The United States is currently experiencing a housing and homelessness crisis. In response, many cities have adopted policies of displacement that move unhoused people from place to place. Recent research indicates that these policies may have negative health impacts on unhoused people who use drugs. We sought to examine health risks associated with forced displacement among unhoused people who inject drugs (PWID). We interviewed a community-recruited sample of opioid-using PWID in Los Angeles, CA and Denver, CO between April 2021 and November 2022 (N = 472) about their demographic/socioeconomic characteristics, drug use patterns, housing status, forced displacement including items discarded during displacements, and health risks. We constructed binomial generalized linear regression to examine the risk ratio of non-fatal overdose, and syringe and cooker/cotton sharing between four groups of participants: housed, unhoused and not displaced, unhoused and moved, and unhoused and displaced in the last three months. In the last 3 months, 52

Background Injection drug use-related infective endocarditis (IDU-IE) and bacterial infections have grown in the United States, but little is known about risk factors for these infections in community samples of people who inject drugs (PWID). Methods During 2021-22, PWID were recruited from community settings and surveyed for history of IDU-IE, serious injection related symptoms (SIRI) and untreated infection symptoms in the last 3 months. We used bivariate analysis and multiple logistic regression to examine factors associated with these outcomes. Results Among participants (n=472), 7% reported ever having IDU-IE, 14% reported having SIRI symptoms and 20% reported untreated infection symptoms in the last 3 months. Ever having IDU-IE was associated with HCV (adjusted odds ratio [AOR]=8.37; 95% confidence interval [CI]=2.46, 28.49), prior MRSA infection (AOR=5.37; 95% CI=2.44, 11.80), identifying as female and/or gender minority person (AOR=3.14; 95% CI=1.42, 6.95). SIRI symptoms were associated with greater material hardship (compared to low; AOR=2.47; 95% CI=1.17, 5.22), fentanyl use (AOR=2.15; 95% CI=1.01, 4.61), sharing filter/cotton (AOR=1.93; 95% CI=1.10, 3.39), and licking needle prior to injection (AOR=1.85; 95% CI=1.02, 3.36). Untreated infection symptoms were associated with poor quality sleep (AOR=2.04; 95% CI=1.21, 3.43), any mental health diagnoses (AOR=2.01; 95% CI=3.56), any chronic pain (AOR=1.89; 95% CI=1.14, 3.11), sharing filters (AOR=1.81; 95% CI=1.10, 2.98), and prior MRSA infection (AOR=1.75; 95% CI=1.04, 2.97). Conclusion Risk factors identified include treatable co-morbidities (i.e., HCV & MRSA history, mental health, pain, opioid use), modifiable health behaviors (i.e., equipment sharing, needle-licking), and addressable structural conditions (material hardship, housing).

Background:Medications for opioid use disorder (MOUD) are considered the gold standard long-term treatment for opioid use disorder (OUD) as they have a range of health and psycho-social benefits. Sudden reduction or interruptions in MOUD can have both immediate and long-term consequences for patients. We sought to qualitatively examine the impact of the prolonged closure of Mexico's main methadone production facility (Psicofarma) in 2023 on MOUD patients in Tijuana, Mexico. Methods:We conducted semi-structured qualitative interviews with 20 MOUD patients in Tijuana, Mexico, from May to August 2023. We transcribed interviews and translated them from Spanish to English for analysis. Our analysis followed a thematic and narrative approach, and code congruency was found by consensus. Analytic and narrative memos provided the foundation for the ultimate findings. Findings:The closure of Psicofarma resulted in a sudden stoppage in MOUD for participants. While some were provided with a benzodiazepine alternative and/or psychotherapy by their clinics, most were completely cut off from medical support. Participants reported returning to the illicit market for solutions to both withdrawal and drug cravings. Increased spending on the illicit market drained participant finances and strained employment and familial relationships. Interpretation:The sudden interruption of MOUD treatment had varied yet predictable effects on our participants. These results demonstrate the need to ensure adequate methadone supply for people with OUD in Mexico and to offer other alternative therapies such as low-threshold buprenorphine. Funding:Support for this study was provided by NIDA (R01DA049644-S4, T32DA023356 and DP2DA049295).

