International Journal of Drug Policy - Articles in Press

Routine exposure to blood within hostel environments might help to explain elevated levels of hepatitis C amongst homeless drug users: Insights from a qualitative study - Corrected Proof

Joanne Neale, Caral Stevenson — 2012-02-06

Abstract: Background: Although homelessness is a risk factor for HCV infection, there is a lack of research exploring the relationship between living in a hostel for homeless people and blood-borne viruses. The tendency to focus on risky injecting practices and HCV has also eclipsed the transmission risks potentially posed by spilt and dried blood.Methods: Semi-structured qualitative interviews were conducted with 40 homeless drug users (HDUs) (29 men and 11 women). The aim of the study was to explore the support needs of HDUs staying in emergency hostels or night shelters, but blood emerged as an unexpected recurring topic within participants’ accounts. Accordingly, all blood data were coded and analysed inductively.Results: Participants reported that spilt and dried blood were routine features of hostel life, particularly in larger night shelters. Given that the hepatitis C virus can survive outside the human body for several weeks and even months, this poses a worrying but largely overlooked transmission risk. According to the HDUs interviewed, hostel providers were often slow to remove blood and other bodily waste, leaving residents to clean it themselves or to avoid soiled areas.Conclusions: The routine presence of blood within hostel environments might help to explain elevated levels of HCV amongst homeless drug users. However, there is a need for robust quantitative and qualitative research to systematically test and explore associations between HCV and hostel life. Recommendations are made for improving hostel cleanliness, apprising hostel staff and residents of HCV and other blood-borne virus transmission risks, and ensuring that blood and other bodily waste are deemed unacceptable features of any hostel setting.

Primary healthcare outlets that target injecting drug users: Opportunity to make services accessible and acceptable to the target group - Corrected Proof

2012-01-27

Six experts from different regions of the world commented on our original paper () and despite their different opinions and perspectives, all agree that providing anonymous, non-judgmental and free-of-charge services under a harm reduction framework can increase the accessibility and acceptability of primary healthcare (PHC) for injecting drug users (IDUs). and point out that the conventional model of healthcare will fail if we presume the needs of IDUs based on our own understandings; we must listen to and observe our clients and adapt services accordingly. Both Nasiri and Bruce recommend integrated, accessible services for IDUs, a notion supported by the literature (). Nasiri goes so far as to argue that for many IDUs, offering referrals only is akin to denying services.

Scale-up of opioid substitution therapy in India: Opportunities and challenges - Corrected Proof

M. Suresh Kumar, Alok Agrawal — 2012-01-27

The National AIDS Control Programme of India (NACO) has been delivering targeted interventions for high risk groups since 1996. Surveillance data for 2008–2009 confirms declining HIV infections amongst female sex workers but there has been an increasing trend in many states amongst injecting drug users (IDUs); the current national HIV prevalence amongst IDUs is 9.2% (). The number of IDU targeted interventions has increased from 90 by the end of 2007 to 268 in July 2011 covering approximately 142000 IDUs (80% of the estimated 177000 IDUs) with interventions such as needle syringe distribution, condom provision, HIV counselling and testing and treatment of sexually transmitted infections. A recent review of harm reduction interventions commissioned by NACO with support from the UK Department for International Development (DFID) identifies various challenges in IDU related interventions; it highlights the significance of scale-up of opioid substitution therapy (OST) for IDUs in India ().

An examination of injection drug use trends in Victoria and Vancouver, BC after the closure of Victoria's only fixed-site needle and syringe programme - Corrected Proof

