Substance Abuse Treatment Prevention and Policy

Background Interest in the health and well-being of university students has increased in the UK and Ireland in the past two decades as their numbers have grown. Recent high-profile deaths of students after using illicit drugs have highlighted the importance of the topic for policy makers. This scoping review maps the state of the existing literature evaluating use of illicit drugs in university students in the UK and Ireland. It aims to highlight research gaps and inform policy. Method We conducted a systematic search of papers related to psychoactive drug use in university students in the UK and Ireland published before August 2021. The 18 extracted study characteristics included author(s); year of publication; journal; location of data collection; study design; delivery method (e.g., online survey, in-person, postal survey); number of participants; response rate; participant course of study, year of study, degree level (i.e., undergraduate, postgraduate), gender and age; time-period assessed (e.g., lifetime, current use, past 12 months); primary aim; primary outcome; ethical approval; and funding source. Results The PRISMA-guided search strategy identified 1583 papers for abstract review; of 110 papers retained for full-text review, 54 studies met criteria for inclusion for this paper. Primary outcomes were coded into five groups: prevalence and patterns of drug use; factors associated with drug use; attitudes and knowledge about, and motivation for, drug use; supply of drugs; consequences of drug use. The results show that there is no coherent body of research in this area. The prevalence of reported drug use has crept up and the range of substances reported has broadened over time, and attitudes to drugs on average have normalised. However, there are significant methodological limitations that limit the utility of these findings. There was little evidence of published work on prevention of, or intervention to reduce, drug-related harms. Conclusion The domains identified offer a framework for university administrators, researchers and policy makers to understand the potential response to drug use in university students in the UK and Ireland. Recommendations are made to fill the gaps in the research evidence base.

Background: Chronic infection with the hepatitis C virus (HCV) is common in people with former or current injection drug use. Among the patients in the opioid substitution treatment (OST) program in Gothenburg, Sweden, more than 50% had been infected with HCV. However, many patients did not have any follow-up for their infection and the linkage to treatment could be improved. Methods: A model of care for HCV was introduced at an OST unit in Gothenburg, Sweden, in 2017. The aim was to increase testing and linkage to HCV treatment. A nurse and a medical doctor, both specialized in infectious diseases, performed on-site testing at the OST unit with transient liver elastography (Fibroscan) to evaluate the fibrosis stage and initiated HCV treatment. This study retrospectively reviewed the patients' medical records to assess information regarding participation in the model of care, hepatitis C status, linkage to treatment and treatment outcome. Results: Among the 225 patients enrolled in OST at baseline, 181 were still in the OST program at the end of study (December 31st, 2018). In total, 29 patients, most of whom did not attend the Clinic of Infectious Diseases, were referred to the model of care. By the end of study, 17 patients (100% of those treated) reached sustained virologic response. In parallel, an additional 19 patients got treatment directly at the Clinic of Infectious Diseases. Conclusion: Integrating HCV screening and examination in an OST unit successfully linked patients to treatment. However, not all patients received treatment. To reach the goal of eliminating HCV, different models of care are needed.

Background Supervised consumption sites (SCS) and overdose prevention sites (OPS) have been increasingly implemented in response to the ongoing overdose epidemic in Canada. Although there has been a dramatic increase in overdose deaths since the start of the SARS-CoV 2 (COVID-19) pandemic, little is known about how SCS access may have been affected by this pandemic. Therefore, we sought to characterize potential changes in access to SCS during the COVID-19 pandemic among people who use drugs (PWUD) in Vancouver, Canada. Methods Between June and December 2020, data were collected through the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), two cohort studies involving people who use drugs. Multivariable logistic regression was used to examine individual, social and structural factors associated with self-reported reduced frequency of SCS/OPS use since COVID-19. Results Among 428 participants, 223 (54.7%) self-identified as male. Among all individuals surveyed, 63 (14.8%) reported a decreased frequency of use of SCS/OPS since COVID-19. However, 281 (66%) reported that they “did not want to” access SCS in the last 6 months. In multivariable analyses, younger age, self-reported fentanyl contamination of drugs used and reduced ease of access to SCS/OPS since COVID-19 were positively associated with a decreased frequency of use of SCS/OPS since COVID-19 (all p < 0.05). Conclusions Approximately 15% of PWUD who accessed SCS/OPS reported reduced use of these programs during the COVID-19 pandemic, including those at heightened risk of overdose due to fentanyl exposure. Given the ongoing overdose epidemic, efforts must be made to remove barriers to SCS access throughout public health crises.

Background Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care. Methods We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment. Results Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities. Conclusions Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.

Background Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs. Methods Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically. Results TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk. Conclusions This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.

Background Young people are disproportionately more likely than other age groups to use substances. The rise in substance use and related harms, including overdose, during the Covid-19 pandemic has created a critical need for more innovative and accessible substance use interventions. Digital interventions have shown effectiveness and can provide more engaging, less stigmatizing, and accessible interventions that meet the needs of young people. This review provides an overview of recent literature on the nature of recently published digital interventions for young people in terms of technologies used, substances targeted, intended outcomes and theoretical or therapeutic models employed. Methods Rapid review methodology was used to identify and assess the literature on digital interventions for young people. An initial keyword search was conducted using MEDLINE the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA) and PROSPERO for the years 2015–2020, and later updated to December 2021. Following a title/abstract and full-text screening of articles, and consensus decision on study inclusion, the data extraction process proceeded using an extraction grid developed for the study. Data synthesis relied on an adapted conceptual framework by Stockings, et al. that involved a three-level treatment spectrum for youth substance use (prevention, early intervention, and treatment) for any type of substance. Results In total, the review identified 43 articles describing 39 different digital interventions. Most were early interventions (n = 28), followed by prevention interventions (n = 6) and treatment interventions (n = 5). The identified digital technologies included web-based (n = 14), game-based (n = 10), mobile-based (n = 7), and computer-based (n = 5) technologies, and virtual reality (n = 3). Most interventions targeted alcohol use (n = 20) followed by tobacco/nicotine (n = 5), cannabis (n = 2), opioids (n = 2), ketamine (1) and multiple, or any substances (n = 9). Most interventions used a personalized or normative feedback approach and aimed to effect behaviour change as the intended outcome. Interestingly, a harm reduction approach guided only one of the 39 interventions. Conclusions While web-based interventions represented the most common type of technology, more recently developed immersive and interactive technologies such as virtual reality and game-based interventions call for further exploration. Digital interventions focused mainly on alcohol use, reflecting less concern for tobacco, cannabis, co-occurring substance use, and illicit drug use. Specifically, the recent exacerbation in the opioid crisis throughout North American underlines the urgent need for more prevention-oriented digital interventions for opioid use. The uptake of digital interventions among youth also depends on the incorporation of harm reduction approaches.

Background Promptly identifying individuals with addictive disorders reduces mortality and morbidity and improves quality of life. Although screening in primary care with the Screening, Brief Intervention and Referral Treatment strategy has been recommended since 2008, it remains underutilized. This may be due to barriers including lack of time, patient reluctance or perhaps the timing and approach for discussing addiction with their patients. Objective This study aims to explore and cross-analyze patient and addiction specialist experiences and opinions about early addictive disorder screening in primary care to identify interaction-related screening obstacles. Design and participants Qualitative study with purposive maximum variation sampling among nine addiction specialists and eight individuals with addiction disorders conducted between April 2017 and November 2019 in Val-de-Loire, France. Main Measures Using a grounded theory approach, verbatim data was collected from face-to-face interviews with addiction specialists and individuals with addiction disorders. These interviews explored their opinions and experiences with addiction screening in primary care. Initially, two independent investigators analyzed the coded verbatim according to the data triangulation principle. Secondly, convergences and divergences between addiction specialist and addict verbatim categories were identified, analyzed, and conceptualized. Key Results Four main interaction-related obstacles to early addictive disorder screening in primary care were identified and conceptualized: the new concepts of shared self-censorship and the patient's personal red line, issues not addressed during consultations, and opposition between how physicians and patients would like to approach addictive disorder screening. Conclusions To continue analysis of addictive disorder screening dynamics, further studies to examine the perspectives of all those involved in primary care are required. The information revealed from these studies will provide ideas to help patients and caregivers start discussing addiction and to help implement a collaborative team-based care approach. Trial registration This study is registered with the Commission Nationale de l’Informatique et des Libertés (CNIL) under No. 2017–093.

