Health Outcomes Associated With Illicit Prescription Opioid Injection a Systematic Review

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• Published: xxx March 2020

Prescription opioid injection amidst young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose

• Honoria Guarino¹,
• Jon E. Zibbell²,
• Jennifer Teubl^three,
• Chunki Fong¹,
• Elizabeth Goodbody^one,
• Brian Edlin^iv,
• Carli Salvati¹ &
• Samuel R. Friedman⁵

Harm Reduction Journal volume 17, Commodity number:22 (2020) Cite this article

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Abstract

Aim

Bear witness is emerging that prescription opioid (PO) injection is associated with increased health risks. This mixed-methods written report compares the mechanics of PO and heroin injection and examines the demographic and drug-related correlates of lifetime PO injection in a sample of young people who inject drugs (PWID) in New York Urban center (NYC).

Methods

Qualitative analysis of 46 semi-structured interviews with young adult opioid users ages xviii–32. Interview segments describing PO injection were analyzed for common themes. Quantitative analysis of structured interviews with 539 young adult opioid users ages 18–29 recruited via respondent-driven sampling (RDS). Analyses are based on the subsample of 353 participants (65%) who reported having always injected drugs. All variables were assessed via self-report, except hepatitis C virus status, which was established via rapid antibody testing.

Results

Participants described injecting POs and reported that preparing corruption-deterrent pills for injection is specially cumbersome, requiring extended manipulation and large amounts of water. Injecting POs, in contrast to injecting heroin, requires repeated injections per injection episode. Among RDS-recruited participants, the bulk of injectors reported injecting POs, sporadically (33%) or regularly (26%), just ofttimes infrequently (≤ vii days/month). In separate multivariable analyses decision-making for syringe- and cooker-sharing, ever injecting POs was a pregnant predictor of testing HCV antibody-positive (AOR = 2.97) and lifetime experience of non-fatal overdose (AOR = ii.51). Ever injecting POs was independently associated with lifetime homelessness (AOR = ii.93) and having grown upwardly in a eye-income ($51,000–100,000/year vs. ≤ $fifty,000/twelvemonth; AOR = 1.86) or a loftier-income household (> $100,000/year vs. ≤ $l,000/year; AOR = 2.54).

Conclusions

Even in an urban environment like NYC with widespread heroin access, nearly young PWID have injected POs, although less frequently than heroin. PO injection involves practices that are known to increase risk for blood-borne viral infection (due east.g., repeated injections) and predicted testing HCV-positive, equally well equally overdose. PO injection may also serve as a marker for a subgroup of PWID at elevated risk for multiple drug use-related comorbidities. Programs that provide prevention services to PWID demand to tailor impairment reduction measures and messaging to the specific practices and harms associated with the injection of POs.

Introduction

Prescription opioid (PO) injection is on the ascension in the USA. Among a nationally representative sample of people 12 years or older, the prevalence of lifetime PO injection increased from 1.6 per 1000 in 2003–2005 to 2.7 per 1000 in 2012–2014 [one]. This trend is likewise reflected in U.s. PO-related treatment admissions, with PO injection amid new admissions to substance use treatment rising from 11.7% in 2004 to 18.1% in 2013 [ii].

The prevalence of PO injection among not-treatment-seeking samples of drug users varies across regions of the USA. In rural Kentucky, 89% of people who inject drugs (PWID) in a cohort sample reported injecting POs in their lifetime [3], while a report of immature, street-involved PWID in urban New York City (NYC) and Los Angeles who reported contempo nonmedical PO utilize constitute that 72% reported having e'er injected POs ("lifetime" PO injection) [4]. In Scott County, Indiana, the site of a large HIV outbreak among PWID in 2015, the vast majority of HIV-infected PWID reported the current injection of extended-release oxymorphone (OpanaER®) every bit their primary drug of choice [five]. In contrast, a report of young PWID in rural New York State who misused POs [6] reported lower rates of current PO injection (58%). Differences in written report design and PO availability across regions are likely influencing the reported variability in PO injection rates.