2012-01-27

Abstract: Background: Needle and syringe programmes (NSPs) have been established as effective harm reduction initiatives to reduce injection drug use (IDU)-related risk behaviours, including sharing needles. On May 31, 2008, Victoria, BC's only fixed site NSP was shut down due to community and political pressure. This study examines and compares IDU trends in Victoria with those in Vancouver, BC, a city which has not experienced any similar disruption of IDU-related public health measures.Methods: Quantitative and qualitative data were collected by interviewer-administered questionnaires conducted with injection drug users (n=579) in Victoria and Vancouver between late 2007 and late 2010.Results: Needle sharing increased in Victoria from under 10% in early 2008 to 20% in late 2010, whilst rates remained relatively low in Vancouver. Participants in Victoria were significantly more likely to share needles than participants in Vancouver. Qualitative data collected in Victoria highlight the difficulty participants have experienced obtaining clean needles since the NSP closed. Recent injection of crack cocaine was independently associated with needle sharing.Conclusions: The closure of Victoria's fixed site NSP has likely resulted in increased engagement in high-risk behaviours, specifically needle sharing. Our findings highlight the contribution of NSPs as an essential public health measure.

Understanding the drug treatment community's ambivalence towards tobacco use and treatment - Corrected Proof

2012-01-27

Abstract: Background: Most clients in drug treatment smoke cigarettes, but few facilities provide treatment for tobacco dependence. We identify subjective experiences and social processes that may influence facility adoption of tobacco treatment policies and practices.Methods: Cross-sectional, semi-structured interviews were conducted with staff, directors and clients of 8 drug treatment facilities in the Midwestern U.S. We assembled a purposive sample stratified by ownership, methadone provision, and treatment service provision. We conducted in-person interviews with clinic directors and 54 staff and clients and employed a mixed-method analytic approach.Results: Facility policies and philosophy related to tobacco differed from those regarding alcohol and other drugs. Participants suggested facilities may not treat tobacco dependence because it does not create legal and social problems that force clients into treatment. Tobacco dependence treatment falls outside of a core function of drug treatment, which is to help clients fix legal problems caused by their drug use. Moreover, proactively treating clients for tobacco dependence creates strong ambivalence amongst staff and directors. On the one hand, staff smoking would violate core principles of drug treatment (i.e., the importance of staff abstinence from drugs of abuse); on the other, staff who smoke feel their personal rights and jobs are threatened. This situation creates strong incentives for staff to resist adoption of tobacco dependence treatment. Unlike other studies, the fear of jeopardising clients’ abstinence from other drugs did not emerge as a downside for treating tobacco dependence.Conclusions: International and national trends will probably increase the pressure to treat tobacco dependence during drug treatment. However, the U.S. context of drug treatment, as a patchwork, under-funded industry with high employee turnover, may undermine true adoption. At present, many facility staff resolve their ambivalence by reporting they “offer” treatment, but actually providing none. To facilitate dissemination of service provision, it may be useful to identify incentives for U.S. facilities that are closely aligned with the criminal justice system, help facilities define policies and treatment roles for staff who smoke, and better define the role of facilities in preventing morbidity and mortality.

Opioid substitution treatment in a public health setting: A collaboration between hospitals and NGOs in the Punjab - Corrected Proof

Rana Ranbir Singh, Atul Ambekar — 2012-01-10

India is facing with an urgent need to scale up opioid substitution treatment (OST) for people who inject drugs. Conventional models for scale up, via expansion of specialist OST facilities may not cover a sizeable target population. Delivering OST in a public health setting, in collaboration with non-government organizations (NGO) delivering targeted interventions has been conceptualized by the Indian National AIDS Control Organization (NACO) as a way to scale-up existing OST services in the country, which currently includes 52 OST centres having 4800 clients.

