International Journal of Drug Policy - Articles in Press

Improving the data to strengthen the global response to HIV among people who inject drugs - Corrected Proof

Bradley Mathers, Catherine Cook, Louisa Degenhardt — 2010-02-08

Abstract: Recent systematic reviews have provided a global picture of injecting drug use, HIV and the global response to HIV epidemics among people who inject drugs. They have also revealed significant gaps in our knowledge, in both the problem and the response. It is clear that the prevalence of injecting drug use, and of HIV among injecting populations, varies geographically, differing hugely both within and across countries. In many cases, however, data on the number of drug injectors, and of the proportion who are living with HIV, is often unavailable or inaccurate, and gaps exist in many low income countries. The response to injecting drug use and HIV also varies hugely; both the nature and the scale of the response show marked geographic variation. The lack of quality data acts as an impediment to accurate assessments of effective and targeted responses to HIV among people who inject drugs. It is encouraging that the comprehensive suite of interventions considered “essential” by UN agencies in the response to HIV among people that inject drugs is being introduced in more countries now than ever before. Nonetheless, there remains an urgent need for more and higher quality data to be collected, in order to sufficiently inform, improve and ultimately evaluate the response.

Longitudinal trajectories of ketamine use among young injection drug users - Corrected Proof

Stephen E. Lankenau, Jennifer Jackson Bloom, Charles Shin — 2010-02-08

Abstract: Background: Ketamine is a dissociative anaesthetic that became increasingly popular in the club and rave scene in the 1980s and 1990s. Reports surfaced in the late 1990s indicating that ketamine was being injected in several U.S. cities by young injection drug users (IDUs). Since all studies on ketamine injection were cross-sectional, a longitudinal study was undertaken in 2005 to determine: characteristics of young IDUs who continue to inject ketamine; frequency of ketamine injection over an extended time period; risks associated with ongoing ketamine injection; and environmental factors that impact patterns of ketamine use.Methods: Young IDUs aged 16–29 with a history of injecting ketamine (n=101) were recruited from public locations in Los Angeles and followed during a 2-year longitudinal study. A semi-structured instrument captured quantitative and qualitative data on patterns of ketamine injection and other drug use. A statistical model sorted IDUs who completed three or more interviews (n=66) into three groups based upon patterns of ketamine injection at baseline and follow-up. Qualitative analysis focused on detailed case studies within each group.Results: IDUs recruited at baseline were typically in their early 20s, male, heterosexual, white, and homeless. Longitudinal injection trajectories included: “Moderates,” who injected ketamine several times per year (n=5); “Occasionals,” who injected ketamine approximately once per year (n=21); and “Abstainers,” who did not inject any ketamine during follow-up (n=40). Findings suggest that ketamine is infrequently injected compared to other drugs such as heroin, cocaine, and methamphetamine. Most IDUs who begin injecting ketamine will stop or curb use due to: negative or ambivalent experiences associated with ketamine; an inability to find the drug due to declining supply; or maturing out of injecting drugs more generally.Conclusion: Reducing ketamine injection among young IDUs may best be accomplished by targeting particular groups of IDUs identified in this study, such as homeless youth and homeless travellers.

In rehabilitation's name? Ending institutionalised cruelty and degrading treatment of people who use drugs - Corrected Proof

Daniel Wolfe, Roxanne Saucier — 2010-02-08

The UN's World Drug Day on June 26th is also the UN International Day in Support of Victims of Torture. While coincidental, the conjunction is unfortunately apt. Across the world, whether the result of police apprehension, diversion to treatment as an alternative to incarceration, or involuntary commitment under health statutes or at the request of family members, people who use drugs are subjected to cruel, inhuman, or degrading practices, many of which rise to the level of torture. These breaches of international law are often conducted in the name of law enforcement or in facilities run by police or military personnel; this highlights the difficulty, and importance, of protecting the rights of criminalised groups in state custody, of whom drug users are almost always the most numerous. Because the so-called health services are so often abusive detention by another name, honest examination of what has been allowed to pass as drug treatment requires that we challenge the notion of “treatment failure,” examining treatment systems more closely rather than unreflectively attributing blame to the individuals within them.

Meth/amphetamine use and associated HIV: Implications for global policy and public health - Corrected Proof

2010-02-01

Abstract: Amphetamine type stimulants (ATS) have become the focus of increasing attention worldwide. There are understandable concerns over potential harms including the transmission of HIV. However, there have been no previous global reviews of the extent to which these drugs are injected or levels of HIV among users. A comprehensive search of the international peer-reviewed and grey literature was undertaken. Multiple electronic databases were searched and documents and datasets were provided by UN agencies and key experts from around the world in response to requests for information on the epidemiology of use. Amphetamine or methamphetamine (meth/amphetamine, M/A) use was documented in 110 countries, and injection in 60 of those. Use may be more prevalent in East and South East Asia, North America, South Africa, New Zealand, Australia and a number of European countries. In countries where the crystalline form is available, evidence suggests users are more likely to smoke or inject the drug; in such countries, higher levels of dependence may be occurring. Equivocal evidence exists as to whether people who inject M/A are at differing risk of HIV infection than other drug injectors; few countries document HIV prevalence/incidence among M/A injectors. High risk sexual behaviour among M/A users may contribute to increased risk of HIV infection, but available evidence is not sufficient to determine if the association is causal. A range of possible responses to M/A use and harm are discussed, ranging from supply and precursor control, to demand and harm reduction. Evidence suggests that complex issues surround M/A, requiring novel and sophisticated approaches, which have not yet been met with sufficient investment of time or resources to address them. Significant levels of M/A in many countries require a response to reduce harms that in many cases remain poorly understood. More active models of engagement with M/A users and provision of services that meet their specific needs are required.

Women's health and use of crack cocaine in context: Structural and ‘everyday’ violence - Corrected Proof

Vicky Bungay, Joy L. Johnson, Colleen Varcoe, Susan Boyd — 2010-02-01

Abstract: Background: There is increasing public health evidence that women who use crack cocaine and are street-involved experience significant health problems and are more isolated with regards to accessing harm reduction and other health-related services. Simultaneously, there is growing acknowledgement that structural and ‘everyday’ violence are significant factors influencing the health of women who use illegal drugs. Little research has examined how these social processes play out for women who use crack cocaine.Methods: A critical ethnography informed by the theoretical constructs of structural and everyday violence and intersectionality was undertaken to explore women's use of crack cocaine within an inner-city neighbourhood in Western Canada. Data collection included baseline survey (n=126), participant observation and field notes, informal interviews (n=53), and in-depth interviews (n=13).Results: Based on thematic and theoretical analysis two interrelated themes were identified that reflected the interrelationships between women's use of crack, poverty, discrimination, racism, gendered relations of power, and legal policies and practices: (a) the context of health care; and (b) the smoking context.Conclusions: Structural inequities and ‘everyday’ violence are perilously damaging for women who use crack. Interventions to reduce these inequities are urgently needed if we are to reduce the significant suffering of women who are street-involved and use crack cocaine.