Beyond the risks associated with injection drug use in general, which include exposure to blood-borne viruses (such every bit HIV and hepatitis C virus [HCV]), also as bacterial infections related to injecting in unsterile environments [7], the injection of PO pills in detail has been shown to exist independently associated with HCV infection in samples of PWID [6, 7]. Several recent studies take found that PWID who report injecting POs take an increased likelihood of being HCV antibody-positive relative to PWID who inject heroin just [3, 4, half-dozen, 8, 9]. A prospective study of drug-using street youth, however, found in a multivariate model that PO injection was not a significant predictor of HCV incidence [x].

While injection-related viral transmission risk has largely been associated with the sharing of contaminated injection equipment (eastward.thousand., syringes and cookers), the risks associated with PO injection may occur at each phase of the process involved in preparing and injecting opioid pills, including pill crushing, the apply of extra water (relative to heroin injection), sharing "rinse shots," and other practices that place pill injectors at increased vulnerability to viral exposure [8]. About recently, the cumbersome and lengthy process of preparing and injecting POs has been shown to frequently involve multiple injections per injection episode which may contribute to the development of new, blood-borne viral transmission pathways [11, 12].

In a systematic review of health outcomes associated with PO injection, Lake and Kennedy [9] report that PO injection has as well been found to be correlated with recent non-fatal overdose among women (not men) in a cohort study of PWID recruited through street outreach [thirteen] and to have marginally significant associations with lifetime non-fatal overdose among street-recruited rural drug users [xiv]. One written report found that PO injection among street-recruited youth who used POs was correlated with lifetime overdose in bivariate analyses, withal did not remain significant in multivariable assay [15], while other studies among street-recruited [16, 17] and syringe substitution program-recruited opioid users [18] did not notice any significant association betwixt PO injection and recent non-fatal overdose.

While prior studies have described the mechanics of PO injection and have found significant associations between PO injection and HCV-positive status or overdose, in this newspaper, we expand on this literature by using a mixed-methods blueprint that allows for a more comprehensive understanding of PO injection. Specifically, we employ qualitative interview information describing the mechanics of preparing and injecting POs to assistance interpret and contextualize our quantitative findings addressing the enquiry question: "What are the associations between PO injection and HCV infection and unintentional opioid overdose?" We also present boosted quantitative data to compare patterns of heroin injection vs. PO injection in the context of young people's opioid apply trajectories. Furthermore, our distinctive study samples of sociodemographically diverse, urban young adults who were actively using opioids, but were not necessarily street-involved, help fill up an important gap in our understanding of the opioid injection patterns of young opioid consumers living in American cities.

Methods

This mixed-methods paper presents select findings from a larger study that assessed the drug use practices and health risks of young adults in NYC who use opioids (including the nonmedical use of POs and/or heroin use). The current analyses focus on patterns and correlates of PO injection in 2 samples of young adults who employ opioids. Qualitative information from i sample are presented to characterize the mechanics used to ready and inject POs. Quotations from face-to-face interviews with young people who inject POs and heroin are presented to place behaviors and techniques specific to the way PO pills are prepared and injected in order to differentiate them from the techniques used with heroin and other illicit drugs. Quantitative information from a second sample are used to institute the prevalence of PO injection amongst the subset of participants who reported having e'er injected drugs and the frequency with which they injected POs and heroin. Quantitative data also establish how PO injection fits into participants' broader opioid utilise trajectories and the associations between PO injection and key sociodemographic (e.g., socioeconomic status) and drug use-related (e.g., having always overdosed) variables.

Qualitative data collection and analysis

The qualitative portion of the analysis is based on information from 46 participants (ages 18–32) who were interviewed in the formative phase of the study. Participants lived in ane of the v boroughs of NYC, reported having used POs for nonmedical reasons at to the lowest degree once in their lifetime (nearly reported utilise in the past 30 days), and spoke English or Spanish. Participants were referred past service providers (due east.g., drug treatment programs, youth-focused harm reduction services), other enquiry projects, or via chain-referral from other participants. Further details on the 46 participants included in the qualitative sample are reported elsewhere [nineteen, 20].

