Showing papers in "Harm Reduction Journal in 2015"

Why the FUSS (Fentanyl Urine Screen Study)? A cross-sectional survey to characterize an emerging threat to people who use drugs in British Columbia, Canada.

Abstract: Fentanyl-detected illicit drug overdose deaths in British Columbia (BC) recently increased dramatically from 13 deaths in 2012 to 90 deaths in 2014, signaling an emerging public health concern. Illicit fentanyl is sold as pills or powders, often mixed with other substances like heroin or oxycodone; reports from coroners suggested that fentanyl was frequently taken unknowingly by people who use drugs. This study aimed to assess the prevalence and characteristics of fentanyl use among clients accessing harm reduction (HR) services in BC. Participants attending HR services at 17 sites across BC were invited to complete an anonymous questionnaire describing drugs they have used within the last 3 days and provide a urine sample to test for fentanyl. Data from eligible participants were analyzed using descriptive, bivariate, and multivariate statistical methods. Surveys from 17 HR sites were received, resulting in analysis of responses from 242 eligible participants. Most participants used multiple substances (median = 3), with crystal meth (59 %) and heroin (52 %) use most frequently reported. Seventy participants (29 %) tested positive for fentanyl, 73 % of whom did not report using fentanyl. Controlling for age, gender, and health authority, reported use of fentanyl (odds ratio (OR) = 6.13, 95 % confidence interval (CI) = [2.52, 15.78], p < 0.001) and crystal methamphetamine (OR = 3.82, 95 % CI = [1.79, 8.63], p < 0.001) use were significantly associated with fentanyl detection. The proportion of those testing positive who did not report knowingly using fentanyl represents a considerable public health concern. The risk of overdose among this vulnerable population highlights the need for targeted HR strategies, such as increased accessibility to naloxone, overdose education, and urine screens.

Long-term self-treatment with methadone or buprenorphine as a response to barriers to opioid substitution treatment : the case of Sweden

Abstract: Background: It is well known that illicit use of methadone and buprenorphine is common among people with an opioid dependence Less notice has been taken of the fact that these substances are also used for extended periods of self-treatment, as a way of handling barriers to OST In this study, motives for self-treatment are investigated, as well as attitudes and perceived barriers to OST among drug users with an opioid dependence in Sweden Method: The study is based on qualitative research interviews with 27 opioid users who have treated themselves with methadone or buprenorphine for a period of at least three months Results: The duration of self-treatment among the interviewees varied from 5 months to 7 years Self-treatment often began as a result of a wish to change their life situation or to cut back on heroin, in conjunction with perceived barriers to OST These barriers consisted of (1) difficulties in gaining access to OST due to strict inclusion criteria, limited access to treatment or a bureaucratic and arduous assessment process, (2) difficulties remaining in treatment, and (3) ambivalence toward or reluctance to seek OST, primarily due to a fear of stigmatization or disciplinary action Self-treatment was described as an attractive alternative to OST, as a stepping stone to OST, and as a way of handling waiting lists, or as a saving resource in case of involuntary discharge Conclusion: Illicit use of methadone and buprenorphine involve risks but may also have important roles to play for users who are unwilling or not given the opportunity to enter OST A restrictive and strict rehabilitation-oriented treatment model may force many to manage their own treatment More generous inclusion criteria, a less complex admission process, fewer involuntary discharges, and less paternalistic treatment may lead to increasing numbers seeking OST Control measures are necessary to prevent diversion and harmful drug use but must be designed in such a way that they impose as few restrictions as possible on the daily life of patients

Orienting patients to greater opioid safety: models of community pharmacy-based naloxone

Abstract: The leading cause of adult injury death in the USA is drug overdose, the majority of which involves prescription opioid medications. Outside of the USA, deaths by drug overdose are also on the rise, and overdose is a leading cause of death for drug users. Reducing overdose risk while maintaining access to prescription opioids when medically indicated requires careful consideration of how opioids are prescribed and dispensed, how patients use them, how they interact with other medications, and how they are safely stored. Pharmacists, highly trained professionals expert at detecting and managing medication errors and drug-drug interactions, safe dispensing, and patient counseling, are an under-utilized asset in addressing overdose in the US and globally. Pharmacies provide a high-yield setting where patient and caregiver customers can access naloxone—an opioid antagonist that reverses opioid overdose—and overdose prevention counseling. This case study briefly describes and provides two US state-specific examples of innovative policy models of pharmacy-based naloxone, implemented to reduce overdose events and improve opioid safety: Collaborative Pharmacy Practice Agreements and Pharmacy Standing Orders.

Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in Northeastern Ontario, Canada

Abstract: As with many Indigenous groups around the world, Aboriginal communities in Canada face significant challenges with trauma and substance use. The complexity of symptoms that accompany intergenerational trauma and substance use disorders represents major challenges in the treatment of both disorders. There appears to be an underutilization of substance use and mental health services, substantial client dropout rates, and an increase in HIV infections in Aboriginal communities in Canada. The aim of this paper is to explore and evaluate current literature on how traditional Aboriginal healing methods and the Western treatment model “Seeking Safety” could be blended to help Aboriginal peoples heal from intergenerational trauma and substance use disorders. A literature search was conducted using the keywords: intergenerational trauma, historical trauma, Seeking Safety, substance use, Two-Eyed Seeing, Aboriginal spirituality, and Aboriginal traditional healing. Through a literature review of Indigenous knowledge, most Indigenous scholars proposed that the wellness of an Aboriginal community can only be adequately measured from within an Indigenous knowledge framework that is holistic, inclusive, and respectful of the balance between the spiritual, emotional, physical, and social realms of life. Their findings indicate that treatment interventions must honour the historical context and history of Indigenous peoples. Furthermore, there appears to be strong evidence that strengthening cultural identity, community integration, and political empowerment can enhance and improve mental health and substance use disorders in Aboriginal populations. In addition, Seeking Safety was highlighted as a well-studied model with most populations, resulting in healing. The provided recommendations seek to improve the treatment and healing of Aboriginal peoples presenting with intergenerational trauma and addiction. Other recommendations include the input of qualitative and quantitative research as well as studies encouraging Aboriginal peoples to explore treatments that could specifically enhance health in their respective communities.

Public opinion and medical cannabis policies: examining the role of underlying beliefs and national medical cannabis policies.

Abstract: Debate about medical cannabis legalization are typically informed by three beliefs: (1) cannabis has medical effects, (2) medical cannabis is addictive and (3) medical cannabis legalization leads to increased used of cannabis for recreational purposes (spillover effects). We examined how strongly these beliefs are associated with public support for medical cannabis legalization and whether this association differs across divergent medical cannabis policy regimes. Robust regression analysis was used to analyse data derived from two nationally representative samples of adults participating in comparable cross-sectional online surveys in one country where medical cannabis smoking is illegal (Norway, n = 2175, 51 % male) and in one country where medical cannabis smoking is legal (Israel, n = 648, 49 % male). The belief that cannabis has medical benefits was more strongly related to support for medical cannabis legalization than were beliefs about addiction and spillover effects. While the support for medical cannabis legalization was stronger in Israel than in Norway (78 vs. 51 %, p < 0.01), the belief variables had, in general, more impact on the policy stand in Norway. The belief that cannabis has medical benefits is particularly salient for support for medical cannabis legalization. It is possible that the recent surge in evidence supporting the medical benefits of cannabis will increase the belief about medical benefits of cannabis in the general population which may in turn increase public support for medical cannabis legalization. Results also suggest that once medical cannabis is legalized, factors beyond cannabis-specific beliefs will increasingly influence medical cannabis legalization support. These conclusions are, however, only suggestive as the current study is based on cross-sectional data. Hopefully, future research will be able to capitalize on changes in medical cannabis policies and conduct longitudinal studies that enable an examination of the causal relation between public opinion and medical cannabis policy changes.

Deficiencies in public understanding about tobacco harm reduction: results from a United States national survey

Abstract: Tobacco products differ in their relative health harms. The need for educating consumers about such harms is growing as different tobacco products enter the marketplace and as the FDA moves to regulate and educate the public about different products. However, little is known about the patterns of the public’s knowledge of relative harms. Data were analyzed from the Health Information National Trends Survey (HINTS) 4 Cycle 2, a population-representative survey of US adults conducted between October 2012 and January 2013 (N = 3630). Participants reported their perceptions of the relative risks of e-cigarettes, smokeless tobacco, and different types of cigarettes compared to “traditional” cigarettes. Relative risk perceptions for each product type, as well as the consistency and accuracy of harm reduction beliefs, were analyzed. About 65 % of the respondents accurately reported that no cigarettes were less harmful than any others. Slightly more than half of US adults perceived e-cigarettes to be safer than regular cigarettes, a belief in line with current scientific evidence. By contrast, only 9 % of respondents perceived some smokeless tobacco products to be safer, a belief strongly supported by the evidence. Only 3.5 % of respondents had patterns of relative risk perceptions in line with current scientific evidence for all three modalities. The discrepancy between current evidence and public perceptions of relative risk of various tobacco/nicotine products was marked; for most tobacco types, a large proportion of the population held inaccurate harm reduction beliefs. Although there was substantial awareness that no cigarettes were safer than any other cigarettes, there could be benefits from increasing the percentage of the public that appreciates this fact, especially among current smokers. Given the potential benefits of tobacco risk reduction strategies, public health education efforts to increase understanding of basic harm reduction principles are needed to address these misperceptions.

