variable that seems to account for most of the variance is the emergence of commercial, as opposed to homemade, heroin as the predominant form of opioid injected.
The expansion of commercial heroin markets to many Russian cities may have served as a trigger for an expanding HIV epidemic among IDUs in that country.
PMCID: PMC3686233  PMID: 23794559
Public Health
16.  Access to syringes for HIV prevention for injection drug users in St. Petersburg, Russia: syringe purchase test study 
BMC Public Health  2013;13:183.
The HIV epidemic in Russia is concentrated among injection drug users (IDUs). This is especially true for St. Petersburg where high HIV incidence persists among the city’s estimated 80,000 IDUs. Although sterile syringes are legally available, access for IDUs may be hampered. To explore the feasibility of using pharmacies to expand syringe access and provide other prevention services to IDUs, we investigated the current access to sterile syringes at the pharmacies and the correlation between pharmacy density and HIV prevalence in St. Petersburg.
965 pharmacies citywide were mapped, classified by ownership type, and the association between pharmacy density and HIV prevalence at the district level was tested. We selected two districts among the 18 districts – one central and one peripheral – that represented two major types of city districts and contacted all operating pharmacies by phone to inquire if they stocked syringes and obtained details about their stock. Qualitative interviews with 26 IDUs provided data regarding syringe access in pharmacies and were used to formulate hypotheses for the pharmacy syringe purchase test wherein research staff attempted to purchase syringes in all pharmacies in the two districts.
No correlation was found between the density of pharmacies and HIV prevalence at the district level. Of 108 operating pharmacies, 38 (35%) did not sell syringes of the types used by IDUs; of these, half stocked but refused to sell syringes to research staff, and the other half did not stock syringes at all. Overall 70 (65%) of the pharmacies did sell syringes; of these, 49 pharmacies sold single syringes without any restrictions and 21 offered packages of ten.
Trainings for pharmacists need to be conducted to reduce negative attitudes towards IDUs and increase pharmacists’ willingness to sell syringes. At a structural level, access to safe injection supplies for IDUs could be increased by including syringes in the federal list of mandatory medical products sold by pharmacies.
PMCID: PMC3616994  PMID: 23452390
Injection drug use; HIV prevention; Syringe access; Pharmacy
17.  Age at First Alcoholic Drink as Predictor of Current HIV Sexual Risk Behaviors Among a Sample of Injection Drug Users (IDUs) and Non-IDUs who are Sexual Partners of IDUs, in St. Petersburg, Russia 
AIDS and Behavior  2012;16(6):1597-1604.
This study investigates whether age at first alcoholic drink is associated with sexual risk behaviors among injection drug users (IDUs) and non-IDUs who are sexual partners of IDUs in St. Petersburg, Russia. A path analysis was used to test a model of age at first drink, age at sexual debut, age at first drug use, current substance use patterns and current sexual risk behaviors among 558 participants. Results revealed that age at first drink had an effect on multiple sex partners through age at sexual debut and injection drug use, but no effect on unprotected sex. Age at first drug use was not related to sexual risk behaviors. Investigation of age of drinking onset may provide useful information for programs to reduce sexual risk behaviors and injection drug use. Different paths leading to unprotected sex and multiple sexual partners call for different approaches to reduce sexual risk behaviors among this population.
PMCID: PMC3320686  PMID: 21800183
Age at first alcoholic drink; HIV sexual risks; IDU; Russia; Age at first drug use; Sexual debut
18.  Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997 – 2007 
Drug and alcohol dependence  2010;115(3):221-228.
The leading cause of injury death among adults in Connecticut (CT), USA is drug poisonings. We analyzed the epidemiology and geographic distribution of opioid-involved accidental drug-involved intoxication deaths (“overdoses”) in CT over an 11-year period.
We reviewed data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner (OCME). Regression analyses were conducted to uncover risk factors for fatal opioid-involved intoxications and to compare heroin- to prescription opioid- and methadone-involved deaths. Death locations were mapped to visualize differences in the geographic patterns of overdose by opioid type.
Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Trends over time revealed increases in total opioid-related deaths although heroin-related deaths remained constant. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities.