Local politics and retail cannabis markets: The case of the Dutch coffeeshops - Corrected Proof

Marije Wouters, Annemieke Benschop, Dirk J. Korf — 2010-02-01

Abstract: Background: Cannabis coffeeshops are concentrated in specific areas in the Netherlands; close to 80% of Dutch municipalities have no coffeeshops. We investigated why such wide local differences exist.Methods: Regression analyses were carried out on data regarding the number of coffeeshops per municipality, local council seat distribution and area demographic characteristics. A contrast analysis of municipalities with no/few vs. many coffeeshops was also performed.Results: Whether a town has one or more coffeeshops can be predicted in part by its population size, but more strongly by political composition of the local council. The larger the percentage of progressive councillors, the greater the probability that coffeeshops are allowed. The number of coffeeshops in a town depends primarily on the demand for cannabis (reflected in factors like local population size); it generally has little to do with national-level party political preferences about drug policy.Conclusion: Both the demand for coffeeshops and local political preference influence coffeeshop policy in the Netherlands.

Security, development and human rights: Normative, legal and policy challenges for the international drug control system - Corrected Proof

Damon Barrett — 2010-02-01

Abstract: This commentary addresses some of the challenges posed by the broader normative, legal and policy framework of the United Nations for the international drug control system. The ‘purposes and principles’ of the United Nations are presented and set against the threat based rhetoric of the drug control system and the negative consequences of that system. Some of the challenges posed by human rights law and norms to the international drug control system are also described, and the need for an impact assessment of the current system alongside alternative policy options is highlighted as a necessary consequence of these analyses.

Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales - Corrected Proof

Elizabeth C. Costenbader, William A. Zule, Curtis C. Coomes — 2010-01-25

Abstract: Background: Injecting drug users (IDUs) are at increased risk of acquiring and transmitting HIV and other bloodborne pathogens through the multi-person use of syringes. Although research has shown that increased access to syringes through syringe exchange programs (SEPs) is an effective strategy to reduce risky injection practices many areas of the United States still do not have SEPs. In the absence of SEPs, legislation allowing pharmacies over-the-counter sales of syringes has also been shown to reduce syringe sharing. The success of pharmacy sales however is limited by other legal stipulations, such as drug paraphernalia laws, which in turn may contribute to fear among IDUs about being caught purchasing and carrying syringes.Methods: Between 2003 and 2006, 851 out-of-treatment IDUs were recruited using street outreach in the Raleigh-Durham (North Carolina) area. Data were collected using audio-computer assisted interview (ACASI) technology. Multiple logistic regression analyses were performed to assess factors associated with purchasing syringes from pharmacies.Results: In our study sample, African-American IDUs were one-fifth as likely as white IDUs to report pharmacies as their primary source of syringes.Conclusions: Given the absence of syringe exchange programs and the relatively high prevalence of HCV and HIV among IDUs in the Raleigh-Durham area, the limited use of pharmacies as a source of syringes among African-American IDUs in this study sample is problematic. The study findings support the need for effective multilevel interventions to increase access to clean needles in this population, as well as for policy interventions, such as legalization of SEPs and elimination of penalties for carrying syringes, to reduce harm and eliminate the health threats posed by receptive syringe sharing.

The informal use of ketum (Mitragyna speciosa) for opioid withdrawal in the northern states of peninsular Malaysia and implications for drug substitution therapy - Corrected Proof

Balasingam Vicknasingam, Suresh Narayanan, Goh Teik Beng, Sharif Mahsufi Mansor — 2010-01-21

Abstract: Background: Ketum (krathom) has been mentioned in the literature as a traditional alternative to manage drug withdrawal symptoms though there are no studies indicating its widespread use for this purpose. This study examines the reasons for ketum consumption in the northern areas of peninsular Malaysia where it is widely used.Methods: A cross-sectional survey of 136 active users was conducted in the northern states of Kedah and Penang in Malaysia. On-site urine screening was done for other substance use.Findings: Ketum users were relatively older (mean 38.7 years) than the larger substance using group. Nearly 77% (104 subjects) had previous drug use history, whilst urine screening confirmed 62 subjects were also using other substances. Longer-term users (use >2 years) had higher odds of being married, of consuming more than the average three glasses of ketum a day and reporting better appetite. Short-term users had higher odds of having ever used heroin, testing positive for heroin and of using ketum to reduce addiction to other drugs. Both groups used ketum to reduce their intake of more expensive opiates, to manage withdrawal symptoms and because it was cheaper than heroin. These findings differ from those in neighbouring Thailand where ketum was used primarily to increase physical endurance.Conclusions: No previous study has shown the use of ketum to manage opioid withdrawal symptoms except for a single case reported in the US. Ketum was described as affordable, easily available and having no serious side effects despite prolonged use. It also permitted self-treatment that avoids stigmatisation as a drug dependent. The claims of so many subjects on the benefits of ketum merits serious scientific investigation. If prolonged use is safe, the potential for widening the scope and reach of substitution therapy and lowering its cost are tremendous, particularly in developing countries.

Harm reduction healthcare: From an alternative to the mainstream platform? - Corrected Proof

M. Mofizul Islam, Carolyn A. Day, Katherine M. Conigrave — 2010-01-21

Abstract: Despite a plethora of health-related problems, access to primary healthcare is often limited for drug users (DUs). Many seek care at emergency departments and tertiary hospitals because of late presentation of illness. The costs to both DUs and the health system are such that harm reduction based healthcare centres (HRHCs) have been established in various settings and utilising a variety of models. These provide a range of medical and sometimes social services, in one, integrated, low-threshold facility, including (or closely linked with) programs such as needle syringe provision. In some countries these HRHCs are becoming an alternative healthcare system for DUs. However, the need to provide such services on a broad, public health scale, in a sustainable, cost-effective manner, raises the question as to whether such programmes should be mainstreamed. This commentary provides insights on advantages and disadvantages to mainstreaming HRHCs, and approaches and barriers to achieving this. Two approaches suggest themselves: (i) providing harm reduction services through the regular healthcare system, or (ii) more closely integrating HRHCs with mainstream services. Funding and stigma are major barriers to mainstreaming. Diverse national policies towards DUs, healthcare systems and contexts, necessitate different approaches. Because of the various barriers to mainstreaming, any steps towards mainstreaming should be taken whilst maintaining the option of continuing the current targeted harm reduction services.

Retail price as an outcome measure for the effectiveness of drug law enforcement - Corrected Proof

David A. Bright, Alison Ritter — 2010-01-18

Abstract: One outcome measure of law enforcement effectiveness is the reduction in drug consumption which occurs as a result of law enforcement interventions. A theoretical relationship between drug consumption and retail price has promoted the use of retail price as a surrogate measure for consumption. In the current article, retail price is examined as a potential outcome measure for the effectiveness of law enforcement.The predictions regarding the relationship between law enforcement intensity and price are only partially supported by research. Explanations for the disconnect between the drug law enforcement activity and retail price include: rapid adaptation by market players, enforcement swamping, assumptions of rational actors, short-run versus long-run effects, structure of the illicit market, simultaneous changes that affect price in perverse ways, the role of violence in markets, and data limitations. Researchers who use retail price as an outcome measure need to take into account the complex relationship between drug law enforcement interventions and the retail price of illicit drugs. Viable outcome measures which can be used as complements to retail price are worth investigation.