Ambivalence about supervised injection facilities among community stakeholders.

Abstract: Background Community stakeholders express a range of opinions about supervised injection facilities (SIFs) We sought to identify reasons for ambivalence about SIFs amongst community stakeholders in two Canadian cities

Women’s injection drug practices in their own words: a qualitative study

Abstract: There are significant gender differences in injection drug practices and relative risks involved for women who inject drug compared with men. This qualitative study aims to explore the social, contextual, and behavioral dimensions of injecting practices among women who inject drugs. Participants were selected by purposive venue-based sampling from a syringe exchange program in 2012–2013. In-depth interviews were conducted with 26 women to elicit detailed perspectives regarding injection drug use practices and women-focused decision-making. All interviews were transcribed verbatim and analyzed with Atlas.ti. Participant’s mean age was 43.2 years, 48% Caucasian, 36% African American, and 16% Latina, poorly educated, mostly single, and heroin self-injectors. Three themes emerged; a) transitioning from non-injection to injection drug use; b) patterns and variations of initiation to injecting; and c) shifting toward autonomy or reliance on others. Women were predominantly influenced to transition to injection drug use by other women with their claims that injecting was a way to curtail their daily drug expenditure. More than half the women received their first injection from another woman in their social network rather than a male sexual partner. Self-injecting women exhibited agency around the circumstances of injection safety and potential risks. Other women revealed that their inability to inject themselves could and did make them dependent on others for unsafe injection practices. The finding that many women were influenced to transition to injection drug use and receive the first injection from a woman is contrary to literature claims that male sexual partners introduce and initiate women to injection drug use. Self-injecting women possessed capacity to act in a way that produced the results they wanted, not sharing prepared drugs or injecting equipment. In stark contrast, women assisted with injections could and did make them vulnerable to unsafe injecting. Findings support early prevention strategies that discourage women’s transition from non-injection to injection and development of female peer-driven experiential interventions to dispel myths for non-injection women and to increase personal capability to self-inject for women who require assistance with injecting, to reduce injection-related harm.

Facilitating a transition from compulsory detention of people who use drugs towards voluntary community-based drug dependence treatment and support services in Asia.

Abstract: Evidence indicates that detention of people who use drugs in compulsory centers in the name of treatment is common in Cambodia, China, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Thailand, and Vietnam. The expansion of such practices has been costly, has not generated positive health outcomes, and has not reduced supply or demand for illicit drugs. United Nations agencies have convened several consultations with government and civil society stakeholders in order to facilitate a transition to voluntary evidence- and community-based drug dependence treatment and support services. In an effort to support such efforts, an informal group of experts proposes a three-step process to initiate and accelerate national-level transitions. Specifically, the working group recommends the establishment of a national multisectoral decision-making committee to oversee the development of national transition plans, drug policy reform to eliminate barriers to community-based drug dependence treatment and support services, and the integration of community-based drug dependence treatment in existing national health and social service systems. In parallel, the working group recommends that national-level transitions should be guided by overarching principles, including ethics, human rights, meaningful involvement of affected communities, and client safety, as well as good governance, transparency, and accountability. The transition also represents an opportunity to review the roles and responsibilities of various agencies across the public health and public security sectors in order to balance the workload and ensure positive results. The need to accelerate national-level transitions to voluntary community-based drug dependence treatment and support services is compelling—on economic, medical, sustainable community development, and ethical grounds—as extensively documented in the literature. In this context, the expert working group fully endorses initiation of a transition towards voluntary evidence- and community-based drug dependence treatment and support services across the region, as well as the steady scale-down of compulsory centers for drug users. Components of voluntary community-based drug dependence treatment and support services are being implemented in Cambodia, China, Indonesia, Malaysia, and Thailand. However, significant technical and financial support will be required to be allocated from national budgets and by international development agencies in order to complete the transition and reduce the reliance on detention of people who use drugs in Asia.