The epidemiology of fatal opioid overdose in CT exhibits distinct longitudinal, risk factor, and geographic differences by opioid type. Each of these trends has implications for public health and prevention efforts.
PMCID: PMC3095753  PMID: 21131140
overdose; opioid; mortality; prescription opioid; heroin
19.  Sub-populations of illicit drug users reached by targeted street outreach and respondent driven sampling strategies: Implications for research and public health practice 
Annals of epidemiology  2011;21(4):280-289.
To determine whether illicit drug users recruited through Respondent-Driven Sampling (RDS) and targeted street outreach (TSO) differ by comparing two samples recruited concurrently with respect to sample selection and potential recruitment biases.
217 heroin, crack, and cocaine users aged 18-40 were recruited through TSO in New York City (2006-2009). 46 RDS seeds were recruited similarly and concurrently yielding a maximum of 14 recruitment waves and 357 peer recruits. Baseline questionnaires ascertained sociodemographic, drug use, and drug network characteristics. Descriptive statistics and log-binomial regression were used to compare RDS and TSO samples.
RDS recruits were more likely to be male (prevalence ratio [PR]:1.28), Hispanic (PR:1.45), black (PR:1.58), older (PR:1.02), homeless (PR:1.19), and crack users (PR:1.37). RDS recruited fewer injectors (PR:0.35) and heroin users (PR:0.74). Among injectors, RDS recruits injected less frequently (PR:0.77) and were less likely to use Needle Exchange Programs (PR:0.35).
These data suggest that RDS and TSO strategies reach different sub-groups of drug users. Understanding the differing capabilities of each recruitment strategy will enable researchers and public health practitioners to select an appropriate recruitment tool for future research and public health practice.
PMCID: PMC3062521  PMID: 21376275
Respondent Driven Sampling; Targeted Street Outreach; HIV; illicit drug users; sampling bias
20.  The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs 
Addiction (Abingdon, England)  2010;106(2):357-365.
To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs).
A national survey of US SEPs.
A total of 111 program managers (representing 59% of all US SEPs).
Program manager self-report.
With overall interference profiles ranging from systematic to totally interference-free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients’ syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction’s syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving pre-dominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients.
Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence-based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control’s new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.
PMCID: PMC3088513  PMID: 21054615
Criminal justice system; HIV; injection drug use; policy interventions; racial disparities; structural barriers; structural interventions; syringe access; syringe exchange programs
21.  Survival of Hepatitis C Virus in Syringes: Implication for Transmission among Injection Drug Users 
The Journal of infectious diseases  2010;202(7):984-990.
We hypothesized that the high prevalence of HCV among injection drug users (IDUs) might be due to prolonged virus survival in contaminated syringes.
We developed a microculture assay to examine the viability of HCV. Syringes were loaded with blood spiked with HCV reporter virus (Jc1/GLuc2A) to simulate two scenarios of residual volumes; low (2 μl) void volume for 1-ml insulin syringes, and high (32 μl) void volume for 1-ml tuberculin syringes. Syringes were stored at 4°C, 22°C, and 37°C for up to 63 days before testing for HCV infectivity using luciferase activity.
The virus decay rate was biphasic (t½ α = 0.4h and t½β = 28h). Insulin syringes failed to yield viable HCV beyond day one at all storage temperatures except for 4o in which 5% of syringes yielded viable virus on day 7. Tuberculin syringes yielded viable virus from 96%, 71%, and 52% of syringes following storage at 4o, 22° and 37o for 7 days, respectively, and yielded viable virus up to day 63.
The high prevalence of HCV among IDUs may be partly due to the resilience of the virus and the syringe type. Our findings may be used to guide prevention strategies.
PMCID: PMC2932767  PMID: 20726768
Hepatitis C virus; injection drug users; syringes; survival; transmission; luciferase activity
22.  Clostridium difficile Infection in Outpatients, Maryland and Connecticut, USA, 2002–2007 
Emerging Infectious Diseases  2011;17(10):1946-1949.
Clostridium difficile, the most commonly recognized diarrheagenic pathogen among hospitalized persons, can cause outpatient diarrhea. Of 1,091 outpatients with diarrhea, we found 43 (3.9%) who were positive for C. difficile toxin. Only 7 had no recognized risk factors, and 3 had neither risk factors nor co-infection with another enteric pathogen.