Among people who inject drugs and use opioids, the vast majority have reported experiencing opioid withdrawal symptoms during the past six months. People who use opioids experience significant impediments from withdrawal symptoms, including increased risk behaviors associated with overdose, bloodborne infection, and other negative health outcomes. We undertook this analysis to understand how social and structural forces shaped experiences of withdrawal risk, navigation, and management among a community sample of people who use opioids and inject drugs in Los Angeles, California. We conducted 30 semi-structured, in-depth interviews at community sites in Los Angeles. Qualitative data were analyzed using constructivist grounded theory. Our findings indicate that: 1) when people who use opioids experienced overlapping structural conditions (such as unsheltered houselessness and material difficulty) withdrawal becamea vulnerability and was prioritized first 2) severe material hardships necessitated that participants prioritized withdrawal to engage in their daily income generation activities, 3) participants engaged in higher risk behaviors in order to manage intense and urgent withdrawal symptoms, which led to shifts towards stigmatized and criminalized identities and negative self-appraisal. Overlapping structural vulnerabilities such as housing insecurity, material hardship, experiencing theft, and financial precarity compress risks associated with withdrawal while simultaneously constricting ways in which individuals can manage symptoms. Our findings point to ways in which existing withdrawal management options may be made more effective and accessible via structural support such as housing, income, and basic needs support. MOUD expansion may empower people who actively use opioids to navigate complex structural vulnerabilities from a place of assurance rather than urgency and fear; thereby serving as a harm reduction tool that disrupts the cycle of withdrawal management and material precarity.

Background Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes. Methods Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period. Results Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes. Conclusions This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

In 2022, approximately 580,000 people experienced homelessness in the United States. In response, many cities have implemented “camping ban” policies enforced by involuntary displacement of homeless encampments. Displacement has been cited as a strategy to protect public health and safety. However, there is mixed evidence that displacement is effective in reducing crime, while it is associated with other adverse health outcomes. To evaluate the neighborhood-level association between displacement and crime, we performed a retrospective (November 2019 to July 2023) pre-post spatiotemporal analysis using administrative data from Denver, CO. We used the Knox test statistic to detect excess clustering and change in total crime, as well as crime stratified by the National Incident-Based Reporting System (NIBRS) category, within spatiotemporal proximity to displacement events. We found that, on average, clustering of crime is high both before and after displacement. Within a 0.25-mile radius, displacement is associated with a statistically significant but modest decrease in crime, between − 9.3

Select Drug Category Opiates/OpioidsTopic Harm ReductionAbstract Detail OtherAbstract Category Original Research Aim Unhoused individuals experiencing material hardship have been increasingly subject to anti-camping policies resulting in forced and coerced displacement. In this study we examine internal validity and reliability of a new measure of material hardship among unhoused individuals, specifically among people who use opioids (PWUO). We examine the association between relocation events and this novel measure of material hardship. Methods Data was collected from an ongoing prospective cohort study of people who use opioids (PWUO), between 2020 and 2022 in Los Angeles, California and Denver, Colorado. Community recruited PWUO completed surveys at baseline, three months, and six months (n = 429). We used four baseline items (four-point ordinal scales) examining access to material resources in confirmatory factor analysis (CFA) to create a scale measuring material hardship. Structural equation modeling (SEM) was used to explore the association between being unhoused and displaced in the past three months (never, monthly, weekly, daily) and mean material hardship score. Results All four items of difficulty accessing food, clothing, showers, and restrooms, loaded well (> 0.7) onto a single latent factor we termed Hardship (range = 1 – 4) where a higher score indicates worse hardship. Fit statistics indicated good model fit (RMSEA = 0.034, 95% CI = 0.000 – 0.139; SRMR = 0.009). Coefficient alpha (0.88) and omega (0.76) values indicated good internal reliability. In SEM, after including demographic covariates, a one-category increase in displacement frequency was associated with a 0.452-point increase in mean Hardship. Conclusions Our Hardship scale showed good internal validity and reliability (data not shown). We found that increased mean Hardship score was associated with more frequent relocation when living outdoors, irrespective of demographic factors. As the crisis of unsheltered houselessness among PWUD in the US continues to grow, it appears that the policy of displacement negatively impacts well-being among PWUO.

