Importance:Approximately 2 million individuals are incarcerated in the US. Surgical needs increase with age, and an aging prison population means an increasing need for surgical care for incarcerated individuals. Challenges in logistics, privacy, communication, and comorbidities put people in law enforcement custody at risk for suboptimal care and outcomes. Little guidance exists for surgeons seeking to provide equitable care for these patients. Observations:No national statistics are available on the need for surgery among incarcerated people. Autopsy data suggest that nearly a quarter of deaths among incarcerated individuals were attributable to causes that could have been treated with surgery, yet few received surgical care before death. Across the spectrum of custody, including police detention, jail, prison, probation, and parole, access to consistent preoperative and postoperative care are major challenges, as is sustaining appropriate levels of privacy and communication. Incarcerated people are often accompanied by guards, preventing privacy. Patients are shackled to hospital beds, restricting mobility. For incarcerated individuals, access to postoperative medication may be curtailed when they return to jail or prison. To be effective advocates for patient-centered care and to achieve the best outcomes, surgeons must remain vigilant to specific barriers to care. Conclusions and Relevance:Individuals in law enforcement custody have particular needs regarding communication, surgical planning, and perioperative and postoperative care. Clinicians must remain alert to these challenges and serve as advocates for these marginalized patients, even adjusting their care practices. Professional societies and health systems can bolster care for this marginalized population by developing and disseminating guidelines and pathways for patient-centered surgical care for individuals in law enforcement custody.

BACKGROUND:Few patient-facing educational materials and interventions exist for the prevention of injection drug use-related infective endocarditis (IDU-IE). We developed a patient and clinician-informed website for patients about IDU-IE to promote education and prevention strategies. METHODS:This mixed-methods study integrated surveys and semi-structured interviews with patients and clinician to develop a patient website about IDU-IE. Patient participants included hospitalized adults with an opioid use disorder, history of injection drug use, and an injection drug use-related infection. Interprofessional healthcare clinicians including trainees participated. A baseline survey and semi-structured interviews were conducted with patients to understand knowledge of IDU-IE and preferences in educational materials content and format. Interviews were analyzed using rapid qualitative analysis. Results informed development of the patient website. Finally, patients and clinicians provided 2 rounds of survey feedback after reviewing the website, assessing the likelihood of using and recommending it to others, helpfulness of information in the website sections, and content satisfaction. RESULTS:Patient participants (n = 15) reported low baseline understanding of injection practice and risk of IDU-IE. After reviewing the website (n = 17), patients reported they were very likely to recommend the website as a reference for themselves (mean of 4.3; 4 = very likely) and for others (mean = 4.3). They found the following sections, on average, to be very helpful (4 = very helpful): complications from injection drug use (4.4), safer injection practice (4.4), and information about infective endocarditis (4.4). Patients on average were satisfied with the website content overall (4.8). Clinicians (n = 27) reported, on average, being very likely to recommend this website to a patient (4.4) and to use the website to counsel patients (4.1). CONCLUSIONS:A patient and clinician-informed website on IDU-IE is acceptable for patients and clinicians to use as a patient education resource to help prevent IDU-IE-related harms.

Given increasing rates of fatal overdoses in the United States and the rapidly changing drug supply, overdose prevention centers (OPCs; also known as safe consumption sites) have been identified as a vital, evidence-based strategy that provide people who use drugs (PWUD) the opportunity to use drugs safely and receive immediate, life-saving overdose support from trained personnel. In addition to providing a safe, supervised space to use drugs, OPCs can house further essential harm reduction drop-in services such as sterile supplies, social services, and medical care. There are established national and international data demonstrating the lifesaving services provided by OPCs, inspiring a groundswell of advocacy efforts to expand these programs in the United States. Thus, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) endorses OPCs, in addition to other harm reduction strategies that protect PWUD. Ultimately, it is imperative to increase access to OPCs across the United States and support key policy changes at the local, state, and federal levels that would facilitate urgent expansion.

