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Background and Aims: During the past decades, people who inject drugs (PWID) have been impacted by the development of combination antiretroviral therapy (cART) to combat HIV/AIDS, the prescription opioid crisis and increased use of lethal synthetic opioids. We measured how these dynamics have impacted mortality among PWID in an urban US city., Design: Prospective cohort study using data from the AIDS Linked to the Intravenous Experience (ALIVE)., Setting: Baltimore, MD, USA from 1988 to 2018., Participants: A total of 5506 adult PWIDs (median age at baseline 37 years)., Measurements: Mortality was identified by linkage to National Death Index-Plus (NDI-Plus) and categorized into HIV/infectious disease (HIV/ID) deaths, overdose and violence-related (drug-related) deaths and chronic disease deaths. Person-time at risk accrued from baseline and ended at the earliest of death or study period. All-cause and cause-specific mortality were calculated annually. The Fine & Gray method was used to estimate the subdistribution hazards of cause-specific deaths accounting for competing risks., Findings: Among 5506 participants with 84 226 person-years of follow-up, 43.9% were deceased by 2018. Among all deaths, 30.5% were HIV/ID deaths, 24.4% drug-related deaths and 33.3% chronic disease deaths. Age-standardized all-cause mortality increased from 23 to 45 per 1000 person-years from 1988 to 1996, declined from 1996 to 2014, then trended upward to 2018. HIV/ID deaths peaked in 1996 coincident with the availability of cART, then continuously declined. Chronic disease deaths increased continuously as the cohort aged. Drug-related deaths declined until 2011, but increased more than fourfold by 2018. HIV/HCV infection and active injecting were independently associated with HIV/ID and drug-related deaths. Female and black participants had a higher risk of dying from HIV/ID deaths and a lower risk of dying from drug-related deaths than male and non-black participants., Conclusions: Deaths in Baltimore, MD, USA attributable to HIV/ID appear to have declined following the widespread use of combination antiretroviral therapy. Increases in the rates of drug-related deaths in Baltimore were observed prior to and continue in conjunction with national mortality rates associated with the opiate crisis., (© 2021 Society for the Study of Addiction.)

Aims: There is limited longitudinal research examining incarceration and subsequent changes in drug use among people who inject drugs (PWID) in the United States. The objective of the current study was to characterize the frequency of incarceration and estimate the association between incarceration and subsequent injection drug use among current and former PWIDs in one US city., Design: ALIVE (AIDS Linked to the Intravenous Experience) is a prospective cohort study of current and former PWIDs, with semi-annual follow-up occurring since 1988., Setting: Baltimore, Maryland, USA., Participants: A total of 3245 participants with 48 738 study visits were included. Participants enrolled from 1988 to 2012 with a median of 13 follow-up visits per participant (Interquartile range = 7-25)., Measurements: Incarcerations were defined as any self-reported jail or prison stays in the previous 6 months that were ≥7 days or longer. The primary outcome was defined as any self-reported injection drug use in the previous 6 months., Findings: At baseline, 29% were female, 90% African American and 33% HIV-positive. Fifty-seven per cent of participants experienced at least one incarceration episode. After adjusting for confounders, there was a positive association between incarceration and subsequent injection drug use [adjusted odds ratio (AOR) = 1.48, 95% confidence interval (CI) = 1.37-1.59]; however, stratified analysis showed that the effect was restricted to those who were not injecting at the time of incarceration (AOR = 2.11, 95% CI = 1.88-2.37)., Conclusions: In the United States, incarceration of people who had previously stopped injecting drugs appears to be associated with an increased risk of subsequent injecting., (© 2015 Society for the Study of Addiction.)

Aims: To understand the environmental and contextual influences of illicit cocaine and heroin use and craving using mobile health (mHealth) methods., Design: Interactive mHealth methods of ecological momentary assessment (EMA) were utilized in the Exposure Assessment in Current Time (EXACT) study to assess drug use and craving among urban drug users in real time. Participants were provided with mobile devices and asked to self-report every time they either craved (without using) or used heroin or cocaine for 30 days from November 2008 through May 2013., Setting: Baltimore, MD, USA., Participants: A total of 109 participants from the AIDS Linked to the IntraVenous Experience (ALIVE) study., Measurements: For each drug use or craving event, participants answered questions concerning their drug use, current mood and their social, physical and activity environments. Odds ratios (OR) of drug use versus craving were obtained from logistic regression models with generalized estimating equations of all reported events., Findings: Participants were a median of 48.5 years old, 90% African American, 52% male and 59% HIV-infected. Participants were significantly more likely to report use rather than craving drugs if they were with someone who was using drugs [adjusted odds ratio (aOR) = 1.45, 95% confidence interval (CI) = 1.13, 1.86), in an abandoned space (aOR = 6.65, 95% CI = 1.78, 24.84) or walking/wandering (aOR = 1.68, 95% CI = 1.11, 2.54). Craving drugs was associated with being with a child (aOR = 0.26, 95% CI = 0.12, 0.59), eating (aOR = 0.54, 95% CI = 0.34, 0.85) or being at the doctor's office (aOR = 0.31, 95% CI = 0.12, 0.80)., Conclusions: There are distinct drug using and craving environments among urban drug users, which may provide a framework for developing real-time context-sensitive interventions., (© 2014 Society for the Study of Addiction.)

Aims: To determine the incidence of long-term injection cessation and its association with residential relocation and neighborhood deprivation., Design: ALIVE (AIDS Linked to the Intravenous Experience) is a prospective cohort with semi-annual follow-up since 1988. Multi-level discrete time-to-event models were constructed to investigate individual and neighborhood-level predictors of long-term injection cessation., Setting: Baltimore, USA., Participants: A total of 1697 active injectors from ALIVE with at least eight semi-annual study visits., Measurements: Long-term injection cessation was defined as 3 consecutive years without self-reported injection drug use., Findings: A total of 706 (42%) injectors achieved long-term cessation (incidence=7.6 per 100 person-years). After adjusting for individual-level factors, long-term injection cessation was 29% less likely in neighborhoods in the third quartile of deprivation [hazard ratio (HR)=0.71, 95% CI: 0.53, 0.95) and 43% less likely in the highest quartile of deprivation (HR=0.57, 95% CI: 0.43, 0.76) compared to the first quartile. Residential relocation was associated with increased likelihood of long-term injection cessation (HR=1.55, 95% CI: 1.31, 1.82); however, the impact of relocation varied depending on the deprivation in the destination neighborhood. Compared to those who stayed in less deprived neighborhoods, relocation from highly deprived to less deprived neighborhoods had the strongest positive impact on long-term injection cessation (HR=1.96, 95% CI: 1.50, 2.57), while staying in the most deprived neighborhoods was detrimental (HR=0.76, 95% CI: 0.63, 0.93)., Conclusions: Long-term cessation of injection of opiates and cocaine occurred frequently following a median of 9 years of injection and contextual factors appear to be important. Our findings suggest that improvements in the socio-economic environment may improve the effectiveness of cessation programs., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Background: Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined., Objective: To estimate the frequency and risk factors for use of street methadone., Methods: Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression., Results: Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment., Conclusion: The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.