Drug policy in Vietnam: A decade of change? - Corrected Proof

Thu Vuong, Robert Ali, Simon Baldwin, Stephen Mills — 2011-12-30

Abstract: Background: Driven by the rapid spread of HIV, Vietnam's response to drug use has undergone significant transformation in the past decade. This paper seeks to identify and analyse factors that prompted these changes and to investigate their impact on the lives of people who use drugs.Method: This policy analysis is based on a review of Vietnamese Government documents, peer-reviewed publications and the authors’ knowledge of and involvement in drug policy in Vietnam.Results: The last decade has witnessed a progressive change in the mindset of political leaders in Vietnam around illicit drug use and HIV issues. This has led to adoption of evidence-based interventions and the evolution of drug policy that support the scale up of these interventions. However, HIV prevalence among drug users at 31.5% remains high due to limited access to effective interventions and impediments caused by the compulsory treatment centre system.Conclusions: The twin epidemics of HIV and illicit drug use have commanded high-level political attention in Vietnam. Significant policy changes have allowed the implementation of HIV prevention and drug dependence treatment services. Nevertheless, inconsistencies between policies and a continued commitment to compulsory treatment centres remain as major impediments to the provision of effective services to drug users. It is critical that Vietnamese government agencies recognise the social and health consequences of policy conflicts and acknowledge the relative ineffectiveness of centre-based compulsory treatment. In order to facilitate practical changes, the roles of the three ministries directly charged with HIV and illicit drug use need to be harmonised to ensure common goals. The participation of civil society in the policymaking process should also be encouraged. Finally, stronger links between local evidence, policy and practice would increase the impact on HIV prevention and drug addiction treatment programming.

Primary care is the best place to care for drug users - Corrected Proof

Chris Ford — 2011-11-21

I have worked with patients who have drug problems in primary care/general practice for over 25 years and feel it is the best place to provide services. I was therefore hopeful and excited to read this paper from its title. However, by the end of it, I felt some disappointment. Throughout myself and my GP colleagues at the Lonsdale Medical Centre, our primary care practice, have always treated the person, not the drug, providing the whole range of general medical services including HIV and hepatitis C care, needle exchange, psychological interventions and opioid substitution treatment in the same environment as all other patients. This is something that Lonsdale has championed with other primary care doctors, through the UK Substance Misuse Management in General practice (SMMGP) network (http://www.smmgp.org.uk/). So I agree with conclusions that providing ‘non-judgmental and cost-free services under a harm reduction framework can increase the accessibility and acceptability of primary healthcare for IDUs.’ But I disagree that this care should be separated out from that of other patients.

Windows of opportunity: Adapting services to the needs of people who inject drugs - Corrected Proof

Bijan Nasiri — 2011-11-18

One way to look at the issues raised by is to look at health care needs and services through the lens of people who inject drugs. If you are down to the level of basic needs and lacking minimum standard of safety and security – as many people who inject drugs are – the Maslow hierarchy of needs starts from food, clothing and shelter. If energy and body reserves are left, and depending on the availability of support services and on the knowledge and motivation of individuals, people who inject might seek HIV rapid testing or an emergency room visit for an infected injection site. Service seeking will be strongly guided by short-term need and immediate satisfaction, especially when there is no regular way of life requiring a strategic plan and goal oriented thinking. Injectors who are homeless have more constraints on their life as they lack one of the most important basic survival needs, making them prone to other problems. A history of traumatic life experiences is one of the frequent findings in routine screening. The issue of concurrent disorder is another confounding problem that makes service provision more complicated.

One stop shopping – Bringing services to drug users - Corrected Proof

R. Douglas Bruce — 2011-11-17

Drug users often come into contact with healthcare systems, but this care is episodic and not specific to the unique needs of drug users. A visit to an emergency department for an abscess or an urgent care clinic for STI screening, for example, may be the most that many drug users encounter. A failure to provide comprehensive healthcare for drug users is a failure to provide a service to a group that should be a public health, and therefore a primary care, priority. One reason for the failure to deliver needed primary care services to drug users has been the requirement that drug users access normal primary care services – services which are unlikely to be organized to meet the specific needs of drug users. In this issue of IJDP, Islam and colleagues report on several models of primary healthcare delivery to injection drug users that resulted in increased healthcare utilisation, improvements in health status and overall cost savings (). Embedded in that discussion are a few key themes on service delivery for drug users.

Clients are central to any independent and rigorous evaluation of the services they use - Corrected Proof

James Rowe — 2011-11-17

In 2005, I spent a year onsite at a newly established primary health centre (PHC), designed to meet the needs of street-based injecting drug users (IDUs) – as well as homeless individuals and sex workers attracted to the area due to the nearby street sex market and the long-established needle and syringe program (NSP) in the adjoining building. The NSP – managed by the same organisation – had served as the site for preliminary research conducted into the health care needs of those who would become the centre's clients.