More than 25% of all arrests made nationwide are related to drug offenses, affecting almost 1.2 million people and their social networks. Furthermore, roughly 20% of people in jails and prisons across the United States are incarcerated for a drug offense and millions more are under community supervision for these charges. This criminalization of drug use has negatively affected the health and well-being of people who use drugs (PWUD) and their communities. Decriminalization-a process of removing criminal sanctions for a previously criminalized behavior-of drug use is central to harm reduction as it mitigates these negative consequences of drug use and supports the health of PWUD. As such, AMERSA supports the decriminalization of drug and paraphernalia possession for personal use for all currently illicit drugs and all associated equipment. AMERSA continues to strongly advocate for the funding of harm reduction strategies and addiction services to improve the health and well-being of PWUD since decriminalization without complementary funding for harm reduction services, addiction treatment services, and social safety nets will be incomplete.

Background: Position statements clarify key issues that are in alignment with the vision, mission, and values of the AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). This Position Statement, endorsed by the AMERSA Board of Directors on October 3, 2023, amplifies the position of the organization, guides their activities, and informs the public and policymakers on the organization’s stance on this issue. Issue: The unregulated drug supply in the United States evolves constantly, leaving those who use drugs potentially unaware of new adulterants in their drugs. Not knowing that information can leave people vulnerable to serious adverse events such as fatal overdoses, wounds, and other health consequences. Without real-time data on the composition of drugs available in a community, healthcare providers and public health practitioners are left with insufficient data, making it increasingly difficult to know how to best serve people who use drugs. In this context, community-based drug checking has become recognized as an important harm reduction strategy with the potential to provide those who use drugs with more information about their supply. Recommendations: It is imperative to expand funding and increase access to drug checking programs in communities across the United States. Key policy changes, such as those related to decriminalizing drug and drug paraphernalia possession, are needed to increase the utilization of drug checking programs. Protection of persons who use drugs through harm reduction strategies, including drug checking programs needs to be widely available and accessible.

Xylazine is increasingly prevalent in the unregulated opioid supply in the United States. Exposure to this adulterant can lead to significant harm, including prolonged sedation and necrotic wounds. In the absence of literature describing healthcare providers’ experiences with treating patients who have been exposed to xylazine, we aimed to explore what gaps must be addressed to improve healthcare education and best practices. From October 2023 to February 2024, we conducted a sequential explanatory mixed-methods study, with (1) a quantitative survey phase utilizing convenience sampling of healthcare providers treating patients in Connecticut and (2) a qualitative semi-structured interview phase utilizing purposive sampling of providers with experience treating patients with xylazine exposure. Summary statistics from the survey were tabulated; interview transcripts were analyzed using thematic analysis. Seventy-eight eligible healthcare providers participated in our survey. Most participants had heard of xylazine (n = 69, 95.8

Background: Primary care is an important yet underutilized resource in addressing the overdose crisis. Previous studies have identified important aspects of primary care for people who use drugs (PWUD) and have found patient involvement in healthcare decisions and goal-setting to be especially critical. However, there has been limited research describing the primary care goals of PWUD. In harm reduction settings, where it is imperative that PWUD set their own goals, this research gap becomes especially relevant. Objective: To explore how PWUD navigate primary care with a focus on understanding their primary care goals. Design: A qualitative study using semi-structured interviews. Participants: PWUD currently engaged in primary care at the Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program, a harm reduction-based primary care program in New York City. Approach: Between June 2022 and August 2022, we conducted 17 semi-structured interviews. Informed by phenomenology, transcripts were coded using both inductive and deductive codes and themes were developed using thematic analysis approaches. Key Results: Phenomenological analysis identified four core components that, together, created an experience that participants described as "a partnership" between patient and provider: (1) patient-provider collaboration around patient-defined healthcare goals; (2) support provided by harm reduction-based approaches to primary care anchored in incrementalism and flexibility; (3) care teams' ability to address healthcare system fragmentation; and (4) the creation of social connections through primary care. This holistic partnership fostered positive primary care experiences and supported participants' self-defined care goals, thereby facilitating meaningful care outcomes. Conclusions: To best meet the primary care goals of PWUD, these findings underscore the importance of primary care providers and programs facilitating such partnerships through organizational-level support anchored in harm reduction. Future research should explore how these experiences in primary care affect patient health outcomes, ultimately shaping best practices in the provision of high-quality primary care for PWUD.