Background Lower-risk substance use guidelines (LRSUGs) are an evidence-based harm reduction strategy used to provide information to people who use drugs so they can reduce harms associated with substance use. Objectives This study aimed to identify LRSUGs accessible to youth and to characterize the recommendations within these guidelines. The overall goal is to identify gaps in current LRSUGs and to inform researchers and policymakers of the kinds of health information youth can access. Methods We conducted a digital assessment using the Google search engine to identify LRSUGs that could be identified by youth when searching for official sources of information related to commonly used substances, including cannabis, caffeine, alcohol, hallucinogens, prescription opioids, nicotine, and/or prescription stimulants. LRSUGs were coded and data were extracted from them to identify gaps. Results One hundred thirty LRSUGs were identified; most focused on alcohol (n = 40, 31%), cannabis (n = 30, 23%), and caffeine (n = 21, 16%). LRSUGs provided recommendations about dosing (n = 108, 83%), frequency of use (n = 72, 55%), and when to use (n = 86, 66%). Most LRSUGs were published by health (n = 51, 39%) and third-sector organizations (n = 41, 32%), followed by provincial/state (n = 18, 14%), government (n = 14, 11%), municipal (n = 4, 3%), and academic (n = 2, 2%) sources. Only 16% (n = 21) of LRSUGs were youth-specific and one-quarter (n = 32, 25%) of LRSUGs provided gender-specific recommendations. Most guidelines featured information on short (n = 76, 58%) and long-term (n = 69, 53%) negative effectives and positive effects of substances (n = 56, 43%). Less than half (n = 50, 38%) of LRSUGs cited evidence in support of the information they provided. Conclusions We identified several areas in the current LRSUGs for youth that need to be addressed. Among the gaps are a lack of LRSUGs developed specifically for youth, a lack of youth engagement in developing harm reduction strategies centered around them, and a lack of evidence-based LRSUGs. Youth-oriented, evidence-based LRSUGs are needed to better support youth who use substances and help them manage the negative effects of substance use.

Background In recent years, emergency departments (EDs) across the nation have implemented peer recovery coach (PRC) services to support patients who use opioids. The majority of such interventions discussed in the literature follow an in-person modality where PRCs engage patients directly at the ED bedside. However, the use of telehealth services in EDs is becoming more popular. These services connect PRCs with ED patients in real-time via secure communications technology, and very little is known about the service- and clinical-based outcomes with which they are associated. The current study sought to assess factors associated with successful post-discharge follow-up of patients with a history of opioid use who received PRC telehealth services while in the ED. Method Data come from records for 917 patients who engaged with a telehealth PRC one or more times (1208 total engagements) at 1 of 13 EDs within the same health system. A multilevel Poisson regression model was used to assess the degree to which variables predicted successful post-discharge follow-up, defined as the number of times a PRC successfully spoke with the patient each month after ED discharge. Results At least one follow-up was successfully completed by a PRC for 23% of enrolled patients. Significant predictors of successful follow-up included patient employment at baseline (Incidence Rate Ratio [IRR]: 2.8, CI: 2.05–3.9), living in a rural area (IRR: 1.8, CI: 1.04–3.2), PRC provision of referrals (IRR: 1.7, CI: 1.2–2.2), number of ED encounters in the previous 365 days (IRR: 0.99, CI: 0.98–0.99), and duration of the initial PRC telehealth interaction (IRR: 0.87, CI: 0.85–0.88). Conclusion Given that relationship development is a key tool in the PRC profession, understanding successful follow-up associated with telehealth engagement has unique importance. The results have potential utility for planning and implementing peer telehealth services in EDs and other locations, which is needed for the development of the PRC profession and the likely expansion of peer telehealth services.

Background Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use. Methods We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 – 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time. Results People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers’ recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social environment, alcohol accessibility and alcohol dependency. Conclusions Interventions that capacity-build professional and lay health care workers with the skills and resources to decrease problematic alcohol use, along with alcohol cessation in peer support structures, should be explored.

Background Alcohol use disorder is prevalent globally and in Kenya, and is associated with significant health and socio-economic consequences. Despite this, available pharmacological treatment options are limited. Recent evidence indicates that intravenous (IV) ketamine can be beneficial for the treatment of alcohol use disorder, but is yet to be approved for this indication. Further, little has been done to describe the use of IV ketamine for alcohol use disorder in Africa. The goal of this paper, is to: 1) describe the steps we took to obtain approval and prepare for off-label use of IV ketamine for patients with alcohol use disorder at the second largest hospital in Kenya, and 2) describe the presentation and outcomes of the first patient who received IV ketamine for severe alcohol use disorder at the hospital. Case presentation In preparing for the off-label use of ketamine for alcohol use disorder, we brought together a multi-disciplinary team of clinicians including psychiatrists, pharmacists, ethicists, anesthetists, and members of the drug and therapeutics committee, to spearhead the process. The team developed a protocol for administering IV ketamine for alcohol use disorder that took into account ethical and safety issues. The national drug regulatory authority, the Pharmacy and Poison’s Board, reviewed and approved the protocol. Our first patient was a 39-year-old African male with severe alcohol use disorder and comorbid tobacco use disorder and bipolar disorder. The patient had attended in-patient treatment for alcohol use disorder six times and each time had relapsed between one to four months after discharge. On two occasions, the patient had relapsed while on optimal doses of oral and implant naltrexone. The patient received IV ketamine infusion at a dose of 0.71 mg/kg. The patient relapsed within one week of receiving IV ketamine while on naltrexone, mood stabilizers, and nicotine replacement therapy. Discussion & conclusions This case report describes for the first time the use of IV ketamine for alcohol use disorder in Africa. Findings will be useful in informing future research and in guiding other clinicians interested in administering IV ketamine for patients with alcohol use disorder.

Tobacco Harm Reduction (THR) offers a promising approach to addressing the significant burden of smoking in Afghanistan. Over three million Afghans smoke daily, making it a leading cause of preventable deaths in the country. While the previous Afghan government implemented various tobacco cessation policies and strategies, these measures were only partially effective in reducing the number of smokers or smoking-related deaths. In 2021, community-based initiatives in Kabul and Herat started advocating for Tobacco Harm Reduction (THR) as a novel, realistic, and practical approach proven to promote smoking abstinence and minimize tobacco harm. However, implementing THR strategies in Afghanistan faces numerous challenges, including a lack of governmental support, funding issues, unfavorable market conditions, the high cost-effectiveness of THR products, and misconceptions about these products. To effectively promote THR in Afghanistan and overcome these challenges, it will be necessary to implement THR policies that support THR products for smokers, regulate the market for these products, produce them locally with healthcare professional oversight, conduct more engaging advocacy campaigns, and secure domestic sponsors.

Background Women with perinatal substance problems experience a multitude of barriers to care. They have specific early intervention needs, they endure societal stigma, and both substances and mental health issues influence the way they navigate within support and treatment systems. Early interventions for women with perinatal substance problems are underresearched contexts. The aim of the study is to describe building relationships and engagement within an outreach and low threshold service encounter tailored for pregnant women with SUD (substance use disorder). Methods The data consist of online written narratives from 11 workers involved in the program and feedback from 504 families in the recovery process comprising 228 open-ended answers. The data were analyzed with a thematic analysis. Results The programs are characterized by flexibility and the implementation of inclusive ways to approach families. The themes for enhancing relationships and engagement within outreach and low threshold programs are Acceptance and attitude: a sensitive approach of approval ; flexibility within strictness to allow for diversity and individuality ; availability and space to ensure a trustful atmosphere ; negotiating via doing to build connections ; and everyday life changes: imagining recovery . The themes represent the need of being available, focusing on the worker’s attitudes and building connections by doing together, and visioning recovery together. Conclusions The study results can add to the understanding of SUD outreach and low threshold work during pregnancy. The elements described in this study need further theoretical development, research and critical assessment. Building relationships during pregnancy were characterized by connecting within everyday life situations and supporting the development of an attachment relationship between the baby and the parents. To promote recovery, a comprehensive approach in which substance-related issues and mental health conditions are interconnected can be favored. Engaging early on during pregnancy might enhance success during future rehabilitation.