Drug use and the risk of HIV infection amongst injection drug users participating in an HIV vaccine trial in Bangkok, 1999–2003 - Corrected Proof

2010-01-15

Abstract: Background: HIV spread rapidly amongst injecting drug users (IDUs) in Bangkok in the late 1980s. In recent years, changes in the drugs injected by IDUs have been observed. We examined data from an HIV vaccine trial conducted amongst IDUs in Bangkok during 1999–2003 to describe drug injection practices, drugs injected, and determine if drug use choices altered the risk of incident HIV infection.Methods: The AIDSVAX B/E HIV vaccine trial was a randomized, double-blind, placebo-controlled trial. At enrolment and every 6 months thereafter, HIV status and risk behaviour were assessed. A proportional hazards model was used to evaluate demographic characteristics, incarceration, drug injection practices, sexual activity, and drugs injected during follow-up as independent predictors of HIV infection.Results: The proportion of participants injecting drugs, sharing needles, and injecting daily declined from baseline to month 36. Amongst participants who injected, the proportion injecting heroin declined (98.6–91.9%), whilst the proportions injecting methamphetamine (16.2–19.6%) and midazolam (9.9–31.9%) increased. HIV incidence was highest amongst participants injecting methamphetamine, 7.1 (95% CI, 5.4–9.2) per 100 person years. Injecting heroin and injecting methamphetamine were independently associated with incident HIV infection.Conclusions: Amongst AIDSVAX B/E vaccine trial participants who injected drugs during follow-up, the proportion injecting heroin declined whilst the proportion injecting methamphetamine, midazolam, or combinations of these drugs increased. Controlling for heroin use and other risk factors, participants injecting methamphetamine were more likely to become HIV-infected than participants not injecting methamphetamine. Additional HIV prevention tools are urgently needed including tools that address methamphetamine use.

Moving from a project to programmatic response: Scaling up harm reduction in Asia - Corrected Proof

Anindya Chatterjee, Mukta Sharma — 2010-01-15

Abstract: The response to the HIV epidemics among people who inject drugs in Asia began to emerge in the early to mid 1990s, with the rather hesitant implementation of small-scale needle syringe programmes and community care initiatives aiming to support those who were already living with the virus. Since then Asia has seen a significant scaling up of harm reduction, despite very limited resources and difficult policy and legislative environments. One of the major reasons this has happened, is the utilisation of programme based approaches and the firm entrenchment of harm reduction thinking within national HIV/AIDS programmes and strategic plans—in most cases aided by multilateral and bilateral donors. Several models of scale up have been noted in Asia. The transition away from project based approaches, while on the whole positive, can also have a negative impact if the involvement of civil society and a client focussed approach is not protected. Also there are implications for which models of capacity building can be systematised for ongoing scale up. Most crucially, the tensions between drug policy, human rights and public health policies need to be resolved if harm reduction services are to be made available to the millions in Asia who are still unable to access these services.

Drug testing in sport: The attitudes and experiences of elite athletes - Corrected Proof

Matthew Dunn, Johanna O. Thomas, Wendy Swift, Lucinda Burns, Richard P. Mattick — 2010-01-15

Abstract: Background: This study aimed to investigate, among a sample of elite Australian athletes, the extent to which this group supports drug testing as a deterrent to drug use.Method: Data was collected from a convenience sample of (n=974) elite Australian athletes who self-completed a questionnaire, and semi-structured telephone surveys with key experts.Results: The athletes surveyed endorsed testing for banned substances as an effective way of deterring drug use; believed that the current punishments for being caught using a banned substance was of the appropriate severity; and indicated that there should be separate policies regarding illicit drug (ID) and performance-enhancing drug (PED) use.Conclusion: A large proportion of elite athletes in Australia endorse drug testing as an effective means of deterring drug use. They perceive a difference between being detected using a PED and an ID and believe that penalties should reflect this difference. Future research may wish to investigate attitudes towards newer methods employed to detection drug use.

Clean Olympians? Doping and anti-doping: The views of talented young British athletes - Corrected Proof

Andrew Bloodworth, Michael McNamee — 2010-01-07

Abstract: Background: Review articles suggest a small but significant proportion (between 3 and 12%) of male adolescents have used anabolic-androgenic steroids (AAS) at some point (Yesalis and Bahrke, 2000; Calfee and Fadale, 2006). In sport, the use of prohibited substances or processes to enhance performance, collectively referred to as ‘doping’, is banned by both sports’ National and International Governing Bodies, and by the World Anti-Doping Agency (WADA) who run an extensive testing programme and educational initiatives designed to foster anti-doping attitudes.Method: A total of 40 talented male and female athletes (mean average age 19.6 years) from 13 different sports attended 12 focus groups held over the UK intended to investigate athletes’ attitudes toward doping. Focus group transcriptions were analysed and coded with the use of QSR NVivo 8.Results: Athletes in general did not report a significant national doping problem in their sport, but exhibited sporting xenophobia with regard to both doping practices and the stringency of testing procedures outside of the UK. Athletes often viewed doping as ‘unnatural’ and considered the shame associated with doping to be a significant deterrent. Athletes perceived no external pressure to use performance enhancing drugs. In response to hypothetical questions, however, various factors were acknowledged as potential ‘pressure’ points: most notably injury recovery and the economic pressures of elite sport. Finally, a significant minority of athletes entertained the possibility of taking a banned hypothetical performance enhancing drug under conditions of guaranteed success and undetectability.Conclusions: The athletes in this study generally embraced those values promoted in anti-doping educational programmes, although there were some notable exceptions. That the social emotion of shame was considered a significant deterrent suggests anti-doping efforts that cultivate a shared sense of responsibility to remain ‘clean’ and emphasise the social sanctions associated with being deemed a ‘drugs cheat’, resonate with this atypical social group.

Young people and drugs: Next generation of harm reduction - Corrected Proof

Simona Merkinaite, Jean Paul Grund, Allen Frimpong — 2009-12-28

Abstract: Globally, young people under 25 accounted for an estimated 45% of all new HIV infections in 2007. Across the Eastern Europe and Central Asia region as many as 25% of injecting drug users (IDUs) are younger than 20. The Eurasian Harm Reduction assessment of young peoples’ (under 25) drug use, risk behaviours and service availability and accessibility confirms, young people at risk of injecting, or those already experimenting with injecting drugs, find themselves isolated from health and prevention services, which increases the risks for health and social harms, while the approach towards young peoples’ use rely heavily on law enforcement. Denying young drug users’ access to life-saving drug treatment and other harm reduction services contributes to the risk environment surrounding their use and violates their right to health and well-being as identified in the Convention on the Rights of the Child. Governments, health care providers and harm reduction services should work together to create an environment in which young people can access needed services, including non-judgmental and low-threshold approaches offered by harm reduction programs.