Fentanyl and fentanyl analogues have disrupted the illicit drug supply through contamination of other substances (i.e., methamphetamine and cocaine) and replacement of heroin in illicit markets. Increasingly, they are contributing to opioid-overdose related deaths. The rapid and growing presence of fentanyl has led to gaps in research on the impact of this illicit market change on people who use drugs (PWUD). We sought to examine how the changing opioid market and growing fentanyl availability influences the role and use of medication for opioid use disorder (MOUD). Semi-structured qualitative interviews were conducted with a community recruited sample of PWUD (N = 22) in Los Angeles, California between September 2021 and April 2022. Interviews examined opioid use history, current opioid use behaviors and consumption patterns, and MOUD experiences and perceptions. Thematic analysis was used to systematically code and analyze textual interview data. The following themes related to fentanyl use and MOUD emerged: (1) Use of deviated MOUD to address fentanyl contamination, (2) Changing perception of the effectiveness of MOUD on fentanyl, and (3) Regulatory limitations of MOUD for fentanyl use disorder. PWUD described several repertoires for adjusting to changes in the illicit market of opioids. Clinicians treating PWUD should ask about recent fentanyl use prior to starting MOUD to account for increased tolerance to opioids. Harm reduction strategies such as naloxone kits, safe supply, and supervised consumption facilities can all prevent overdose deaths due to fentanyl.

Importance:At least 500 000 people in the US experience homelessness nightly. More than 30% of people experiencing homelessness also have a substance use disorder. Involuntary displacement is a common practice in responding to unsheltered people experiencing homelessness. Understanding the health implications of displacement (eg, "sweeps," "clearings," "cleanups") is important, especially as they relate to key substance use disorder outcomes. Objective:To estimate the long-term health effects of involuntary displacement of people experiencing homelessness who inject drugs in 23 US cities. Design, Setting, and Participants:A closed cohort microsimulation model that simulates the natural history of injection drug use and health outcomes among people experiencing homelessness who inject drugs in 23 US cities. The model was populated with city-level data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system and published data to make representative cohorts of people experiencing homelessness who inject drugs in those cities. Main Outcomes and Measures:Projected outcomes included overdose mortality, serious injection-related infections and mortality related to serious injection-related infections, hospitalizations, initiations of medications for opioid use disorder, and life-years lived over a 10-year period for 2 scenarios: "no displacement" and "continual involuntary displacement." The population-attributable fraction of continual displacement to mortality was estimated among this population. Results:Models estimated between 974 and 2175 additional overdose deaths per 10 000 people experiencing homelessness at 10 years in scenarios in which people experiencing homelessness who inject drugs were continually involuntarily displaced compared with no displacement. Between 611 and 1360 additional people experiencing homelessness who inject drugs per 10 000 people were estimated to be hospitalized with continual involuntary displacement, and there will be an estimated 3140 to 8812 fewer initiations of medications for opioid use disorder per 10 000 people. Continual involuntary displacement may contribute to between 15.6% and 24.4% of additional deaths among unsheltered people experiencing homelessness who inject drugs over a 10-year period. Conclusion and Relevance:Involuntary displacement of people experiencing homelessness may substantially increase drug-related morbidity and mortality. These findings have implications for the practice of involuntary displacement, as well as policies such as access to housing and supportive services, that could mitigate these harms.

IntroductionWe examined COVID-19 trends and the socio-structural correlates of infections and vaccinations among people who inject drugs (PWID).MethodsWe collected retrospective survey data from PWID (n = 472). We examined changes in COVID-19 testing, infection, and housing assistance for the first year of the pandemic, and then used multivariate logistic regression to examine factors with ever having an infection and receiving at least one vaccination from April 2020-March 2021.ResultsThe sample was mostly male, White and Latinx, and unhoused. Testing by quarter ranged from 46% to 33%. Housing assistance declined from 10% to 7% by the last quarter, while infections ranged from 6% to 4%. Ever being COVID-19 positive was associated with being male, having an income source, and being arrested in the last 3 months. Almost half of participants reported vaccination (47%). Receiving a vaccination was associated with prior U.S. armed forces service, older age, receiving substance use disorder treatment, and having ever received COVID-19 testing.DiscussionEfforts to vaccinate PWID fell short and housing assistance declined. Receiving targeted assistance, including better access to housing and medication treatments for opioid use disorder, could be important efforts to mitigate the heightened risks of COVID-19 and the ongoing harms PWID face that predate the pandemic.