In 2020, an estimated 91 799 people in the USA died of substance-related overdose—75% were related to opioids, and 85% of these opioid deaths were related to fentanyl. In 2021, overdose deaths increased to over 108 000 and provisional data from 2022 show a further increase.1 The presentation of opioid withdrawal in hospitals is sometimes overlooked or even ignored, both of which are unacceptable. Possible reasons for overlooking or ignoring opioid withdrawal in hospitals include: implicit bias, poor knowledge regarding approaches to the management of opioid-related presentations, or a misunderstanding of the implications of unmanaged opioid use disorder (OUD).

BACKGROUND:Xylazine is an α 2 -adrenergic agonist that is commonly used as a veterinary tranquilizer and is increasingly present in the unregulated US drug supply since at least 2019. There are many suspected clinical complications of xylazine use, including unusual skin wounds, atypical overdose presentations, and possible dependence and withdrawal syndromes. However, there are few reports of cutaneous manifestations of xylazine in patients who inject drugs that can guide diagnosis and management in patients with confirmed xylazine toxicology.CASE SUMMARY:We present the cases of 3 stably housed patients in Connecticut with opioid use disorder and intravenous use of fentanyl who presented with atypical, chronic wounds at the site of injection drug use. Xylazine toxicology sent on all 3 patients was positive. All patients were seen by wound care and dermatology, and 1 patient was followed by infectious diseases. Wound care management strategies are discussed as well as harm reduction strategies. For all patients, the dose of their medication for opioid use disorder was increased to decrease frequency of drug use given concern that patients were exposed to a drug supply containing xylazine.CLINICAL SIGNIFICANCE:This case report presents wound characteristics that raise the index of suspicion for xylazine-involved injection wounds and might assist in their diagnosis and management. There is urgent need for more reporting of such cases as well as rigorous research to understand the potential impact of xylazine on people who use drugs. Multidisciplinary best practices should be established.

Importance:An increasing number of emergency departments (EDs) are initiating buprenorphine for opioid use disorder (OUD) and linking patients to ongoing community-based treatment, yet community-based clinician and staff perspectives regarding this practice have not been characterized.Objective:To explore perspectives and experiences regarding ED-initiated buprenorphine among community-based clinicians and staff in geographically distinct regions.Design, Setting, and Participants:This qualitative study reports findings from Project ED Health, a hybrid type 3 effectiveness-implementation study designed to evaluate the impact of implementation facilitation on ED-initiated buprenorphine with referral to ongoing medication treatment. Clinicians and staff from community-based treatment programs were identified by urban academic EDs as potential referral sites for ongoing OUD treatment in 4 cities across the US in a formative evaluation as having the capability to continue medication treatment. Focus groups were held from April 1, 2018, to January 11, 2019, to examine community OUD treatment clinician and staff perspectives on accepting patients who have received ED-initiated buprenorphine. Data were analyzed from August 2020 to August 2022.Main Outcomes and Measures:Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework, focusing on domains including evidence, context, and facilitation.Results:A total of 103 individuals (mean [SD] age, 45.3 [12.0] years; 76 female and 64 White) participated in 14 focus groups (groups ranged from 3-22 participants). Participants shared negative attitudes toward buprenorphine and variable attitudes toward ED-initiated buprenorphine. Prominent barriers included the community site treatment capacity and structure as well as payment and regulatory barriers. Perceived factors that could facilitate this model included additional substance use disorder training for ED staff, referrals and communication, greater inclusion of peer navigators, and addressing sociostructural marginalization that patients faced.Conclusions and Relevance:In this study of community-based clinicians and staff positioned to deliver OUD treatment, participants reported many barriers to successful linkages for patients who received ED-initiated buprenorphine. Strategies to improve these linkages included educating communities and programs, modeling low-barrier philosophies, and using additional staff trained in addiction as resources to improve transitions from EDs to community partners.