Opportunities for enhancing and integrating HIV and drug services for drug using vulnerable populations in South Africa - Corrected Proof

Charles D.H. Parry, Petal Petersen, Tara Carney, Richard Needle — 2009-12-28

Abstract: Background: Little has been done to improve the integration of drug use and HIV services in sub-Saharan Africa where substance use and HIV epidemics often co-exist.Methods: Data were collected using rapid assessment methods in two phases in Cape Town, Durban and Pretoria, South Africa. Phase I (2005) comprised 140 key informant and focus group drug using interviewees and 19 service providers (SPs), and Phase 2 (2007) comprised 69 drug using focus group interviewees and 11 SPs.Results: Drug users put themselves at risk for HIV transmission through various drug-related sexual practices as well as through needle sharing. Drug users in both phases had limited knowledge of the availability of drug treatment services, and those that had accessed treatment identified a number of barriers, including affordability, stigma and a lack of aftercare and reintegration services. SPs identified similar barriers. Drug users displayed a general awareness of both HIV transmission routes and prevention strategies, but the findings also indicated a number of misperceptions, and problematic access to materials such as condoms and safe injection equipment. Knowledge around HIV treatment was low, and VCT experiences were mixed. SPs recognized the importance of integrating HIV and substance use services, but barriers such as funding issues, networking/referral gaps and additional burden on staff were reported in Phase 2.Conclusion: A comprehensive, accessible, multi-component intervention strategy to prevent HIV risk in drug users needs to be developed including community outreach, risk reduction counselling, VCT and substance use treatment.

Normalization and harm reduction: Research avenues and policy agendas - Corrected Proof

Patricia G. Erickson, Andrew D. Hathaway — 2009-12-18

Abstract: An affinity between the evidence and arguments for drug normalization and the policy and programme directions favoured by harm reduction is often assumed but seldom critically examined. This commentary looks at parallels and contradictions emerging with respect to different cultures, social settings, types of problems and responses where the match is less than perfect. Mounting evidence of normalization has also led to backlash in some countries and the mobilization of forces reaffirming prohibition. We call for further research on normalization that focuses on substance use, risks, harms, and social context across a broader spectrum of the population, and in a variety of cultures. By emphasizing the most serious harms experienced by persons in the smallest segments of drug using populations, harm reduction often has neglected broader research and policy suggestions that might be implemented to benefit controlled, recreational drug users. Future policy development with respect to normalization will require more research and more serious discussion of its implications for informing the transition toward a global public health approach to substance use.

Learning from HIV epidemics among injecting drug users - Corrected Proof

Don C. Des Jarlais — 2009-12-17

Abstract: HIV/AIDS was the defining issue for international harm reduction during its first twenty years. This issue was marked by strong contrasts: rapid HIV transmission in some populations of injecting drug users, and close to elimination of HIV in other populations; a formidable research base for designing effective HIV programmes and persistent political problems in implementing evidence-based programmes on a public health scale. Elevated rates of HIV infection among ethnic minority drug users have occurred in many different countries. We do not yet have systematic knowledge of how to reduce stigmatization of AIDS or people who use drugs. Nevertheless, international harm reduction for people who use drugs has moved beyond HIV/AIDS to a variety of other health and social problems, while retaining firm bases in science and human rights.

Illicit drugs policy through the lens of regulation - Corrected Proof

Alison Ritter — 2009-12-14

Abstract: The application of regulatory theory to the problem of illicit drugs has generally been thought about only in terms of ‘command and control’. The international treaties governing global illicit drug control and the use of law enforcement to dissuade and punish offenders have been primary strategies. In this paper I explore the application of other aspects of regulatory theory to illicit drugs—primarily self-regulation and market regulation. There has been an overreliance on strategies from the top of the regulatory pyramid. Two other regulatory strategies – self-regulation and market regulation – can be applied to illicit drugs. Self-regulation, driven by the proactive support of consumer groups may reduce drug-related harms. Market strategies such as pill-testing can change consumer preferences and encourage alternate seller behaviour. Regulatory theory is also concerned with partnerships between the state and third parties: strategies in these areas include partnerships between police and pharmacies regarding sale of potential precursor chemicals. Regulatory theory and practice is a rich and well-developed field in the social sciences. I argue that governments should consider the full array of regulatory strategies. Using regulatory theory provides a rationale and justification to strategies that are currently at the whim of politics, such as funding for user groups. The greater application of regulatory approaches may produce more flexible and structured illicit drug policies.

Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms - Corrected Proof

John F. Kelly, Cassandra M. Westerhoff — 2009-12-14

Abstract: Objective: Stigma is a frequently cited barrier to help-seeking for many with substance-related conditions. Common ways of describing individuals with such problems may perpetuate or diminish stigmatizing attitudes yet little research exists to inform this debate. We sought to determine whether referring to an individual as “a substance abuser” vs. “having a substance use disorder” evokes different judgments about behavioral self-regulation, social threat, and treatment vs. punishment.Method: A randomized, between-subjects, cross-sectional design was utilized. Participants were asked to read a vignette containing one of the two terms and to rate their agreement with a number of related statements. Clinicians (N=516) attending two mental health conferences (63% female, 81% white, M age 51; 65% doctoral-level) completed the study (71% response rate). A Likert-scaled questionnaire with three subscales [“perpetrator-punishment” (α=.80); “social threat” (α=.86); “victim-treatment” (α=.64)] assessed the perceived causes of the problem, whether the character was a social threat, able to regulate substance use, and should receive therapeutic vs. punitive action.Results: No differences were detected between groups on the social threat or victim-treatment subscales. However, a difference was detected on the perpetrator-punishment scale. Compared to those in the “substance use disorder” condition, those in the “substance abuser” condition agreed more with the notion that the character was personally culpable and that punitive measures should be taken.Conclusions: Even among highly trained mental health professionals, exposure to these two commonly used terms evokes systematically different judgments. The commonly used “substance abuser” term may perpetuate stigmatizing attitudes.

Islam and harm reduction - Corrected Proof

A. Kamarulzaman, S.M. Saifuddeen — 2009-12-14

Abstract: Although drugs are haram and therefore prohibited in Islam, illicit drug use is widespread in many Islamic countries throughout the world. In the last several years increased prevalence of this problem has been observed in many of these countries which has in turn led to increasing injecting drug use driven HIV/AIDS epidemic across the Islamic world. Whilst some countries have recently responded to the threat through the implementation of harm reduction programmes, many others have been slow to respond. In Islam, The Quran and the Prophetic traditions or the Sunnah are the central sources of references for the laws and principles that guide the Muslims’ way of life and by which policies and guidelines for responses including that of contemporary social and health problems can be derived. The preservation and protection of the dignity of man, and steering mankind away from harm and destruction are central to the teachings of Islam. When viewed through the Islamic principles of the preservation and protection of the faith, life, intellect, progeny and wealth, harm reduction programmes are permissible and in fact provide a practical solution to a problem that could result in far greater damage to the society at large if left unaddressed.

