Stephen Koester

Drug Sharing Among Heroin Networks: Implications for HIV and Hepatitis B and C Prevention

Qualitative and quantitative findings from the baseline survey of a longitudinal, socially-focused blood-borne disease intervention study among 611 heroin IDU in Denver indicate that high risk injection practices—the sharing of contaminated drug solution in particular—often occur as a consequence of how heroin is obtained, the quantity obtained and the setting where it is injected. Contamination occurs if a contaminated syringe is used to liquefy and apportion the shared drug. In our cohort of 304 heroin injecting networks there was at least one member who, when asked to describe their last injection, reported dividing the drug as a liquid (82%), using a reservoir of water that syringes had been rinsed in to mix drugs (67%), using a common cooker (86%)—a proxy for drug sharing—and beating a shared cotton filter (58%). In contrast, only 22% reported syringe sharing. Variables associated with various injection practices included location of the last injection episode, quantity of drug injected, dope sickness, and years injecting. When compared to those who injected in a safe setting, those in an unsafe location had almost three times the odds (OR = 2.9; 95% CI: 1.9, 4.6) of being part of an injection episode where there was cooker sharing; and the smaller the quantity of heroin (≤1/4 gram v. > 1/4 gram) present at the episode, the greater the odds that cooker sharing occurred (OR = 1.8; 95% CI: 1.2, 2.6). Use of a used, unbleached syringe to prepare shared drugs had twice the odds of occurring in “unsafe” v. safe settings (OR = 2.2; 95% CI: 1.3, 4.0) and in episodes in which a participant was dopesick (OR = 2.1; 95% CI: 1.2, 3.6). In summary, risky injection practices occur within an injection process that is, in part, a response to a structurally imposed risk environment. Lessening the blood-borne disease risks embedded within this process requires interventions designed to mitigate the environmental factors that influence it, including syringe accessibility, law enforcement strategies and the settings where IDU inject drugs.

Non-medical use of prescription drugs and sexual risk behavior in young adults

In recent years, the non-medical use of prescription drugs (without a doctors prescription) has increased dramatically, particularly in young adults. Previous work has noted associations between the non-medical use of prescription drugs and the use of illicit drugs, and associations between the use of illicit drugs and sexual risk behavior. Investigations examining associations between the non-medical use of prescription drugs (NMUPD) and sexual risk behavior are sparse. In the present study, undergraduate students (n=435) ages 18-25 completed an instrument assessing these behaviors. Overall, 35.6% of participants reported NMUPD. Individuals who reported NMUPD were more likely to also report the use of alcohol, marijuana, ecstasy, cocaine, methamphetamine, and poppers. Participants who indicated they had used prescription medications without a doctors consent had significantly higher rates of sexual risk behavior, including more sexual partners and more instances of unprotected sex in the previous 3 months. Results suggest that a significant minority of young adults are using prescription medication recreationally and are risking negative consequences, including the potential for addiction, dangerous interactions between prescription and recreational drugs, and greater risk for contracting sexually transmitted infections.

Co-management of Tropical Coastal Zones: The Case of the Soufriere Marine Management Area, St. Lucia, WI

Centralized, top-down fisheries management models based on biological stock-recruitment have, at best, achieved limited success when adapted to Third World fisheries. Comanagement, a resource management approach oriented towards resource users and their communities, has been proposed as an alternative strategy for managing Third World fisheries. We examine the initial success and subsequent problems of one such collaborative coastal zone management project on St. Lucias leeward coast. Factors that must be considered in the development, implementation, and maintenance of coastal comanagement systems operating in the contexts of tropical marine ecosystems in developing nations are identified and discussed.Centralized, top-down fisheries management models based on biological stock-recruitment have, at best, achieved limited success when adapted to Third World fisheries. Comanagement, a resource management approach oriented towards resource users and their communities, has been proposed as an alternative strategy for managing Third World fisheries. We examine the initial success and subsequent problems of one such collaborative coastal zone management project on St. Lucias leeward coast. Factors that must be considered in the development, implementation, and maintenance of coastal comanagement systems operating in the contexts of tropical marine ecosystems in developing nations are identified and discussed.

Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff

ABSTRACTBACKGROUNDThe rate of fatal unintentional pharmaceutical opioid poisonings has increased substantially since the late 1990s. Naloxone is an effective opioid antidote that can be prescribed to patients for bystander use in the event of an overdose. Primary care clinics represent settings in which large populations of patients prescribed opioids could be reached for overdose education and naloxone prescription.OBJECTIVEOur aim was to investigate the knowledge, attitudes and beliefs about overdose education and naloxone prescription among clinical staff in primary care.DESIGNThis was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators.SETTINGTen primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems.METHODSA focus group guide was developed based on behavioral theory. Focus group transcripts were coded for manifest and latent meaning, and analyzed for themes using a recursive approach that included inductive and deductive analysis.RESULTSThemes emerged in four content areas related to overdose education and naloxone prescription: knowledge, barriers, benefits and facilitators. Clinical staff (N = 56) demonstrated substantial knowledge gaps about naloxone and its use in outpatient settings. They expressed uncertainty about who to prescribe naloxone to, and identified a range of logistical barriers to its use in practice. Staff also described fears about offending patients and concerns about increased risk behaviors in patients prescribed naloxone. When considering naloxone, some providers reflected critically and with discomfort on their own opioid prescribing. These barriers were balanced by beliefs that prescribing naloxone could prevent death and result in safer opioid use behaviors.LIMITATIONSFindings from these qualitative focus groups may not be generalizable to other settings.CONCLUSIONIn addition to evidence gaps, logistical and attitudinal barriers will need to be addressed to enhance uptake of overdose education and naloxone prescription for patients prescribed opioids for pain.

Misuse of prescription stimulants for weight loss, psychosocial variables, and eating disordered behaviors

In recent years there has been a dramatic increase in the non-medical use of prescription drugs among young adults including an increase in the use of prescription stimulants normally used to treat ADHD. Reported motivations for the non-medical use of prescription stimulants (NPS) include enhancing academic performance and to get high. Although a common side effect of these medications is appetite suppression, research examining weight loss as a motivation for NPS among young adults is sparse. In the present study, undergraduate students (n=705) completed an online survey assessing weight loss behaviors, motivations for weight loss, and eating behaviors. Nearly 12% of respondents reported using prescription stimulants to lose weight. Participants who reported using prescription stimulants for weight loss had greater appearance-related motivations for weight loss, greater emotion and stress-related eating, a more compromised appraisal of their ability to cope, lower self-esteem, and were more likely to report engaging in other unhealthy weight loss and eating disordered behaviors. Results suggest some young adults are misusing prescription stimulants for weight loss and that this behavior is associated with other problematic weight loss strategies. Interventions designed to reduce problematic eating behaviors in young adults may wish to assess the misuse of prescription stimulants.

Nonmedical Use of Prescription Drugs and HIV Risk Behavior in Gay and Bisexual Men

Background: Previous research has demonstrated associations between substance use and sexual risk behavior in men who have sex with men (MSM). Recent trends in substance use show increasing use of prescription medications (e.g., Vicodin) without a physicians prescription, yet associations between the nonmedical use of prescription drugs (NMUPD) and HIV risk behavior have not been well examined in MSM. Methods: MSM attending a gay pride festival completed a self-report measure assessing NMUPD, motivations for use, use of traditional recreational drugs, and HIV risk behavior. Results: More than one-third of the sample (38%) reported lifetime NMUPD and 17% reported NMUPD in the previous 3 months. The most common class of medications used was prescription analgesics. Men reporting NMUPD also reported higher rates of the use of marijuana, poppers, ecstasy, cocaine, methamphetamine, GHB, ketamine, heroin, and rohypnol, and had significantly higher rates of HIV risk behaviors, including more sexual partners and more unprotected sex. Conclusions: A significant minority of MSM are using prescription medications without a doctors consent. Men who do so are risking negative consequences of such use, including the potential for addiction, potentially dangerous interactions between prescription and recreational drugs, and greater risk for contracting HIV.

Issues and Approaches to Evaluating HIV Outreach Interventions

The lack of a medical cure or preventive vaccine for HIV calls for interventions that reduce the occurrence of the behaviors known to be associated with infection. The development of effective interventions requires rigorous evaluations that, to date, have been noticeably lacking in the field. In particular, assessments of HIV prevention efforts have considered interventions as “black boxes,” with little attention to the actual services delivered. In this paper, issues related to evaluating outreach interventions are presented and an evaluation strategy to measure the delivery of outreach services, using both quantitative and qualitative techniques, is recommended.