PMCID: PMC3310666  PMID: 22000379
Clostridium difficile; diarrhea; outpatient; enteric; pathogen; bacteria; Maryland; Connecticut; United States; dispatch
23.  Prevalence and predictors of transitions to and away from syringe exchange use over time in 3 US cities with varied syringe dispensing policies 
Drug and alcohol dependence  2010;111(1-2):74-81.
Syringe exchange programs (SEPs) can reduce HIV risk among injecting drug users (IDUs) but their use may depend heavily on contextual factors such as local syringe policies. The frequency and predictors of transitioning over time to and from direct, indirect, and non-use of SEPs are unknown. We sought, over one year, to: (1) quantify and characterize transition probabilities of SEP attendance typologies; (2) identify factors associated with (a) change in typology, and (b) becoming and maintaining direct SEP use; and (3) quantify and characterize transition probabilities of SEP attendance before and after changes in policy designed to increase access. Using data collected from 583 IDUs participating in a three-city cohort study of SEPs, we conducted a latent transition analysis and multinomial regressions. Three typologies were detected: Direct SEP users, Indirect SEP users and Isolated IDUs. Transitions to direct SEP use were most prevalent. Factors associated with becoming or maintaining direct SEP use were female sex, Latino ethnicity, fewer injections per syringe, homelessness, recruitment city, injecting speedballs (cocaine and heroin), and police contact involving drug paraphernalia possession. Similar factors influenced transitions in the syringe policy change analysis. Policy change cities experienced an increase in Indirect SEP users (43% to 51%) with little increased direct use (29% to 31%). We found that, over time, IDUs tended to become Direct SEP users. Policies improving syringe availability influenced SEP use by increasing secondary syringe exchange. Interactions with police around drug paraphernalia may encourage SEP use for some IDUs and may provide opportunities for other health interventions.
PMCID: PMC3087197  PMID: 20537814
syringe exchange; injecting drug use; HIV/AIDS; longitudinal study; latent transition analysis
24.  Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States 
Addiction (Abingdon, England)  2008;103(6):979-989.
This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose–response in the United States.
Design and participants
Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62).
US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico.
Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics.
Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t60 = 3.76, P < 0.001) and instances where naloxone was indicated (t59 = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0).
Results suggest that naloxone training programs in the United States improve participants’ ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.
PMCID: PMC3163671  PMID: 18422830
Cocaine; harm reduction; injection drug use; naloxone distribution; opioids; overdose
25.  Patterns of drug use and abuse among aging adults with and without HIV: A latent class analysis of a US Veteran cohort* 
Drug and alcohol dependence  2010;110(3):208-220.
This study characterized the extent and patterns self-reported drug use among aging adults with and without HIV, assessed differences in patterns by HIV status, and examined pattern correlates. Data derived from 6351 HIV infected and uninfected adults enrolled in an eight-site matched cohort, the Veterans Aging Cohort Study (VACS). Using clinical variables from electronic medical records and sociodemographics, drug use consequences, and frequency of drug use from baseline surveys, we performed latent class analyses (LCA) stratified by HIV status and adjusted for clinical and socio-demographic covariates. Participants were, on average, age 50 (range 22–86), primarily male (95%) and African-American (64%). Five distinct patterns emerged: non-users, past primarily marijuana users, past multidrug users, current high consequence multidrug users, and current low consequence primarily marijuana users. HIV status strongly influenced class membership. Non -users were most p revalent among HIV uninfected (36.4%) and current high consequence multidrug users (25.5%) were most prevalent among HIV infected. While problems of obesity marked those not currently u sing drugs, current users experienced higher prevalences of medical or mental health disorders. Multimorbidity was highest among past and current multidrug users. HIV-infected participants were more likely than HIV-uninfected participants to be current low consequence primarily marijuana users. In this sample, active drug use and abuse were common. HIV infected and uninfected Veterans differed on extent and patterns of drug use and on important characteristics within identified classes. Findings have the potential to inform screening and intervention efforts in aging drug users with and without HIV.
PMCID: PMC3087206  PMID: 20395074
aging; Veterans; HIV; substance-related disorders; latent class analysis; illicit drugs; cohort studies

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