Harm reduction policies for tobacco users - Corrected Proof

Coral Gartner, Wayne Hall — 2009-11-30

Abstract: Tobacco harm reduction is a controversial policy due to the experience with filtered and ‘light’ cigarettes and concerns that the tobacco industry will use reduced harm products to undermine tobacco control strategies. The most promising harm reduction products are high dose pharmaceutical nicotine preparations and low nitrosamine smokeless tobacco, such as Swedish snus. However, despite widespread availability, existing pharmaceutical nicotine preparations have not been taken up by smokers as an alternative to smoking. In Sweden, increased snus use was associated with decreased cigarette smoking and mortality from tobacco-related disease. We suggest a graduated series of policies to explore of the public health costs and benefits of encouraging smokers to switch to these less harmful nicotine products.

Coexisting or conjoined: The growth of the international drug users’ movement through participation with International Harm Reduction Association Conferences - Corrected Proof

Jude Byrne, Eliot Ross Albert — 2009-11-30

The development of the international drug users’ movement has been intrinsically linked to the growth and development of the international harm reduction movement but more particularly with the annual International Harm Reduction Association (IHRA) conferences. These conferences gave drug user activists a chance to meet in an environment where our lives were being talked about and our treatments decided and our views have, over the years, been given increasing consideration. The impetus for us to have a visible presence was extremely important. We had not had much success in making an impact on the drug and alcohol fields in our individual countries. It was the outbreak of HIV/AIDS that gave us our voice in the local situation and led to the birth of harm reduction initiatives, in particular, the provision of needle exchange. However, it was the drug and alcohol arena that had such a big and so often negative impact on the majority of drug users’ lives, particularly in the late eighties and early nineties. It has been said that it was learning activism in the HIV/AIDS movement that led to us bringing our newly found voices to the emerging harm reduction movement. It is true to say that except for the Dutch MDHG Belangenvereniging voor Druggebruikers (Interest Association for Drug Users) experience of setting up the world's first needle exchange in 1984, in response to an outbreak of Hepatitis B amongst people who inject drugs (), activist drug users were a rarity prior to HIV/AIDS. They were not seen as having any worthwhile experience or knowledge to give to the wider community. In this crucial respect, it was drug users themselves who kick-started the harm reduction movement. However, in the early years our voices were largely stifled by the increasing professionalisation of the field and the marginalisation of people who used drugs.

Methadone as HIV prevention: High Volume Methadone Sites to decrease HIV incidence rates in resource limited settings - Corrected Proof

R. Douglas Bruce — 2009-11-20

Abstract: The link between injection drug use and HIV has been extensively described. Despite worldwide prevention efforts, injection drug use continues to be a risk factor for HIV transmission and both HIV and injection drug use continues to spread across the globe. Although methadone has demonstrated multiple health benefits including the reduction in injection drug use and HIV acquisition, the utilisation of methadone in many areas of the world remains one of secondary, rather than primary, HIV prevention. As a result, many who finally begin methadone enter treatment having accumulated medical and mental health problems as a result of delayed treatment. Rapid access to treatment and a more aggressive policy that realizes that methadone can help reduce opioid drug use is necessary if methadone is effectively going to act as primary HIV prevention. To delay access to methadone only increases the probability that the individual will acquire an infectious disease that is more costly to the individual in terms of morbidity and mortality and more costly to society as a whole.

Warning labels on alcohol containers as a source of information on alcohol consumption in pregnancy among New Zealand women - Corrected Proof

Sherly M. Parackal, Mathew K. Parackal, John A. Harraway — 2009-11-20

Abstract: Background: The addition of a warning label on alcohol containers is a policy measure yet to be adopted in New Zealand. The current study aims to report the rating of a national sample of 16–40-year-old non-pregnant New Zealand women on a warning label on alcohol containers as a source of information on risks associated with alcohol consumption in pregnancy.Methods: A nationwide, cross-sectional survey was conducted in 2005 on a random sample of 1129 non-pregnant women aged 16–40 years. Data were collected via an interviewer-administered questionnaire using a Web-assisted telephone interviewing system.Results: Overall, the survey achieved a response rate of 65%. Just over half of the women surveyed (53%; 95% CI 50.2–56.0) gave a high rating for a warning label as a source of information on alcohol consumption in pregnancy. Women below 30 years of age and who were of non-European ethnicity were more likely to give a high rating compared with older women and European women, respectively (p<0.05).Conclusions: Introduction of a warning label on alcohol containers in New Zealand may be effective in increasing awareness of the risks associated with alcohol consumption in pregnancy among at-risk drinkers, namely, younger women and New Zealand women of Maori and Pacific ethnicities. However, to accentuate behavioural change, other prevention approaches within a health promotion framework may be needed to complement this approach.

Feasibility of buprenorphine and methadone maintenance programmes among users of home made opioids in Ukraine - Corrected Proof

2009-11-19

Abstract: Background: Opioid substitution therapy (OST) in the Ukraine was not provided until 2004. Methadone maintenance therapy only became available in May 2008. Injecting drug users in Ukraine are predominantly injecting self-made opioid solution (‘Shirka’). A feasibility study on buprenorphine and methadone maintenance treatment was conducted in 2008.Methods: A total of 331 opioid dependent patients were given buprenorphine (n=191) or methadone (n=140) as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at six months follow-up.Results: Illegal substance use, illegal activities, incomes and HIV related transmission risks were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high among the patients in buprenorphine (84.8%) and in methadone maintenance treatment (85.0%) after six months of treatment.Conclusion: These data show the successful implementation of OST in the Ukraine among drug users who were predominantly injectors of self-made opioid solutions. Continuing scale-up of OST in the Ukraine is therefore both feasible and highly recommended.

Drinking before going out—A predictor of negative nightlife experiences in a German inner city area - Corrected Proof

Sonja Wahl, Levente Kriston, Michael Berner — 2009-11-13

Abstract: Objective: The aim of the presented study is to identify target groups for early interventions to reduce negative effects of nightlife alcohol consumption and negative nightlife experiences (e.g. involvement in fights) as well as to examine the consumption patterns and identify the need for further interventions.Method: A cross-sectional survey of 308 persons in a German city centre during night time. Measurements: A questionnaire including questions on basic demographics, alcohol consumed prior to and during a typical night out, drug usage and experiences of the city's nightlife in the previous 12 months.Results: Two-thirds of the interviewees repeated a hazardous or high alcohol consumption pattern on a night out. We found several predictors for negative nightlife experiences: those who are male, younger than 25, have a low level of education, show higher alcohol consumption (especially before going out), and take illicit drugs are at a particularly great risk of experiencing negative nightlife events.Conclusions: We found several factors which increase the risk of experiencing negative effects of alcohol consumption. In particular, drinking before going out seems to be associated with aversive consequences.

