Background: Increased drug use has disproportionately impacted rural areas across the U.S. People who use drugs are at risk of overdose and other medical complications, including infectious diseases. Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, particularly in rural settings where resources may be limited. Methods: We conducted 20 semi-structured interviews with people who use drugs, including 17 who inject drugs, in rural southern Illinois between June 2018 and February 2019. Interviews were analyzed using a modified grounded theory approach where themes are coded and organized as they emerge from the data. Results: Participants reported breaches of trust by healthcare providers, often involving law enforcement and Emergency Medical Services, that dissuaded them from accessing medical care. Participants described experiences of mistreatment in emergency departments, with one account of forced catheterization. They further recounted disclosures of protected health information by healthcare providers, including communicating drug test results to law enforcement and sharing details of counseling sessions with community members without consent. Participants also described a hesitancy common among people who use drugs to call emergency medical services for an overdose due to fear of arrest. Conclusion: Breaches of trust by healthcare providers in rural communities discouraged people who use drugs from accessing medical care until absolutely necessary, if at all. These experiences may worsen healthcare outcomes and further stigmatize this marginalized community. Structural changes including reforming and clarifying law enforcement's role in Emergency Departments as well as instituting diversion policies during arrests may help rebuild trust in these communities. Other possible areas for intervention include stigma training and harm reduction education for emergency medicine providers, as well as developing and implementing referral systems between Emergency Departments and local harm reduction providers and medically assisted drug treatment programs.

/pdf/breaching-trust-a-qualitative-study-of-healthcare-1b1dz0q5rs.pdf

Breaching Trust: A Qualitative Study of Healthcare Experiences of People Who Use Drugs in a Rural Setting

Hepatitis C infection is a major public health concern globally. In Ireland, like other European countries, people who use drugs (PWUD) and prisoners carry a larger HCV disease burden than the general population. Recent advances in HCV management have made HCV elimination across Europe a realistic goal. Engaging these two marginalised and underserved populations remains a challenge. The aim of this review was to map key findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWUD and prisoners. A scoping review guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey & O’Malley). A total of 58 studies were identified and divided into the following categories; Epidemiology, Guidelines and Policy, Treatment Outcomes, HCV-related Health Issues and qualitative research reporting on Patients’ and Health Providers’ Experiences. This review identified significantly higher rates of HCV infection among Irish prisoners and PWUD than the general population. There are high levels of undiagnosed and untreated HCV infection in both groups. There is poor engagement by Irish PWUD with HCV services and barriers have been identified. Prison hepatology nurse services have a positive impact on treatment uptake and outcomes. Identified gaps in the literature include; lack of accurate epidemiological data on incident infection, untreated chronic HCV infection particularly in PWUD living outside Dublin and those not engaged with OST. Ireland like other European countries has high levels of undiagnosed and untreated HCV infection. Collecting, synthesising and identifying gaps in the available literature is timely and will inform national HCV screening, treatment and prevention strategies.

/pdf/hepatitis-c-virus-infection-in-irish-drug-users-and-4tsj34gpk3.pdf

Hepatitis C virus infection in Irish drug users and prisoners – a scoping review

This pilot study provides a conceptual framework for the application of the anthropological analysis of skeletal features andsurgical interventions for the purpose of identification in cases of unknown deceased individuals with unavailable fingerprint, genetic or odonto-logical antemortem data. The study sample includes 276 individuals with known demographic and clinical information from the Italian CALMilano Cemetery Skeletal Collection. In the sample, 124 (45%) individuals showed one or more skeletal features that may be potentially indi-vidualizing. Of these, 79% showed two and more features, which occurred in a multitude of different combinations. Skeletal findings may pro-vide useful postmortem information that can be compared with antemortem witness statements and clinical imaging. However, more researchinto the utility of dry bone findings and the availability of comparative material, including imaging, and epidemiological data needs to beundertaken before skeletal features can be implemented into identification protocols and databases.

The Utility of Skeletal and Surgical Features for the Personal Identification Process : a Pilot Study

Background Previously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach. Objectives We examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED. Methods Retrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion. Results There were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%. Conclusions Nontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.

Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City.

Background: Injecting drug use (IDU) is a growing concern in India. This problem may coexist with other psychiatric disorders. The psychiatric comorbidity in IDUrs affects the psychosocial functioning of this population. This study aimed to assess psychiatric comorbidities, psychosocial problems, and global functioning of people who inject opioids. Methods: This cross-sectional study included opioid-dependent individuals with a history of injecting opioids who visited an outpatient clinic for buprenorphine maintenance treatment. The patients were assessed by SCID-I and SCID-II for Axis–I and Axis–II psychiatric disorders, respectively. The diagnosis was confirmed according to DSM-IV-TR. Moreover, the assessment of psychosocial and environmental problems was done according to Axis-IV of DSM-IV. Functioning was assessed using the Global Assessment of Functioning Scale (GAF). Substance use severity was also assessed using Addiction Severity Index (ASI). Findings: A total of 100 participants were included in the study. All participants were male, and the majority (63%) were in the age range of 18-40 years with the mean age of 36.96 (SD=10.12). Moreover, 76% of the participants had psychiatric comorbidity. Mood disorder (28.95%), anxiety disorder (13.16%), any personality disorder (27.63%) were the most common comorbidities. The results also revealed psychosocial and environmental problems were significantly higher in participants with comorbidity and their global functioning was poor. Conclusion: Psychiatric comorbidities are quite common and are associated with various psychosocial and environmental problems. Early identification and interventions for comorbid conditions along with community-based psychosocial rehabilitation should be considered for better outcomes.

https://ahj.kmu.ac.ir/article_92055_ae0787ed300527c489cac3757128576e.pdf

Psychiatric Comorbidity, Psychosocial Problems, and Functioning of People Who Inject Opioids: An Observational Study

A man presented to the emergency department with a stab wound to his right upper quadrant. His vital signs were in the normal range. Examination revealed a 1.5 cm wound at the junction of the subcostal margin and the linea semilunaris. There was localised peritonitic tenderness. Lactate was elevated at 4.3 mmol/l.

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https://emj.bmj.com/content/emermed/early/2012/04/03/emermed-2012-201336.full.pdf

Looking beyond Morison's pouch in focused assessment with sonography for trauma: penetrating hepatobiliary trauma and a new sign for emergency physicians

Background The affliction of injecting drug use (IDU) has resulted in the emergence of a subgroup of people with a unique set of medical issues. We aimed to describe the emergency department (ED) presentations of IDUs. Methods In a prospective observational study over a 3-month period, we identified characteristics of patients with a history of active IDU presenting to the ED. Results From 1 January 2010 to 31 March 2010, 146 patients with a history of IDU were identified. These contributed to 222 acute presentations to the ED. Baseline characteristics revealed that patients were predominantly male, of Irish nationality, with high levels of homelessness, unemployment and lack of stable family or intimate partner relationships. 45% of presentations occurred as a result of infection (95% CI 38.5% to 51.5%). Trauma, pure toxicological issues, thromboembolic phenomena and psychiatric issues comprised the other common acute diagnoses. The burden of comorbid medical illness was substantial with high rates of hepatitis C infection (74%) and HIV infection (13.8%). Healthcare utilisation indices for this cohort are extreme on multiple measures. We found an ED attendance rate of 445 per 100 patient-years, an admission rate of 68.8 per 100 patient-years and mortality rate of 4.86 per 100 patient-years. Conclusions Our study characterises the emergency presentations of active IDUs. We describe considerable acute and chronic medical consequences and high healthcare utilisation associated with IDU. This study is of particular relevance to any institution that provides acute medical care to this group of patients.

https://emj.bmj.com/content/emermed/31/8/625.full.pdf

Cross-sectional study of the characteristics, healthcare usage, morbidity and mortality of injecting drug users attending an inner city emergency department

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Looking beyond Morison's pouch in focused assessment with sonography for trauma: penetrating hepatobiliary trauma and a new sign for emergency physicians

Cross-sectional study of the characteristics, healthcare usage, morbidity and mortality of injecting drug users attending an inner city emergency department