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Objectives. To describe the current financial health of syringe services programs (SSPs) in the United States and to assess the predictors of SSP budget levels and associations with delivery of public health interventions. Methods. We surveyed all known SSPs operating in the United States from February to June 2022 (n = 456), of which 68% responded (n = 311). We used general estimating equations to assess factors influencing SSP budget size and estimated the effects of budget size on multiple measures of SSP services. Results. The median SSP annual budget was $100 000 (interquartile range = $20 159‒$290 000). SSPs operating in urban counties and counties with higher levels of opioid overdose mortality had significantly higher budget levels, while SSPs located in counties with higher levels of Republican voting in 2020 had significantly lower budget levels. SSP budget levels were significantly and positively associated with syringe and naloxone distribution coverage. Conclusions. Current SSP funding levels do not meet minimum benchmarks. Increased funding would help SSPs meet community health needs. Public Health Implications. Federal, state, and local initiatives should prioritize sustained SSP funding to optimize their potential in addressing multiple public health crises. (Am J Public Health. 2024;114(4):435-443. https://doi.org/10.2105/AJPH.2024.307583).

BackgroundGiven the housing instability and frequent residential relocation (both volitional and hegemonic) of people who inject drugs, we sought to determine whether residential relocation (defined as sleeping in a different place in the past 30 days) is associated with health outcomes in a sample of people who inject drugs (PWID).MethodsWe recruited 601 PWID using targeted sampling and interviewed them between 2016 and 2018 in San Francisco and Los Angeles, CA about housing, drug use practices, and service utilization. We then developed multivariable regression models to investigate how residential relocation is associated with violence, health outcomes, and social service access. We analyzed our data between June 2018 and October 2019.ResultsParticipants who relocated in the past 30 days had lower odds of being in substance use treatment (Adjusted Odds Ratio [AOR] = 0.62, 95% Confidence Interval [CI] = 0.42, 0.89) and higher odds of nonfatal overdose (AOR = 2.50, CI = 1.28, 4.90), receptive syringe sharing (AOR = 2.26, CI = 1.18, 4.32), severe food insecurity (AOR = 1.69, CI = 1.14, 2.50), having belongings stolen (AOR = 2.14, CI = 1.42, 3.21), experiencing physical assault (AOR = 1.58, CI = 1.03, 2.43), arrest (AOR = 1.64, CI = 1.02, 2.65), and jail (AOR = 1.90, CI = 1.16, 3.13) in the past 6 months when compared to those who did not relocate.ConclusionsPWID who have relocated in the past 30 days have higher odds of experiencing violence and life- threatening adverse outcomes, and policies that disrupt living circumstances of PWID should be ended in favor of those that support housing stability.

IntroductionYoung adult never-smokers who vape are at elevated risk of initiating cigarettes, while young adults who smoke often begin vaping to substitute or reduce cigarette use. Reasons underlying different use patterns of tobacco products are not well-understood.Aims and methodsWe conducted 1-on-1 qualitative interviews with young adults (N = 62) who vape in Los Angeles, California from June 2018 to June 2019. Participants were 18-25 years old (79% male; racially/ethnically diverse) and self-reported vaping ≥1x/week. We used a semi-structured interview guide and applied thematic analysis method to analyze data.ResultsYoung adults initiated vaping due to peer socialization and e-liquid flavor novelty. They often reported vaping (after first smoking) due to a belief that e-cigarettes are healthier, social pressure to quit smoking, and convenience of use. Participants reported smoking (after first vaping) when traveling outside of the United States where vaping products were less accessible, and cigarettes were normative. Many of the personal narratives described patterns of dual and cyclical use, which was often attributed to nicotine dependence and cost, or described as dependent upon the current environment (eg, at a party).ConclusionsThe current study characterizes nicotine use trajectories and reasons why young adults vape, and smoke cigarettes. Dual and cyclical use of both e-cigarettes and cigarettes was common; this pattern of use should be considered in policy and prevention work to address nicotine dependence among young people.ImplicationsWe display findings from the current study in a model depicting common trajectories of nicotine use, along with reasons for initiation, transitions between products, and dual/cyclical e-cigarette and combustible cigarette use.