Impact of a methadone maintenance therapy pilot in Vietnam and its role in a scaled-up response

Abstract: As a dual response to the HIV epidemic and the high level of injecting drug use in Vietnam, the Ministry of Health (MOH) initiated a pilot methadone maintenance therapy (MMT) program in Hai Phong and Ho Chi Minh City (HCMC) in early 2009 The objectives of the pilot were to provide evidence on whether MMT could be successfully implemented in Vietnam and scaled up to other localities A prospective study was conducted among 965 opiate drug users admitted to the pilot Data on demographic characteristics, sexual behaviors, substance use behaviors (including heroin use), and blood-borne virus infection (HIV, hepatitis B, and hepatitis C) were collected at treatment initiation and then again at 3-, 6-, 9-, 12-, 18-, and 24-month intervals thereafter Twenty-four months after treatment initiation, heroin use as measured by urine test or self-report had reduced from 100 % of participants at both sites to 146 % in Hai Phong and 229 % in HCMC When adjusted for multiple factors in Generalized Estimating Equations (GEE) logistic regression modeling, independent predictors of continued heroin use after 24 months of MMT in HCMC were the following: poor methadone adherence (adjusted odds ratio (AOR) = 37, 95 % confidence interval (CI) 18–78); currently on antiretroviral treatment (ART) (AOR = 18, 95 % CI 14–24); currently on TB treatment (AOR = 22, 95 % CI 14–34); currently experiencing family conflict (AOR = 16, 95 % CI 11–24); and currently employed (AOR = 08, 95 % CI 06–10) For Hai Phong participants, predictors were the following: currently on ART (AOR = 20, 95 % CI = 14–30); currently experiencing family conflict (AOR = 20, 95 % CI = 10–39); and moderate adherence to methadone (AOR = 21, 95 % CI = 12–19) In Hai Phong, the percentage of participants who were employed had also increased by end of study from 350 to 528 %, while in HCMC the level remained relatively unchanged, between 522 and 551 % Study findings were used in multiple fora to convince policymakers and the public on the significant and vital role MMT can play in reducing heroin use and improving quality of life for individuals and families Four years after this study was completed, Vietnam had expanded MMT to 162 clinics in 44 provinces serving 32,000 patients

Preference of methadone maintenance patients for the integrative and decentralized service delivery models in Vietnam

Abstract: Integrating and decentralizing services are essential to increase the accessibility and provide comprehensive care for methadone patients. Moreover, they assure the sustainability of a HIV/AIDS prevention program by reducing the implementation cost. This study aimed to measure the preference of patients enrolling in a MMT program for integrated and decentralized MMT clinics and then further examine related factors. A cross-sectional study was conducted among 510 patients receiving methadone at 3 clinics in Hanoi. Structured questionnaires were used to collect data about the preference for integrated and decentralized MMT services. Covariates including socio-economic status; health-related quality of life (using EQ-5D-5 L instrument) and HIV status; history of drug use along with MMT treatment; and exposure to the discrimination within family and community were also investigated. Multivariate logistic regression with polynomial fractions was used to identify the determinants of preference for integrative and decentralized models. Of 510 patients enrolled, 66.7 and 60.8 % preferred integrated and decentralized models, respectively. The main reason for preferring the integrative model was the convenience of use of various services (53.2 %), while more privacy (43.5 %) was the primary reason to select stand-alone model. People preferred the decentralized model primarily because of travel cost reduction (95.0 %), while the main reason for not selecting the model was increased privacy (7.7 %). After adjusting for covariates, factors influencing the preference for integrative model were poor socioeconomic status, anxiety/depression, history of drug rehabilitation, and ever disclosed health status; while exposure to community discrimination inversely associated with this preference. In addition, people who were self-employed, had a longer duration of MMT, and use current MMT with comprehensive HIV services were less likely to select decentralized model. In conclusion, the study confirmed the high preference of MMT patients for the integrative and decentralized MMT service delivery models. The convenience of healthcare services utilization and reduction of geographical barriers were the main reasons to use those models within drug use populations in Vietnam. Countering community stigma and encouraging communication between patients and their societies needed to be considered when implementing those models.

Drug-related HIV epidemic in Pakistan: a review of current situation and response and the way forward beyond 2015.

Abstract: Pakistan is among four countries in Asia where the estimated number of new HIV infections has been increasing year by year ever since 1990. The Asian Epidemic Modelling (AEM), conducted in 2015, reconfirmed that the use of contaminated injection equipment among people who inject drugs (PWID) remains the main mode of HIV transmission in the country. The estimated number of PWID ranges from 104,804 to 420,000 PWID. HIV prevalence in this population is above 40 % in several cities, including Faisalabad (52.5 %), D.G. Khan (49.6 %), Gujrat (46.2 %), Karachi (42.2 %) and Sargodha (40.6 %), respectively. Harm reduction service delivery is being implemented through a public-private partnership led by the National and Provincial AIDS Control Programmes and Nai Zindagi with funding support from the Global Fund. Current programmatic coverage of the needle and syringe programme, HIV testing and counselling and antiretroviral treatment among PWID remain insufficient to control ongoing transmission of HIV in the country. While opioid substitution therapy (OST) is yet to be introduced, significant progress and coordination among various ministries have taken place recently to register buprenorphine in the dosage required for treatment of opioid dependence, and possible introduction of OST will greatly facilitate adherence to antiretroviral treatment among PWID living with HIV.