Awareness of legal blood alcohol concentration limits amongst respondents of a national roadside survey for alcohol and traffic behaviours in Brazil - Corrected Proof

2011-11-17

Abstract: Background: In Brazil the legal blood alcohol content (BAC) allowed for driving was changed to zero in 2008. If the BAC found is above 0.6g/L, drivers may be arrested. However, there are limited data on drivers’ awareness of such limits.Methods: Drivers from 27 major metropolitan areas (n=3397) were randomly asked to participate in roadside survey from 12 a.m. to 12 p.m. on Fridays and Saturdays. They were breathalized by highway patrol officers, and after consent interviewers collected data on drinking behaviours, knowledge about the law, and breath tests results.Results: The mean age was 37.3±11.3 years; 94.3% were male and 26.5% had some college education. When asked about the BAC that could result in arrest, 34.5% of the subjects claimed to know it. However, only 23.5% (8.1% of the total sample) provided correct answers. Factors associated with the right answers were: male gender (p=0.04; OR=2.08; CI=1.01–4.27); higher education (p<0.0001); negative BAC or self-report of driving under the influence (DUI) (p=0.02); higher family income (p=0.01) and non-professional driving (p=0.041). Age was not statistically different between groups. After multivariate analysis, male gender (p=0.002), higher education (p<0.0001) and negative BAC or DUI (p=0.046) remained in the model.Conclusions: The knowledge that BAC levels over 0.6g/L may result in arrest is sparse amongst Brazilian drivers, notably amongst women, the less educated and those who drink and drive. Educational programmes targeted at those specific groups may be necessary in order to increase awareness about the legal BAC limit and its consequences.

Maybe not perfect—but surely good enough? - Corrected Proof

Ingrid van Beek — 2011-11-16

This paper by highlights the fact that despite there being a range of primary health care (PHC) models operating throughout the world focused on the prevention of HIV and other transmissible infections, which have apparently proven acceptable and accessible to people who inject drugs (PWID), the evidence for their effectiveness is patchy at best. This presumably renders them vulnerable when competing for scarce public health resources with other interventions for which there is such evidence. And as the authors suggest, this also potentially limits their ability to inform future health planning and be replicated in new settings.

Harm reduction, students and pleasure: An examination of student responses to a binge drinking campaign - Corrected Proof

Fiona Hutton — 2011-11-16

Abstract: Background: Recent debates about ‘binge drinking’ in New Zealand have positioned alcohol consumption amongst young drinkers as of concern. Research notes that students drink more heavily than their peers and that they have a higher incidence of alcohol related harms. In response, a harm reduction campaign aimed at first year university students was developed at a New Zealand university.Methods: This mixed methods study used questionnaires (225) and a small number of semi-structured interviews (4) to elicit student responses to the harm reduction campaign.Results: The majority of students in this study can be characterised as binge drinkers, although their drinking does not appear to cause them concern. The term ‘binge drinking’ is explored in three developed categories; ‘light’, ‘moderate’ and ‘heavy’ bingeing. Results are considered within a discussion of pleasure as a hindrance to harm reduction campaigns.Conclusions: The concept of ‘determined drunkenness’ and the notion of pleasure are important in students’ motivations for drinking and may contribute to the resistance they have in viewing their alcohol consumption as concerning. It is argued that students already felt that they exercised control over their drinking for pleasure and this produced contradictions in responses towards the campaign compared to actual behaviour.

Primary health care for people who inject drugs in low and middle income countries - Corrected Proof

Bronwyn J. Myers — 2011-10-26

Much has been written about needle and syringe programmes (NSPs), opioid substitution treatment (OST) and antiretroviral (ARV) therapies as essential components of evidence-based harm reduction initiatives for people who inject drugs (PWIDs) (see for example ). In contrast, significantly less attention has been given to the provision of primary health care (PHC) for people who inject drugs (PWIDs), even though these services may contribute to better outcomes for other harm reduction services such as OST. As PWIDs often face structural barriers to accessing conventional PHC (), PHC services targeted at PWIDs specifically have been touted as a way of overcoming these obstacles. The evidence base for these targeted services however has been limited. synthesis of the literature on PHC services targeted at PWIDs is timely and represents one of the first attempts to establish an evidence base in support of these services.

