Roman Ivasiy

Introduction: Multiple naloxone administration (MNA), defined as the use of two or more naloxone doses during a single overdose event, has been increasingly reported during the fourth wave of the opioid overdose death crisis, which is characterized by polysubstance combined with intentional or unintentional fentanyl exposure. This has contributed to community-based concerns around naloxone dosing and effectiveness in reversing overdoses among people who inject drugs (PWID) who use multiple substances in addition to fentanyl and other synthetic/non-synthetic opioids. We examined the prevalence and correlates of MNA among opioid-using PWID to inform naloxone distribution strategies and community-based overdose response in the fourth wave of the opioid crisis. Methods: We used data from a prospective cohort study of opioid-using PWID in Los Angeles, CA and Denver, CO (April 2021-November 2022), restricted to participants who witnessed a heroin, fentanyl, or opioid overdose in the prior 3 months. MNA was assessed among those reporting at least one witnessed overdose involving non-EMS naloxone administration (N=233). Bivariable and multivariable logistic regression were used to evaluate demographic, economic, drug use, harm reduction, and service utilization correlates of MNA. Results: Most participants (79%) reported a recent witnessed overdose where more than one dose of naloxone was used. In multivariable analysis, witnessed overdose frequency (AOR=1.49; 95% CI: 1.15, 1.94), past 3- month fentanyl use (AOR=2.13; 95% CI: 1.00, 4.52), and daily polysubstance use were associated with significantly increased odds of MNA. Compared with participants reporting no daily drug use, those reporting daily use of one drug had nearly four times the odds of MNA (AOR=3.95; 95% CI: 1.72, 9.07), and those reporting daily use of three or more drugs had more than five times the odds (AOR=5.48; 95% CI: 1.11, 26.98). Conclusion: MNA was common among PWID who witnessed overdoses and was associated with greater overdose exposure, fentanyl use, and daily polysubstance use. Results support continued efforts to strengthen the naloxone cascade through community-based naloxone distribution to increase naloxone availability and use among people who use drugs and their peers to facilitate timely overdose response and prevent fatalities in an increasingly dangerous illicit drug supply.

Stigma in healthcare settings is a critical barrier to HIV prevention and treatment among people who inject drugs (PWID). While previous tools have measured anticipated stigma, few account for the intersectional and provider-specific experiences of PWID—particularly from syringe service programs (SSPs). We developed and validated the Substance Use Anticipated Provider Stigma Scale (SU-APSS), a multidimensional instrument assessing anticipated stigma from four provider types: healthcare workers, substance use treatment staff, pharmacists, and SSP personnel. Data were drawn from a cross-sectional survey of 264 PWID who were 18 or older, HIV-negative, had injected drugs and used opioids within the past 30 days, and showed visible signs of recent injection. We conducted confirmatory factor analysis (CFA) on responses from 218 participants to evaluate structural validity and used Cronbach’s alpha to assess internal consistency. The CFA supported a four-factor structure with strong model fit indices (CFI = 0.97, RMSEA = 0.09 [0.07, 0.11], SRMR = 0.04). All items significantly loaded onto their respective factors (loadings: 0.62–1.06). Internal consistency was high across all subscales (α = 0.85–0.96) and for the overall scale (α = 0.87). Attribution analysis revealed drug use, physical appearance, and income level as the most common perceived reasons for anticipated stigma. The SU-APSS offers a practical tool for identifying provider-specific stigma, informing stigma-reduction interventions, and evaluating implementation strategies to improve HIV prevention and care engagement among PWID.

The incidence and mortality of human immunodeficiency viruses (HIVs) are rising in Eastern Europe and Central Asia (EECA), particularly among people who inject drugs. Opioid agonist therapies (OATs), such as methadone or buprenorphine, are the most effective treatments for opioid use disorder and serve as a key HIV-prevention strategy in EECA. OAT uptake across the region, however, has been limited. The Kyrgyz Republic was the first Central Asian country to initiate OAT and remains a pioneer in the region. To understand the progression of OAT scale-up, all legislations related to drug policies or methadone in the Kyrgyz Republic were analyzed from the country’s founding to March 2023 and compared with policies in neighboring countries, particularly Kazakhstan and Tajikistan. Concurrently, local news coverage and policy reports were also assessed. OAT has been available in the Kyrgyz Republic since 2001, initially as a pilot project funded by international donors, and then with gradually increasing state support. Since its inception, the methadone program has evolved and influenced neighboring countries in Central Asia, despite numerous political challenges. The Kyrgyz Republic has expanded access to methadone, revised clinical protocols, and increased the number of distribution sites in communities and the carceral system to ensure broader access, aiming for program sustainability. While methadone policies and implementation in the Kyrgyz Republic have advanced earlier and more expansively than in neighboring countries, some challenges persist. Based on the findings, the suggestions provided may support the sustainable scale-up of methadone programs, enabling continued growth and improvement.

HIV incidence and mortality are increasing in Eastern Europe and Central Asia and are concentrated in people who inject drugs. Maintenance with opioid agonist therapies (OAT) like methadone or buprenorphine is the best treatment for opioid use disorder and a key HIV-prevention strategy in the region. In Kazakhstan, the scale-up of methadone has been minimal since methadone’s introduction in 2008 and has been supported through international charitable organizations. As the Republic of Kazakhstan is designated to assume financial and administrative oversight of OAT, legislative gains can ensure treatment continuity and scale-up. Here, we review legislative barriers to OAT scale-up in Kazakhstan using an implementation science lens. We review legislative, political, and cultural barriers that undermine the efficient distribution and allocation of medications and impose burdensome clinical and administrative demands on patients and clinicians. Legislative reform is required to support further OAT expansion. We therefore provide policy recommendations to overcome these barriers to increase access to this life-saving, life-prolonging, evidence-based medical treatment. Minimally, these include increased numbers of clinical sites and patients at these sites; re-engineering OAT delivery across the country and directly to patients; introducing newer formulations of OAT; and creating an open bidding process to procure treatment medications.