Assessment of compliance with US Public Health Service Clinical Practice Guideline for tobacco by primary care physicians

Abstract: The US Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication. To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended “any” (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange). This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued.

Risk environments facing potential users of a supervised injection site in Ottawa, Canada.

Abstract: Background: Supervised injection sites (SISs) have been effective in reducing health risks among people who inject drugs (PWID), including those who face issues of homelessness, mental health illness, interactions with local policing practices, and HIV infection. We investigate the risk behaviours and risk environments currently faced by potential users of an SIS in Ottawa to establish the need for such a service and to contribute to the design of an SIS that can address current health risks and reduce harm. Methods: The PROUD cohort is a community-based participatory research (CBPR) project that examines the HIV risk environment among people who use drugs in Ottawa. From March to October 2013, 593 people who reported using injection drugs or smoking crack cocaine were enrolled through street-based recruitment in the ByWard Market neighbourhood, an area of the city with a high concentration of public drug use and homelessness. Participants completed a demographic, behavioural, and risk environment questionnaire and were offered HIV point-of-care testing. We undertook descriptive and univariate analyses to estimate potential use of an SIS by PWID in Ottawa and to explore risk behaviours and features of the risk environment faced by potential users of the service. Results: Of those participants who reported injecting drugs in the previous 12 months (n= 270), 75.2 % (203) reported a willingness to use an SIS in Ottawa. Among potential SIS users, 24.6 % had recently injected with a used needle, 19.0 % had trouble accessing new needles, 60.6 % were unstably housed, 49.8 % had been redzoned by the police, and 12.8 % were HIV positive. Participants willing to use an SIS more frequently injected in public (OR = 1.98, 95 % CI = 1.06–3.70), required assistance to inject (OR = 1.84, 95 % CI = 1.00–3.38), were hepatitis C positive (OR = 2.13, 95 % CI = 1.16–3.91), had overdosed in the previous year (OR = 2.00, 95 % CI = 1.02–3.92), and identified as LGBTQ (OR = 5.61, 95 % CI = 1.30–24.19). Conclusion: An SIS in Ottawa would be well-positioned to reach its target group of highly marginalized PWID and reduce drug-related harms. The application of CBPR methods to a large-scale quantitative survey supported the mobilization of communities of PWID to identify and advocate for their own service needs, creating an enabling environment for harm reduction action.

Overdose prevention for prisoners in New York: a novel program and collaboration.

Abstract: This is a brief report on the establishment of a new program in New York State prisons to prepare prisoners to avoid the increased risks of drug overdose death associated with the transition to the community by training them in overdose prevention and making available naloxone, a medication that quickly reverses the effects of an opioid overdose, to all prisoners as they re-enter the community. It is a milestone collaboration in the USA between public health, the correctional system, and a community-based harm reduction program in response to the growth of heroin and opioid analgesic use and related morbidity and mortality, working together to get naloxone into the hands of the people at high risk of overdosing and/or of witnessing an opioid overdose.

Sexual and reproductive health risks amongst female adolescents who use amphetamine-type stimulants and sell sex: a qualitative inquiry in Yunnan, China

Abstract: Background: China, as other Southeast Asian countries, has wi tnessed an increased use in amphetamine-type stimulants (ATS) amongst urban youth. Amongst female adolescents who both sell sex and use ATS, risk behaviours are compounded resulting in even poorer health outcomes. However, limited knowledge exists on ATS use patterns and ATS-related risk behaviours, particularly in this context. This research aimed to improve the understanding of these issues amongst female adolescents who use ATS and sell sex, and to inform future programming. Method: This study utilised monthly focus group discussions (four in total) with the same study participants in Yunnan, China. From within a drug-treatment programme, female adolescents who reported both a history of drug use and selling sex were purposively enrolled in the study.

A qualitative analysis of transitions to heroin injection in Kenya: implications for HIV prevention and harm reduction.

Abstract: Background Heroin injection is emerging as a significant dimension of the HIV epidemic in Kenya. Preventing transitions to injecting drug use from less harmful forms of use, such as smoking, is a potentially important focus for HIV prevention. There is, however, little evidence to support comprehensive programming in this area, linked to a shortage of analysis of the social and structural context for transitions, particularly in low-income settings. We explore accounts of transitions from smoking to injecting in Kenya to understand the role of individual, social and structural processes.

Acquiring hepatitis C in prison: the social organisation of injecting risk.