The COVID-19 pandemic, with its multiplicative harms, has wreaked havoc across the world: illness, pain, death, supply shortages, unemployment, school interruptions, and more. However, this pandemic also ushered in new societal norms and health policies that present opportunities to improve the quality of life for those who survive the pandemic. For example, thematic qualitative analyses revealed that some people report positive changes resulting from COVID-19–related policies, such as increased access to work-from-home options and improvements to health literacy.1 In addition, the COVID-19 pandemic created local public health states of emergencies, which allowed for the creation of legislation that sought to increase access to prevention, harm reduction, and treatment programs,2-4 all of which can improve the health of people who inject drugs (PWID). Harm reduction centers, even throughout the pandemic, continue to offer much more than sterile syringes. Many programs provide on-site wound care treatment, counseling, housing supports, food, and access or referrals to buprenorphine or methadone.5 Thus, the precedents set by COVID-19 policies provide an opportunity to create sustained programmatic and policy-level success for the fields of harm reduction and public health. The health of PWID is at an important juncture that necessitates evidence-based interventions, as drug overdose death rates are at an all-time high.6 Simultaneously, injectionrelated bloodborne infections such as HIV are on the rise.7,8 As a result, the fields of harm reduction and health care must promote and use evidence-based policies and practices to ensure the health and engagement of PWID. Decades of evidence demonstrate that syringe service programs (SSPs) limit harms and promote health, through preventing transmission of viral infections such as HIV and hepatitis C, abscesses, skin and soft-tissue infections, and endocarditis, and provide other health benefits.9,10 To this end, more than 450 SSPs in the United States self-report to the North American Syringe Exchange Network.11 We assert that harm reduction programs and strategies must include steady and ample access to sterile syringes and equipment to meet the needs of PWID, who should have access to a sterile, new syringe for each injection. As recommended by the Centers for Disease Control and Prevention, needs-based strategies operate through supplying people with the number of syringes they state they need for a period of time.12 This need is based on many factors, including the frequency of one’s drug use, one’s social network, and financial or transportation concerns.13 Thus, 89% of SSPs in the United States surveyed by the 2019 Dave Purchase Memorial survey permitted more than simply one-for-one exchange, which requires 1 used syringe to be exchanged for access to 1 new sterile syringe.14 However, in many parts of the United States, this costeffective and efficacious infection prevention intervention is either unavailable or inefficient because of restrictive policies that are not based on evidence.11,15-17 Some localities still use the antiquated one-for-one exchange scheme.11,18 In addition, some local or state regulators further limit syringe access or efficiency by requiring local law enforcement approval, zoning restrictions, or direct limits on syringe dispensing.19 The 2014-2015 HIV and hepatitis C virus epidemics in Scott County, Indiana, provide a historical example of how such barriers (eg, imposing limited operational hours for SSP locations) interfere with programmatic success and positive outcomes for PWID.2

