Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use

Abstract

Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.

Keywords: injection drug use; injection initiation assistance; people who inject drugs; substance use; systematic reviews.

Figure 1

Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) diagram for a systematic review of the prevalence of and correlates associated with providing and receiving assistance with injection drug initiation. A systematic search of the literature (from individual database inception to October 9, 2019) identified 3,269 citations representing 1,164 unique texts. After title and abstract screening, 150 full texts were identified as potentially eligible for inclusion. After full text screening, 57 texts met eligibility criteria and were included in the present review.

Figure 2

Prevalence of receiving assistance with initiation of drug injection in the published literature through October 9, 2019. The prevalence of being injected with drugs by another person at injection initiation ranged from 53% to 95% across 29 estimates (A). The prevalence of receiving help, guidance, or another type of injection initiation assistance ranged from 74% to 100% across 13 estimates (B). Note: The 2014 prevalence estimate of Rotondi et al. (59) was adjusted for respondent-driven sampling. Bars, 95% confidence intervals (CIs).

Figure 3

Correlates associated with receiving assistance with initiation of drug injection in 1 or more studies in the published literature through October 9, 2019. Correlates are classified according to Rhodes’ risk environments or other individual characteristics related to health or substance use. Correlates associated with receiving assistance are denoted in red as “risk-promoting” factors, and correlates inversely associated with receiving assistance are denoted in green as “risk-diminishing” factors. Many risk-promoting factors arise from the microsocial risk environment, supporting the potential influence that injecting norms may have on the receipt of assistance.

Figure 4

Prevalence of providing assistance with initiation of drug injection in the published literature through October 9, 2019. The prevalence of ever providing help, guidance, or other assistance with someone else’s injection initiation ranged from 13% to 69% across 13 estimates (A). The prevalence of having provided help, guidance, or other assistance with someone else’s injection initiation in the past 6 months ranged from 4% to 27% across 6 estimates (B). Note: The 2018 prevalence estimates of Uuskülaa et al. (58) were adjusted for respondent-driven sampling. Bars, 95% confidence intervals (CIs).

Figure 5

Correlates associated with providing assistance with initiation of drug injection in 1 or more studies in the published literature through October 9, 2019. Correlates are classified according to Rhodes’ risk environments or other individual characteristics related to health or substance use. Correlates associated with providing assistance are denoted in red as “risk-promoting” factors, and correlates inversely associated with providing assistance are denoted in green as “risk-diminishing” factors. The most well-studied risk-promoting factors arose from the microsocial risk environment, supporting the potential influence that injecting norms and practices during one’s own first injection may have on the provision of assistance. CA, California; HIV, human immunodeficiency virus.