Background Medication for opioid use disorder (MOUD) is the gold standard treatment for opioid use disorder. Traditionally, “success” in MOUD treatment is measured in terms of program retention, adherence to MOUD, and abstinence from opioid and other drug use. While clinically meaningful, these metrics may overlook other aspects of the lives of people with opioid use disorder (OUD) and surprisingly do not reflect the diagnostic criteria for OUD. Methods Authors identified items for a pilesorting task to identify participant-driven measures of MOUD treatment success through semi-structured interviews. Interviews were transcribed verbatim and coded in Nvivo using directed and conventional content analysis to identify measures related to treatment success and quality of life goals. Participants of a low-threshold MOUD program were recruited and asked to rank identified measures in order of importance to their own lives. Multidimensional scaling (MDS) compared the similarity of items while non-metric MDS in R specified a two-dimensional solution. Descriptive statistics of participant demographics were generated in SPSS. Results Sixteen semi-structured interviews were conducted between June and August 2020 in Philadelphia, PA, USA, and 23 measures were identified for a pilesorting activity. These were combined with 6 traditional measures for a total list of 29 items. Data from 28 people were included in pilesorting analysis. Participants identified a combination of traditional and stakeholder-defined recovery goals as highly important, however, we identified discrepancies between the most frequent and highest ranked items within the importance categories. Measures of success for participants in MOUD programs were complex, multi-dimensional, and varied by the individual. However, some key domains such as emotional well-being, decreased drug use, and attendance to basic functioning may have universal importance. The following clusters of importance were identified: emotional well-being, decreased drug use, and human functioning. Conclusions Outcomes from this research have practical applications for those working to provide services in MOUD programs. Programs can use aspects of these domains to both provide patient-centered care and to evaluate success. Specifics from the pilesorting results may also inform approaches to collaborative goal setting during treatment.

Background This study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes. Methods A cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively. Results Profile 1 patients (47% of the sample), labeled “Low outpatient service users”, received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled “Moderate outpatient service users”, received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled “High outpatient service users”, received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles. Conclusions Frequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.

Background Drug addiction is stigmatized, and this stigma contributes to poor outcomes for individuals with addiction. Researchers have argued that providing genetic explanations of addiction will reduce stigma, but there has been limited research testing this prediction. Methods We presented participants (N = 252) with news articles that either provided genetic or anti-genetic explanations of addiction. Results There was no effect of article condition on stigma. Participants’ biological essentialism correlated with stigma in the context of both opioid and methamphetamine addiction. However, participants’ non-biological essentialism was a significantly stronger correlate with stigma. Conclusions This suggests that other essentialist beliefs, like belief that categories are discrete, may be more useful than biological essentialism for understanding addiction stigma.

Background Considering different factors, such as high withdrawal rates in methadone maintenance treatment (MMT) programs alongside mental health (MH) problems appearing in patients with opioid use disorder and the lack of prior research on the effect of zinc supplementation in this respect, the present study aimed to investigate the effect of zinc supplementation on the probability of relapse (PoR) and MH problems in patients with opioid use disorder undergoing MMT. Methods For this purpose, a randomized controlled trial with a clinical basis was fulfilled on a total of 68 patients with opioid use disorder receiving MMT, allocated to two groups, viz. intervention, and control (each one consisting of 34 individuals). Then, the participants in the intervention group were given zinc supplements combined with methadone for three months, and the controls only took methadone, according to the treatment plan. The data were collected using the Relapse Prediction Scale (RPS) and the Depression, Anxiety, and Stress Scale 21 (DASS-21) before, one month after, and at the end of the intervention program. Findings Compared to the control group, the likelihood of drug use ( p = 0.01), drug craving ( p = 0.002), and the RPS total score ( p = 0.002) in the intervention group was significantly lower. Moreover, the results revealed a significant decreasing trend in depression ( p = 0.01), anxiety ( p < 0.001), stress ( p = 0.001), and the DASS-21 total score ( p = 0.001) in the intervention. Compared to the control group, the DASS-21 total score ( p < 0.001) in the intervention group was significantly lower. Conclusion Accordingly, it was concluded that zinc supplementation could reduce the PoR and improve MH problems in patients with opioid use disorder experiencing MMT. However, further research is recommended to fill the gaps. Trial registration The research protocol has also been listed on the Iranian Registry of Clinical Trials (IRCT) with code no. IRCT2020050904736N1.

Background Research indicates that stigma impacts the care provided to individuals with Substance Use Disorders (SUDs), but perceptions of SUDs in various healthcare training programs are not well known. We aimed to characterize perceptions of faculty, staff, and students about SUD stigma in professional healthcare training programs. Methods We conducted a cross-sectional survey of faculty, staff, and students employed at or enrolled in one of six health-related colleges at one Mid-South health science center in the United States, including medicine, pharmacy, dentistry, nursing, health professions, and graduate health sciences. Data collection occurred between February and March 2021. We used descriptive and frequency statistics to assess the constructs within the survey instrument. Results A total of 572 respondents participated in this study (response rate = 9%; students, n = 428, 75%; faculty, n = 107, 19%; staff, n = 32, 6%). Most respondents reported interacting with persons with a SUD, cited challenges with the interaction, and perceived SUDs to be mental health condition ( n = 463) or biological disease ( n = 326). Most respondents believed that their college: emphasizes learning about SUDs; promotes an accurate perception of SUDs; and fosters respect for persons with. Few respondents reported they hear faculty, staff, or students express negative comments about persons with SUDs, but they were sometimes expressed by students. Conclusions Most faculty, staff, and students reported experiencing challenges when interacting with a person with a SUD, mainly communication, but few recalled hearing negative comments from their peers. Whether interventions tailored towards improving communication in academic healthcare training settings could minimize challenges experience by faculty, staff, and students when serving individuals with SUDs should be further evaluated.

Background Concerns about youth alcohol and drug use have risen since the declaration of the global COVID-19 pandemic due to the pandemic’s impact on known risk and protective factors for substance use. However, the pandemic’s immediate and long-term impact on youths’ substance use patterns has been less clear. Thus, this study sought to determine how the COVID-19 pandemic impacted alcohol or drug use and its risk and protective factors among youth accessing integrated youth services. Methods We conducted a repeated cross-sectional study of patient-reported outcomes data collected between May 2018 and February 2022 among youth ( n = 6022) ages 10–24 accessing a provincial network of integrated youth services in Canada. The main exposure of interest was the COVID-19 pandemic (March 2020 – February 2022) compared with a pre-pandemic period (May 2018 – February 2020). As measured by the Global Appraisal of Individual Needs – Short Screener, outcomes included the average number of past month alcohol or drug use symptoms and past month likelihood of service need for alcohol/drug use (moderate/high vs. low need). Interrupted time series (ITS) examined change in average monthly alcohol/drug use symptoms between the pre- and pandemic periods. Stratified multivariable logistic regression investigated how the pandemic modified the effects of established risk/protective factors on likelihood of alcohol/drug use service need. Results Fifty-percent of youth met the criteria for moderate/high likelihood of alcohol/drug use service need, with the odds being 2.39 times (95% confidence interval = 2.04, 2.80) greater during the pandemic compared to the pre-pandemic period. Results from the ITS indicated significant immediate effects of the pandemic on monthly substance use symptoms ( p = 0.01). Significant risk/protective factors for service need included exposure to violence, engagement in meaningful activities, and self-rated physical and mental health; and the direction of their effects remained consistent across pandemic and pre-pandemic periods. Conclusions This study demonstrated that the COVID-19 pandemic corresponded with increased alcohol or drug use among youth accessing integrated services. This signals an urgent need for increased clinical capacity in existing youth services and policies that can respond to risk/protective factors for substance use earlier.