Interviews were semi-structured, digitally audio-recorded, and lasted approximately 90 min. Interviews were transcribed verbatim, and the software plan ATLAS.ti was used to facilitate the coding and assay of qualitative data. Following a semantic thematic assay approach [21, 22], the explicit meaning of participants' words served equally the basis for thematic coding. Interview transcripts were read to identify all quotes related to PO and heroin injection practices. Using these quotes, themes were identified on the basis of recurring patterns through multiple participants' accounts. The themes established in this analysis were oftentimes related to the relatively more involved process of preparing and injecting an opioid pill (vs. injecting heroin). Themes respective to the general process of preparing a PO as opposed to heroin for injection included the "need for more than water" and "applying heat." Themes that were specific to injecting POs vs. heroin included "using larger syringes," "multiple injections per injection episode (MIPIE)," and/or "reusing cottons."

All names have been changed to pseudonyms to protect participants' confidentiality, and some quotations have been slightly edited for clarity.

Quantitative data collection

For the quantitative stage of the study, a unlike sample was recruited using respondent-driven sampling (RDS), a grade of concatenation-referral sampling designed to engage hard-to-achieve populations that uses participants' personal network connections to drive recruitment. This method, which reaches people who may not frequent street settings, may yield a more representative sample than street recruitment. Using this method, an initial set of 20 "seeds" was straight recruited by research staff from referrals by harm reduction services, drug handling programs, participants in the qualitative component, and other research projects. These participants completed structured assessments and were invited to refer up to 3 eligible peers from amidst their opioid-using contacts to participate in the report. This process was repeated with the seeds' recruits and for successive sample waves leading to a total of 539 participants recruited from August 2014 to April 2016. Eligibility criteria included nonmedical utilise of POs and/or heroin utilise iii or more than times in the past 30 days, current residence in NYC, xviii–29 years old, English-speaking, and the ability to provide informed consent. Participants were compensated $60.00 USD for completing the interview, and an additional incentive was provided for each eligible participant they referred. Further details on the RDS methods used in this study are reported in Mateu-Gelabert et al. [23].

Participants completed a calculator-assisted, interviewer-assisted structured assessment lasting xc–120 min. The instrument included sociodemographic and behavioral questions (951 questions organized in 27 sections) related to the following: substance use and drug injection history and current practices, injection-related HIV/HCV adventure behavior, opioid use and injection networks, and lifetime and recent overdose experiences, among other topics. The nowadays analysis is based on the subset of the total sample who reported injecting whatever drug for nonmedical purposes at whatsoever signal in their lifetime (north = 353/539, 66%). Because 6 participants did not reply to the questions specific to PO injection, analyses requiring these variables are based on a sample of 347.

Variable definitions

In structured assessments and statistical analyses, nonmedical use of POs was defined equally the "use of POs not prescribed for the respondent or apply of these drugs merely for the feel or feeling they caused" [24]. PO injection was divers as injecting whatever PO intended for oral intake. For the variables included in this written report, "regular" injection was defined as injecting a given drug 3 or more times a week for at least 1 calendar month. "Sporadic" injection was defined having injected a given drug at least once but not having done then regularly. Duration of regular injection of POs and heroin was measured past the number of months a participant had regularly injected the drug in their lifetime. The frequency of PO and heroin injection in the past 30 days was measured by the number of days each drug was injected. "Non-fatal overdose" was defined as any event in which a participant "lost consciousness, stopped breathing or was unresponsive equally a issue of drug use." Opioid utilise trajectory variables included ages at first nonmedical PO use, first heroin use, starting time heroin injection, and first PO injection. Two injection take chances variables were assessed, sharing syringes and sharing cookers, measured by the number of people with whom the sharing took place in the past 12 months. Sharing syringes was defined equally receiving a syringe that had been previously used by someone else. Sharing cookers was defined every bit using a cooker someone else had previously used or using it simultaneously with someone else. All variables were based on self-report data except HCV antibody status, which was assessed with betoken-of-care rapid testing using the OraQuick Advance Rapid HCV Antibody Test (manufactured past OraSure Technologies, Inc., Bethlehem, PA).