Missing targets on drugs-related deaths, and a Scottish paradox - Corrected Proof

Sheila M. Bird, Sharon J. Hutchinson, Gordon Hay, Ruth King — 2009-11-09

Abstract: The 10-year drug strategy for England and Wales was published in February 2008. It dropped drugs-related deaths (DRDs) as a key performance indicator. Scotland retained a necessary strong focus on DRDs. Scotland's DRDs numbered 1006 in 2000–02 and 1009 in 2003–05. The previous Scottish administration's claim that its number of current injectors had decreased substantially between 2000 and 2003 implied, paradoxically, that their DRD rate would have to have increased. Worse was to come: Scotland's DRDs had increased to 876 in 2006+2007.We analyse UK's DRDs by sex and age-group to reveal temporal trends (2000–02 versus 2003–05 versus 2006+2007) with different public health and epidemiological implications. We also address the above Scottish paradox and assess, by age-group, how consistent Scotland's 876 DRDs in 2006+2007 are with Scottish injectors’ DRD rate in 2003–05 of around 1 per 100 injector-years.Public health success in the UK in reducing DRDs at younger ages should not be overshadowed by the late consequence in terms of older-age DRDs of UK's injector epidemics; in the early 1980s in Scotland, and late 1980s in England and Wales. Targets for reducing DRDs should pay heed to UK's injector epidemics.

Looking for a solution for drug addiction in China: Exploring the challenges and opportunities in the way of China's new Drug Control Law - Corrected Proof

Yu Liu, Juncheng Liang, Chengzheng Zhao, Wenhua Zhou — 2009-11-09

Abstract: In the wake of the deteriorating situation of drug addiction and related infectious diseases among injecting drug users (IDUs) in China in recent years, the Standing Committee of the National People's Congress of China adopted the new Drug Control Law which came into force in June 1, 2008. This law is part of a broad reform movement in China where drug addiction is no longer understood as simply a legal or moral issue but rather, as a complicated medical condition requiring comprehensive therapeutic strategies. Although the Drug Control Law draws a distinct line from previous Drug Control regulations in the country, there have still been dilemmas along the implementation process. This paper is intended to elaborate on the general principles of China's latest Drug Control Law from the point of view of scholars who are involved in the field of drug addiction research and treatment in China. This paper will also discuss the challenges we are currently facing, based on the observations and practical experiences the authors have obtained in China. It is hoped that by addressing these issues, we will be able to implement the new Drug Control Law more successfully and ensure that we deal more effectively with drug addiction in China.

Challenges in providing services in methadone maintenance therapy clinics in China: Service providers’ perceptions - Corrected Proof

2009-10-09

Abstract: Background: The Methadone Maintenance Therapy (MMT) program has been initiated in China since 2004. As of the end of November, 2008, 558 MMT clinics had been established countrywide. The objective of this study was to elucidate the difficulties and challenges as perceived by service providers working in MMT clinics.Methods: One service provider from each of the 28 MMT study clinics in Zhejiang and Jiangxi Provinces of China participated in a face-to-face in-depth interview for about 1–2h to describe their perceptions of working in MMT clinics. Qualitative data were analysed using ATLAS.ti. The grounded theory was used to guide the data analysis.Results: Participants identified major problems in providing services in MMT clinics including lack of resources, professional training, and institutional support. Difficulties in pursuit of career, concern for personal safety, low income, heavy working load, and poor opinion of MMT by Chinese society often contributed to greater stress and burnout among the service providers.Conclusion: The MMT programs in China desperately need additional resource allocation and institutional support for the current and perhaps future expansion of the programs. The service providers are in urgent need of professional training to improve the quality of care they can offer MMT clients.

Strategies to avoid opiate withdrawal: Implications for HCV and HIV risks - Corrected Proof

2009-09-28

Abstract: Background: Research on heroin withdrawal has primarily been done clinically, thus focussing on symptom severity, physiological manifestations, and how withdrawal impairs normal functioning. However, there is little scientific knowledge on how heroin withdrawal affects injection behaviour. This paper explores how withdrawal episodes heighten unsafe injection practices and how some long-term injectors manage such risks.Methods: We interviewed 32 injection drug users in New York City who had been injecting drugs for 8–15 years (21 HIV and HCV uninfected; 3 HIV and HCV infected; and 8 singly infected with HCV). We used in-depth life history interviews to inquire about IDUs’ life history, injection practices and drug use behaviour over time. Analysis used grounded theory techniques.Results: Withdrawal can enhance risk by undermining IDUs’ willingness to inject safely; increasing the likelihood of attending risky settings; raising the number of injection partners; and seeking ad hoc partners for drug or needle sharing. Some IDUs have developed practices to cope with withdrawal and avoid risky practices (examples include carrying clean needles to shooting galleries and sniffing rather than injecting). Strategies to avoid withdrawal include back up methods, resorting to credit, collaborating with others, regimenting drug intake, balancing drug intake with money available, and/or resorting to treatment.Conclusion: Withdrawal periods can heighten risky injection practices. Some IDUs have applied strategies to avoid withdrawal or used practices to cope without engaging in risky practices. These behaviours might in turn help IDUs prevent an infection with hepatitis C or HIV.

Differences in alcohol-related mortality between foreign-born and native-born Spaniards - Corrected Proof

Inmaculada Fierro, José Luis Yáñez, F. Javier Álvarez — 2009-09-27

Abstract: Background: Alcohol consumption is associated with high rates of mortality. This study aimed to analyse mortality attributable to alcohol consumption in foreign-born and native-born Spaniards in 2004 and to determine whether differences existed between these groups.Methods: The number of deaths attributable to alcohol consumption was calculated by means of the alcohol-attributable fractions devised by the Center for Disease Control and Prevention for calculating mortality rates in the USA. Alcohol-related mortality rates and age-adjusted mortality rates per 100,000 persons (using European standard population) were calculated by gender.Results: The mortality rates attributable to alcohol per 100,000 inhabitants were lower among foreign-born Spaniards (7.0) than native-born Spaniards (16.7). Chronic conditions accounted for only 23.6% of all alcohol-related mortality for foreign-born Spaniards, but 60% for native-born Spaniards. The former were much more likely to suffer unintentional injuries, particularly road traffic accidents, while the latter showed high rates of alcohol-related death for digestive diseases, cardiovascular disorders, intentional injuries and malignant neoplasm.Conclusion: Alcohol consumption is an important cause of death among the native-born Spanish population. The observed differences in alcohol-related mortality between native and foreign-born Spaniards should be considered when developing targeted harm reduction policies.

Expanding the reach of harm reduction in Thailand: Experiences with a drug user-run drop-in centre - Corrected Proof

2009-09-22

Abstract: Background: Despite an ongoing epidemic of HIV among Thai people who inject drugs (IDU), Thailand has failed to implement essential harm reduction programmes. In response, a drug user-led harm reduction centre opened in 2004 in an effort to expand reduction programming in Thailand.Methods: We examined experiences with the Mitsampan Harm Reduction Centre (MSHRC) among IDU participating in the Mitsampan Community Research Project (Bangkok). Multivariate logistic regression was used to identify factors associated with MSHRC use. We also examined services used at and barriers to the MSHRC.Results: 252 IDU participated in this study, including 66 (26.2%) females. In total, 74 (29.3%) participants had accessed the MSHRC. In multivariate analyses, MSHRC use was positively associated with difficulty accessing syringes (Adjusted Odds Ratio [AOR]=4.05; 95% Confidence Interval [CI]: 1.67–9.80), midazolam injection (AOR=3.25; 95%CI: 1.58–6.71), having greater than primary school education (AOR=1.88; 95%CI: 1.01–3.52), and was negatively associated with female gender (AOR=0.20; 95%CI: 0.08–0.50). Forms of support most commonly accessed included: syringe distribution (100%), food and a place to rest (83.8%), HIV education (75.7%), and safer injecting education (66.2%). The primary reason given for not having accessed the MSHRC was “didn’t know it existed.”Conclusion: The MSHRC is expanding the scope of harm reduction in Thailand by reaching IDU, including those who report difficulty accessing sterile syringes, and by providing various forms of support. In order to maximise its benefits, efforts should be made to increase awareness of the MSHRC, in particular among women.