The implementation of equine-assisted services (EAS) during treatment for psychological disorders has been frequently documented; however, little is known about the effect of EAS on outcomes for populations with substance use disorder (SUD). The purpose of this scoping review was to synthesize existing literature reporting the effects of EAS when incorporated into SUD treatment. This review followed guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for scoping reviews. A search of four databases (MEDLINE/PubMed, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Academic OneFile) identified studies reporting quantitative and/or qualitative data for an EAS intervention that was implemented among a population receiving treatment for and/or diagnosed with SUD. Of 188 titles, 71 underwent full-text assessment and six met inclusion criteria. Three additional articles were identified through other sources. Quantitative data suggested a potential positive effect of EAS on SUD treatment retention and completion as well as participants’ mental health; however, studies were limited by small sample sizes. Qualitative data indicated that in addition to participants developing bonds with the horses and perceiving EAS as welcomed breaks from traditional treatment, they experienced increased self-efficacy, positive emotional affect, and SUD treatment motivation. Due to methodological limitations and an overall dearth of available studies, the effectiveness of EAS as adjuncts to SUD treatment is inconclusive. Additional research is necessary before supporting broad implementation of EAS as adjuncts to SUD treatment.

Background Alcohol use during pregnancy is a preventable risk factor for Fetal Alcohol Spectrum disorders. Psycho-social and educational interventions have been reported to enable women reduce alcohol intake levels during pregnancy and help improve some health outcomes of unhealthy alcohol use. We set out to assess the effect of a communication intervention on alcohol use during pregnancy in post conflict northern Uganda. Methods The study employed a quasi - experimental design to assess the effect of a community health worker led communication strategy on pregnant women’s knowledge, attitudes and various patterns of alcohol use using Difference in Difference(DiD). 420 respondents were recruited at baseline as at endline. Results The communication messages were significantly associated with reduced odds of binge drinking ( P = 0.018; OR = 0.09; CI = 0.012–0.66). Also those who received the intervention were less likely to drink frequently ( P = 0.80; OR = 0.75; 95%CI = 0.074–7.5) or be harmful alcohol users( P = 0.948). The intervention also positively influenced having fair (β =0.49; P = 0.217;RRR =1.63)or adequate knowledge(β = 0.89; P = 0.25;RRR = 2.44) and having positive(β = 0.37;RRR =1.44; P = 0.46) or fair attitude(β = 0.19;RRR = 1.21; P = 0.693) although not to a significant level. Conclusions The communication intervention affected some patterns of alcohol use among pregnant women and not others. Our results contribute to existing evidence that communication interventions are a promising approach in reduction of alcohol exposed pregnancies. Interventions aimed at promoting alcohol abstinence during pregnancy should be implemented alongside other strategies that address factors that influence pregnant women to drink to achieve maximum results.

A pilot study of Safety First: Real Drug Education for Teens showed significant results pre to post curriculum with high school freshmen. Negative outcomes of drug education are linked to a failure to engage students because of developmentally inappropriate materials that include activities that have no relevance to real experiences of young people. The few harm reduction studies showed increased student drug related knowledge. Students were less likely to consume substances, and less likely to consume to harmful levels. More studies are necessary to evidence harm reduction efficacy in the classroom. The goal of this study was to measure harm reduction knowledge and behaviors, including drug policy advocacy, before and after Safety First. Data were analyzed using McNemar’s test, ANOVA, linear regression, t-tests and thematic coding. Survey results, corroborated by the qualitative findings, showed a significant increase (p < .05) in high school freshmen harm reduction knowledge and behaviors in relationship to substance use pre to post Safety First. This increase related to a decrease in overall substance use. Harm reduction is often perceived as a controversial approach to substance use. These findings have implications for further study of what could be a promising harm reduction-based substance use intervention with teens.

Background Since the imposition of the 2018 excise tax, new tobacco products (electronic nicotine delivery system, heated tobacco products, and nicotine pouches) have been considered legal, and their sale has grown rapidly in Indonesia. This study aims to assess the variety of new tobacco products available on the market and evaluate the point-of-sale (POS) environment. Methods Data collection was carried out by 12 trained surveyors between March 7 and 13, 2022, in three provinces that had the most e-cigarette users: Yogyakarta, East Kalimantan, and Jakarta. All the vape stores with a Google rating of 4.5 stars or higher and a minimum of 100 reviews were included. In addition to vape stores, the nearest retail stores were included. The data collected included information about available products, product displays, and whether the POS followed tobacco-control measures, such as health warnings and smoke-free regulations. Results A total of 27 vape stores and 35 retail stores were observed. The available liquid volumes ranged from 15 to 100 ml, with nicotine levels from 3 to 50 mg. No stores sold flavorless products, and all the products were sold without pictorial health warnings (PHWs). Most of the vape stores (92.6%) reported selling products that used cartoon images or public figures, and most (96.3%) allowed customers to use the products inside the store. Five vape stores and four retail stores reported that they did not require customers to undergo an identity-verification process to buy products. More than half (55.6%) of the vape stores and 46.6% of the retail stores reported that they were located less than 500 m from a school. Conclusion The available products were widely varied, and they were easy to access through online and offline stores. The new tobacco products had successfully avoided several tobacco-control measures, including smoke-free regulations and the appearance of PHWs on the products. The government needs to impose regulations sufficient to prevent youth from consuming new tobacco products.

Opioid related overdose deaths in the United States claimed over 100,000 thousand lives during the 12-month period ending in April 2021, an increase of 28.5% from the previous period. Syringe services programs (SSPs) are an evidence-based harm reduction strategy that have been shown to be effective in reducing opioid overdose deaths and infectious complications and increasing rates of entry into recovery programs. Ignoring this evidence, South Carolina (SC) and several states have yet to legalize SSPs. In the absence of full legalization, the operation of SSPs in SC faces many barriers. Despite these barriers, Challenges Inc. has been successful in playing a critical role in preventing opioid overdoses through naloxone and fentanyl test strip distribution, reducing infectious complications by providing clean needles, treating individuals with hepatitis C and HIV, and helping patients remain in sustained recovery from opioids. In order for SSPs to function at their full potential to curb the rising tides of opioid overdose deaths and related health complications, policymakers in SC and similar states need to urgently legalize them.

International drug policy is rapidly evolving in tandem with promising evidence for psychedelic-assisted psychotherapy (PAP) in treating a range of mental health conditions. Canada is among the countries increasingly expanding access to psychedelic substances for therapeutic purposes. The 8-year ban on medical exemptions through the Canadian Special Access Programme was recently reversed in January 2022 and the first exemptions for legal possession and personal use of psilocybin mushrooms were granted in 2020, nearly 50 years since their criminalization. In view of the evolving evidence base and regulatory landscape for PAP illustrated by recent shifts in Canadian and international drug policy, this piece seeks to clarify the special range of factors which ought to be considered to safely expand access to psychedelics. Streamlining access to safe and evidence-based compassionate use of PAP will provide a timely treatment option to those currently in need while encouraging further research and outcome surveillance to refine best practices.

Background Drug-related psychiatric comorbidity or death among adolescents has grown to become a public health threat in Taiwan. In an atmosphere of abstinence, few alternatives or rehabilitative options for troubled young people have caused many juveniles to be driven away from home and placed in closed institutions. The intersectionality of illegal substance use, deviant behaviours, and criminal offences among adjudicated adolescents is a challenge for the development of adolescent users’ harm reduction strategies. In addition, the relationships among the adolescents, their families, and practitioners might be undermined by coercive and mandatory court measures. As developing a harm reduction approach includes minimizing the negative effects on not only adolescents and also their families, this study aims to explore Taiwanese practitioners’ perspectives of family-based programmes for drug-using adolescents. Methods This study adopted a qualitative approach. Through face-to-face interviews and a focus group, accounts were collected from 28 key informants working in youth delinquency. The interviews were transcribed for analysis using qualitative analysis software, namely NVivo10. Results Practitioners tend to refer to an “adolescent-centred model” when describing their work with drug-using young people. From the frontline practitioners’ descriptions, the families of those youth needing treatment services are often vulnerable and disadvantaged. These families are seldom onboard because of low readiness and scarce resources. Although a legal framework is in place, resources, workforce, and programmes to engage and involve parents in the intervention are lacking. Despite the obstacles, practitioners have utilized a variety of strategies to obtain limited success, such as parent meetings, resources referrals, parent counselling, court support, voluntary parenting courses, illicit substance information sharing, and home visits. Practitioners also pointed out that therapeutic interventions are more effective than coercive or mandatory interventions for adolescents and also for their families. Conclusions Since most practitioners have an adolescent-centred work principle, their work with parents falls into professional-centred or family-allied work models. It is therefore suggested that resources be reallocated to involve parent counselling and intense treatment instead of mandatory parental education.

