Unmet needs and harm reduction preferences of syringe services program participants: Differences by co-use of street opioids and methamphetamine

doi:10.21203/rs.3.rs-4076057/v1

Background

The current fourth wave of the United States opioid overdose epidemic is characterized by the co-use of opioids and stimulants, including street opioids and methamphetamine. The co-use of these two drugs, known as “goofballing,” is associated with higher risk for several adverse outcomes, including more frequent injections, greater health risks, and higher morbidity. Considering these differences, this unique subpopulation of people who inject drugs (PWID) may also have unique unmet needs and/or harm reduction preferences.

Methods

We collected self-reported data from participants (N = 50) of a syringe services program (SSP), including basic needs and harm reduction preferences. Using bivariate analyses, we examined for differences between SSP participants who do and do not co-use street opioids and methamphetamine.

Results

In the overall sample, the mean level of need was highest for bus passes or other transportation, a person who can help you get the services you need, medication for opioid use disorder, and a job or job training. Additionally, all participants reported being either interested or very interested in fentanyl test strips, safe consumption sites, delivery of syringe service supplies, and delivery of naloxone. Those who endorsed co-use had a greater need for food, healthcare, substance use disorder treatment, a support person to help them access needed services, and bus passes/transportation.

Conclusions

Unmet needs were prevalent, and the desire for more harm reduction services was high among these PWID. Results also suggest people who co-use street opioids and methamphetamine may have the greatest unmet needs and desire for additional harm reduction services.

injection drug use

co-use

unmet needs

harm reduction preferences

The United States has seen three distinct waves of the opioid overdose epidemic: the first characterized by prescription opioids, the second by heroin, and the third by synthetic opioids (e.g., fentanyl) and their analogs (Ciccarone, 2019). The proliferation of fentanyl has been rapid and detrimental, accounting for a majority of all opioid-related overdoses since 2010 (Mallama et al., 2019). Consequently, there has been a large and diverse public health response, in which service programs (SSPs) play a critical role in combatting injection-related health risks and other substance-related harms (Des Jarlais et al., 2015).

Simultaneously, methamphetamine use has spread from predominantly rural regions to large swathes of the United States, contributing to a 50-fold increase in methamphetamine-related mortality from 1999 to 2021 (Hoopsick & Andrew Yockey, 2023; Korthuis et al., 2022). These trends are in part reflective of an emerging fourth wave of the opioid epidemic, characterized by the combined use of methamphetamine and street opioids (Jenkins, 2021). Indeed, recent findings suggest a dramatic increase in opioid/stimulant co-use mortality (Dai et al., 2022; Hedegaard et al., 2021).

There is a wealth of literature addressing the heightened risks associated with polysubstance use, including adverse mental health outcomes (Kandel et al., 2001) and infectious diseases (Compton et al., 2021). More recently, studies have also examined risks specific to methamphetamine and opioid co-use. These include more frequent injecting (Palmer et al., 2021), experiences of stigma (Brener et al., 2022), and considerable health risks and morbidity (Glick et al., 2021). Given these differences, it is possible that the needs of this subpopulation are not comprehensively addressed by SSPs, which were conceptualized to meet the needs of people who use opioids. However, the body of literature in this area remains limited, and further investigation is warranted.

The present pilot study aims to explore unmet needs and harm reduction preferences of individuals co-using methamphetamine and street opioids as well as PWID more broadly. Participants were recruited over a 4-month period in 2022 from a small midwestern SSP. These participants (N = 50) consisted of adults who had accessed syringe services either in person or via a contact-free supplies box. After providing informed consent, eligible participants completed a brief online survey. Upon completion, participants received $10 in cash. The study protocol was approved by the Institutional Review Board at the University of Illinois at Urbana-Champaign.

2.1 Measures

2.1.1 Drug Use

Participants were asked the question, “In the past three months, which of the following drugs have you used? Check all that apply.” Each option included examples and/or colloquial names of that drug type. Street opioids included heroin, opium, and street fentanyl. Methamphetamine included speed, crystal meth, and ice. Participants were considered co-users if they endorsed both street opioids and methamphetamine.