IntroductionPrevious studies suggest that young adults who vape nicotine experience difficulty when answering survey items assessing the quantity of vaping. The current study asked young adults who vape to provide suggestions for improving the scientific measurement of vaping.Aims and methodsWe conducted semi-structured qualitative interviews with 62 young adults who vape in Los Angeles, California between June 2018 and June 2019. We analyzed participants' responses to the following question: "What do you think is the best way for us to understand how much people vape?" using thematic content analysis.ResultsWe identified two major themes: (1) challenges stemming from differences between the way researchers query about vaping and how individuals self-monitor vaping frequency, and (2) insights for future measurement of vaping. Participants reported that challenges of accurately quantifying vaping were due to inherently hard-to-answer questions (eg, puffs per day), lack of awareness of or not actively monitoring consumption of vaping products, or because vaping behaviors vary considerably between and within individuals over time, making "on-average" questions challenging. Participants discussed ideas for improving survey measures that could accurately assess vaping quantity, including querying about the type of device used, and frequency of replenishment of nicotine solutions.ConclusionsExisting vaping behavior survey measures may not accurately capture the quantity of vaping as they differ from how (or if) participants track their own vaping consumption patterns. While continued research is needed to optimally refine survey measures on vaping consumption, future measures may better align with vapers' self-monitoring by including questions on device-type and replenishment frequency.ImplicationsThe present study provides insights regarding the variability that exists between vaping quantity measurements utilized by researchers and individuals who consume e-cigarettes. The qualitative data analyzed for this study support previous reports of difficulties faced by vapers when asked questions by researchers related to their vaping behavior. Furthermore, the present findings suggest the direction for the future development of accurate measurements of vaping frequency.

PurposeThis study explored potentially underreported healthcare contexts, clinical experiences, and motivations for adherence in care among virally suppressed Black sexual minority men (BSMM) living with HIV (LWHIV) in Baltimore, MD.MethodsGo-alongs with two virally suppressed BSMM LWHIV supplemented 27 in-depth interviews of a larger qualitative study guided by Positive Deviance and Life Course Theory. The go-alongs involved accompanying participants' follow-up HIV care visit to obtain a better account of contextual healthcare factors. Observations focused on (1) clinic location and resources, (2) sources of HIV and sexuality stigma or support in the clinic, and (3) patient-provider interactions.ResultsWe found that facilitators and barriers to viral suppression for BSMM LWHIV included structural factors (i.e., healthcare setting, facility, and services), quality of patient-provider interactions, and personal motivations to achieve viral suppression.ConclusionClinic accessibility, co-located clinical services, and rapport with clinicians and healthcare staff could be key contextual conditions that facilitate retention in care among BSMM LWHIV.

AbstractThe goals and strategies of Black sexual minority men living with HIV (BSMMLWH) who achieve viral suppression require further investigation. This study explored treatment adherence strategies among BSMMLWH with sustained viral suppression. We conducted 27 in-depth qualitative interviews with BSMMLWH in Baltimore, Maryland, and Los Angeles, California, between December 2018 and May 2019. Interviews included questions guided by Positive Deviance and Life Course theoretical frameworks regarding multilevel factors and explicit strategies for antiretroviral therapy adherence. Themes regarding intentional, age group-specific strategies such as using technology (among younger men) and taking HIV medications with other daily pills (among older men) were identified. Participants also reported symbiotic goals and values that encouraged adherence, such as having a desire to live, strong familial relationships with clinicians, and support networks. Identifying personal goals and having supportive clinical and social relationships could be key to improving treatment adherence and viral suppression among BSMMLWH.

BackgroundWhile rates of e-cigarette use ('vaping') continue to potentiate concern, there is limited data on common symptoms of e-cigarette dependence among young adults who vape. This study sought to critically explore how young adults experience, manifest, and conceptualize vaping dependence symptoms in their everyday lives.MethodsBetween June 2018 and 2019, in-depth qualitative interviews were conducted with 62 young adults who use e-cigarettes (aged 18-25) and live in Southern California. We explored participants' product preferences, daily e-cigarette use patterns, vaping history, withdrawal experiences, and quit attempts or periods of cessation. We used a thematic analysis approach to interpret the transcripts.ResultsYoung adults discussed nine dimensions of vaping dependence that were organized into two categories: 1) general nicotine dependence symptoms, and 2) unique dependence symptoms related to vaping. Nicotine dependence symptoms included cravings and urgency to use, increased use to achieve desired effects, and unsuccessful quit attempts and withdrawal. Symptoms unique to vaping dependence included greater nicotine consumption due to accessibility and lack of restrictions, habitual vaping, inability to track vaping frequency, immediate gratification and comfort, social acceptability and norms, and awareness of vaping dependency.ConclusionsIn addition to nicotine dependence symptoms that have been characterized for other tobacco products, young adult e-cigarette users described unique symptoms of vaping dependence that necessitate the need for more refined measures. All dimensions of vaping dependence should be considered in discussions of policies as well as treatment and education efforts intended to protect young people from e-cigarette dependence.

