Increasing methamphetamine injection among non-MSM who inject drugs in King County, Washington

doi:10.1016/j.drugalcdep.2017.10.011

Drug and Alcohol Dependence

Volume 182, 1 January 2018, Pages 86-92

https://doi.org/10.1016/j.drugalcdep.2017.10.011 Get rights and content

Highlights

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Methamphetamine injection among PWID in King County, WA, has increased since 2009.
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Most of the increase in methamphetamine injection occurred among non-MSM.
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Injecting methamphetamine in combination with heroin (“goofballs”) is common.
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Most PWID who injected methamphetamine reported sharing any injection equipment.
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There is equipment sharing between MSM and non-MSM who inject methamphetamine.

Abstract

Background

In King County, Washington, the HIV prevalence among men who have sex with men (MSM) who inject methamphetamine is high, while it is low among other people who inject drugs (PWID). Local drug problem indicators suggest that methamphetamine use is increasing. The extent to which this increase affects MSM and non-MSM, and whether MSM and non-MSM networks are connected through injection equipment sharing, is unknown.

Methods

We used data from two serial cross-sectional surveys of PWID including five biannual surveys of Public Health–Seattle and King County Needle and Syringe Exchange Program clients (NSEP, N = 2135, 2009–2017) and three National HIV Behavioral Surveillance IDU surveys (NHBS, N = 1709, 2009–2015).

Results

The proportion of non-MSM PWID reporting any recent methamphetamine injection increased significantly from approximately 20% in 2009 to 65% in 2017. Most of this increase was attributable to injecting methamphetamine in combination with heroin (goofballs). PWID who injected goofballs were more likely to be younger, homeless or unstably housed, report daily injection, and self-report an opioid overdose in the past year than other PWID. The majority of PWID who injected methamphetamine reported sharing any injection equipment. Among these PWID, 43% of MSM had last shared injection equipment with a non-MSM. Eight percent of non-MSM men and 15% of women had last shared equipment with an MSM.

Conclusions

Given non-trivial rates of sharing injection equipment with methamphetamine-using MSM, a population with an HIV prevalence of 40%, non-MSM who inject methamphetamine could be an emerging population at risk for acquiring HIV.

Introduction

A notable success in HIV prevention has been the substantial decrease in HIV/AIDS incidence among people who inject drugs (PWID) in the United States. The number of AIDS diagnoses among PWID peaked in 1993 at approximately 23,000 new diagnoses and by 2016 had declined by nearly 90% (Centers for Disease Control et al., 2017a). This is in contrast to an approximate 70% decline in AIDS cases among men who have sex with men (MSM) during the same time period (Centers for Disease Control and Prevention;Viral Hepatitis, Sexual Transmitted Diseases and Tuberculosis Prevention, Division of HIV/AIDS Prevention, 2017). In addition to the use of antiretroviral therapy, this reduction in risk among PWID is likely due to expanded harm reduction services like needle and syringe exchange programs (NSEP), decreased needle and syringe sharing among PWID, and decreased transmission risk from HIV-infected persons due to antiretroviral therapy (Aspinall et al., 2014, Burt and Thiede, 2016, Montaner et al., 2010). However, the recent HIV outbreak among PWID injecting pharmaceutical opioids in Scott County, Indiana, demonstrated the ongoing potential for explosive transmission when HIV is introduced in the context of injection equipment sharing and uncontrolled HIV viral load (Peters et al., 2016).

Despite the overall reduction in new HIV diagnoses among PWID, in some U.S. jurisdictions HIV risk has been strongly associated with methamphetamine use (both injection and non-injection use) among men who have sex with men (MSM) (Buchacz et al., 2005, Plankey et al., 2007, Thiede et al., 2009). For example, in King County, Washington, HIV prevalence among MSM who have used methamphetamine in the past year is approximately 40%, which is higher than any other subgroup (Glick et al., 2016, Glick et al., 2015). This is in contrast to the prevalence among all MSM (15–20%) and non-MSM and women who inject drugs (∼3%) (Glick et al., 2016). Moreover, methamphetamine use has been associated with lower levels of viral suppression among HIV-infected persons (Fairbairn et al., 2011, Feldman et al., 2015).

There have been recent signals of increased methamphetamine use in King County, Washington. The number of methamphetamine-involved overdose deaths, the number of police cases involving methamphetamine, and wastewater measures have all indicated an increase in methamphetamine use (Banta-Green et al., 2016). Recently published data from Denver also reported an increase in methamphetamine use over the past decade, especially methamphetamine injected with heroin (goofballs) (Al-Tayyib et al., 2017). However, these reports have not indicated if the increase in methamphetamine use was among MSM, where use has historically been concentrated in King County, or among non-MSM. An increase in methamphetamine use among MSM would suggest the need for more targeted HIV prevention efforts. An increase in methamphetamine use among non-MSM men and women – particularly in the context of injection equipment sharing – could predict an emerging population at risk for HIV.