This editorial reviews literature on xylazine as well as major clinical considerations for treatment and management of suspected xylazine-involved overdoses and xylazine-related wounds. The clinical presentation and management of xylazine overdoses in the emergency setting are covered. Finally, it presents important programmatic considerations for improving care of people using xylazine. Xylazine, an α-2 agonist with a chemical structure similar to phenothiazines and pharmacologic similarities to clonidine, tizanidine and dexmedetomidine, is a substance used in veterinary medicine known to cause sedation, analgesia and muscle relaxation, and it has increasingly become present in the United States (US) illicit drug supply over the last 5 years [1-3]. The Food and Drug Administration (FDA) has recently issued clinical guidance on xylazine [4] and the Office of National Drug Control and Policy has also issued additional clinical recommendations with policy and research guidance [5]. Xylazine initially was studied as a potential anesthetic or sedative-hypnotic agent, however, early trials in humans were limited by severe hypotension and central nervous system depression [6]. Xylazine was approved for veterinary use in 1972. In the early 2000s, xylazine was reported in Puerto Rico among people injecting heroin; at the time, it was noted to cause large skin wounds and profound sedative effects that differed from opioid intoxication [7, 8]. Clinical effects of xylazine in humans have been mostly derived from case reports. Currently, most xylazine overdoses are concomitant with fentanyl [1, 9]. However, xylazine in and of itself can be fatal: one review article reported 21 non-fatal and 22 fatal cases involving xylazine; several fatalities were intentional overdoses of xylazine in combination with alcohol or benzodiazepines [10]. The effects of xylazine poisoning in humans are largely driven by the decreased release of norepinephrine and dopamine in the central nervous system. Bradycardia, central nervous system depression, respiratory depression, hyperglycemia, miosis, hypothermia, premature ventricular contractions and transient hypertension followed by sustained hypotension have been reported, from central and peripheral reduction in sympathetic tone, including increased vagal tone [10-12]. Time to onset of clinical effect is minutes, with an estimated half-life of 23 to 50 minutes per the FDA [4], however, duration of effects in large animals has been typically 3 to 4 hours [12]. Given overlap in clinical presentation of opioids and xylazine overdoses, mixed overdose presentations are often indistinguishable on presentation, with the exception that naloxone, may partially improve the respiratory rate or miosis without improvement of mental status. In these situations, treatment is primarily supportive, including vital sign monitoring, supplemental oxygen, intravenous fluids and/or vasopressors and endotracheal intubation when needed. Extrapolation from what is known about pharmacologically similar medications (i.e. dexmedetomidine, clonidine) has been an important factor in our developing understanding of xylazine-associated deaths. Intranasal or IV naloxone should be given as indicated every 2 to 3 minutes if there is improvement in mental status to reverse any opioid involvement, alongside oxygen and ongoing circulation support as needed. There are no known human reversal agents for xylazine overdose, although yohimbine and tolazoline are used as reversal agents in horses [13]. Although xylazine testing could be an important component for patient education and clinician decision making, urine toxicology testing is rarely available during an acute overdose event, and therefore, is unlikely to change pre-hospital or emergency clinician management. The combination of opioids and xylazine likely potentiates sedation and respiratory depression, however, the exact mechanism of xylazine in these processes is unclear. Animal studies suggest that the presence of xylazine blunts the compensatory hyperoxic phase of the biphasic oxygen response that had been identified in rats exposed to fentanyl or heroin alone [14], thereby eliminating a protective central nervous system compensatory mechanism [15]. However, in a recent large prospective, multicenter cohort of individuals presenting to emergency departments with opioid overdose, cardiac arrest and coma were significantly less common in those testing positive for xylazine than for opioids alone, which may be related to lower comparative opioid content in samples containing xylazine or different patterns of use [16]. Although xylazine may cause an opioid overdose like toxidrome on its own in the absence of fentanyl, the extent to which xylazine is replacing more potent fentanyl in the illicit drug supply and the downstream impact that may have on day-to-day drug use patterns and overdose risk is poorly understood. Additional studies are needed to better delineate the role of xylazine in overdose deaths. Diagnosing and managing xylazine-related wounds relies on a high index of suspicion, a thorough history of substance use and diagnosis of potential substance use disorders, and familiarity with local xylazine prevalence. Much of what is known about management is based on case reports only because of no known trials in humans. These wounds are primarily noted at or around the site of previous injection, with necrosis or black eschar formation at the site within 1 to 3 days of injection [17]. It is not clear how small wounds become confluent into larger body surface area wounds. Potential pathophysiology involves peripheral vasoconstrictive effects of xylazine, impairing wound healing, obliterative vascular damage from repeated injection, locally toxic extravasation or an immunologic phenomenon. Similar to burns or wounds with larger body surface area, they could be a risk for superinfection, but are not intrinsically infected. Once wounds are recognized as potentially xylazine-related, efforts to help patients cease injection drug use into or near the wound are critical. In many cases, this involves initiating or increasing doses of medication to treat opioid use disorder (e.g. buprenorphine or methadone), harm reduction strategies to decrease injection episodes, switch route of administration to intranasal and consistent access to wound care supplies and education. Keeping the wound moist, clean and covered at all times is imperative. In our clinical experience, chemical or enzymatic debridement of eschar is often preferred by patients over surgical debridement; we advise patients to avoid drying agents like alcohol swabs. Keeping the wound covered at all times with petrolatum gauze, antimicrobial dressings and self-adhesive wraps or large bandages is recommended. Currently, it is not clear at this time whether xylazine dependence [18] and withdrawal [19] are diagnostic entities, although reported symptoms of anxiety and restlessness have been managed with analogue agents such as dexmetometidine, clonidine or adjunct benzodiazepines. It is not known if xylazine is impacting the difficulty of initiating medication for opioid use disorder or people's ability to enter treatment programs; however, some patients have anecdotally conveyed being turned away from programs because of xylazine wounds or have not entered treatment for fear their xylazine dependence will go untreated. There is also fear that stigma related to xylazine wounds could prevent patients from seeking help from healthcare professionals. There are urgent research, clinical and policy considerations surrounding xylazine in humans. Increased testing for xylazine, low barrier access and affordable, therapeutic doses of medication treatment for opioid use disorder, as well as expanded access to harm reduction services, including drug checking, overdose prevention centers, safer opioid supply programs and wound care supplies, are essential considerations moving forward. Kimberly L. Sue: Conceptualization (equal); writing—original draft (equal); writing—review and editing (equal). Kathryn Hawk: Conceptualization (equal); writing—original draft (equal); writing—review and editing (equal). The authors acknowledge harm reduction programs and the National Survivors Union who have shared their experiences with caring for people with xylazine wounds and responding to xylazine-involved overdoses. K.L.S. has no conflicts of interest to declare. K.H. has research funding from the Elevance Foundation and the Foundation for Opioid Response Efforts. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Background Housing environments shape injection drug-related risks and harms and thus represent a critical implementation setting for syringe services programs (SSPs). As critical harm reduction measures, SSPs provide safe injecting equipment to people who inject drugs (PWID). Vancouver, Canada, has well-established syringe distribution programs through which PWID have low-threshold access to unlimited syringes and related injecting equipment, including through non-profit operated supportive housing and single-room occupancy hotels. This study examines the role of housing-based SSPs in distributing injecting equipment to PWID in Vancouver. Methods Between January and March 2020, semi-structured, in-depth interviews were conducted in Vancouver with 26 PWID. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using inductive and deductive approaches. Results Many participants accessed SSPs in housing facilities and expressed preference for these programs over those offered at other locations and through other health and social services. Three major themes emerged to explain this preference. First, most participants injected in the buildings where they resided, and housing-based SSPs made injecting equipment available when and where it was most needed. Second, many participants preferred to avoid carrying syringes outside of the places where they inject due to fears that syringe possession may lead to criminal charges or confiscation of syringes and/or illicit drugs by police. Third, for some participants, anti-drug user stigma and concerns over unwillingly disclosing their drug use hindered access to SSPs outside of housing settings. Programs operated within housing facilities often offered greater client anonymity along with more supportive and less stigmatizing environments, particularly in the presence of peer staff. Conclusion The current study advances understanding of access to injecting equipment in a setting with city-wide syringe distribution programs. Our findings underscore the benefits of housing-based SSPs and encourage the expansion of such services to maximize access to harm reduction supports for PWID.