Background: Prior research has shown that men who have sex with men (MSM) who use drugs are at increased risk of sexually transmitted infections (STI) and Human Immunodeficiency Virus (HIV). Often, MSM who use drugs use multiple substances at once and research has indicated that certain substances are used in combination more frequently. As a vulnerable population, it is important to understand the various ways in which this population uses drugs in order to structure prevention, harm reduction, and treatment programs to their needs.Methods: Data for this analysis were taken from a cohort of geographically diverse U.S. national sample of cisgender men who have sex with men ( n = 6111). After assessing prevalence of drug use in the sample, we used iterative latent class analysis to determine substance use classes for 10 substances. After a model was selected, class assignments were examined for association with mean number of insertive and receptive condomless anal sex (CAS) partners in the past three months.Results: The final model indicated six latent classes: class 1 = "cannabis use " (n = 1,996), class 2 = "diverse use " (n = 299), class 3 = "cocaine and inhalant use " (n = 421), class 4 = "methamphetamine, GHB, and inhalant use " (n = 345), class 5 = "no use " (n = 2431), class 6 = "sedative use " (n = 619). Age, race, annual income, residence in EHE jurisdictions, past history of houselessness, and past history of incarceration was significantly associated with membership in some classes. In outcome modeling, participants best assigned to Class 4 had the highest mean number of insertive (Mean = 9.70, 95% CI: 5.92 - 13.47) and receptive (Mean = 8.71, 95% CI: 6.75 - 10.66) condomless anal sex (CAS) partners in the prior three months. Conclusion: The six heterogenous classes may indicate discrete typologies of use behavior corresponding to dif-ferent settings or activities, which may themselves differ by regional HIV incidence trends and participant de-mographics. Programs seeking to address substance use among MSM may be well served to tailor toward these divergent clusters of substance use.

BACKGROUND:Unhoused people who use drugs in the United States are at risk for a variety of negative health outcomes. As the crisis of houselessness continues to impact major urban areas, a wave of punitive policies has been enacted to remove visible unhoused people from public spaces. There is reason to believe that harsh policies of encampment displacement will have negative immediate and downstream impacts on this community.METHODS:Participant observation was conducted weekly or bi-weekly at unhoused encampments in Los Angeles County, USA over the course of two years (2021, 2022). Data were generated through the lens of ontological security theory via in-field jottings and comprehensive field notes. Formal, semi-structured qualitative interviews were conducted with 30 unhoused people who use drugs recruited primarily through peer-referral sampling at these same venues. Data were coded and analyzed thematically using the Template Analysis approach. Field notes were used to triangulate and further contextualize thematic analysis of interview data.RESULTS:Encampment sweeps impacted nearly all participants and occurred multiple times at every visited field site. They were observed to occur both with and without the presence of police, but always resulted in the loss of the personal property of encampment residents. Sweeps occurred across seasons, hazardous weather, and without offers of alternative shelter. Participants described sweeps as impacting all aspects of their ontological security, including dismantling material and social constancy, disrupting routines of daily life and resource management, increasing feelings of surveillance, and potentially creating negative identity formation.CONCLUSIONS:In both ethnographic observation and participant interviews, encampment sweeps were noted to be physically, psychologically, and socially destructive. Sweeps left participants feeling anger, loss, and hopelessness while further driving the societal marginalization of unhoused people who use drugs. Sweeps should be discontinued as they harm the capacity of unhoused people to improve their well-being.

BACKGROUND AND OBJECTIVES While inadequate nutrition can weaken the immune system and lead to negative health sequelae for vulnerable populations, little is known about nutritional intake among people who inject drugs (PWID). We aimed to quantify nutritional intake among PWID and to explore associations between protein intake and drug use. METHODS A cross-sectional design was used to analyze self-reported participant data. PWID were recruited from community settings in California in 2016/2017. Participants reported on food consumption per day for a 30-day period, from which a continuous protein intake variable was created. RESULTS Modal characteristics of participants (N = 937) were: white (42.5%), male (75.3%), healthy body mass index (BMI) (56.6%), and unhoused (82.9%). Less than 1% of participants met or exceeded recommended guidelines for protein intake (0.80 g/day/1 kg body weight). The final multiple regression model found protein intake to be significantly positively associated with older age, high school or greater education, frequency of opiate and marijuana use, while Latinx ethnicity was inversely associated with protein intake, adjusting for gender. DISCUSSION AND CONCLUSIONS Our study shows PWID are generally not underweight, yet they are grossly protein deficient, which can be harder to recognize. Poverty, homelessness, and other structural barriers likely contribute to this issue, which demonstrates the need for communities to provide more access to nutrient-rich food to PWID. SCIENTIFIC SIGNIFICANCE Our study demonstrates the novel findings that opiate and marijuana use frequency, but not stimulants (methamphetamine and cocaine) may increase preference for protein-rich foods among PWID.