Quantitative analyses

All statistical analyses were conducted in the program R, versions 3.two.2 and iii.2.4 (R Core team, 2015) and IBM SPSS 25. For bivariable and multivariable analyses, response categories for lifetime PO injection were complanate into two groups—never injected POs and ever injected POs—after a chi-squared test indicated a significant effect for several variables. Get-go, binary associations of the iii variables of interest (HCV-positive status, lifetime overdose, and lifetime PO injection) with a series of sociodemographic (gender, race/ethnicity, household income growing upwardly, lifetime homelessness) and injection take a chance variables (syringe- and cooker-sharing in the past 12 months) were computed. Log ratios and p values were computed for all binary associations using a Wald chi-squared exam, with a 95% confidence interval [25].. Following the strategy described in Hosmer et al., blocks of variables with p < 0.25 in bivariable analyses were then included in separate multivariable models for each of the three dependent variables of interest [26,27,28]. Multivariable models were run using generalized linear model (R version 3.2.4, glm_4.xiii-19), and adjusted odds ratios were computed using the model estimate. Results were verified with logistic regression in SPSS. Associations of PO injection with HCV-positive status and with non-fatal overdose were adamant by separate multivariable models with HCV-positive status and non-fatal overdose as dependent variables, respectively. Potential sociodemographic predictors of lifetime PO injection were adamant by a tertiary multivariable model with PO injection as a dependent variable.

Results

Qualitative findings

Of the 46 qualitative interviewees, 27 were male, eighteen female person, and 1 transgender female. Participants were 25.3 years old on average (SD = 3.nine years; range = 18–32 years). In response to interview questions regarding participants' opioid utilise, some participants provided detailed descriptions of their PO injection practices.

Participants described multiple methods for converting solid pills into injectable solutions. Each blazon of preparation method was tailored to the specific type and conception of opioid. Participants preferred immediate-release (IR) oxycodone pills considering they can be easily crushed and dissolved in water without the cumbersome process of trying to circumvent extended-release and/or abuse-deterrent applied science. Respondents described the difficulties involved in trying to separate the opioid from the pill's fillers and binders. Their stated goal was to maximize the amount of overall pill content that dissolved in h2o so the drug was suspended in a solution that was watery-plenty to be fatigued into a syringe. Bruce, a 26-year-quondam white male, described the method he used to prepare blue oxycodone pills for injection:

I'll put the whole pill in there [in a cooker]. I'll have a i cc syringe with at least 75 units of water in it, preferably warmish. I'll squirt half on, I'll accept the back of a plunger of another needle…kickoff crushing it every bit fine as I tin, rest of the water mix information technology up with, again, the plunger, fold information technology, estrus it for mayhap v full seconds until your finger starts to hurt…I see the actual sediment, like the binders, you lot know it separates, you've got this pile of gook, and and then you've got this blue water, information technology looks like a Smurf got melted. Throw in the cotton, and I suck it up, and and so I'll movement the cotton around 'cause a lot of it's [the drug] stuck in the actual gel of the residue.

Bruce'south description is adequately representative of the techniques interviewees reported using to set up opioid pills for injection. Converting extended-release and/or abuse-deterrent opioid formulations into an aqueous solution that is watery-enough to be fatigued into a syringe typically requires a larger amount of water relative to the volume needed to dissolve the powder heroin available in NYC. The objective need for more water is of critical importance because the volume of the resulting pill-based solution is also big (> 0.5 cc) for the mutual syringe used past PWID in NYC (0.five cc) to hold. To inject an opioid solution whose volume is greater than 0.5 cc requires a person to either administer multiple injections in a single injection episode using a 0.5-cc syringe [11, 12] or to utilize a larger syringe (≥ one.0 cc) to inject the entire solution in a single injection.

Respondents also reported the need for heat when dissolving most opioid pill formulations, either heating the cooker with the flame from a lighter or heating the pill in a microwave or conventional oven. After adding water to the pill and adding heat, Bruce described the resulting material as sticky, referring to it as "gook," and reported needing to perform additional steps to fully dissolve the pill. He described an intense and repeated process of manipulation whereby a water-soaked pill is repetitively crushed with the flat summit of a syringe plunger while extra water is added and the filter is continuously repositioned in the cooker to create a solution that is watery enough to exist finer filtered and drawn into a syringe.

