Drug overdose is now the leading cause of injury death in the United States. Most overdose fatalities involve opioids, which include prescription medication, heroin, and illicit fentanyl. Current data reveal that the overdose crisis affects all demographic groups and that overdose rates are now rising most rapidly among African Americans. We provide a public health perspective that can be used to mobilize a comprehensive local, state, and national response to the opioid crisis. We argue that framing the crisis from a public health perspective requires considering the interaction of multiple determinants, including structural factors (eg, poverty and racism), the inadequate management of pain, and poor access to addiction treatment and harmreduction services (eg, syringe services). We propose a novel ecological framework for harmful opioid use that provides multiple recommendations to improve public health and clinical practice, including improved data collection to guide resource allocation, steps to increase safer prescribing, stigma-reduction campaigns, increased spending on harm reduction and treatment, criminal justice policy reform, and regulatory changes related to controlled substances. Focusing on these opportunities provides the greatest chance of making a measured and sustained impact on overdose and related harms.
Drug paraphernalia and prescription laws make syringe exchange programs (SEPs) illegal in most states in the U.S. Nonetheless, SEPs have been started in 25 states and the District of Columbia as of September 1995. In some states like California and New Jersey, SEPs have operated despite police arrest of volunteers and clients. We examine the impact of police action and threat on SEPs by comparing an underground syringe exchange site (SES) in West Oakland to a tolerated SES in the Fillmore neighborhood of San Francisco. The following data sources are utilized: demographic and service utilization data from Alameda County Exchange (ACE) in West Oakland and Prevention Point Needle and Syringe Exchange (PPNSE) in the Fillmore, San Francisco; demographic and syringe exchange utilization information collected from street-recruited samples of injection drug users (IDUs) in West Oakland and the Fillmore; and participant observation of SES in these two communities. We found that police action and the threat of police action in West Oakland decreased utilization of SEP by IDUs, limited the number and diversity of volunteers at SES, and inhibited the operation and expansion of SEP.
Giving and receiving injections is common among IDUs in the San Francisco Bay area. Qualitative and epidemiological studies are needed to understand better the infectious disease risks associated with giving and receiving injections. Interventions need to address these issues and provide practical solutions.
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