In reply: In this commentary, we respond to Dr Vogel and Dr Dürstelar's letter to our original piece "A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine Are Urgently Needed in the Fentanyl Era" published in this journal in July to August 2022. We agree with much of their comment on buprenorphine initiation and point to the need for rapid expansion of medication for opioid use disorder (OUD) treatments here in the United States. It is critical to understand the context of current buprenorphine and methadone access. We point out how the treatment of OUD with agonist therapy remains limited to methadone or buprenorphine despite an increasingly toxic drug supply within our particular legal and regulatory environment and call for urgent research and pilot programs to trial additional agonist therapies for those with opioid OUD as well as regulatory changes to increase access to both methadone and buprenorphine.

With the worst opioid overdose death crisis in the United States history, urgent new approaches to assist people who use drugs onto medication for opioid use disorder are necessary. In this commentary, addiction medicine clinicians and drug user union representatives align to argue that conventional ways of buprenorphine initiation that require periods of withdrawal must be augmented with additional novel approaches to initiation. In the fentanyl era, members of the New England Users Union and Portland Users Union report encountering precipitated withdrawal, being unable to stop using full agonist opioids for a required period of time, and difficulty initiating this medication that could offer them some stability and life-saving treatment. People who use drugs should be involved at all levels with ongoing research, clinical and policy efforts to improve buprenorphine initiation as their lives and their suffering are at stake.