Off the street and into “the cut”: Deterrence and displacement in NYC's quality of life marijuana policing - Corrected Proof

Luther Elliott, Andrew Golub, Eloise Dunlap — 2011-10-17

Abstract: This paper examines the accounts of NYC marijuana smokers about the information and values underlying decisions about where to smoke. We do so to assess the deterrent value of NYC's “quality of life” policing of marijuana in public view. Participants indicated a general awareness of escalated marijuana policing and its attendant risks and almost universally spoke of avoiding public use in high-traffic locations and in the city's cultural and commercial centres. Beyond that, however, the deterrent value of aggressive marijuana policing appears limited. Individuals without access to private space reported outdoor marijuana use as a normalized peer group activity that has increasingly been displaced to marginal and interstitial public spaces that were collectively referred to by participants as “the cut.”

HIV prevalence amongst injecting drug users in Iran: A systematic review of studies conducted during the decade 1998–2007 - Corrected Proof

2011-10-17

Abstract: Background and objectives: Iran is a country with low HIV prevalence in the general population and concentrated prevalence amongst injecting drug users (IDUs). Various studies have been carried out on HIV prevalence amongst IDUs in Iran and diverse results have been reported. This systematic review intended to find and collect all relevant studies, assess the quality of data and provide estimations on the national prevalence over time.Methods: A broad search strategy was used, including searching international and local databases, research reports, and extensive personal contacts. All studies of IDUs conducted between 1998 and 2007 including clear description of method and HIV testing and confirmative western blot test were entered and qualitatively assessed. HIV prevalence rates were pooled for gender and stratified into several categories.Results: Twenty-two studies involving 3916 IDUs were included. Half of the studies had been conducted in Tehran. Ten studies were conducted in prisons, seven in treatment centres and five in the Drop-in-centres or communities. After 2005 the pooled HIV prevalence was 18.4% [95% Confidence Interval (CI) 16.7–20.2] significantly higher than the prevalence rate before 2005 [8.7% (95% CI 7.5–10].Conclusion: HIV prevalence amongst IDUs has increased over time and has the potential to increase exponentially. Scaling up harm reduction measures, increasing their availability and coverage, and improving the quality of services is highly recommended in order to prevent a future catastrophic epidemic.

Behavioural interventions for preventing hepatitis C infection in people who inject drugs: A global systematic review - Corrected Proof

Rachel Sacks-Davis, Danielle Horyniak, Jason Grebely, Margaret Hellard — 2011-10-14

Abstract: Background: A systematic review was conducted to determine whether behavioural interventions are effective in preventing transmission of hepatitis C virus (HCV) amongst people who inject drugs.Methods: Medline, EMBASE, the Cochrane Clinical Trial Database, PSYCHINFO and hand-searching of bibliographies were used to identify controlled trials of behavioural interventions for reducing HCV transmission amongst people who inject drugs. Behavioural interventions were defined as non-pharmacological interventions that aimed to change individual behaviours without explicitly attempting to change population norms.Results: Six trials evaluating peer-education training and counselling interventions were included in the review. There was considerable variation between trials with respect to intervention duration, control and study population. Trials evaluated the impact of interventions on HCV incidence (three studies, 1041 participants) and frequency of injecting risk behaviours (six studies, 2472 participants). Amongst the three studies which measured the impact of the intervention on HCV incidence, none found a statistically significant difference between intervention and control groups. Measures of frequency of injecting risk behaviours varied greatly and could not be pooled. Only two studies (n=418, 854) showed significantly greater reductions in injecting risk behaviours in the intervention group compared with the control group.Conclusions: There was considerable variation in study design, outcome measures and magnitude, direction and statistical significance of findings between studies. Nonetheless, it is unlikely that behavioural interventions can have a considerable effect on HCV transmission. It is likely that multi-component interventions are required.