2.1.2 Unmet Needs

Participants were asked to “Rate your level of need for the following supplies and services.” Items were scored as 0 (Not needed), 1 (Needed), or 2 (Urgently needed).

2.1.3 Harm Reduction Preferences

Participants were asked to “Rate your level of interest in the following supplies and services not currently provided by the Syringe Services Program.” Items were scored as 0 (Very uninterested), 1 (Uninterested), 2 (Neither interested nor uninterested), 3 (Interested) and 4 (Very interested).

2.2 Analytic Plan

Bivariate analyses were used to examine potential differences in the unmet needs, and harm reduction preferences of these PWID according to whether they reported the co-use of street opioids and methamphetamine or the use of just one of these substances. Correcting for multiple comparisons with the Benjamini-Hochberg procedure resulted in a p-value cutoff of 0.017 for assessing significance.

Our sample ranged in age from 23-65 years old and consisted of men (n = 22), women (n = 27), and nonbinary people (n = 1). Refer to Table 1 for additional participant characteristics.

In the overall sample, the mean (± SD) level of need was highest for bus passes or other transportation (1.48 (± 0.71)). Other needed items include a person who can help you get the services you need (1.26 (± 0.72)), medication for opioid use disorder (1.08 (± 0.72)), and a job or job training (1.02 (± 0.82)). Additionally, all participants reported being either interested or very interested in fentanyl test strips, safe consumption sites, delivery of syringe service supplies, and delivery of naloxone. Responses to other items are shown in Table 2.

Analyses revealed significant differences between participants who did and did not endorse co-use. From our unmet needs measure, we observed significant differences for food, healthcare, substance use disorder treatment, and a person that can help them get the services they need. Responses to our harm reduction preferences measure did not differ by co-use status, however this could be due to a ceiling effect since all participants reported a high level of interest in all items.

Among this sample of PWID, unmet needs were prevalent and desire for more harm reduction services was high, especially among those who co-use methamphetamine and street opioids. The current study is consistent with previous work identifying mental health services, housing, harm reduction, and infectious disease prevention as critical for PWID (Hassan et al., 2022). Unsurprisingly, fentanyl strips were also identified as a critical need, reflecting the high mortality risk associated with synthetic opioids (Ciccarone, 2017; Zoorob, 2019). In addition, our results add to the small but growing body of literature examining methamphetamine/street opioid co-use by extensively assessing co-users for a broad range of needs and preferences.

While we observed a moderate level of need for many healthcare-related supplies and services, (e.g., treatment for Hepatitis C, injection supplies, mental health treatment), many of the most critical areas of need identified by PWID lie beyond healthcare. Most participants in the current study reported urgently needing a job or job training, bus passes or other transportation, or food; these needs were amplified among co-using participants. However, these basic living necessities are beyond the scope of services offered by most SSPs.

As SSPs do not holistically address all of the needs of PWID, alternative models of care may be better positioned to provide or connect individuals to certain resources. Peer recovery support services (PRSS), for instance, have been found to reduce substance use disorder (SUD) relapse rates, improve social support, and increase treatment retention rates (Eddie et al., 2019). These groups are led by individuals with lived experience of SUDs who provide a range of support including transportation to healthcare appointments, assistance with insurance enrollment, and connecting participants to other resources (Kawasaki et al., 2019). As such, they may be particularly beneficial for co-using individuals who have greater needs for basic living necessities, are less likely to be enrolled in treatment, and find drug use to be more central to their identity (Brener et al., 2022).

Finally, while the needs of PWID are manifold, their ability to access vital services are limited (Al-Tayyib et al., 2015). In our study, a person who can help you get the services you need was among the most urgent needs, especially among co-using participants. Indeed, the structure of many public health interventions (e.g., sustained treatment models) often collide with the lived experiences of PWID (White & Kelly, 2011). Many qualitative studies have emphasized that for PWID, immediate priorities (e.g., food, shelter) and existing difficulties impede treatment accessibility (Allen et al., 2020).