Some participants described reusing cottons that had been previously used past peers to filter PO-containing solutions in social club to access the drug residue contained inside them. In addition, participants as well reported preparing an boosted drug solution from the pill residue that remained in the cooker after the original solution was injected, despite being aware of the reduced opioid content associated with residual. For example, William, a 28-twelvemonth-old, white male, stated:

I'll do another shot out of it [the residue]. I'll put h2o on it and I'll mix it upward again, and I'll get a small rush out of it, not a lot but some… I'll do my shot and so I'll put h2o in it and I'll mix it up and I'll do it right after I exercise the shot. I'll do two shots at once, yep, or 1 right subsequently the other.

As evident from William's comment, and in contrast to injecting heroin, report participants typically described the injection of POs equally more than cumbersome and time-consuming. Dissolving heroin requires less water than extended-release and/or abuse-deterrent PO formulations and thus smaller-book (e.g., 0.5 cc) syringes can be used to inject an entire heroin solution in a single injection. Because heroin in NYC is widely available in pulverization form and readily dissolves in h2o with petty to no estrus, needing less than 0.5 cc of water is standard practice. In the following excerpt, Elton, an xviii-year-old male of Asian descent, summarizes why he prefers injecting heroin to pills: "Equally far equally the pills become, I feel similar it'due south kind of inefficient. Maybe there is too much pulverization, doesn't go absorbed fully, but for some reason, I don't get the full rush as if y'all were shooting heroin."

Quantitative findings

The sociodemographic characteristics of the sub-sample of 353 PWID who participated in the written report's RDS phase are presented in Table one. Nearly participants were male (65%), White/non-Latino (73%), and 36% grew up in households with annual incomes of less than $51,000). However, a considerable minority (23%) grew up in households with annual incomes of $101,000 or more. Thirty-nine percent reported never injecting POs, while 33% reported injecting POs sporadically, and 26% reported doing so regularly. In dissimilarity, the vast majority (98%) had injected heroin and 89% had done so regularly.

Table 1 Characteristics of RDS-recruited Participants (n = 353)

Full size tabular array

Participants' opioid apply histories, drug used at commencement injection, and frequency of PO and heroin injection are presented in Table 2. On average, participants' outset nonmedical PO use occurred about 4 years prior to any opioid injection and 2.6 years prior to heroin employ. Among those who reported always injecting POs, beginning PO injection typically occurred shortly after the first heroin injection. As well, the drug used at first injection was overwhelmingly heroin (82%), followed by POs (seven%).

Table ii Prescription opioid (PO) and heroin injection history and behavior among young adult PWID (north = 353)

Full size table

On average, participants had regularly injected heroin for a full of 34.5 months (SD = 34.9), which is 24.3 months longer than they had regularly injected POs (10.2 months, SD = 20.4). A bulk (84%) reported injecting heroin in the by calendar month, with an average of xviii.6 days of heroin injection in the past 30 days. Fewer participants (14%) had injected POs in the past month, averaging only 5 days of PO injection in the past 30 days (see Table 2).

Tabular array 3 presents the bivariable and multivariable associations of lifetime PO injection with HCV-positive status when controlling for socio-demographics and injection risk variables. Lifetime homelessness, the number of people with whom the participant shared syringes in the past 12 months, and the number of people with whom the participant shared cookers in the past 12 months were associated with HCV-positive condition in bivariable analyses and thus, forth with household income growing up which had an autobus p value < 0.25 (p = 0.xviii), were entered as covariates in determining the association between PO injection and HCV-positive condition [27, 28]. PO injection was constitute to be associated with HCV-positive status (AOR 2.97, 1.l–5.86, p < 0.01).

Tabular array iii Correlates of HCV antibody-positive serostatus among young adult PWID (n = 347)

Total size tabular array

Tabular array 4 presents a similar tabular array to Table three except with the dependent variable being lifetime experience of non-fatal overdose. The same sociodemographic and injection risk variables associated with HCV-positive condition were also found to exist associated with not-fatal overdose in bivariable analyses: lifetime homelessness, the number of people with whom the participant shared syringes in the past 12 months, and the number of people with whom the participant shared cookers in the past 12 months. In add-on, considering the omnibus examination for race/ethnicity and for household income growing up had p values of < 0.25 (p = 0.17 and p = 0.18, respectively), these variables were also included in the model. PO injection was plant to be associated with non-fatal overdose (AOR two.51, 1.47–four.28, p < 0.01) when controlling for these five sociodemographic and injection take chances variables.