As overdose mortality is spiking during the COVID-19 pandemic, few race/ethnicity-stratified trends are available. This is of particular concern as overdose mortality was increasing most rapidly in Black and Latinx communities prior to the pandemic. We used quarterly, age-standardized overdose mortality rates from California to assess trends by race/ethnicity and drug involved over time. Rates from 2020 Q2-Q4 were compared to expected trends based on ARIMA forecasting models fit using data from 2006 to 2020 Q1. In 2020 Q2-Q4 overdose death rates rose by 49.8% from 2019, exceeding an expected increase of 11.5% (95%CI: 0.5%-22.5%). Rates significantly exceeded forecasted trends for all racial/ethnic groups. Black/African American individuals saw an increase of 52.4% from 2019, compared to 42.6% among their White counterparts. The absolute Black-White overdose mortality gap rose from 0.7 higher per 100,000 for Black individuals in 2018 to 4.8 in 2019, and further increased to 9.9 during the pandemic. Black overdose mortality in California was therefore 34.3% higher than that of White individuals in 2020 Q2-Q4. This reflects growing methamphetamine-, cocaine-, and fentanyl-involved deaths among Black communities. Growing racial disparities in overdose must be understood in the context of the unequal social and economic fallout from the COVID-19 pandemic, during which time Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality. Increased investments are required to ameliorate racial/ethnic disparities in substance use treatment, harm reduction, and the structural drivers of overdose, as part of the COVID-19 response and post-pandemic recovery efforts.

California's Welfare and Institutions code 5150 allows for a temporary psychiatric hold (TPH) of individuals who present a danger to themselves or others and/or may be gravely disabled due to mental illness. Little is known about the frequency and predictors of involuntary holds among people who inject drugs (PWID).MethodsWe sought to identify the prevalence and predictors of recent TPHs (within the past 12 months) among a community-recruited sample of PWID in Los Angeles and San Francisco, California during 2017-2018 (N = 531). Multivariable logistic regression modeling was used to evaluate demographic (e.g., age), economic (e.g., homelessness), drug use (e.g., types of drugs used), incarceration (e.g., recent arrest history) and mental health (e.g., lifetime mental health diagnosis) variables associated with recent TPH.ResultsAge (40-49 years old vs age 50 or older: AOR = 5.85; 95 % CI = 2.18, 15.67), current homelessness (AOR = 3.75; 95 % CI = 1.28, 11.0), lifetime mental health history (AOR = 6.23; 95 % CI = 2.08, 18.66), and frequency of methamphetamine use (AOR = 1.01; 95 % CI = 1.00, 1.01) were statistically associated with increased odds of having experienced a TPH, while frequency of past month heroin/opioid use was associated with decreased odds of reporting a TPH (AOR = 0.99; 95 % CI = 0.99, 1.00) in multivariable analysis.ConclusionsDiverse factors were associated with TPH among PWID. Our analysis underscores the need for research on PWID with co-occurring substance-use and mental illness disorders and homelessness. There is urgent need for expanding access to lower barrier publicly funded mental health treatment from a harm-reduction approach.

Mindfulness-based interventions (MBIs) may offer a means for Latinx families to ameliorate stress, enhance emotion regulation, and foster social support. We assessed pilot data from Latinx parents in Eastside Los Angeles (n = 27) matched with their children aged 10-16 (n = 32) to determine whether participation in a community-derived MBI was associated with greater improvements in dispositional mindfulness, perceived stress, emotion regulation, and family social support compared to a control condition. Compared to the control group, parents in the MBI group showed greater reductions in perceived stress scale (PSS) scores (B =  - 2.94, 95% CI [- 5.58, - 0.39], p = 0.029), while their children reported greater increases in perceived social support from family (B = 2.32, 95% CI [0.26, 4.38], p = 0.027). Findings show a community-derived MBI may improve stress in Latinx parents and social support for their children.