Abstract: The potential for transmission of hepatitis C virus (HCV) in prison settings is well established and directly associated with sharing of injecting and tattooing equipment, as well as physical violence. This study is one of the first to examine the circumstances surrounding the acquisition of HCV in the prison setting via inmates’ own accounts. This is a sub-study of a cohort of prison inmates in New South Wales, Australia. Cohort participants were inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. Cohort participants were monitored every 3 to 6 months for HCV antibodies and viraemia and via behavioural risk practices questionnaire. Participants with a documented HCV seroconversion were eligible to participate in in-depth interviews with a research nurse known to them. Participants included six inmates (four men, two women) with documented within-prison HCV seroconversion. Participants reported few changes to their injecting practices or circumstances that they attributed to HCV acquisition. Participants believed that they were sharing syringes with others who were HCV negative and trusted that others would have declared their HCV status if positive. Some participants described cleaning equipment with water, but not with disinfectant. In a departure from usual routine, one participant suggested that he may have acquired HCV as a result of using a syringe pre-loaded with drugs that was given to him in return for lending a syringe to another inmate. Participants described regret at acquiring HCV and noted a number of pre- and post-release plans that this diagnosis impacted upon. Acquiring hepatitis C was not a neutral experience of participants but generated significant emotional reactions for some. Decisions to share injecting equipment were influenced by participants’ assumptions of the HCV status of their injecting partners. The social organisation of injecting, in trusted networks, is a challenge for HCV prevention programs and requires additional research.

Effects of publicly funded and quality of life on attendance rate among methadone maintenance treatment patients in Taiwan: an 18-month follow-up study

Abstract: Background Methadone maintenance treatment programs (MMTPs) are important public health intervention to control the human immunodeficiency virus (HIV) and the drug use problems. For expanding treatment coverage, publicly funded programs may be necessary for heroin users with low socio-economic status. We evaluated the difference of demographics, clinical features, and quality of life (QoL) of heroin users enrolled in publicly funded and self-paid MMTP and explored determinants influencing their attendance rate, respectively, for these two groups.

Pharmacology, physiology and performance: occupational drug use and HIV risk among female entertainment and sex workers in Cambodia.

Abstract: Background In Cambodia, HIV prevalence among female entertainment and sex workers (FESW) is up to twenty times higher than in the general population. Use of amphetamine-type stimulants (ATS) has been associated with increased risk of HIV and other sexually transmitted infections in key populations, including FESW. While one in four Cambodian FESW report recent ATS use, little attention has been paid to how the occupational contexts of sex work shape patterns of use. Currently, no HIV prevention interventions target ATS use in this population.

Social context, diversity and risk among women who inject drugs in Vietnam: descriptive findings from a cross-sectional survey

Abstract: Background Women who inject drugs (WWID) are neglected globally in research and programming yet may be likelier than males to practise sexual and injecting risks and be infected with HIV and more stigmatised but seek fewer services. Little is known about characteristics, practices and nexus between drugs and sex work of WWID in Vietnam, where unsafe injecting has driven HIV transmission, and commercial sex and inconsistent condom use are prevalent. This was the first quantitative investigation of Vietnamese WWID recruited as injecting drug users. This article summarises descriptive findings.

Factors that influence the characteristics of needles and syringes used by people who inject drugs in Tajikistan

Abstract: Background: “Low dead space” syringes with permanently attached needles retain less fluid, blood, and HIV after use than standard “high dead space” syringes. This reduces the probability of HIV transmission if they are shared by people who inject drugs (PWID). The World Health Organization recently recommended that needle and syringe programs (NSP) offer clients low dead space syringes. The success of this recommendation will depend on PWID switching to low dead space needles and syringes. This paper examines the needles and syringes that PWID in Tajikistan use and factors that influence their choices. Methods: In May 2014, we conducted six focus groups in Kulob and six in Khorog, Tajikistan, with a total of 100 participants. NSP staff members recruited participants. Focus group topics included the needles and syringes used and factors that influence choice of needles and syringes. Focus groups were conducted in Russian and Tajik, audio recorded, transcribed, and translated into English. The translated files were imported into NVivo 10 for coding and analysis. Results: All participants in both cities were male and reported injecting heroin. Everyone also reported using syringes with detachable needles almost exclusively. The most popular syringe sizes were 2 and 5 ml. Needles ranged in gauge from 25 to 21 g. Needle gauge was influenced by the size of the vein, the viscosity of drug solution to be injected, and problems with blood clotting. Needles ranged in length from 12 to 38 mm, with 25 and 32 mm being the most popular. Needle length was influenced by the depth of the vein being used. Many PWID inject volumes of fluid greater than 1 ml into deep veins that require needles at least 25 mm long and 25 g in diameter. Conclusion: Most low dead space syringes are 1-ml insulin syringes with 12 mm 28 g permanently attached needles. Findings from this project suggest that these will not be acceptable to PWID who need larger syringes and longer and thicker needles that are detachable. Low dead space detachable needles appear to be an acceptable option that could overcome barriers to the widespread use of low dead space equipment for reducing HIV and HCV transmission.