Table iv Correlates of non-fatal overdose amid young adult PWID (n = 340)

Full size tabular array

Table 5 presents the bivariable and multivariable associations of lifetime PO injection with the aforementioned serial of sociodemographic independent variables. Gender and race/ethnicity were non significantly associated with PO injection in bivariable analyses. Nevertheless, race/ethnicity was included in the multivariable analysis due to its passenger vehicle p value of < 0.25 (p = 0.10). In multivariable logistic regression, compared to growing up in depression-income households, PO injection was significantly correlated with growing up in centre- (AOR 1.86, 1.07–3.21, p = 0.03), or high-income households (AOR 2.54, 1.35–4.76, p < 0.01). PO injection was besides associated with lifetime homelessness (AOR 2.93, 1.75–4.91, p < 0.01).

Table v Correlation betwixt sociodemographics and lifetime PO injection among young adult PWID (due north = 347)

Full size tabular array

Discussion

This paper provides a qualitative description of the PO injection practices of immature PWID in NYC. Qualitative interview findings reveal that PO injection frequently necessitates the use of 1.0 cc syringes or the administration of multiple injections with smaller syringes (0.5 cc) due to the additional water that is needed to dissolve extended-release and/or abuse-deterrent opioid pills in aqueous solution. These multi-stride pill injection practices tin can increase the likelihood of sharing and cross-contaminating injection equipment, thereby increasing the risk of HIV [29] and HCV transmission [6, 28, thirty]. Our findings approve results from other qualitative studies that draw the unique mechanics involved in preparing and injecting POs [8, 11]. Past contrast, the mechanics required to prepare and inject heroin—particularly, the powder form of heroin that predominates in the Eastern part of the USA—are considerably less cumbersome, and consequently, intrinsically less risky. The nominal amount of residue that remains in cookers later episodes of heroin injection reduces the likelihood that PWID will be motivated to consume or share "rinse shots," equally was reported past written report's participants in reference to injecting POs, too as by Bruneau et al. and Broz et al. [7, 11].

Quantitative results bespeak that, in improver to injecting heroin, a majority of young PWID in our sample (59%) have also injected POs. The prevalence of PO injection, however, is considerably lower than the 75% reported by Bruneau et al. in Montreal and the 89% reported by Havens et al. in rural Appalachia [3, 7]. The lower prevalence of PO injection in our NYC sample might be explained by regional differences in drug markets. Heroin in NYC is widely available and significantly cheaper than diverted POs, allowing PWID to choose between POs and heroin based on their income-generating strategies and SES, whereas in Canada [29], heroin is bachelor simply more expensive than POs, and in certain rural areas of the USA, like Kentucky [3], heroin is difficult to access, which can necessitate more frequent PO injection, even in places where POs are exceedingly expensive (e.g., Scott County, Indiana).

Our qualitative findings illustrate how the preparation and injection practices associated with the parenteral administration of POs (eastward.chiliad., multiple drug washes, reuse of drug paraphernalia containing drug residue, multiple injections per injection episode) identify PWID at increased risk for blood-borne infection. Adapted odds ratios from multivariable analysis indicate that participants who tested HCV antibody-positive had 2.3 times the odds of having injected POs than those who had never injected them. These results support similar findings reported in both urban [4, 7] and not-urban settings [three, six]. Taken together, our research findings from NYC contribute to an emerging trunk of literature indicating that PO injection is independently associated with increased take a chance of HCV infection. This heightened risk may explicate, in part, the sharp increase in astute HCV infections in many jurisdictions throughout the U.s. where PO injection is prevalent [31]. It also raises the possibility of an HIV outbreak driven past sharing injection paraphernalia other than syringes when PWID reinsert their ain used needle into the cooker in training of multiple washes [32]. Additionally, to the extent that PO injection motivates PWID to re-use drug-residual-containing filters or cottons, information technology could potentially raise risk for endocarditis, as damp filters provide an platonic breeding basis for bacteria.

