This unexpected finding may be a result of several factors. First, the psychometric properties of the questionnaire used to measure sexual risk behaviors in our study have not been reported and thus measurement error may be influencing our reported associations. Although there is no agreed upon “gold-standard” for measuring sexual risk behavior, recommendations from a review of 56 sexual risk behavior measures in the literature have been developed and future studies should be encouraged to adopt these measurement strategies to improve accuracy of sexual risk behavior characterization. Second, recall deficits may result in sexual risk behavior reporting errors. This is particularly a concern when measuring sexual risk behavior retrospectively over large spans of time as was done in the current study. Post-hoc analysis within our sample showed no significant difference in recall deficit by COMT genotype, albeit there did appear to be a trend = 2.89; P = .058 in which carriers of the Val/Val genotype had greater deficits than that of Val/Met and Met/Met genotypes . Thus, it is possible that recall deficits within the Val/Val group biased our findings toward those in the Met/Met group and should be interpreted with caution. Finally and most speculative, harm reduction campaigns have long aimed to increase condom use within both HIV-infected and METH using populations and our finding may be an artifact of their success. Collectively, these findings provide a preliminary model of differential susceptibility to sexual risk behavior via executive dysfunction, dependent on COMT genotype,flood table particularly the Met/Met genotype . Although the role of the Met/Met genotype is contrary to our hypothesis, our findings, when placed in the context of previous research are informative.
Recent research has linked the COMT Met/Met genotype to novelty seeking behavior in healthy and methamphetamine using populations. In addition, work by Gonzalez et al.on executive functioning and sexual risk behavior demonstrated that sensation seeking was independently associated with sexual risk, particularly among HIV-seropositive individuals. Thus, it appears that individuals with the Met/Met genotype may have a lower tolerance for monotony and may seek and participate in higher risk behaviors such as METH use or unprotected sex. Furthermore, work by our group and others have suggested that possession of the Met allele enhances executive functioning in healthy controls;however, this neuroprotective effect is significantly reduced among individuals exposed to methamphetamine. Thus, it is probable that in our sample, of which approximately half were methamphetamine dependent, the putative protective effect of the Met/Met genotype is diminished and propensity to sexual risk behavior enhanced. It is apparent that the associations between COMT, executive dysfunction, and sexual risk behavior are highly complex and context dependent. The current study provides preliminary evidence of these complex relationships and advocates for larger investigations that improve upon and consider several of the limitations that have been presented. Future work should also attempt to address independent and interaction effects of other putative polymorphisms particularly those involved in dopamine synthesis , metabolism , and reception . In addition, future transdisciplinary work that combines genetic and neurocognitive factors with psychosocial factors will provide valuable insights and elucidate a clearer picture of sexual risk behavior. Completion of such work in combination with the current as well as others previous work will further our understanding of the genotypic and endophenotypic factors involved in the phenotypic expression of sexual risk behaviors and potentially assist with risk identification, prevention, and treatment efforts in the future.These interruptions are a result of both widespread closure of services deemed nonessential in order to reduce social interactions and slow the spread of the novel coronavirus that causes COVID-19, and voluntary avoidance of situations perceived to be high risk for contracting COVID-19.
These non-pharmaceutical interventions reduced the incidence of COVID-19 , allowing time for the development of effective vaccines and preventing potentially tens of thousands of deaths. However, interventions also led to substantial disruption of health and healthcare services , possibly at the expense of the health of people who relied on this medical care. Disruptions caused by the COVID-19 pandemic may have been disproportionately harmful to people who use illicit drugs. Since March of 2020, the United States and Canada have experienced large increases in drug overdoses, overdose-related emergency department visits, and drug overdose deaths across multiple jurisdictions, particularly those involving stimulants and fentanyl . While the cause of this increase is not fully understood, and could be multi-factorial, disruptions in treatment and harm reduction services may have played a role. In particular, there may have been disruptions in access to medications for opioid use disorder and/or syringe service programs. Medications such as methadone and buprenorphine reduce risk of overdose and improve functional outcomes for people with opioid use disorder ; however, the COVID-19 pandemic may have disrupted access to these medications. For example, from May to June of 2020, one study of a sample of methadone clinics in the United States and Canada found more than 1 in 10 were not taking any new patients, with greater barriers to access in the United States than Canada . Another survey of drug users from Baltimore conducted between April and June of 2020 found fewer than half of respondents on methadone treatment had a four-week supply of methadone available . Syringe service programs, where clients can obtain sterile syringes, reduce risk of HIV transmission among people who use drugs and may facilitate access to other essential health services for people who use drugs like substance use treatment and infectious disease treatment . However, the COVID-19 pandemic caused many syringe service programs to reduce services and sometimes to close .