In conclusion, we observe a critical need for both basic living and health-related supplies and services. Moreover, we found high levels of interest in delivery services and safe consumption sites. Participants who endorsed the co-use of street opioids and methamphetamine reported significantly greater levels of need for numerous basic living necessities, fentanyl testing strips, and substance use treatments. Following these findings, we encourage SSPs to include or link to broader support services such as PRSSs to address underlying social needs. Ultimately, continued efforts to expand accessibility, legality, and breadth of services providing comprehensive prevention, harm reduction, and healthcare services for PWID are vital.

4.1 Limitations

Sample size is a major limitation of the current pilot study. Our study was exploratory in nature, and further investigation is necessary to confirm our findings or uncover other differences. A second limitation is the lack of racial/ethnic diversity in our sample, therefore limiting this study’s ability to capture potentially unique characteristics of non-white PWID. Although non-white PWID are highly represented in total opioid overdose deaths, feelings of shame, mistrust for predominantly white institutions, and an increased fear of policing continue to drive disparities in SSP access (Godkhindi et al., 2022). Finally, we did not assess whether participants who reported use of both methamphetamine and street opioids also used the two simultaneously. Simultaneous use (sometimes referred to as “goofballing”) produces greater effects than using either drug alone (Hazani et al., 2022), and is associated with additional risks, including homelessness, injecting daily, and self-reported opioid overdose (Glick et al., 2021). However, it is unknown whether the increased needs of co-using PWID in this study were associated with “goofballing.”

4.2 Conclusions

Findings from the current pilot study suggest that PWID have many unmet needs and desire additional harm reduction services. Our exploratory analyses also suggest that people who co-use street opioids and methamphetamine may have the greatest unmet needs and desire for additional harm reduction services. There is an imminent need for expanded access to a wider breadth and depth of harm reduction services for PWID in the United States, particularly for those who co-use street opioids and methamphetamine.

Author Disclosures

Role of Funding Source: Research reported in this manuscript was supported by the Community-Academic Scholars Program and the Mary Jane Neer Fund of the University of Illinois Urbana-Champaign. The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Illinois Urbana-Champaign.

Contributors: Rachel Hoopsick conceived of, designed, and implemented the study. Rachel Hoopsick and Rachel Sun conducted the statistical analysis. Rachel Sun conducted the literature review and wrote the first draft of the manuscript with sections contributed by Rachel Hoopsick and Tonazzina Sauda. All authors critically reviewed the manuscript for content. All authors contributed to and approve the final manuscript.

Conflict of Interest: No conflict declared.

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Table 1. Participant Characteristics (N = 50)

Overall Sample

(N = 50)

Mean (SD) or % (n)

Use of Street Opioids or Methamphetamine

(n = 30)

Mean (SD) or % (n)

Co-use of Street Opioids and Methamphetamine

(n = 20)

Mean (SD) or % (n)

Age, years

34.8 (8.6)

36.1 (9.6)

32.8 (6.6)

Gender Identity

Woman

Man

Nonbinary/genderqueer

54.0% (27)

44.0% (22)

2.0% (1)

60.0% (18)

40.0% (12)

0.0% (0)

50.0% (10)

45.0% (9)

5.0% (1)

Race/Ethnicity

Non-Hispanic white

Hispanic

More than one race

90.0% (45)

8.0% (4)

2.0% (1)

96.7% (29)

0.0% (0)

3.3% (1)

80.0% (16)

20.0% (4)

0.0% (0)

Education

Less than high school

High school diploma or equivalent

At least some college

16.0% (8)

54.0% (27)

30.0% (15)

16.7% (5)

50.0% (15)

33.3% (10)

15.0% (3)

60.0% (12)

25.0% (5)

Employment Status

Unemployed or disabled

Working part-time

Working full-time

52.0% (26)

32.0% (16)

16.0% (8)

28.0% (14)

26.7% (8)

60.0% (12)

40.0% (8)

0.0% (0)

Income

Less than $10,000

$10,000 - $29,999

$30,000 - $49,999

$50,000 or more

40.0% (20)

38.0% (19)

16.0% (8)

6.0% (3)

30.0% (9)

40.0% (12)

26.7%% (8)

3.3% (1)

55.0% (11)

35.0% (7)

0.0% (0)

10.0% (2)

Living Situation

In a house or apartment

In my car, unsheltered on the street, under a bridge, etc.