In this paper, we as well contrast patterns of heroin and PO injection amongst immature adult PWID in NYC. In a drug market with a steady heroin supply, such as NYC, the preponderance of young PWID in this study initiated their opioid use with oral intake of POs at most 16 years old. Oral consumption of POs occurred for an average of 2–3 years prior to the start heroin utilize at age nineteen. Despite years of nonmedical PO apply without heroin, a large bulk of PWID (82%) chose heroin as their first injected drug. In abrupt contrast to the reported 62% of PWID in rural Appalachia who initiated injection with POs [3], only vii% of young PWID in our sample chose POs as their first injected drug. This geographic variation may indicate that in areas where both heroin and POs are readily attainable, opioid users are far more likely to choose heroin instead of POs as the showtime drug they inject. This might also result from wanting to avoid the complicated hassle of preparing PO for injection.

Despite the predominance of heroin as the drug of choice for initiating injection, a majority of participants (59%) did report always having injected POs, indicating a pregnant prevalence of PO injection fifty-fifty in an urban location with a well-established heroin market. The widespread availability of heroin in NYC, nonetheless, appears to influence the frequency with which participants reported injecting POs relative to heroin. Although many participants had experimented with injecting POs, it was not oftentimes a regular practise: just 26% of respondents reported regular PO injection for at to the lowest degree 1 calendar month (vs. 89% who reported regular heroin injection). On average, these young PWID, who ranged in age from xviii to 29 years old, reported having injected heroin regularly for 2.eight years—about 2 years longer than their reported average duration of regular PO injection (0.eight years). Similarly, when considering the number of days participants reported injecting POs vs. heroin in the past 30 days, heroin was injected far more than ofttimes: 84% reported having injected heroin in the past xxx days, for an average of 18.six days, while but xiv% report having injected POs in the by 30 days, for an average of only 5 days. Notwithstanding, the loftier prevalence of occasional PO injection still poses significant health risks for PWID.

Analyses presented here also betoken that PO injection is significantly correlated with lifetime experience of non-fatal overdose. Like to other studies [14, 15], our bivariable results indicate a strong correlation between PO injection and overdose. In contrast to these previous studies, however, the clan of overdose with PO injection in the current study remained pregnant in the multivariable model, suggesting a robust association in this sample of young New Yorkers who inject drugs. There are several possible explanations for the observed human relationship between PO injection and overdose. On the one manus, PO injectors in this sample are more likely to accept grown up in centre- or upper-income families; ergo, they may accept more than coin to spend on opioids and other drugs, which may allow for college drug intake or polysubstance utilise, thereby contributing to increased overdose risk. PO injection could likewise exist serving as a marker for a subset of youth who engage in a range of high-risk drug-use behaviors, including behaviors, such as binging on drugs and/or engaging in polysubstance use, that are known to increase gamble of overdose.

PO injection was also correlated with having been raised in a higher-income household. This association may possibly reflect the ability of people with college incomes to continue purchasing POs while concurrently using heroin, which tends to occur in drug contexts where heroin is cheaper and easier to access than POs [xx]. Yet, to complicate matters, findings also signal that lifetime homelessness is significantly correlated with PO injection. This may show that different subsets of the population of young PWID in NYC may be engaging in the injection of multiple drugs [4].

This study has some limitations, specially pertaining to the utilize of self-reported and cross-sectional data. Participants' power to recollect past events and behaviors, including those that may have occurred years prior, is unknown. There is also the possibility that self-reported data is susceptible to social desirability bias, especially given the sensitive and stigmatized topic of illicit drug use. Because of the cross-sectional nature of the data, our findings cannot found causation, only correlation. Additionally, as this sample was comprised entirely of young adults who live in NYC, results may not generalize to other populations, specially those in non-urban areas. The use of a non-random recruitment strategy—respondent-driven sampling—may also accept introduced bias into the sample that limits the generalizability of the findings. An additional limitation in the qualitative information is participants' imprecise description of the pills used for injection, thus limiting our ability to make up one's mind which preparation methods are most common to specific PO formulations (regular extended-release and/or corruption-deterrent).