To identify the populations in which methamphetamine use is increasing and the potential of HIV transmission risk across MSM and non-MSM networks, we investigated temporal trends in methamphetamine use and injection equipment sharing in King County among MSM and non-MSM who inject drugs. We also evaluated characteristics of people who inject methamphetamine – alone and in combination with other drugs – as well as characteristics of recent equipment sharing partners.

Section snippets

Data and measures

We analyzed data from two serial, cross-sectional surveys of PWID in King County.

Sample characteristics

The characteristics of participants in the NSEP and NHBS-IDU surveys are shown in Table 1. Comparing all NSEP clients to all NHBS-IDU participants, NSEP clients were more likely to be younger (mean age, 37.7 vs. 42.6 years, P < 0.01), male (69% vs. 65%, P = 0.01) and non-Hispanic White (72% vs. 61%, P < 0.01). Approximately 16% of all men reported sex with a man in the past year. Homelessness and unstable housing were very common in both samples. The majority of participants reported injecting drugs

Discussion

In King County, Washington, non-MSM who inject methamphetamine may be an emerging population at risk for HIV infection. Our data present clear evidence of a dramatic increase in methamphetamine injection among PWID, with the most significant increase occurring among non-MSM. Based on data from our NSEP study population, most of this increase among non-MSM can be attributable to PWID injecting methamphetamine and heroin together (goofballs) and this is likely to be the case in the NHBS-IDU study

Conclusions

These findings highlight the profound importance of maintaining and expanding evidence-based HIV prevention efforts among PWID. King County has housed one of the longest-running and most robust NSEPs in the United States, and is likely one of the reasons that HIV prevalence has remained low among local PWID. Maintaining, if not increasing, these services is critical for preventing HIV transmission. Routine HIV testing, keeping HIV-infected PWID virally suppressed, and efforts to diminish

Role of funding source

Funding for the National HIV Behavioral Surveillance survey came from cooperative agreements with the Centers for Disease Control and Prevention (5U62PS000969, 5U1BPS003250, 1U62PS005094). Funding for the electronic data collection tool used in the 2015 and 2017 Needle and Syringe Exchange Surveys came from REDCap (Research Electronic Data Capture) at the Institute of Translational Health Sciences is supported by the National Center For Advancing Translational Sciences of the National

Conflict of interest statement

No conflict declared.

Contributors

All authors participated in the research and article preparation, and all have approved of the final article. SNG conceptualized the original study, conducted the analysis, and wrote the initial draft of the manuscript. RB assisted with the analyses, data interpretation, and manuscript writing. KK performed preliminary analyses. JT and CJBG assisted with data collection. MRG conceptualized the original study.

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Emerging research suggests the rise in methamphetamine-related harms is attributed, at least in part, to increases in methamphetamine injection, including among persons injecting both methamphetamine and opioids. National, as well as several smaller, U.S. studies in both the general population and in treatment samples have documented increases in methamphetamine injection (Al-Tayyib et al., 2017; Glick et al., 2018; Jones et al., 2020; Glick et al., 2021; Han et al., 2021a;). These trends are consistent with increases in methamphetamine injection seen in other countries, including Vancouver, British Columbia, and Australia (Degenhardt et al., 2017; Bach et al., 2020).
Prior research indicates rising methamphetamine use and harms in the U.S., potentially related to increases in methamphetamine injection. To date, research on trends and correlates of methamphetamine injection is limited.
Analysis of trends and correlates of methamphetamine injection among treatment admissions among persons aged ≥ 12 whose primary substance of use at admission is methamphetamine. Data are from the Treatment Episode Data Set. Analyses includes descriptive statistics, trend analyses, and multilevel multivariable logistic regression.
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Full length articleIncreasing methamphetamine injection among non-MSM who inject drugs in King County, Washington

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Data and measures

Sample characteristics

Discussion

Conclusions

Role of funding source

Conflict of interest statement

Contributors

Ann. Epidemiol.

Drug Alcohol Depend.

Int. J. Drug Policy

Addict. Behav.

Drug Alcohol Depend.

J. Biomed. Inf.

Lancet

Drug Alcohol Depend.

Heroin and methamphetamine injection: an emerging drug use pattern

Subst. Use Misuse

Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs? A systematic review and meta-analysis

Int. J Epidemiol.

2015 Drug Use Trends in King County, Washington

Trends in production, trafficking, and consumption of methamphetamine and cocaine in Mexico

Subst. Use Misuse

Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco

AIDS

Evidence for risk reduction among amphetamine-injecting men who have sex with men; results from national HIV behavioral surveillance surveys in the Seattle Area 2008–2012

AIDS Behav.

Reduction in needle sharing among Seattle-area injection drug users across 4 surveys, 1994–2013

Am. J. Public Health

A decline in HIV testing among persons who inject drugs in the Seattle Area, 2004–2015

J. Acquir. Immune Defic. Syndr.

Full length article
Increasing methamphetamine injection among non-MSM who inject drugs in King County, Washington