Background Online platforms are used to manage aspects of our lives including health outside clinical settings. Little is known about the effectiveness of using online platforms to manage hypertension. We assessed effects of tweeting/retweeting cardiovascular health content by individuals with poorly controlled hypertension on systolic blood pressure (SBP) and patient activation. Methods and Results We conducted this 2‐arm randomized controlled trial. Eligibility included diagnosis of hypertension; SBP >140 mm Hg; and an existing Twitter account or willingness to create one to follow study Twitter account. Intervention arm was asked to tweet/retweet health content 2×/week using a specific hashtag for study duration (6 months). The main measures include primary outcome change in SBP; secondary outcome point change in Patient Activation Measure (PAM). We remotely recruited and enrolled 611 participants, mean age 52 (SD, 11.7). Mean baseline SBP for the intervention group was 155.8 and for control was 155.6. At 6 months, mean SBP for intervention group was 137.6 and for control was 135.7. Mean change in SBP from baseline to 6 months for the intervention group was −18.5 and for control was −19.8 (P=0.48). Mean PAM at baseline for the intervention group was 70.3 for control was 72.7. At 6 months, mean PAM scores were 71.1 (intervention) and 75.6 (control). Mean change in PAM score for the intervention group was 0.0 and for control was 3.3 (P=0.12). Conclusions Recruiting and engaging patients and collecting outcome measures remotely are feasible using Twitter. Encouraging patients with poorly controlled hypertension to tweet or retweet health content on Twitter did not improve SBP or PAM score at 6 months. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02622256.

Introduction: Prescription stimulants and methamphetamine have similarities in chemical structure and impact on biological functioning. However, there is limited literature on prescription stimulant misuse among sexual and gender minorities as well as how prescription misuse may impact later methamphetamine use. Methods: We used data collected from a HIV prevention cohort to describe (e.g., frequencies, percentages) prescription stimulant use/misuse and methamphetamine use at baseline and 12-month follow-up (n = 4857). We then used multivariable logistic regression models to determine the impact of baseline prescription stimulant misuse and methamphetamine use on 12-month prescription stimulant misuse and methamphetamine use. Results: At baseline, 10.2 % of participants misused prescription stimulants and 12 % of participants used methamphetamine in the past 3 months, while at 12-month follow-up 11.6 % of participants misused prescription stimulants and 11.2 % of participants used methamphetamine in the past 3 months. Multivariable regression analyses indicated that participants who misused prescription stimulants (in the absence of meth amphetamine) at baseline had 2.51 (95 % CI: 1.44-3.59, ref. no stimulant or methamphetamine use) times the odds of using methamphetamine at 12-month follow-up. Discussion: Findings suggest that prescription stimulant use is a risk factor for continued meth use. Therefore, earlier and targeted public health interventions could reduce methamphetamine use by disrupting the progression from prescription stimulant misuse to methamphetamine use through early screening and interventions for prescription stimulant misuse.

Objective: Prior research has associated assisted injection with risk behaviors, but other risks such as injury, missed veins, and incidental exposures to blood-borne infections during an injection episode have not been assessed. In the following, we present the frequency of these other risks and determine factors associated with missing a vein and incidental blood exposure among people who inject drugs (PWID). Methods: We conducted a cross-sectional analysis of data from PWID who were recruited using targeted sampling in Los Angeles and San Francisco, California, during 2016 and 2017. The analytic sample consist of 336 participants who reported providing injection assistance in the last 6 months. Multivariate logistic regression models were developed for reporting the following risks: missing a vein; getting the recipient's blood on the injection provider; and getting blood on clothes or surfaces. Results: In the last 6 months, the most common negative consequences were getting blood on clothes or surfaces (40%), getting the recipient's blood on the injection provider (23%), and missing a vein (17%). In multivariate logistic regression analysis, missing the vein was significantly associated with higher odds of assisting a leg injection while getting the injection recipient's blood on the provider or getting blood on clothes or nearby surfaces was associated with higher odds of assisting a groin injection injecting in the groin. Conclusion: Providing injection assistance can result in incidental blood exposures and injury, particularly when injecting in sensitive locations on the body. Harm reduction interventions to reduce risks associated with this practice are essential to improving the well-being of PWID.