Study results illustrate the need for impairment reduction strategies to address the specific wellness risks, specially with regard to HCV transmission, posed by the injection of POs. Knowledgeable people who use drugs, prevention projects and agencies should explicitly inform PWID of the increased viral transmission risk associated with PO injection practices and how to mitigate such adventure, mainly by e'er using new, sterile equipment for every injection, and fugitive the sharing of whatever injection paraphernalia (syringes, cookers, filters, diluting water, and water containers), even if information technology contains drug residual. In group injection situations where people are doing multiple injections per injection episode, it can be very difficult to avert accidental cross-contamination. If at that place is any sharing or splitting of drug solution from a communal cooker, then all PWID involved need to use a sterile syringe for each injection. In situations where individuals will be re-using their own syringes for repeated injections, all those involved in the group injection should mix their ain drugs in their own cooker. If larger syringes are to be used, those with detachable needles should never be used, as they agree a larger corporeality of rest blood and therefore increase the risk of transmitting HCV or HIV [33]. If sharing POs and injecting, users should try to carve up the pill before breaking information technology down for injection, with each individual using exclusively their ain injection equipment. Recent enquiry suggests that heating a PO-containing drug solution until boiling reduces the risk of HIV transmission [32]; the extent to which this process may protect against HCV transmission is yet unknown but warrants future research.

In summary, these results propose that a high proportion of young PWID in NYC take injected POs, although information technology appears to be less frequent than heroin injection. Further, lifetime experience of not-fatal overdose and HCV antibody-positive serostatus were independently associated with having ever injected POs. Existing harm reduction efforts should inform PWID of the increased risks associated with injecting POs and tailor harm reduction messages to accost the risky practices associated with preparing and injecting POs, including multiple injections per injection episode and the re-use of drug remainder-containing cookers and filters.

Availability of data and materials

All data generated or analyzed during this report are unavailable due to the presence of identifiers.

Abbreviations

PO:

Prescription opioid

PWID:

People who inject drugs

NYC:

New York Urban center

HIV:

Human immunodeficiency virus

HCV:

Hepatitis C virus

RDS:

Respondent-driven sampling

IR:

Immediate release

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Acknowledgements

We would like to thank all the individuals who participated in this study and to Courtney Ciervo for preparing the manuscript for final submission.

Funding

This enquiry was supported by the National Institutes of Health (NIH)/National Institute on Drug Abuse (NIDA), Grants No. R01DA035146 and R01DA041501. The content is the sole responsibility of the authors and does not necessarily reflect the official views of NIDA or NIH.

Author data

Affiliations

1. CUNY Graduate Schoolhouse of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125th Street, New York, NY, 10027, USA

   Pedro Mateu-Gelabert, Honoria Guarino, Chunki Fong, Elizabeth Goodbody & Carli Salvati

2. RTI International, 2987 Clairmont Road, Century Plaza 1, Suite 400, Atlanta, GA, 30329-4434, United states

   Jon E. Zibbell

3. National Evolution Inquiry Institutes, Inc., 71 West 23rd St, New York, NY, 10010, USA

   Jennifer Teubl

4. Contained Consultant, New York, NY, USA

   Brian Edlin

5. NYU School of Medicine, 550 First Artery, New York, NY, 10016, USA

   Samuel R. Friedman

Contributions

PMG adult the interview guide, conducted the interviews, and wrote the offset draft of the manuscript. HG and PMG developed the quantitative survey. JT and CF ran the statistical analysis. EG, HG, and PMG contributed to the qualitative analysis. EG and CS contributed to the groundwork information and literature review. PMG, HG, JZ, JT, EG, Exist, CS, and SF contributed to the assay and the writing of the manuscript. BE and SF wrote various drafts of the manuscript and provided cardinal contributions for analysis and discussion. All authors approved of the last version of the manuscript.

Corresponding author

Correspondence to Pedro Mateu-Gelabert.

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This study was approved by the National Development & Enquiry Institutes, Inc. Internal Review Board.

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The authors declare that they have no competing interests.

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Mateu-Gelabert, P., Guarino, H., Zibbell, J.Eastward. et al. Prescription opioid injection among young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose. Harm Reduct J 17, 22 (2020). https://doi.org/10.1186/s12954-020-00367-2

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• Received: x January 2020

• Accepted: 13 March 2020

• Published: xxx March 2020

• DOI : https://doi.org/10.1186/s12954-020-00367-2

Keywords

• Prescription opioid misuse
• Prescription opioid injection
• Immature PWID
• Heroin
• Drug overdose
• Hepatitis C virus (HCV) infection

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