Tracing retail cannabis in the United States: Geographic origin and cultivation patterns - Corrected Proof

Janet M. Hurley, Jason B. West, James R. Ehleringer — 2009-09-18

Abstract: Background: Although cannabis is the most readily available and widely used illicit drug in the United States, there remains significant uncertainty about the importance of different production regions and trafficking patterns.Methods: We analysed 628 “retail” cannabis seizures from over 50 municipalities across the United States for hydrogen and carbon isotope ratios to predict their growth locations and environments.Results: Results are presented for 22 consolidated retail locations across the United States. Evaluation of specimens from within these retail areas suggested that cannabis seizures had region-dependent origins, often from both domestic and foreign sources, and although indoor growth was common in many areas, there was also regional dependence in the proportions cultivated under indoor versus outdoor conditions.Conclusion: Street-available cannabis exhibits region-specific trafficking patterns, both Mexican- and Canadian-grown cannabis are apparently widely available, and indoor-grown cannabis appears to be cultivated and trafficked in both warm and cool weather localities throughout the United States.

How to find non-dependent opiate users: A comparison of sampling methods in a field study of opium and heroin users - Corrected Proof

Dirk J. Korf, Patrick van Ginkel, Annemieke Benschop — 2009-09-11

Abstract: Background/aim: The first aim is to better understand the potentials and limitations of different sampling methods for reaching a specific, rarely studied population of drug users and for persuading them to take part in a multidisciplinary study. The second is to determine the extent to which these different methods reach similar or dissimilar segments of the non-dependent opiate-using population.Method: Using ethnographic fieldwork (EFW) and targeted canvassing (TARC; small newspaper advertisements and website announcements), supplemented by snowball referrals, we recruited and interviewed 127 non-dependent opiate users (lifetime prevalence of use 5–100 times; 86.6% had used heroin and 56.7% opium). Average age was 39.0; 66.1% were male and 33.9% female.Results: In addition to opiates, many respondents had wide experience with other illicit drugs. The majority had non-conventional lifestyles. Both EFW and TARC yielded only limited numbers of snowball referrals. EFW requires specific skills, is labour-intensive, thus expensive, but allows unsuitable candidates to be excluded faster. Respondents recruited through EFW were significantly more likely to have experience with opium and various drugs other than opiates. TARC resulted in larger percentages of women and respondents with conventional lifestyles. TARC is less labour-intensive but requires more time for screening candidates; its cost-effectiveness depends on the price of advertising for the recruitment.Conclusion: Different methods reach different segments of the population of non-dependent opiate users. It is useful to employ a multi-method approach to reduce selectivity.

Timothy Leary, Richard Alpert (Ram Dass) and the changing definition of psilocybin - Corrected Proof

Colin Wark, John F. Galliher — 2009-09-10

Abstract: Background: This research focuses on the events leading to the 1968 U.S. federal prohibition of psilocybin. It is a study of duelling moral entrepreneurs—Timothy Leary and Richard Alpert vs. the Harvard University Administration. The goal is to show how the primary active compound in an ostensibly harmless fungus (the psilocybin mushroom) became controversial in less than a decade.Methods: We used books, newspapers, magazine articles and previously unpublished materials (including documents from the Harvard Archives) to analyze Leary and Alpert's lives and careers through the early 1970s.Results: The prohibition of psilocybin in the U.S. was largely a product of Leary and Alpert's involvement in the “Harvard drug scandal” and their transformation from Harvard professors to countercultural icons. They tested the substance on a variety of human subjects and in doing so piqued the interest of Harvard undergraduates while drawing condemnation from other faculty and Harvard administrators. This case is theoretically interesting because unlike most illegal drugs, psilocybin was never linked to a threatening minority group, but to some of the nation's most privileged youth.Conclusion: The Harvard administrators were not really moral entrepreneurs but Leary and Alpert clearly were. Although they were far from being prohibitionists, they were self-righteous crusaders on different but equally holy missions for the good of young and minority Americans. Ironically, due to their successes the possession of psilocybin was criminalized under United States federal law in 1968 (Pub. L. No. 90-639, Stat. 1361 1968 and ). This case study demonstrates that crusaders can be successful in changing culture even when laws are passed in futile attempts to control their behaviour, just as Leary predicted.

Methamphetamine use among gay men across the UK - Corrected Proof

Christopher P. Bonell, Ford C.I. Hickson, Peter Weatherburn, David S. Reid — 2009-09-03

Abstract: Background: Concerns about gay men's methamphetamine use reflect its physical and psychological harms, and association with sexual-risk behaviour and HIV infection. Existing research suggests gay men's use in the UK is low and may be largely confined to London.Methods: Cross-sectional survey of convenience sample of UK gay men.Results: Methamphetamine was used by a significant minority of gay men in London but also in other regions. Overall, use was highest among those men aged 30–49, HIV-positive and reporting sexual-risk behaviours.Conclusion: Methamphetamine was used by a significant minority of gay men in and outside London. Targeted prevention and treatment services should be developed and evaluated.

Assessing a drop box programme: A spatial analysis of discarded needles - Corrected Proof

Luc de Montigny, Anne Vernez Moudon, Barbara Leigh, Kim Young — 2009-09-03

Abstract: Background: Distributing sterile injection equipment to injection drug users is one of few proven ways of lowering the transmission rate of blood borne viruses. Distribution of equipment has also been linked to increased needle discarding, which is a public health risk for both injectors and their host communities. Drop boxes (anonymous and public-access sharps containers) are a promising and increasingly popular means of reducing unsafe disposal, yet there is little empirical research to support or guide their implementation.Methods: Using a dataset containing the locations of 7274 discarded needles and syringes collected monthly in the non-park open spaces of a 2.5km2 neighbourhood of Montréal, Canada for a period of five years, we compared levels of discards before and after the installation of 12 drop boxes. We used quasi-Poisson regression to test the effects of drop boxes on monthly counts of collected discards for areas within a walking distance of 25, 50, 100 and 200m of a drop box. We adjusted for known time-dependent covariates linearly and unknown time-dependent covariates using a smoothing function.Results: We found strong evidence of reduced discarding following the installation of drop boxes; drop boxes were associated with reductions of up to 98% (95% CI: 72–100%) and significant reductions for areas up to 200m from a drop box. Reductions were inversely proportional to walking distance from drop boxes. No measure of weather or use of needle exchange programmes (NEPs) had a consistent relationship with discard counts.Conclusion: Our research suggests that IDUs changed their needle-disposal behaviour in response to increased safe disposal options. In addition to being relatively low-threshold, economical and rapid, drop boxes appear to be a highly effective intervention to reduce discarded needles.