Mortality in the Melbourne injecting drug user cohort study (MIX).

Abstract: There are few studies of mortality amongst people who inject drugs (PWID) in Australia. In this study, we estimate mortality in a cohort of PWID in Melbourne and examine predictors of mortality including health service use, demographic characteristics, drug use and personal wellbeing. We linked identifiers from the Melbourne injecting drug use cohort study (MIX; n = 655) to the National Death Index from 2008 to 2012 to estimate standardised mortality ratios (SMRs). Cox regression was used to examine the bivariate relationship between exposures determined at baseline and subsequent mortality. There were 24 (3.6 %) deaths over the study period. The mortality rate in the cohort was 1.0 per 100 PY (95 % CI 0.71–1.57), with an SMR of 17.3 (95 % CI 11.6–25.8). Baseline reports of four or more lifetime incarcerations (HR 3.65, 95 % CI 1.16–11.52), past month ambulance attendance (HR 4.43, 95 % CI 1.76–11.17), past month emergency department presentation (HR 3.44, 95 % CI 1.47–8.03) and past 6-month self-reported heroin overdose (HR 3.14, 95 % CI 1.24–7.96) were associated with increased mortality risk. Contact with emergency services, particularly for drug overdose, remains a lost opportunity to provide referrals for harm reduction and naloxone training programmes to PWID at greater risk of mortality.

A qualitative study of referring agents' perceptions of access barriers to inpatient substance abuse treatment centres in the Western Cape.

Abstract: Despite empirical support for the individual and public health benefits of treating substance use disorders (SUDs) , access to these services is impeded by several barriers. Although many studies on access barriers have been put forward in the literature, few have explored the barriers to accessing state-funded inpatient substance abuse treatment or the views of referral agents. A qualitative study was conducted to explore referring agents’ perceptions of the barriers to accessing state-funded inpatient substance abuse treatment centres in the Western Cape Province of South Africa. Six individual in-depth interviews were conducted and analysed using theoretical thematic analysis. The key barriers to emerge from the analysis pertained to referring agents’ perceptions of the following: service users, the substance abuse referral and treatment system and community dynamics. Recommendations are made for interventions to address the identified barriers.

The interplay between drug-use behaviors, settings, and access to care: a qualitative study exploring attitudes and experiences of crack cocaine users in Rio de Janeiro and São Paulo, Brazil.

Abstract: Despite the growing attention surrounding crack cocaine use in Brazil, little is understood about crack users’ histories, use patterns and the interplay of drug-use behaviors, settings, and access/barriers to care. Qualitative studies seldom cross-compare findings regarding people who use crack from different settings. This study aims to explore the insights of regular crack users in two major Brazilian cities and to examine how social and contextual factors, including stigma and marginalization, influence initial use and a range of health and social issues. In-depth interviews and focus groups were conducted with 38 adult crack cocaine users recruited from impoverished neighborhoods in Rio de Janeiro and Sao Paulo. Interviews and focus groups were audio recorded and transcribed verbatim. Qualitative analysis was carried out, and content was organized and analyzed by recurrent themes relevant to study interests. For study participants from both cities, frequent crack cocaine use plays a central role in daily life and leads to a range of physical, psychological, and social consequences. Common concerns among users include excessive crack use, engagement in risky habits, infrequent health service utilization, marginalization, and difficulty reducing use. Disadvantaged conditions in which many crack cocaine users grow up and live may perpetuate risk behaviors and stigma may further marginalize users from necessary health and recovery services. Reducing stigma and moralizing discourse related to drug use, especially among health professionals and law enforcement personnel, may help encourage users to seek necessary care. New harm-reduction-based care and treatment alternatives for marginalized drug users are being developed in parts of Brazil and elsewhere and should be adapted and expanded for other populations in need.

Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan.

Abstract: Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan. Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007–December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models. Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9–125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3–44.6) and 1.5/100 p-y (95 % CI 0.6–3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31–0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01–1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01–100.3) independently predicted HIV infection. There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

How far will they go?: assessing the travel distance of current and former drug users to access harm reduction services

Abstract: Background Prior research has explored spatial access to syringe exchange programs (SEPs) among people who inject drugs (PWID), but little is known about service utilization by former PWID who continue to access services (e.g., HIV screenings and referrals for social services) at harm reduction providers. The purpose of this research is to examine differences in access to SEPs between current and former PWID seeking services at a mobile SEP in Washington, DC.