AbstractObjectiveTo investigate how the COVID‐19 pandemic impacted low‐income individuals with substance use disorder (SUD) in New York City (NYC) during the beginning of the pandemic, using a structural competency and structural vulnerability theoretical framework and a qualitative research approach.Data SourcesPrimary qualitative data were collected from racial/ethnic minority adults enrolled in Medicaid receiving outpatient substance use treatment (e.g., medication, counseling) in NYC.Study DesignSemi‐structured in‐depth qualitative interviews (N = 20) were conducted during “stay‐at‐home” orders in NYC, the first epicenter of the COVID‐19 pandemic in the United States. Interviews were conducted over the phone during the earlier stages of the pandemic, between April 2020 and June 2020.Data Collection/Extraction MethodsSemi‐structured in‐depth interviews were conducted and audio recorded, transcribed, and analyzed using a thematic analysis approach.Principal FindingsThree themes were yielded from our thematic analysis: (1) COVID‐19 heightened food insecurity and housing conditions increased risks of infection; (2) stay‐at‐home orders limited access to resources but had positive impacts in strengthening social relationships and reducing substance use triggers; and (3) although COVID‐19 created challenges for treatment, most described that SUD care improved during the pandemic.ConclusionsWhile COVID‐19 exacerbated numerous structural vulnerabilities among low‐income individuals with SUD, programmatic adaptations to COVID‐19 SUD care, including telehealth and loosening restrictions around medications for opioid use disorders mitigated past difficulties that patients had faced. Reducing structural vulnerabilities for Medicaid patients will require continuation of telehealth treatment delivery, retaining flexible medication regulations, and mobilizing community resources to mitigate economic disparities.

BACKGROUND:Polysubstance use is common among people who use drugs, including the co-use of stimulants and opioids. Research suggests the practice of simultaneous co-injection of methamphetamines and opioids, often referred to as "goofballs", is increasing. As a relatively unique drug use practice, little qualitative research currently exists on goofball injecting. This study explores the practice and embodied experiences of goofball injecting.METHODS:This article draws on in-depth interviews conducted across two qualitative studies undertaken in Vancouver, Canada's Downtown Eastside neighbourhood examining changing dynamics in relation to stimulant use and experiences with an overdose prevention site-based safer supply intervention, respectively. Interviews containing discussions of goofball use (n=29) were extracted from each study and merged into a single qualitative dataset. Data were analysed thematically and focused on the practices and embodied experiences of goofball injection.RESULTS:Our analysis uncovered how goofball injection represented a complex drug use practice driven by the desire to achieve particular embodied experiences not attainable by using either drug individually. We identified three distinct practices of goofball use: 1) to alter or enhance the effects of opioids; 2) to alter or enhance the effects of methamphetamines; and 3) to balance out the effects of both drugs.CONCLUSION:Our study fills an important gap in the polysubstance use literature specifically exploring the co-injection of methamphetamines and opioids. Our findings highlight the need to implement and expand interventions and services attentive to polysubstance use and the role of pleasure in drug taking practices, including expanding non-medicalized opioid and stimulant safer supply initiatives across North America.

In this article, I describe the dilemmas of working as a physician-ethnographer within the Rikers Island jail healthcare system before and at the beginning of the COVID-19 epidemic in April 2020. The Rikers Island jail system in New York City has been in the national spotlight as a space of violence, trauma, and death amidst calls to decarcerate by community members and abolition advocates. This article is a personal reflection on the labor and subjectivity of healthcare providers and their positionality to multiple axes of structural and interpersonal violence while attempting to provide care in carceral institutions. I observe how COVID-19 functioned as an additional form of structural violence for incarcerated people. Clinical ethnography remains an essential tool for understanding complex social phenomena such as violence. However, physician-ethnographers working in these spaces of structural violence can have unique and conflicting constraints: tasked with providing evidence-based medicine but also simultaneously participating in an unusual form of labor that is an amalgamation of care, social suffering, and punishment. Despite and across at-times conflicting roles and obligations, I propose that these fragmented subjectivities can foment social criticism, propel advocacy toward decarceration, and produce a critically engaged dialogue between fields of anthropology and medicine toward a goal of health justice.