Transition to injection amongst opioid users in Iran: Implications for harm reduction - Corrected Proof

Mohsen Malekinejad, Mohsen Vazirian — 2011-10-14

Abstract: Driven by opioid use, HIV prevalence is high (15–27%) amongst injection drug users (IDU) in Iran. Harm reduction programmes are associated with a reduction in high risk injecting behaviours; however, Iran has a large number of non-injecting opioid users not immediately targeted by harm reduction programmes. The vast majority of heroin injectors tend to have a history of several years of smoking opium or heroin before transitioning to injection, and a small fraction may even start their drug career by injection of opioids, behaviours that can undermine the effectiveness of the harm reduction programmes. In this study, we have reviewed evidence on the HIV epidemic, extent and pattern of opioid use, and correlates of the transition to injection in Iran. We have concluded that harm reduction policies should also emphasize prevention of the transition to injection amongst high-risk non-injecting opioid users as an additional strategy against the spread of HIV infection in Iran.

The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature - Corrected Proof

2011-10-13

Abstract: Background: Injecting drug users (IDUs) are at increased risk of health problems ranging from injecting-related injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed. However, there is insufficient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature of study designs. Nevertheless, an integrative literature review of IDU-targeted PHC may provide useful insights into the range of operational models and strategies to enhance the accessibility and acceptability of these services to the target population.Methods: Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced from relevant journal publications, grey literature and policy documents.Results: Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall healthcare utilisation and health status of this population with consequent savings to the health system due to a reduction in visits to emergency departments and tertiary hospitals.Conclusions: Although such findings are promising, there remains a dearth of rigorous evaluations of these targeted PHC, with the public health impact of such outlets yet to be systematically documented.

Street-level policing in the Downtown Eastside of Vancouver, Canada, during the 2010 winter Olympics - Corrected Proof

Will Small, Andrea Krusi, Evan Wood, Julio Montaner, Thomas Kerr — 2011-09-01

Abstract: Background: Police presence within street-based drug scenes has the potential to disrupt injection drug users’ (IDUs) access to health services and prompt increased injection-related risk behaviour. We examined street-level policing in the Downtown Eastside (DTES) of Vancouver during the Olympic Winter games, to assess the potential impact on access to harm reduction services and injection-related risk behaviour.Methods: We analysed data from observational activities documenting police and drug user behaviour, unstructured interviews with drug users in street settings (n=15), expert interviews with legal and health professionals (n=6), as well as utilisation statistics from a local supervised injection facility (SIF).Results: Although police presence was elevated within the DTES during the Olympics, there was little evidence to suggest that police activities influenced IDUs’ access to health services or injection-related risk behaviour. SIF attendance during the Olympics was consistent with regular monthly patterns.Conclusion: Police presence during the Olympics did not reduce access to health services amongst local IDUs or prompt increased injection-related risk behaviour. Increased cooperation between local law enforcement and public health bodies likely offset the potential for negative health consequences resulting from police activity.

Ayahuasca and the process of regulation in Brazil and internationally: Implications and challenges - Corrected Proof

Beatriz Caiuby Labate, Kevin Feeney — 2011-08-19

Abstract: Background: This paper provides a summary and analysis of the regulation of ayahuasca in Brazil, from its prohibition in the mid-eighties to the recent adoption of CONAD's (Conselho Nacional de Políticas sobre Drogas) 2010 Resolution, which established a set of rules, norms and ethical principles to be applied to religious and ritual uses of ayahuasca. Brazil's regulatory process is used as a starting point to explore emerging international regulatory themes as various nations respond to the global expansion of the Santo Daime and UDV (União do Vegetal) ayahuasca religions.Methods: The text reviews the primary legislative and court documents, academic literature, as well as solicited expert opinions.Results: Three prominent themes have emerged internationally. The first concerns the scope of international treaties regarding plant-based psychoactive substances, as well as the responsibilities of individual nations to adhere to said treaties. The second concerns the scope of religious liberty and how to determine religious legitimacy. The final theme addresses the potential dangers of ayahuasca to health and public safety.Conclusion: Over the past 20 years the Brazilian ayahuasca religions have established a global presence, with congregations in the USA, Canada, Japan, South Africa, Australia, and throughout Europe and Latin America. As a result, many nations are faced with the predicament of balancing the interests of these religious minorities with the international “war on drugs.” The regulatory process applied in Brazil exemplifies a progressive approach, one which considered issues of anthropology and involved representatives of ayahuasca religions, and which provided a degree of deference to the principle of religious liberty. The Brazilian process has influenced judicial and administrative decisions internationally, and stands as a model worthy of further consideration.