Qualitative studies of people who use drugs in both the United States and Canada suggest that service disruptions, combined with fear of COVD-19, led some people who use drugs to reduce their use of health and harm reduction programs . The aggregate impact of these qualitative studies are corroborated by quantitative research showing visits to substance use treatment programs in 2020 were lower than the same time periods in 2019, with greater reductions in places experiencing more cases of COVID-19 . In summary, there is evidence the COVID-19 pandemic impeded access to important health services programs offering medicated treatment for opioid use disorder and syringe service programs, both because of reduced or disrupted operation of those programs, and also because program clients chose to avoid services because of fear of COVID-19. However, to date, there is no research documenting individual-level risk factors for eschewing or avoiding health and harm reduction services among people who use drugs. This in part reflects the challenge of recruiting and assessing risk in a sufficiently large sample of people who use drugs during a pandemic. However, understanding change in use of these services,indoor plant table and individual and community-level factors associated with this change, is key to future research that seeks to understand understanding how much and why outcomes related to infectious disease and overdose have changed among people who use drugs during the COVID-19 pandemic. However, understanding these risks is essential to mitigating their impact on service use, both in the context of the current ongoing COVID-19 pandemic, and in the event of future crises that result in significant societal disruption. This study uses data from a subset of participants with a history of illicit drug use recruited from a consortium of cohort studies actively following more than 12,000 people in the United States and Canada to examine self-reported COVID-19 pandemic-related disruption in two harm reduction services—1) use of medications for opioid use disorder and 2) use of syringe service programs—among people who have injected drugs during the COVID-19 pandemic. We focus on a limited but important set of characteristics that were assessed in all cohort studies and either relate to core demographic characteristics or pandemic-related attitudes and behaviors . Data come from the Collaborating Consortium of Cohorts Producing NIDA Opportunities : a consortium of nine cohort studies with more than 6000 active participants funded in part or in full by the United States National Institute on Drug Abuse to study HIV/ AIDS and related outcomes in people who use drugs . The cohorts are spread across five cities in the United States and Canada: Baltimore, MD; Vancouver, BC; Miami, FL; Los Angeles, CA; and Chicago, IL. Recruitment and protocols for each cohort are described elsewhere . In response to the COVID-19 pandemic, investigators in each cohort deployed a supplemental questionnaire examining COVID-19 related factors such as disruptions to healthcare or harm reduction services resulting from the pandemic, self-reported history of COVID-19 testing or infection, self-reported history of vaccination and attitudes about vaccination, adoption of COVID-19 safety measures, and general mental health questions. C3PNO participants were recruited for participation in this supplemental survey if they had attended a regular study visit during the 12 months prior to March, 2020, and were able and willing to complete the interview remotely. Data were collected between May, 2020, and March, 2021. All data – including both the COVID-19 supplement and general study questionnaires – were collected through telephone interviews or online forms to accommodate social distancing precautions.
Participants received compensation for completing the interview. The study was approved by the institutional review/research ethics boards of the member cohorts and each participant provided informed consent for their study participation. Data from this analysis are drawn from two sub-samples of individuals who completed the C3PNO COVID-19 supplement: 1) To analyze disruptions in use of medication treatment for opioid use disorder, we included 702 participants who either a) reported any recent methadone treatment on their most recently completed study questionnaire or b) reported avoiding picking up medications for opioid use disorder, and c) for whom complete data was available for all other covariates of interest. 2) To analyze disruptions in syringe services program use, we included 304 participants who a) reported any injection drug use in the past month on their most recently completed study questionnaire, and b) for whom complete data was available for all other covariates of interest. Detailed dates of collection and response rates for each cohort and for the full survey are shown in Appendix A. In this analysis of 702 people who had been on methadone treatment in the United States and Canada, approximately one quarter reported avoiding picking up medications because of the COVID-19 pandemic. However, this number masks enormous disparities between countries and cities: in Vancouver, almost no respondents reported avoiding picking up medications for opioid use disorder, while in Chicago, Los Angeles, and Miami, most respondents did; Baltimore one-in-twelve reported avoidance. These wide disparities are consistent with other research on methadone access during the COVD-19 pandemic, and may reflect differences in regulatory context between Canada and the United States: in the United States, methadone can only be administered/ dispensed as specialty Opioid Treatment Programs , and buprenorphine can only be prescribed by physicians who complete special training and receive a waiver to do so. By contrast, in Canada, methadone treatment is more integrated into general medical care and can be prescribed or administered by many physicians and dispensed at pharmacies, and buprenorphine can be prescribed by any physician . Similarly, in Vancouver, local health authorities recognized substance use services to be essential services during the COVID-19 pandemic. Importantly, the United States made emergency policy changes during the COVID-19 pandemic, permitting states to in turn permit patients already initiated on methadone treatment to receive 14 or 28 days of take-home medication from an OTP, and permitting buprenorphine prescriptions to be initiated following a telemedicine visit with a licensed provider . There is evidence of widespread adoption of these options—including expanded use of telemedicine for addiction treatment and buprenorphine prescribing and expanded use of two- and four-week take-home methadone dispensation—with no accompanying evidence of reduction in care quality or harm to clients associated with this adoption . Maintaining this enhanced flexibility—even after the need for acute social distancing to prevent transmission of the virus that causes COVID-19 dissipates—may be appropriate . After accounting for differences across jurisdiction, no individual characteristics were associated with self-reported avoidance of picking up medications for opioid use disorder. This suggests the local policy and service context was much more important for preserving access to these medications than characteristics of individual clients.