The reach of a free hepatitis B vaccination programme: Results of a Dutch study among drug users - Corrected Proof

Jessica E. Baars, Brigitte J.F. Boon, Henk F.L. Garretsen, Dike van de Mheen — 2009-08-25

Abstract: Background: The objective of the study was to explore the reach of an ongoing hepatitis B vaccination programme in terms of awareness of the programme among drug users (DUs), vaccination uptake and compliance, as well as to investigate reasons for non-participation.Methods: Ethnographic mapping and targeted sampling were used to recruit 309 DUs in three regions in the Netherlands. Results were based on univariate statistics (Chi-square and t-tests) and multivariate logistic regression analysis.Results: Of the sample, 63% were aware of the free vaccine, and 44% said they had been vaccinated. DUs who visited drug consumption rooms were more likely to be aware of the programme than those who did not. Vaccination uptake was negatively associated with older age of onset of drug use. Uptake was positively associated with being informed personally about the free vaccination by drug service staff. A history of STD infection, and having sexual intercourse with casual partners were negatively associated with compliance with the vaccination schedule (receiving three vaccinations).Conclusion: Our results suggest that marginalised DUs have been reached by the programme. Attention should be paid to those at risk of hepatitis B infection through sexual contacts, since they are less likely to be fully vaccinated. Most importantly, our results suggest that immediate vaccination on location after personal communication is one of the most effective ways to increase vaccination uptake.

Compulsory detoxification is a major challenge to harm reduction in China - Corrected Proof

Sarah Larney, Kate Dolan — 2009-06-09

are right to applaud the increasing acceptance and implementation of harm reduction in China. They have provided a useful analysis of challenges that have to be overcome to strengthen harm reduction in that country. However, greater attention must be given to the effect of China's policy of compulsory detoxification on harm reduction.

Using ethnographic fieldwork to inform hepatitis C vaccine preparedness studies with people who inject drugs - Corrected Proof

2009-06-01

Abstract: Background: Feasibility studies are an important component of preparations for field trials of biomedical prevention interventions, including vaccines.Methods: We conducted ethnographic fieldwork to assess feasibility, including eligibility and willingness to participate, prior to recruitment of a prospective observational study of hepatitis C negative people who inject drugs (PWID) in Sydney, Australia. Five staff conducted ethnographic fieldwork in 16 locations during 2008. Observations and interactions with PWID were recorded as field notes and data were used iteratively to guide targeting of locations and the follow-up of networks and individuals.Results: Findings informed the development of the study protocol, resulting in changes in the amount and type of participant reimbursement and the quantity of blood collected at screening, as well as highlighting the need for increased emphasis on communicating eligibility and exclusion criteria and study remuneration procedures.Conclusion: Results illustrate the value of ethnographic research in facilitating consultation and discussion with potential participants in natural settings, identifying motivations and concerns prior to study commencement and providing affected community input into the development of research protocols.

Preventing transitions to injecting amongst young people: What is the role of Needle and Syringe Programmes? - Corrected Proof

Loren Brener, Catherine Spooner, Carla Treloar — 2009-05-08

Abstract: Needle and Syringe Programmes (NSP) play an important role in providing targeted services for people who inject drugs to prevent the harms associated with drug use. This commentary considers whether the role of NSP could be expanded to include prevention of initiation to injecting. In an Australian case study, consultations were undertaken with 13 stakeholders working with at-risk youth and/or in the drug field. Ongoing formal and informal discussion in other forums expanded on the points raised during the stakeholder interviews. Incorporating strategies to prevent initiation to injecting within the existing NSP framework is complex and requires attention to the following: the current focus and success of NSP, the target group that access NSP, concerns about perceived moralism, workforce development concerns and the culture and setting of NSP. Without careful consideration of these important issues, a strategy to prevent initiation to injecting could undermine the core business of NSPs – of preventing harms associated with injecting drug use – and could alienate injecting drug users who are their primary target group.

A qualitative inquiry into methadone maintenance treatment for opioid-dependent prisoners in Tehran, Iran - Corrected Proof

2009-04-23

Abstract: Background: This study aimed to investigate the context in which methadone maintenance treatment (MMT) is provided for opioid-dependent prisoners, and to identify barriers against further scale-up of MMT in Ghezel Hesar prison in Tehran.Methods: This was a cross-sectional qualitative study using field observations, focus group discussions, and individual interviews. In total, 30 prisoners and 15 prison staff and health policymakers participated in this study in November 2006.Results: The rate of drug injecting in the prison unit was unanimously reported to have decreased drastically since introducing the MMT program. In addition to the health benefits to MMT recipients, interview data indicates that MMT has had positive effects on socio-economic status of prisoners’ families. Nevertheless, several impediments to the provision of MMT services and to its further expansion were also identified, including staff shortages, some degree of methadone diversion, widespread concerns over the possible side effects of methadone, and the stigma attached to methadone treatment.Conclusion: MMT constitutes one of the main components of the Iran Prison Organization's comprehensive HIV prevention package and is becoming increasingly accessible to opioid-dependent prisoners in Iran. Our findings indicate that the MMT program in Ghezel Hesar prison has been helpful for many opioid-dependent prisoners to reduce their risk of drug-related harm and to ease social and financial burden over their families. Meanwhile, existing barriers against provision of MMT should be properly addressed before further scale up of the program.

Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA - Corrected Proof

2009-03-06

Abstract: Background: Fatal opioid overdose is a significant cause of mortality among injection drug users (IDUs).Methods: We evaluated an overdose prevention and response training programme for IDUs run by a community-based organisation in Los Angeles, CA. During a 1-h training session participants learned skills to prevent, recognise, and respond to opioid overdoses, including: calling for emergency services, performing rescue breathing, and administering an intramuscular injection of naloxone (an opioid antagonist). Between September 2006 and January 2008, 93 IDUs were trained. Of those, 66 (71%) enrolled in the evaluation study and 47 participants (71%) completed an interview at baseline and 3-month follow-up.Results: Twenty-one percent of participants were female, 42% were white, 29% African American, and 18% Latino. Most were homeless or lived in temporary accommodation (73%). We found significant increases in knowledge about overdose, in particular about the use of naloxone. Twenty-two participants responded to 35 overdoses during the follow-up period. Twenty-six overdose victims recovered, four died, and the outcome of five cases was unknown. Response techniques included: staying with the victim (85%), administering naloxone (80%), providing rescue breathing (66%), and calling emergency services (60%). The average number of appropriate response techniques used by participants increased significantly from baseline to follow-up (p<0.05). Half (53%) of programme participants reported decreased drug use at follow-up.Conclusion: Overdose prevention and response training programmes may be associated with improved overdose response behaviour, with few adverse consequences and some unforeseen benefits, such as reductions in personal drug use.