Short-term safety of buprenorphine/naloxone in HIV-seronegative opioid-dependent Chinese and Thai drug injectors enrolled in HIV Prevention Trials Network 058 - Corrected Proof

2011-08-18

Abstract: Background: Buprenorphine/naloxone (BUP/NX) is not licenced for use in China or Thailand and there was little clinical experience with this drug combination in these countries at the inception of HIV Prevention Trial Network (HPTN) 058, a randomized trial comparing risk reduction counselling combined with either short-term or long-term medication assisted treatment with BUP/NX to prevent HIV infection and death amongst opioid-dependent injectors.Methods: We conducted a safety phase that included the first 50 subjects enrolled at each of the three initial study sites (N=150). Clinical and laboratory assessments were conducted at baseline and weekly for the first 4 weeks. Changes in laboratory parameters were estimated with random effects models.Results: BUP/NX was well tolerated by study subjects and opioid withdrawal scores decreased substantially during the 3-day induction. Two participants experienced grade 3 clinical adverse events, which were categorized as probably not related to the study drug. Grade 2 or 3 increases in alanine aminotransferase (ALT) occurred in 25 (17%) subjects. The magnitude of ALT increase over 4-week follow-up was strongly associated with baseline ALT elevation.Conclusions: In Chinese and Thai opioid-dependent injectors, we found BUP/NX to be effective in reducing opioid withdrawal symptoms and safe during short-term use. ALT increases were observed over 4-week-follow-up, which are consistent with reports from Western populations. Long-term safety and efficacy evaluations are indicated.

Where harm reduction meets housing first: Exploring alcohol's role in a project-based housing first setting - Corrected Proof

2011-08-18

Abstract: Background: Housing first (HF) programmes provide low-barrier, nonabstinence-based, immediate, supportive and permanent housing to chronically homeless people who often have co-occurring substance-use and/or psychiatric disorders. Project-based HF programmes offer housing in the form of individual units within a larger housing project. Recent studies conducted at a specific project-based HF programme that serves chronically homeless individuals with alcohol problems found housing provision was associated with reduced publicly funded service utilisation, decreased alcohol use, and sizable cost offsets. No studies to date, however, have qualitatively explored the role of alcohol use in the lives of residents in project-based HF.Methods: We collected data in a project-based HF setting via naturalistic observation of verbal exchanges between staff and residents, field notes taken during staff rounds, and audio recorded staff focus groups and resident interview sessions. Qualitative data were managed and coded using a constant comparative process consistent with grounded theory methodology. The goal of the analysis was to generate a conceptual/thematic description of alcohol's role in residents’ lives.Results: Findings suggest it is important to take into account residents’ motivations for alcohol use, which may include perceived positive and negative consequences. Further, a harm reduction approach was reported to facilitate housing attainment and maintenance. Residents and staff reported that traditional, abstinence-based approaches are neither desirable nor effective for this specific population. Finally, elements of the moral model of alcohol dependence continue to pervade both residents’ views of themselves and the community's perceptions of them.Conclusions: Findings suggest it is necessary to set aside traditional models of alcohol use and approaches to better understand, align with, and address this population's needs. In doing so, we might gain further insights into how to enhance the existing project-based HF approach by applying more tailored, alcohol-specific, harm reduction interventions.