Background Concurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC. Methods Linked health and corrections records were retrieved for releases between January 1 st 2015 and December 29 th 2018 ( N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC’s Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC’s provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release. Results Cases of release among people with an opioid use disorder were identified ( N = 13,380). Approximately 25% ( N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64–0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70–1.13]. Conclusions People with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.

Nevada, like the rest of the United States, is undergoing substantial challenges with opioid misuse and overdose deaths, further exacerbated by the COVID-19 pandemic. While much of the attention around opioid overdose prevention is centered on treatment and recovery, it is important to understand the factors that influence initiation of use, and the function opioids play in people’s everyday lives. We conducted qualitative semi-structured individual interviews using purposive and snowball sampling among 35 people across Nevada with a current or prior history of illegal opioid or nonmedical opioid use. Our study aimed to understand why people start to use drugs, why they continue to use, what motivates them to continue to use or to seek treatment, and why individuals maintain recovery or return to use. We found five significant themes as perceived by the participants: that trauma is a risk factor for drug misuse; that the function of opioids in everyday life is a source of temporary relief but highly disruptive in the longer term; that recovery is most often a complicated and nonlinear process; that there are many barriers to accessing services that are both logistical and psychosocial; and that compassion, hope, and having a sense of purpose are crucial to the recovery process. The experiences of the study participants portray opioid use as a rational choice to escape the emotional ramifications of trauma. However, due to the physiological dependence and physical risk of opioids, drug policies that criminalize addiction, societal stigma, and the barriers to timely access of harm reduction, treatment, and recovery services, opioid users often become trapped in a distressing and dangerous cycle. Lastly, respondents indicated that hope, value, belonging, and purpose are powerful factors in cultivating intrinsic motivation for making positive changes and fostering resilience in the recovery process. Opioid misuse services should help meet basic needs and incorporate holistic approaches to recovery that acknowledge past trauma and the complexity of the recovery process.

Background Despite increasing substance use globally, substance use treatment utilisation remains low. This study sought to explore and measure substance use treatment barriers among young adults in South Africa. Methods The study was done in collaboration with the Community-Oriented Substance Use Programme run in Tshwane, South Africa . A mixed methods approach employing focus group discussions with key informants ( n = 15), a survey with a random sample of people using substances and receiving treatment ( n = 206), and individual semi-structured interviews ( n = 15) was used. Descriptive statistics and thematic analysis were used to analyse data. Results Contextual barriers seemed more prominent than attitudinal barriers in the South African context. Fragmented services, stigma-related factors, an information gap and lack of resources and support (contextual factors), perceived lack of treatment efficacy, privacy concerns, and denial and unreadiness to give up (attitudinal factors) were treatment barriers that emerged as themes in both quantitative and qualitative data. Culture and religion/spirituality emerged as an important barrier/facilitator theme in the qualitative data. Conclusion Interventions need to embrace contextual factors such as culture, and more resources should be channelled towards substance use treatment. Multi-level stakeholder engagement is needed to minimise stigmatising behaviours from the community and to raise awareness of available treatment services. There is a need for strategies to integrate cultural factors, such as religion/spirituality and traditional healing, into treatment processes so that they complementarily work together with pharmacological treatments to improve health outcomes.

Background Workforce diversity is a key strategy to improve treatment engagement among members of racial and ethnic minority groups. In this study, we seek to determine whether workforce diversity plays a role in reducing racial and ethnic differences in wait time to treatment entry and retention in different types of opioid use disorder treatment programs. Methods We conducted comparative and predictive analysis in a subsample of outpatient opioid treatment programs (OTPs), who completed access and retention survey questions in four waves of the National Drug Abuse Treatment System Survey (162 OTPs in 2000, 173 OTPs in 2005, 282 OTPs in 2014, and 300 OTPs in 2017). We sought to assess the associations between workforce diversity on wait time and retention, accounting for the role of Medicaid expansion and the moderating role of program ownership type (i.e., public, non-profit, for-profit) among OTPs located across the United States. Results We found significant differences in wait time to treatment entry and retention in treatment across waves. Average number of waiting days decreased in 2014 and 2017; post Medicaid expansion per the Affordable Care Act, while retention rates varied across years. Key findings show that programs with high diversity, measured by higher percent of African American staff and a higher percent of African American clients, were associated with longer wait times to enter treatment, compared to low diversity programs. Programs with higher percent of Latino staff and a higher percent of Latino clients were associated with lower retention in treatment compared with low diversity programs. However, program ownership type (public, non-profit and for-profit) played a moderating role. Public programs with higher percent of African American staff were associated with lower wait time, while non-profit programs with higher percent of Latino staff were related to higher retention. Conclusions Findings show decreases in wait time over the years with significant variation in retention during the same period. Concordance in high workforce and client diversity was associated with higher wait time and lower retention. But these relations inverted (low wait time and high retention) in public and non-profit programs with high staff diversity. Findings have implications for building resources and service capacity among OTPs that serve a higher proportion of minority clients.

Background COVID-19 dramatically limited the scale and scope of local health department (LHD) work, redirecting resources to the response. However, the need for essential public health services—including substance use prevention—was not reduced. Methods We examined six quantitative data sources, collected between 2016 and 2021, to explore the impact of the COVID-19 pandemic on LHD substance use-related services. Results Before the pandemic, the proportion of LHDs providing some level of substance use prevention services was increasing, and many were expanding their level of provision. During the pandemic, 65% of LHDs reduced their level of substance use-related service provision, but the proportion of LHDs providing some level of services remained steady from prior to COVID-19. Conclusion We discuss policy recommendations to mitigate the risk of service disruptions during future public health emergencies, including direct and flexible funding for LHDs and federal directives declaring substance use prevention services as essential.

Background According to the National Alcohol Beverage Control Association, twelve states in the United States (U.S.) have government retail monopolies on spirits/liquor sales. With a new federal minimum legal sales age for tobacco (raised from 18 to 21, the minimum legal sales age for alcohol), we examine possible unintended consequences of a hypothetical policy change restricting retail tobacco sales to state-run spirits/liquor stores in alcohol control states, which has been proposed as a tobacco endgame strategy. Methods We used cross-sectional survey data from 14,821 randomly-selected adults ages 21 and older who responded to the 2015 or 2020 U.S. National Alcohol Survey (51.8% female; 65.8% identified as non-Hispanic White, 12.4% as Black or African American, 14.2% as Hispanic or Latinx; 34.0% had a low level of education), including 2,274 respondents (18.9%) residing in one of the alcohol control states (representing 42.2 million (M) adults ages 21+). We estimated associations between tobacco measures (lifetime smoking status, lifetime daily smoking, past-year daily smoking) and alcohol measures (drinking status, beverage choices, lifetime alcohol use disorder (AUD) status, recovery status) overall and for specific subgroups. Results In control states, 55.1% of people who smoked daily in the past year also reported lifetime AUD, including an estimated 3.56 M adults ages 21 + who reported prior (but not current) AUD. The association of daily smoking with lifetime AUD was stronger among those with low education compared to those with higher education. Further, 58.8% of people in recovery from an alcohol and/or drug problem (1.49 M adults ages 21+) smoked daily, and this was more marked among women than men in control states. Conclusion There could be negative consequences of an endgame strategy to restructure tobacco retail sales, including increased risk for relapse to drinking among people who smoke daily, especially among women and people with low levels of education. Strategies to mitigate unintended harms would be needed if such a policy were implemented.

Background Based on the US DARE-kiR, a version of the Keepin’ it REAL program, the Drug and Violence Resistance Educational Program (PROERD) is the most widely implemented Brazilian prevention program. It originates from the translation of the DARE-kiR, a version of the Keepin’ it REAL program. Previous results suggest its inefficiency in preventing drug use among Brazilian adolescents. Since kiR fidelity can impact program outcomes, this mixed-methods study evaluates the PROERD implementation fidelity and its effects on preventing drug use among adolescents. Methods Data from two cluster randomized controlled trials (cRCTs) with 4,030 students from 30 public schools in São Paulo (1,727 fifth graders and 2,303 seventh graders), assessed at two-time points, were analyzed quantitatively. After implementing each lesson during the cRCT, 19 PROERD instructors answered fidelity forms. The effect of PROERD fidelity on alcohol, cigarettes, marijuana, inhalant, and cocaine use (the last two only among seventh graders) in the six months prior to follow-up assessment was analyzed by logistic regressions for fifth grade and mixed effect models for seventh graders. For qualitative analysis, semi-structured interviews were conducted with PROERD instructors and investigated by thematic analysis. Results Quantitative analysis showed that PROERD implementation fidelity had no impact on drug use among fifth and seventh graders. Conversely, the qualitative analysis revealed important aspects that may influence implementation fidelity and consequently program effectiveness, such as adaptations made by instructors, school infrastructure, among others, besides program application. Conclusion PROERD requires cultural adaptation to improve its implementation in Brazilian public schools.