We developed and tested Passport to Wellness (PtW), a client-centered intervention to improve engagement in HIV/STI prevention and services to improve social determinants of health among Black men who have sex with men (BMSM) using incentives and peer support. We assessed PtW's impact on HIV/STI screening and pre/post-exposure prophylaxis (PrEP/PEP) knowledge/uptake using a randomized trial that compared the full intervention to one lacking peer support. We compared changes within groups surveyed at baseline and 6 months. We enrolled 80 eligible BMSM, among 399 screened. Among retained participants (34 peer-supported; 27 comparison), overall increases were observed in HIV (30% to 87%; p < .001) and STI (28% to 80%; p < .001) testing within the prior 6 months, as well as in PrEP and PEP awareness, and PrEP use. Statistically significant between group differences were not observed. Tailored prevention planning, incentives, and addressing social determinants may help move Black MSM along the HIV prevention continuum.

Background HIV testing, treatment initiation and treatment adherence have been emphasised for Black men who have sex with men (BMSM). However, many BMSM do not get tested, obtain HIV treatment or adhere to treatment. It is essential to highlight barriers to HIV testing, treatment adherence and the ideal components for an intervention: peer mentors, socioeconomic resources and participant incentives.MethodsFive focus groups (n=24) were conducted among HIV-negative and HIV-positive BMSM aged ≥18 years in Los Angeles, California, USA to explore motivations and barriers to testing and treatment and the components of an ideal, culturally competent HIV testing intervention for BMSM.ResultsBarriers to HIV testing included fear and stigma associated with discovering a HIV-positive status and drug use. Motivations for testing included experiencing symptoms, beginning new relationships, perceptions of risk and peer mentors.ConclusionsFuture HIV prevention and treatment efforts should consider these components to improve health outcomes among BMSM.

Estimates show a 50% lifetime human immunodeficiency virus (HIV) risk among Black men who have sex with men (BMSM) in the United States(U.S.). Studying the dynamics of sexual positioning practices among BMSM could provide insights into the disparities observed among U.S. groups of men who have sex with men (MSM). This study explored sexual positioning dynamics among HIV-negative BMSM and how they aligned with a theoretical model of sexual positioning and HIV/sexually transmitted infection (STI) risk among MSM. In-depth qualitative interviews were conducted with 29 HIV-negative BMSM between ages 25 and 35 in Los Angeles. Comments related to sexual behaviors were reviewed for relevance regarding oral or anal sexual positioning practices. Data presented represent the range of themes related to decision making regarding sexual positioning. Personal preference, partner attraction, HIV avoidance, and feeling obligated to practice partner preferences influenced sexual positioning. Drug use also affected decision making and was sometimes preferred in order to practice receptive anal intercourse. These variables build on the conceptual model of sexual positioning practices and sexual risk, and add understanding to the relationship between preferences, practices, and risk management. Future research on risk among HIV-negative BMSM should quantify the relative impact of personal preferences, partner attraction, partner type, compromise, and substance use on sexual positioning practices and risk.

Little attention has focused on generational or age-related differences in human immunodeficiency virus/sexually transmitted infection (HIV/STI) risk behaviors among Black men who have sex with men and women (BMSMW). We examined sexual risk behaviors between BMSMW ages 40 and under compared to over age 40. Analysis was conducted using Centers for Disease Control and Prevention (CDC)-sponsored intervention data among BMSMW in Los Angeles, Chicago, and Philadelphia (n = 546). Pearson's chi-square tests were conducted to evaluate associations between age groups and behavioral outcomes. Logistic regression was used to evaluate the odds of behavioral outcomes by age group, adjusting for sexual orientation and study location, within strata of HIV status. HIV-positive BMSMW over age 40 had 62% reduced odds of having a nonmain female partner of HIV-negative or unknown status compared to those ages 40 and under (adjusted odds ratio [AOR] 0.38, 95% confidence interval [CI] = 0.15, 0.95). Among HIV-negative BMSMW, the older cohort was associated with greater odds of having condomless insertive anal intercourse (IAI) with most recent main male partner (AOR 2.44, 95% CI = 1.12, 5.32) and having a concurrent partnership while with their recent main female partner (AOR = 2.6, 95% CI = 1.10, 4.67). For both groups, odds of engaging in certain risk behaviors increased with increasing age. Prevention efforts should consider generational differences and age in HIV risks among BMSMW.