Impact of a transient instability of the ecstasy market on health concerns and drug use patterns in The Netherlands - Corrected Proof

Tibor M. Brunt, Raymond J.M. Niesink, Wim van den Brink — 2011-07-11

Abstract: Background: A recent decline in MDMA-like substances in ecstasy tablets has been reported by a number of countries in the European Union. This study describes the instability of the ecstasy market in The Netherlands during 2008 and 2009, and investigates whether this had any impact on drug testing or patterns of drug use.Methods: The health concerns of drug users handing in drug samples at drug testing facilities was measured using intervention time-series analysis. In addition, these ecstasy users were asked about changes in their drug use.Results: Nationally, the unstable market situation for ecstasy has increased the number of users handing in ecstasy tablets for testing because of health concern. There was no change in the number of users handing in cocaine or gamma hydroxybutyrate (GHB). Respondents reported no major changes in their drug use resulting from the shortage of MDMA-like substances.Conclusions: These findings provide further insight in drug policy based on both harm reduction and use reduction. In the event of reduced ecstasy quality, ecstasy users in The Netherlands have increasingly used drug testing as a potential harm reduction tool, rather than changing their patterns of drug use. This might indicate that a transient reduction of drug quality does not serve as a good drug use reduction strategy for ecstasy users.

Are drug detection dogs and mass-media campaigns likely to be effective policy responses to psychostimulant use and related harm? Results from an agent-based simulation model - Corrected Proof

2011-07-11

Abstract: Background: Agent-based simulation models can be used to explore the impact of policy and practice on drug use and related consequences. In a linked paper (), we described SimAmph, an agent-based simulation model for exploring the use of psychostimulants and related harm amongst young Australians.Methods: In this paper, we use the model to simulate the impact of two policy scenarios on engagement in drug use and experience of drug-related harm: (i) the use of passive-alert detection (PAD) dogs by police at public venues and (ii) the introduction of a mass-media drug prevention campaign.Results: The findings of the first simulation suggest that only very high rates of detection by PAD dogs reduce the intensity of drug use, and that this decrease is driven mainly by a four-fold increase in negative health consequences as detection rates rise. In the second simulation, our modelling showed that the mass-media prevention campaign had little effect on the behaviour and experience of heavier drug users. However, it led to reductions in the prevalence of health-related conditions amongst moderate drug users and prevented them from becoming heavier users.Conclusion: Agent-based modelling has great potential as a tool for exploring the reciprocal relationships between environments and individuals, and for highlighting how intended changes in one domain of a system may produce unintended consequences in other domains. The exploration of these linkages is important in an environment as complex as the drug policy and intervention arena.

Heroin users’ views and experiences of physical activity, sport and exercise - Corrected Proof

Joanne Neale, Sarah Nettleton, Lucy Pickering — 2011-07-11

Abstract: Background: Although there is limited research on heroin users’ participation in physical activity, sport and exercise, public health literature asserts that being physically active is good for individuals. Critics, however, caution that the benefits of sport and exercise are overstated and sport may itself reinforce or create inequalities.Methods: In-depth interviews were conducted with 40 current or ex-heroin users, of whom 37 were re-interviewed three months later. Data from all 77 interviews were analysed to explore individuals’ self-reported participation in physical activity, sport and exercise; their desire to participate; and any barriers to participation experienced.Findings: Participants were very interested in sport and exercise and engaged in a wide variety of active pastimes. Although they did little structured sport or exercise during periods of heavy heroin use, they still often walked or cycled. Enjoyment was a key feature of being physically active in treatment and in early recovery. Additionally, individuals reported diverse health and social gains and felt that sport and exercise helped them to reduce their heroin use. These benefits notwithstanding, there were personal, social and structural barriers to being active and so individuals were generally keen to take advantage of any sport or exercise opportunities offered to them by services.Conclusions: By focusing on the meanings that heroin users themselves attribute to being active, our analyses reveal that members of this population derive great pleasure from all manner of physical pastimes. A small but growing literature on embodied sporting practices helps us to interpret this. We conclude that there is an important role for physical activity, sport and exercise within policy and practice responses to heroin use, but with a need to be creative and flexible regarding the kinds of activities promoted.