Background To evaluate provider perspectives on the development and implementation of an inpatient Addiction Medicine Consult Service, including their awareness of the service, its perceived role in the continuum of care, and changes over time in their perceptions of care quality for inpatients with substance use disorders. Methods Repeated cross-sectional survey of hospital-based physicians, nurses and social workers performed at service launch (April–June, 2017) and 4 years later (March–June, 2021). Results Providers had generally positive perceptions of the service and its impact on care quality, but encountered significant barriers at both time points in meeting patient needs (related to high patient complexity and difficulty connecting patients with community services post-discharge). Relative to physicians and social workers, nurses were less likely to be familiar with the service or see it as beneficial. Conclusions Findings indicate that the service fills a gap that existed previously in the local system of care; however, numerous opportunities exist to further strengthen the system beyond the hospital setting to promote longer-term health among people who use substances. For nurses in particular, outreach, education, and other resources (e.g., dedicated nursing role support, nurse liaison) are warranted to ensure that nurses feel supported and confident caring for this patient population.

Background According to a landmark decision by the Swiss Federal Supreme Court, people with a substance use disorder (SUD) are now eligible for disability benefits if their disorder impairs their ability to work. Alcohol use disorder (AUD) is one of the most common SUDs in Switzerland and is associated with high societal and economic costs. This study aimed to gain an in-depth understanding of the views of professional stakeholder groups regarding AUD and their opinions on the new legal precedent. Methods Swiss social insurance lawyers, insurance medical experts, and addiction-specialist therapists (N = 79) answered an online questionnaire. Due to violations of the assumption of normality, non-parametric tests are reported in most cases. Results Therapists held significantly higher regard for patients with AUD than both lawyers and insurance medical experts. All three groups strongly supported a disease view of AUD but agreed significantly less that it was a disease like cancer, suggesting that AUDs might be seen as at least partially self-inflicted. Overall, moralist views of AUD received considerably less support than the disease view, with lawyers agreeing with moralist views more than therapists. All groups were well-informed and largely supportive about the new legal precedent. When asked about stipulating participation in medical treatment to mitigate damages associated with a claim, attending therapy was supported the most amongst the groups (80% of participants felt this was somewhat or fully appropriate), followed by a reduction in drinking quantity (58%), and abstinence (18%). In all three groups, we identified associations between certain views and opinions on AUD and support for the new legal precedent. Conclusions Whilst there were differences between the stakeholder groups in their regard for and views of AUD, all three adopted a clear harm-reduction approach with respect to measures to mitigate damages associated with the insurance disability claim. A possible connection of this stance with the Swiss national drug policy in recent years is discussed together with limitations of the study and practical implications of the findings.

Background There is a higher prevalence of substance use disorder (SUD) among justice-involved children (JIC). It is critical to ensure that JIC who report current use are referred for SUD assessment and potentially life-saving treatment services. Prior research suggests that certain minoritized groups may be less likely to have ever been referred for screening, and research on intersectionality suggests that these disparities may be exacerbated for racially minoritized females. Methods Multivariate logistic regression and interaction effects were employed to analyze longitudinal data from the Florida Department of Juvenile Justice on 12,128 JIC who reported SU in the past 6 months. The main and interaction effects of race and gender on the odds of having a history of reporting a referral to SUD assessment were tested. The primary outcome variable was a self-reported measure of a youth’s history of being referred to service. The control variables included substance type, household income, current SU problems, history of mental health problems, number of misdemeanors, risk to recidivate, and age at first offense. Results There were no significant differences in the likelihood of having a history of reporting being referred to SUD assessment between White females, White males, and Latinx females. However, Black females (AOR = 0.62), Latinx males (AOR = 0.71), and Black males (AOR = 0.65) were significantly less likely to self-report having a history of being referred than White males. Black females were 34% likely to report a history of being referred as White males and females. Conclusion In this sample, Black females who use substances were substantially less likely to self-report being referred to SUD screening. According to officials, FLDJJ has solid process to ensure referrals are made. Therefore, the results are likely to be due to external factors and alternative explanations. Community leaders and stakeholders may consider culturally relevant and gender-sensitive programs to expand access to services for minoritized adolescents in their communities, schools, and other institutions.

Introduction and aims There is increasing interest and evidence for the use of cannabinoid medications in the treatment of cannabis use disorder, but little examination of the correlates of successful treatment. This paper is a secondary analysis of a randomised placebo-controlled trial of nabiximols for the treatment of cannabis use disorder (CUD), aiming to identify which client and treatment characteristics impact treatment engagement and outcomes. Method Bayesian multiple regression models were used to examine the impact of age, gender, duration of regular cannabis use, daily quantity of cannabis, cannabis use problems, self-efficacy for quitting, sleep, mental health, pain measures, and treatment group upon treatment engagement (retention, medication dose, and counselling participation) and treatment outcomes (achieving end-of-study abstinence, and a 50% or greater reduction in cannabis use days) among the 128 clients participating in the 12-week trial. Results Among the treatment factors, greater counselling attendance was associated with greater odds of abstinence and ≥ 50% reduction in cannabis use; nabiximols with greater odds of ≥ 50% reduction and attending counselling, and reduced hazard of treatment dropout; and higher dose with lower odds of ≥ 50% reduction. Among the client factors, longer duration of regular use was associated with higher odds of abstinence and 50% reduction, and lower hazard of treatment dropout; greater quantity of cannabis use with reduced hazard of dropout, greater odds of attending counselling, and higher average dose; greater pain at baseline with greater odds of ≥ 50% reduction and higher average dose; and more severe sleep issues with lower odds of ≥ 50% reduction. Males had lower odds of attending counselling. Discussions and conclusions These findings suggest that counselling combined with agonist pharmacotherapy may provide the optimal treatment for cannabis use disorder. Younger clients, male clients, and clients with sleep issues could benefit from extra support from treatment services to improve engagement and outcomes. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12616000103460) https://www.anzctr.org.au

Background Novel public health interventions are needed to address the toxic drug supply and meet the needs of people who use drugs amidst the overdose crisis. Safer supply – low-barrier distribution of pharmaceutical grade substances – has been implemented in some jurisdictions to provide safer alternatives to the unregulated drug supply, yet no studies to date have explored professional stakeholder perspectives on this approach. Methods We used purposive sampling to recruit professional stakeholders (n = 17) from four locations in British Columbia, Ontario, and Nova Scotia, including program managers, executive directors, political and health authority representatives, and healthcare providers involved in the design, implementation, and/or operation of safer supply programs in their communities. Semi-structured, one-to-one interviews were conducted, and interview data were coded and analyzed using thematic analyses. Results Participants defined safer supply as low-barrier access to substances of known quality and quantity, offered on a continuum from prescribed to a legal, regulated supply, and focused on upholding autonomy and liberation of people who use drugs. Stakeholders expressed support for safer supply but explained that current iterations do not meet the needs of all people who use drugs and that implementation is limited by a lack of willing prescribers, stigma towards people who use drugs, and precarity of harm reduction programs to political ideology. Stakeholders expressed strong support for wider-reaching approaches such as decriminalization, legalization, and regulation of substances as a way to fully realize a continuum of safer supply, directly address the overdose crisis and toxic drug supply, and ensure equity of access nationally. Conclusion The results of this study highlight the need for innovative strategies to address the overdose crisis and that safer supply has the potential to benefit certain people who use drugs. A one-size-fits-all approach is not sufficient and the perspectives of professional stakeholders should be considered alongside those of people who use drugs when designing and implementing future safer supply.