We conducted a randomized controlled trial of a six-session behavioral intervention designed to reduce frequency of condomless sex and numbers of sex partners among recently incarcerated, bisexual Black men. One hundred participants were assigned to the small-group intervention, Men in Life Environments (MILE), and 112 were assigned to the control condition. Among those assigned to MILE, 69% attended at least one session, 88% of whom attended all sessions. At 3-months' follow-up, large reductions in risk behaviors were reported by both groups. Means for episodes of condomless sex in the previous 3 months declined from 27.7 to 8.0 for the intervention and 25.6 to 6.7 for the control group. Reductions were not greater for the intervention than those of the control group. Regression to the mean, respondent burden, and implementation issues, such as moving from office-based to field-based survey administration at follow-up, may have contributed to the large declines reported by both groups.

BackgroundHeroin use is increasing in the US. Heroin use may predispose users towards injection routes of drug administration as compared to other illicit substances.ObjectiveTo explore the relationship between heroin use and drug injection, we compared time from first use to first injection (referred to as time to injection onset by drug [TTIOD]) of heroin, methamphetamine/speed, cocaine, and crack cocaine among people who inject drugs (PWID).MethodsAge of first use and first injection by drug was collected from 776 PWID. Survival analyses were used to determine TTIOD and to examine demographic factors associated with TTIOD. Cox regression analysis was used to determine demographic factors associated with drug-specific injection onset.ResultsThe eventual injection onset rate by the drug was 99% for participants who used heroin, 85% for participants who used methamphetamine/speed, 80% for participants who used powder cocaine, and 38% for participants who used crack cocaine. Hazard ratios for injection use within one year of first use by drug were: 1.37 (median survival time [MST] = 0.61 years) for heroin, 0.66 (MST = 1.10 years) for methamphetamine/speed, 0.50 (MST = 2.93 years) for powder cocaine, and 0.12 (MST = 39.59 years) for crack cocaine. Demographic differences in TTIOD were found for each drug. Demographic differences were found for eventual injection by drug for all substances except heroin.ConclusionAmong PWID, heroin use was associated with a more rapid transition to injection and a higher rate of eventual heroin injection regardless of demographics. More robust, innovative efforts to reduce heroin use and prevent injection initiation are urgently needed.

Black men who have sex with men and women (BMSMW) are at increased HIV risk, but few efficacious interventions meet their unique needs. Three HIV prevention interventions were evaluated with a common protocol. Baseline data were pooled to describe sexual behavior involving transmission risk with male, female, and male-to-female transgender partners and identify factors associated with transmission risk. BMSMW from Los Angeles, Philadelphia, and Chicago who reported sexual risk and bisexual behavior in the past year were recruited via modified chain referral sampling and community recruitment. Baseline assessments were conducted via audio computer-assisted interview and sexual behaviors assessed over the past 3 months. From December 2010 to November 2012, 584 BMSMW were enrolled across the three cities. More than half (55%) were recruited by other participants. Overall, the mean age was 43 years. Seventy-five percent reported an annual income

African-American men who have sex with men and women (MSMW) are among those most heavily impacted by HIV in the United States, and those who have histories of incarceration are at further risk of infection. The Men in Life Environments (MILE) HIV prevention intervention was developed to provide culturally appropriate skills-based education and support for African-American MSMW with recent histories of incarceration. The MILE's conceptual framework was informed by three theories: Theory of Reasoned Action and Planned Behavior, Critical Thinking and Cultural Affirmation Model, and Empowerment Theory. The theory-based framework posits that improving racial pride is crucial in building self-efficacy and intentions that in turn promote health-protective behaviors. Therefore, our study aimed to assess whether baseline associations between racial pride and condom use self-efficacy, intentions, and behaviors among African-American MSMW with histories of incarceration align with our conceptual model. We report data on 212 participants recruited from Los Angeles County Sheriff's Department Men's Central Jail and the local community. Using structural equation modeling, we tested two separate models: one with female sexual partners and one with male sexual partners, while stratifying by participant's HIV status. Only among HIV-negative participants was greater racial pride associated with less condomless intercourse with men. In this group, greater self-efficacy and intentions-but not racial pride-predicted less condomless intercourse with women. Our findings suggest that racial pride is an important factor to address in HIV prevention interventions for post-incarcerated African-American MSMW.