Correlates of property crime in a cohort of recently released prisoners with a history of injecting drug use

Abstract: Injecting drug use (IDU) is a strong predictor of recidivism and re-incarceration in ex-prisoners. Although the links between drug use and crime are well documented, studies examining post-release criminal activity and re-incarceration risk among ex-prisoners with a history of IDU are limited. We aimed to explore factors associated with property crime among people with a history of IDU recently released from prison. Individuals with a history of IDU released from prison within the past month were recruited via targeted and snowball sampling methods from street drug markets and services for people who inject drugs (PWID) into a 6-month cohort study. A multivariate logistic regression analysis of baseline data identified adjusted associations with self-reported property crime soon after release. Interviews were conducted a median of 23 days post-release with 141 participants. Twenty-eight percent reported property crime in this period and 85 % had injected drugs since release. Twenty-three percent reported injecting at least daily. Reporting daily injecting (adjusted odds ratio (aOR) 4.36; 95 % confidence interval (CI) = 1.45–13.07), illicit benzodiazepine use (aOR = 2.59; 95 % CI = 1.02–5.67), being arrested (aOR = 6.12; 95 % CI = 1.83–20.45) and contact with mental health services (aOR = 4.27; 95 % CI = 1.45–12.60) since release were associated with property crime. Criminal activity soon after release was common in this sample of PWID, underscoring the need for improved pre-release, transitional and post-release drug use dependence and prevention programmes. Addressing co-occurring mental disorder and poly-pharmaceutical misuse among those with a history of IDU in prison, and during the transition to the community, may reduce property crime in this group.

Motivation for smoking cessation among drug-using smokers under methadone maintenance treatment in Vietnam.

Abstract: Smoking cessation treatment service is concerned to be a critical element in methadone maintenance treatment (MMT) in order to diminish the effect of smoke on health outcomes. To implement the smoking cessation services in Vietnam, we examined the stages of change to quit and determined associated factors among MMT patients. We conducted a cross-sectional survey with 1016 MMT patients in five clinics in Hanoi and Nam Dinh province, of those, 932 (91.7 %) were ever-smokers. Patients were classified into four groups: “pre-contemplation,” “contemplation,” “preparation,” and “action and maintenance” by using the transtheoretical model. Multivariate logistic regression was applied to determine the associated factor for intention and action to quit smoking. Overall, 96 % were not actively trying to quit or maintain abstinence. Age older than 45, HIV-positive status, and residence in Hanoi were negatively associated with intention to quit. Meanwhile, higher levels of nicotine dependence and number of years of smoking negatively associated with quitting and abstinence. The study indicated the high rate of MMT smokers being in pre-contemplation stage but low proportion of quitting and maintaining abstinence. It emphasizes the importance of availability and accessibility of information about smoking cessation therapies and services. Integrating cessation programs into health-care services should be considered to provide tailored interventions for different patient groups.

Coalition building by drug user and sex worker community-based organizations in Vietnam can lead to improved interactions with government agencies: a qualitative study.

Abstract: Drug users and female sex workers are among the groups most vulnerable to HIV infection in Vietnam. To address the HIV epidemic within these communities, former drug users and sex workers established the first community-based organizations (CBOs) in 2009. The study provides a focused assessment of CBOs’ expanding efforts to advocate for their members that identifies existing collaborations with Vietnamese government programs. This assessment explores the barriers to and facilitators of expansion in order to propose recommendations to improve the working relationship between CBOs and government programs. Thirty-two individuals from drug user and sex worker CBOs (n = 24) and relevant government programs (n = 8) participated in face-to-face interviews in Hanoi, Ho Chi Minh City, and Hai Phong. Coded interview transcripts were analyzed qualitatively concerning the purpose of CBOs, the interactions between CBOs and government programs, and the perceived barriers, facilitators, and feasibility of future CBO-government program collaborations. Services provided by the CBOs were considered to improve members’ quality of life. The formation of coalitions among CBOs increased efficiency in meeting members’ specific service needs, in addition to internal capacity building. Government field staff interacted with CBOs by providing CBOs with technical and legal support. CBOs and methadone maintenance treatment (MMT) clinics collaborated to help the clinics meet patient enrollment quotas and facilitate entry into treatment for CBO members. Barriers to CBO-government program collaboration included perceived conflicting missions on how to address drug use and sex work in the community, limited CBO-government program communication, CBO mistrust of the MMT system, and lack of legal status for CBOs. To reduce these barriers, we recommend (1) introduction of CBO consultative services at government healthcare centers, (2) enlistment of CBO outreach to ensure full access to the imminent scaled-up MMT program, and (3) establishment of standards by which CBOs can obtain legal status.