Multiple injections per injection episode: High-risk injection practice among people who injected pills during the 2015 HIV outbreak in Indiana

Broz, Dita; Zibbell, Jon E.; Foote, C.E.; Roseberry, Jeremy C.; Patel, Monita R.; Conrad, Caitlin; Chapman, Erika; Peters, Philip J.; Needle, Richard; McAlister, Cameron; Duwve, Joan

doi:10.1016/j.drugpo.2017.12.003

Cited by 59 publications

(48 citation statements)

References 17 publications

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“…It is hoped that such properties may improve public health by deterring progression to snorting, smoking, and injecting. However, rapid displacement of nonabuse deterrent opioids may influence the use of illicitly manufactured drugs (eg, heroin) or drive people to riskier forms of injection …”

Section: Discussionmentioning

confidence: 99%

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Causal inference for evaluating prescription opioid abuse using trend‐in‐trend design

Dasgupta

Schwarz

Hennessy

et al. 2019

Pharmacoepidemiology and Drug

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Purpose One response to the opioid crisis in the United States has been the development of opioid analgesics with properties intended to reduce non‐oral use. Previous evaluations of abuse in the community have relied on population averaged interrupted time series Poisson models with utilization offsets. However, competing interventions and secular trends complicate interpretation of time‐series analyses. An alternative research design, trend‐in‐trend, accounts for heterogeneity in per capita opioid dispensing and unmeasured time‐varying confounding, which provides a causal evaluation, provided that underlying assumptions are met. Methods Trend‐in‐trend can be modeled using a logistic regression framework. In logistic regression, exposure was any product‐specific outpatient dispensing by three‐digit ZIP code and calendar quarter, for 22 opioids. The outcome was any product‐specific abuse case ascertained from poison centers and drug treatment programs, covering 94% of the US population, between July 2009 and December 2016. Product‐specific odds ratios compared places without dispensing with places with any dispensing; the causal contrast represents the odds of product‐specific abuse in the community given exposure. Results Dispensing of new and low‐volume opioids varied considerably across the country, with no region showing high of all products. Of 22 opioids analyzed, the three with approved labeling as intended to deter abuse ranked near the lowest in both absolute (population‐adjusted rates: 1.7, 0.9, and 8.2 per million people per quarter, respectively) and relative measures (trend‐in‐trend ORs: 1.96, 1.79, 1.69, respectively). Conclusions Postmarketing studies of prescription opioid abuse may benefit by evolving from unadjusted surveillance rates to a causal inference approach.

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Section: Discussionmentioning

confidence: 99%

“…However, rapid displacement of nonabuse deterrent opioids may influence the use of illicitly manufactured drugs (eg, heroin) or drive people to riskier forms of injection. 7,53 Abbreviations: ZIP, zone improvement plan.…”

Section: Discussionmentioning

confidence: 99%

Causal inference for evaluating prescription opioid abuse using trend‐in‐trend design

Dasgupta

Schwarz

Hennessy

et al. 2019

Pharmacoepidemiology and Drug

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“…In Scott County, Indiana, between 2014 and 2015, 181 people were diagnosed with HIV infection in a county that had seen only 5 diagnoses from 2004 to 2013. Eighty-eight of those diagnosed reported injection use of extended-release oxymorphone which may be crushed, dissolved, and cooked (42,43).…”

Section: Discussionmentioning

confidence: 99%

Heroin Type, Injecting Behavior, and HIV Transmission. A Simulation Model of HIV Incidence and Prevalence

Bobashev

Mars

Murphy

et al. 2019

Preprint

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Background and Aims. Using mathematical modeling to illustrate and predict how different heroin source-forms: "black tar" (BTH) and powder heroin (PH) can affect HIV transmission in the context of contrasting injecting practices. By quantifying HIV risk by these two heroin source-types we show how each affects the incidence and prevalence of HIV over time. From 1997 to 2010 PH reaching the United States was manufactured overwhelmingly by Colombian suppliers and distributed in the eastern states of the United States. Recently Mexican cartels that supply the western U.S. states have started to produce PH too, replacing Colombian distribution to the east. This raises the possibility that BTH in the western U.S. may be replaced by PH in the future.Design. We used an agent-based model to evaluate the impact of use of different heroin formulations in high-and low-risk injecting drug user populations who use different types of syringes (high vs. low dead space) and injecting practices. We obtained model parameters from peer-reviewed publications and ethnographic research.Results. Heating of BTH, additional syringe rinsing, and subcutaneous injection can substantially decrease the risk of HIV transmission. Simulation analysis shows that HIV transmission risk may be strongly affected by the type of heroin used. We reproduced historic differences in HIV prevalence and incidence. The protective effect of BTH is much stronger in high-risk compared with low-risk populations. Simulation of future outbreaks show that when PH replaces BTH we expect a long-term overall increase in HIV prevalence. In a population of injectors with mixed low-and high-risk clusters we find that local HIV outbreaks can occur even when the overall prevalence and incidence are low. The results are dependent on evidencesupported assumptions. Conclusions.The results support harm-reduction measures focused on a reduction in syringe sharing and promoting protective measures of syringe rinsing and drug solution heating.

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“…Furthermore, the components of hydromorphone-CR capsules that provide the controlled release, increase survival of HIV (19) and Staphylococcus aureus (12), which cause the vast majority of IE cases (7). Moreover, residual drug remains in cookers and filters after an initial injection, allowing PWID to resolubilize the remaining drug and conduct multiple injections (11,14,16,19,20) (Fig. 1).…”

Section: Introductionmentioning

confidence: 99%

“…1). This high-risk practice of multiple injections, involves keeping, sharing and reusing injection drug preparation equipment (IDPE), which increases infections among PWID (14,16,20). However, studies have also found that heating the injectate before injection of hydromorphone-CR can significantly reduce the inoculum of bacteria causing IE (12).…”

Section: Introductionmentioning

confidence: 99%

Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

Shah

Wong

Ball

et al. 2020

Preprint

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Background: The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. Details of injection practices leading to IE are not well characterized.Methods: A case-control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3 months, were > 18 years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls were recruited from outpatient clinics in patients without IE and addiction clinics in London, Ontario. Results: 33 cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Using clean injection equipment from the provincial distribution network was a protective factor against IE (p<0.001). Furthermore, using lighters during the injection process was also protective for IE (OR 2.5; 95% CI 1.11–5.63). Female sex (OR 3.63; 95% CI 1.58-8.36) and injection into multiple sites (OR 4.31; 95% CI 1.33-13.93) were associated with IE. Injection into the feet (57.6% cases; 36.6% control; p= 0.034) was also associated with IE. Discussion: Our pilot study highlights the importance of distributing clean injection materials for IE prevention. Injection into multiple areas may indicate a greater difficulty in accessing common and safer injection sites such as the arm, and thus multi-site injections may be a surrogate marker for injection-related venous damage in entrenched drug users. Moreover, the use of lighters may be correlated with the best practice of heating preparations of drugs prior to injection, which is known to reduce bacterial burden. Lastly, gender differences in injection techniques, which may place women at higher risk of IE, requires further study.

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Multiple injections per injection episode: High-risk injection practice among people who injected pills during the 2015 HIV outbreak in Indiana

Cited by 59 publications

References 17 publications

Causal inference for evaluating prescription opioid abuse using trend‐in‐trend design

Causal inference for evaluating prescription opioid abuse using trend‐in‐trend design

Heroin Type, Injecting Behavior, and HIV Transmission. A Simulation Model of HIV Incidence and Prevalence

Risk Factors Of Infective Endocarditis In Persons Who Inject Drugs

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