ObjectivesA robust literature documents generational trends in drug use. We examined the implications of changing national drug use patterns on drug injection histories of diverse people who inject drugs (PWID).MethodsDrug use histories were collected from 776 active PWID in 2011-13. Using descriptive statistics, we examine drug use initiation by year and birth cohort (BC) differences in drug first injected. A multivariate linear regression model of time to injection initiation ([TTII] (year of first injection minus year of first illicit drug use) was developed to explore BC differences.ResultsThe first drug injected by BC changed in tandem with national drug use trends with heroin declining from 77% for the pre-1960's BC to 58% for the 1960's BC before increasing to 71% for the 1990's BC. Multivariate linear regression modeling found that shorter TTII was associated with the 1980's/1990's BC (-3.50 years; 95% Confidence Interval [CI]=-0.79, -6.21) as compared to the 1970's BC. Longer TTII was associated with being female (1.65 years; 95% CI=0.40, 2.90), African American (1.69 years; 95% CI=0.43, 2.95), any substance use treatment prior to injection (4.22 years; 95% CI=2.65, 5.79), and prior non-injection use of drug that was first injected (3.29 years; 95% CI=2.19, 4.40).ConclusionNational drug trends appear to influence injection drug use patterns. The prescription opiate drug era is associated with shorter TTII. Culturally competent, demographically and generationally-targeted prevention strategies to combat transitions to drug injection are needed to prevent or shorten upstream increases in risky drug use practices on a national level.

Issues: To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors. Approach: Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer‐reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual‐level risk factors. Key Findings: Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder. Implications: There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk‐phenomena tied to multi‐level forms of entrenched disenfranchisement. Conclusion: There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines. [ABSTRACT FROM AUTHOR]

Adam, a justice-involved young man, was brought into the emergency department at the county hospital in cardiogenic shock due to a recurring episode of injection-drug-use-related infective endocarditis (IDU-IE). Adam had initiated injection opioid use in prison. He was surgically treated for the previous episodes of IDU-IE but was unable to fully recover due to limitations in care within penal medicine. This case report explores the prison as a determinant of health, interactions between clinical, welfare, and penal medicine, to produce and maintain health inequities, and structural drivers of physician moral injury through an interview with Adam and reflexive writings from emergency medicine physicians. This case demonstrates the need for three types of structural health interventions: (1) restorative justice, community-based reentry programs, and housing as welfare medicine, (2) increased harm reduction services across healthcare, especially penal medicine, and (3) equitable institutional protocols (contrary to ambiguous guidelines) to treat clinical conditions like IDU-IE that disproportionately impact structurally vulnerable patients. [ABSTRACT FROM AUTHOR]

Practices and interventions that aim to slow progression or reduce negative consequences of substance use are harm reduction strategies. Often described as a form of tertiary prevention, harm reduction is key to caring well for people who use drugs. Evidence-based harm reduction interventions include naloxone and syringe service programs. Improving equitable outcomes for those with opioid use disorder (OUD) requires access to the continuum of evidence-based OUD care, including harm reduction interventions, as well as dismantling policies that undermine mental health and substance use disorder treatment continuity, housing stability, and education and employment opportunities. [ABSTRACT FROM AUTHOR]

Opioid withdrawal symptoms are a highly salient and consequential health condition experienced by people who use opioids (PWUO). This study utilized qualitative interviews to explore opioid withdrawal experiences and consequences among PWUO in Los Angeles County, USA. Semi-structured qualitative interviews were conducted with 22 PWUO (aged 27–63 years) between May 2021 and May 2022. Participants self-reported opioid and injection drug use in the last 30 days. We employed an inductive thematic approach to systematically code and synthesize textual interview data. Participants experienced withdrawal symptoms frequently, with many going to great lengths to avoid them. Withdrawal pain was described as incapacitating and interfered with PWUO's ability to sustain regular employment and ensure stable housing. Avoiding withdrawal was described as influential in driving decisions to continue using opioids. Mechanisms for managing withdrawal included using other substances to the point of sedation. PWUO who transitioned from heroin to fentanyl use revealed more frequent, painful, and faster onset of withdrawal symptoms. Adverse withdrawal experiences and fear of precipitated withdrawal from buprenorphine were barriers to treatment initiation and continuation. Withdrawal symptoms among PWUO increase health risk. Improved strategies to treat opioid withdrawal are urgently needed. Solutions such as safe supply and intentional opioid withdrawal interventions (educational trainings, withdrawal comfort kits) are needed to improve withdrawal management and reduce opioid-related harm. [ABSTRACT FROM AUTHOR]