Background Several reports have described a growing prevalence of illicit drug use in Afghanistan, with recognition of a recent shift from traditional modes of consumption involving inhalation and oral ingestion to injecting drug use. Objective Conduct a comprehensive review of existing literature to map the injecting drug use situation in Afghanistan. The review intends to describe risk factors and impacts of injecting drug use, drug use characteristics and risk behaviours among people who inject drugs (PWID), and access to harm reduction and treatment. Methods We searched Embase, Global Health, Medline, PsycINFO, Web of Science, and grey literature to identify English language publications up to March 26th, 2022. Studies were eligible for inclusion if they explicitly targeted PWID or injecting drug use in Afghanistan and provided information relevant to the review questions. Two reviewers independently screened titles and abstracts for inclusion and extracted information based on the review objectives. Results A total of 25 articles were identified representing 15 studies (11 quantitative, 2 qualitative, 2 mixed methods). All but one studies were cross-sectional. In majority of the studies, over 95% of the participants were male and most were conducted over a decade ago, in urban settings, mainly Kabul. Only one study examined risk factors of injecting drug use. Eleven studies described drug use characteristics and 9 reported risk behaviours among PWID. Health and social burden of injecting drug use were reported by 8 and 5 studies, respectively. Nine studies described access to harm reduction and treatment. Afghan PWID had high levels of injecting and sexual risk behaviours compared to global estimates. They reported high prevalence of incarceration and displacement. Access to harm reduction and treatment was very limited. This scoping review revealed important knowledge gaps including a gender gap in research with serious implications for drug policy and substance use care. Conclusions Development of a national public health-oriented drug policy and substance use care programme is warranted along with efforts to develop health research capacity to address the need for epidemiological data. The current humanitarian crisis necessitates continued access to evidence-based harm reduction and treatment in Afghanistan.

Background The aim of this study was to examine the effect of a practice change intervention to support the implementation of guideline-recommended care for addressing alcohol use in pregnancy on self-reported alcohol use during pregnancy. Methods A randomized, stepped-wedge controlled trial in three clusters (sectors) within the Hunter New England Local Health District (NSW, Australia). We evaluated a practice change intervention that supported the introduction of a new model of care for reducing alcohol use in pregnancy, consistent with local and international guidelines, and implemented in random order across the sectors. Each week throughout the study period, pregnant women who attended any public antenatal services within the previous week, for a 27–28 or 35–36 week gestation visit, were randomly sampled and invited to participate in the survey. The intended intervention for all women was Brief advice (to abstain from alcohol and information about potential risks). Women identified as medium-risk alcohol consumers using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) were to be offered referral to a phone coaching service, and women identified as high-risk were to be offered referral to a Drug and Alcohol Service. Rates of self-reported alcohol use (AUDIT-C risk level and special occasion drinking) were summarized and compared in groups of women pre-intervention and post-intervention using multivariable logistic regression. Results Surveys were completed by 1309 women at pre-intervention and 2540 at post-intervention. The majority of women did not drink during pregnancy (pre-intervention: 89.68%; post-intervention: 90.74%). There was no change in the proportion of women classified as No risk from drinking (AUDIT-C score = 0) or Some risk from drinking (AUDIT-C score ≥ 1) pre- or post-intervention ( p = 0.08). However, a significant reduction in special occasion drinking was observed (pre-intervention: 11.59%; post-intervention: 8.43%; p < 0.001). Conclusions Special occasion drinking was reduced following implementation of guideline-recommended care. Failure to change other patterns of alcohol use in pregnancy may reflect barriers to implementing the model of care in antenatal care settings and the need to address other social determinants of alcohol use. Trial registration Australian and New Zealand Clinical Trials Registry (registration number: ACTRN12617000882325; date: 16 June 2017).

Background People living in rural and remote communities in Canada are often disproportionately impacted by opioid use disorder. When compared to urban centres, rural and remote populations face additional barriers to treatment, including geographical distance as well as chronic shortages of health care professionals. This integrative review of the literature was conducted to explore the facilitators and barriers of OAT in rural and remote Canadian communities. Methods A search of the literature identified relevant studies published between 2001 and 2021. Results The search strategy yielded 26 scholarly peer-reviewed publications, which explored specific barriers and facilitators to rural and remote OAT in Canada, along with two reports and one fact sheet from the grey literature. Most of the scholarly articles were descriptive studies ( n = 14) or commentaries ( n = 9); there were only three intervention studies. Facilitators and barriers to OAT programs were organized into six themes: intrapersonal/patient factors, social/non-medical program factors, family/social context factors (including community factors), infrastructure/environmental factors, health care provider factors, and system/policy factors. Conclusions Although themes in the literature resembled the social-ecological framework, most of the studies focused on the patient-provider dyad. Two of the most compelling studies focused on community factors that positively impacted OAT success and highlighted a holistic approach to care, nested in a community-based holistic model. Further research is required to foster OAT programs in rural and remote communities.

Background: Appointment no-show and early dropout from treatment represent major challenges in outpatient substance use disorder treatment, adversely affecting clinical outcomes and health care productivity. In this quasi-experimental study, we examined how a brief reminder intervention for new patients before their first appointment affected treatment participation and retention. No-shows (not attending any sessions) and dropouts (discontinuation of initiated treatment because of three consecutively missed appointments) were compared between a period with pre-admission telephone calls (intervention) and a period without such reminders (non-intervention). Methods: Participants were all eligible patients (N = 262) admitted to a Norwegian specialist clinic for substance use disorder treatment. We used the Chi-square test for the no-show analysis. Of the eligible patients, 147 were included in a subsequent dropout analysis. We used the number of visits up to 10 appointments as a measure for time to event. Group differences were analyzed using a Kaplan-Meier plot and the log-rank test. To control for relevant sociodemo-graphic variables, as well as substance use and mental distress severity, we used Cox regression. Results: No-show rates did not differ between the two periods (12% for non-intervention vs. 14% for intervention; χ 2 = 0.20, p = 0.653). Of those consenting to participate in the dropout analysis (n = 147), 28 (19%) discontinued treatment within the time frame of 10 appointments, with no differences between the two periods (log-rank test = 0.328, p = 0.567). Controlling for baseline characteristics did not alter this finding. In fact, of the registered covariates at base-line, only higher education level was associated with attrition, linked to a reduced risk for dropout (hazard ratio = 0.85, 95% CI = 0.74-0.98, p = 0.025). Conclusion: These findings do not provide support for the systematic use of a brief pre-admission telephone reminder in the current treatment setting. Trial registration: The study was retrospectively registered 13 Jan 2021 at ClinicalTrials.gov, NCT04707599.

Background Provision of aftercare services for persons with substance use disorders (PWSUD) within a rural context is typically met with various intersecting challenges, including unclear policy implications and lack of resources. In the South African context, service providers are expected to provide aftercare services that should successfully reintegrate persons with PWSUD into society, the workforce, family and community life as mandated by Act No. 70 of 2008, despite population diversity. Little has been established on the provision of aftercare services in South Africa and specifically within a rural context. This article explores service providers’ perspectives in aftercare service provision for PWSUD in a rural district. Methods A qualitative exploratory study design was conducted in a rural district in South Africa using semi-structured interviews and focus group discussions with forty-six service providers from governmental and non-governmental institutions, ranging from implementation to policy level of service provision. Data were analyzed thematically using a deductive approach. Codes were predetermined from the questions and the aims and objectives of the study used Beer’s Viable Systems Model as a theoretical framework. NVivo Pro 12 qualitative data analysis software guided the organization and further analysis of the data. Results Four themes emanated from the data sets. Theme 1 on reflections of the interactional state of aftercare services and program content identified the successes and inadequacies of aftercare interventions including relevant recommendations for aftercare services. Themes 2, 3, and 4 demonstrate reflections of service provision from implementation to policy level, namely, identifying existing barriers to aftercare service provision, situating systemic enablers to aftercare service provision, and associated aftercare system recommendations. Conclusions The intersecting systemic complexities of providing aftercare services in a rural context in South Africa was evident. There existed minimal enablers for service provision in this rural district. Service providers are confronted with numerous systemic barriers at all levels of service provision. To strengthen the aftercare system, policies with enforcement of aftercare services are required. Moreover, a model of aftercare that is integrated into the existing services, family centered, sensitive to the rural context and one that encourages the collaboration of stakeholders could also strengthen and sustain the aftercare system and service provision.