Motel or hotel

Other

72% (36)

16% (8)

6.0% (3)

73.3% (22)

6.7% (2)

0.0% (0)

12.0% (6)

70.0% (14)

5.0% (1)

10.0% (2)

15.0% (3)

Drug Use

Street Opioids

Methamphetamine

Cannabis

Sedatives

Cocaine

Prescription Opioids

Other

82.0% (41)

58.0% (29)

54.0% (27)

36.0% (18)

28.0% (14)

20.0% (10)

--

Table 2. Level of Need or Preference for Supplies and Services

Overall Sample

(N = 50)

Mean (SD)

Use of Street Opioids or Methamphetamine

(n = 30)

Mean (SD)

Co-use of Street Opioids and Methamphetamine

(n = 20)

Mean (SD)

p-value

Needs

Housing/Shelter

Food

Job or Job Training

Healthcare

Testing and Treatment for HIV

Testing and Treatment for Hepatitis C

Medication for Opioid Use Disorder

Substance Use Disorder Treatment

Mental Health Treatment

A Person That Can Help You Get the Services You Need

Bus Passes or Other Transportation

Wound Treatment

Other Safer Injection Supplies

Preferences

Fentanyl Test Strips

Safer Smoking Supplies

Safe Consumption Site

Delivery of Syringe Service Supplies

Delivery of Naloxone

0.98 (0.87)

0.88 (0.75)

1.02 (0.82)

0.84 (0.62)

0.52 (0.61)

0.86 (0.73)

1.08 (0.72)

1.04 (0.64)

0.96 (0.73)

1.26 (0.72)

1.48 (0.71)

0.58 (0.70)

0.90 (0.65)

3.58 (0.78)

2.74 (1.12)

3.18 (0.85)

3.64 (0.75)

3.44 (0.93)

0.77 (0.86)

0.63 (0.72)

0.83 (0.87)

0.67 (0.61)

0.40 (0.56)

0.70 (0.70)

0.90 (0.66)

0.87 (0.57)

0.97 (0.67)

1.00 (0.74)

1.23 (0.73)

0.47 (0.68)

0.77 (0.68)

3.50 (0.90)

2.63 (1.22)

3.13 (0.94)

3.57 (0.90)

3.23 (1.10)

1.30 (0.80)

1.25 (0.64)

1.30 (0.66)

1.10 (0.55)

0.70 (0.66)

1.10 (0.72)

1.35 (0.75)

1.30 (0.66)

0.95 (0.83)

1.65 (0.49)

1.85 (0.49)

0.75 (0.72)

1.10 (0.55)

3.70 (0.57)

2.90 (0.97)

3.25 (0.72)

3.75 (0.44)

0.032

0.003

0.048

0.014

0.091

0.056

0.030

0.017

0.938

0.001

0.165

0.074

0.383

0.416

0.639

0.402

0.053

Note. T-tests for differences in means. Bold values are statistically significant after Benjamini-Hochberg correction.

No competing interests reported.

Unmet needs and harm reduction preferences of syringe services program participants: Differences by co-use of street opioids and methamphetamine

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

1. Introduction

2. Methods

2.1 Measures

2.1.1 Drug Use

2.1.2 Unmet Needs

2.1.3 Harm Reduction Preferences

2.2 Analytic Plan

3. Results

4. Discussion

4.1 Limitations

4.2 Conclusions

Declarations

References

Tables

Additional Declarations

Status:

Version 1