Invisible homelessness: anonymity, exposure, and the right to the city

ABSTRACT The city of Denver, Colorado recently outlawed camping in all open space. Part of a broad effort to accelerate the profit potential of prime urban land through real estate speculation and commerce, the camping ban has dislocated homeless people from the city’s marginal spaces. Based on ethnographic fieldwork and archival research in Denver, this article develops a tripartite approach to public space—prime, everyday, and marginal—to analyze challenging ways in which people who are homeless in Denver must now manage their exposure to others in everyday public spaces. In addition to eliminating places of hard-won safety and security, this singular new code disrupts hygiene, mobility, and sociability routines, thus throwing already precarious lives into further disarray by rendering housing status visible. To demonstrate how everyday social justice springs from interaction between different people co-present in public space, we foreground the voices of Denver’s homeless people, those most impacted by quality of life laws. Evicting individuals from marginal spaces and rendering them visibly homeless in everyday and prime spaces, the ban deprives them of a fundamental right to the city: anonymity.

Attitudes Toward Methamphetamine Use and HIV Risk Behavior in Men Who Have Sex with Men

BACKGROUND AND OBJECTIVES Methamphetamine use has been strongly associated with high-risk sexual behaviors, and its use has been increasing among men who have sex with men (MSM). Although the behavioral implications of methamphetamine use and sexual risk have been broadly examined, fewer studies have examined attitudes about methamphetamine use. METHODS This study investigates the relationship between personal beliefs regarding methamphetamine use, patterns of use, and sexual risk behaviors within a sample of MSM attending a gay pride event (N= 342). RESULTS A minority of MSM reported lifetime (27%) or recent (7%) methamphetamine use. Only a minority of MSM who had used methamphetamine believed that it enhanced sexual pleasure (32%) or incorporated methamphetamine use into their sexual activity (31%). Individuals who used methamphetamine during sexual activity were more likely to be recent users of the drug and more likely to engage in high-risk behaviors. A significant minority of participants endorsed items assessing the disinhibiting effects of methamphetamine including being less likely to use a condom (35%) and less selective in their choice of partners (26%). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Results suggest that prevention efforts may benefit from targeting the minority of methamphetamine users who perceive methamphetamine as enhancing sexual activity and use it for this purpose.

Attitudes Toward Naloxone Prescribing in Clinical Settings: A Qualitative Study of Patients Prescribed High Dose Opioids for Chronic Non-Cancer Pain

BackgroundOver the last 2 decades, medical providers have increasingly prescribed pharmaceutical opioids for chronic non-cancer pain, while opioid overdose death rates have quadrupled. Naloxone, an opioid antagonist, can be prescribed to patients with chronic pain to reverse an opioid overdose, yet little is known about how patients perceive this emerging practice.ObjectiveThis study assessed the knowledge and attitudes toward naloxone prescribing among non-cancer patients prescribed opioids in primary care.DesignQualitative study design using semi-structured interviews.ParticipantsAdults (N = 24) prescribed high-dose (≥100 morphine mg equivalent daily dose) chronic opioid therapy in eight primary care internal medicine, family medicine and HIV practices in three large Colorado health systems.ApproachInductive and deductive methods were used to analyze interview transcripts.Key ResultsThemes emerged related to knowledge of and benefits, barriers and facilitators to naloxone in primary care. Patients reported receiving limited education about opioid medication risks from providers and limited knowledge of naloxone. When provided with a description of naloxone, patients recognized its ability to reverse overdoses. In addition to pragmatic barriers, such as medication cost, barriers to naloxone acceptance included the perception that overdose risk stems from medication misuse and that providers might infer that they were misusing their opioid medication if they accepted a naloxone prescription, prompting an opioid taper.Facilitators to the acceptance of naloxone included medical providers’ using empowering, non-judgmental communication practices, framing naloxone for use in “worst case scenarios” and providing education and training about opioids and naloxone.ConclusionsWhile patients recognized the utility of naloxone prescribing, we identified important barriers to patient acceptance of naloxone prescribing. To improve the naloxone prescribing acceptability in primary care practice, medical providers and health systems may need to enhance patient education, employ empowering, non-judgmental communication styles and adequately frame discussions about naloxone to address patients’ fears.