Background Interdisciplinary collaborations (i.e., where various disciplines work coordinated and interdependently toward shared goals) are stated to yield higher team effectiveness than multidisciplinary approaches (i.e., where various disciplines work in parallel within their professional boundaries) in somatic health care settings. Nevertheless, research is lacking on interdisciplinary approaches for alcohol use disorder (AUD) treatment of hospitalized patients as these types of approaches are still uncommon. This study aims to evaluate an innovative interdisciplinary AUD treatment initiative at a general hospital department by 1) identifying which and to what extent network partners are involved and 2) to explore how network partners experienced the interdisciplinary collaboration. Methods A mixed-method study was conducted, using 1) measures of contact frequency and closeness in a social network analysis and 2) semi-structured interviews, which were analyzed thematically. Respondents were network partners of an interdisciplinary collaboration in a general hospital department, initially recruited by the collaborations’ project leader. Results The social network analysis identified 16 network partners, including a ‘core’ network with five central network partners from both inside and outside the hospital. The project leader played an important central role in the network and the resident gastroenterologist seemed to have a vulnerable connection within the network. Closeness between network partners was experienced regardless of frequency of contact, although this was especially true for the ‘core’ group that (almost) always consisted of the same network partners that were present at biweekly meetings. Interview data showed that presence of the ‘core’ network partners was reported crucial for an efficient collaboration. Respondents desired knowledge about the collaborations’ effectiveness, and one structured protocol with working procedures, division of responsibilities and agreements on information sharing and feedback. Conclusions The design of this interdisciplinary collaboration has potential in improving the treatment of hospital patients with AUD and was evaluated positively by the involved network partners. Interdisciplinary collaborations may offer a critical solution to increase treatment rates of patients with AUD and should be adopted in hospitals on a larger scale. Research towards the effectiveness of interdisciplinary collaborations in the treatment of hospitalized patients with AUD is needed.

Background There is a growing evidence base around predictors of retention and completion in a range of recovery residence models, particularly Oxford Houses and Sober Living Houses, and recovery housing is recognized as a clearly evidenced area of recovery intervention. The aim of the study was to quantitatively assess recovery capital in a sample of recovery residence clients. Method The study used a repeated measures self-completion of a standardized recovery capital instrument (REC-CAP) for clients retained across various houses within one Level 2 recovery residence provider whose program was based on a 12-step approach. While 823 clients participated in the baseline assessment, a sample of 267 clients was achieved for six-month follow-up interview, based on those retained in the residence. A logistic regression model examined factors associated with retention and a repeated measures marginal mixed model evaluated the factors associated with changes in recovery capital between the baseline and the follow-up assessment. Results Members of the group that remained in recovery residences were more likely to be older with a record of high participation in recovery groups, with greater drop-out among younger residents, female residents and those with an identified housing need. For those retained to follow-up, greater recovery capital growth was associated with employment, higher levels of social support and more recovery group involvement, as well as age and a higher quality of life. The need for family support was shown to reduce levels of recovery capital. However, those younger people who were retained reported better recovery capital growth during the initial six months of residence. Conclusion The key conclusion is that while recovery capital generally increases during a stay in a recovery residence, it does not do so consistently across the sample population. This has implications for how pathways to recovery group engagement are supported for women and young people and how social support (encompassing housing, employment and family issues) is provided to those populations during periods of residence. This suggests the potential need for training and guidance for house managers working with these groups.

Background In Colombia, a person caught in possession of an illicit substance is not judicially sanctioned as long as the quantity does not exceed the maximum allowable amounts. Given that the public is divided on the appropriateness of this policy, an examination of the various public positions was undertaken. Method A convenience sample of 302 adults were presented with 48 vignettes depicting a situation of everyday life easily recognizable by all in Colombia; that of a male person who is apprehended in the street by the police because he is suspected of illicit trafficking. These vignettes were created by orthogonal variation of four factors: Type of substance, amount of substance, type of charge against the offender, and offender’s age. Results Through cluster analysis, six qualitatively different positions were found. These positions corresponded to three distinct, classical philosophies (a) a libertarian, free-market philosophy – punishment should never be extremely severe because the trade in psychotropic substances is a trade like any other (6%), (b) a moralistic, conservative philosophy – punishment should always be extremely severe except perhaps in certain cases (52%), and (c) a progressive, human rights-inspired philosophy – punishment should always be proportional to the seriousness of the facts (42%). Conclusion Half of Colombian people supported a control policy according to which the use of psychotropic substances is considered profoundly immoral. Most of the other segment of the population express views similar to those of international organizations. It is therefore desirable that legislators rely on progressive international legislation to support domestic policies that are not strictly moralistic and conservative.

Introduction Canada and the United States continue to experience increasing overdose deaths attributed to highly toxic illicit substances, driven by fentanyl and its analogues. Many bystanders report being hesitant to call 9-1-1 at an overdose due to fears around police presence and arrests. In Canada, a federal law was enacted in 2017, the Good Samaritan Drug Overdose Act (GSDOA), to provide protection from simple drug possession and related charges when 9-1-1 is called to an overdose. There is limited evidence, however, that the GSDOA has improved rates of intention to call 9-1-1 at overdose events. We therefore sought to examine intent to call 9-1-1 among persons who received GSDOA education and were at risk of witnessing an overdose. Methods A cross-sectional survey was conducted with people at risk of witnessing an overdose recruited at 19 Take Home Naloxone (THN) program sites across British Columbia as well as online through Foundry from October 2020 to April 2021. Descriptive statistics were used to examine intention to call 9-1-1 at future overdoses. Multivariable logistic regression models were built in hierarchical fashion to examine factors associated with intention to call 9-1-1. Results Overall, 89.6% ( n = 404) of the eligible sample reported intention to call 9-1-1. In the multivariable model, factors positively associated with intention to call 9-1-1 included identifying as a cisgender woman (adjusted odds ratio [AOR]: 3.37; 95% CI: 1.19–9.50) and having previous GSDOA awareness ([AOR]: 4.16; 95% CI: 1.62–10.70). Having experienced a stimulant overdose in the past 6 months was negatively associated with intention to call 9-1-1 ([AOR]: 0.24; 95% CI: 0.09–0.65). Conclusion A small proportion of the respondents reported that, despite the enactment of GSDOA, they did not intend to call 9-1-1 and those who were aware of the act were more likely to report an intention to call at future overdose events. Increasing GSDOA awareness and/or additional interventions to support the aims of the GSDOA could address ongoing reluctance to seek emergency medical care by people who use drugs.

Background Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use. Methods We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use. Results The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection. Conclusions A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

Background Outdoor smoke-free policies (SFPs) at sports clubs can contribute to protecting people from second-hand smoke (SHS). However, in absence of national legislation, it is uncertain whether and how sports clubs decide to adopt an SFP. The aim of this study was to explore the decision-making process at sports clubs in relation to the adoption of an outdoor SFP. Methods Semi-structured interviews were held with key stakeholders at 20 Dutch sports clubs (in field hockey, football, tennis, or korfball) with an outdoor SFP. Thematic analysis was applied, and themes were defined in line with the four streams of the Garbage Can Model (GCM). Results We identified four motivating factors for sports clubs to start the decision-making process: 1) SHS as a problem, 2) intolerance of smoking behavior, 3) advantages of an outdoor SFP, and 4) external pressure to become smoke-free. The decision-making process involved a variety of participants, but the board, influential club members, and smokers usually played major roles. Decisions were discussed during both formal and informal choice opportunities, but only made during formal choice opportunities. With regard to solutions, sports clubs adopted a partial or total outdoor SFP. In addition, sports clubs followed different strategies with regard to the decision-making process, which we classified along two dimensions: 1) autocratic vs. democratic and 2) fast vs. slow. Conclusion A number of factors motivated sports clubs to start the decision-making process. These factors were mainly linked to a strong non-smoking norm. Decision-making involved different participants, with a key role for the board, influential club members, and smokers. Governments and other external organizations may contribute to SFP adoption at sports clubs in several ways. They may advise clubs on strategies of decision-making and how to involve smokers in this process.