Community Drug Use Research Articles

Towards finding a population biomarker for wastewater epidemiology studies

Wastewater analysis has the potential to provide objective information on community drug use. Introducing a population biomarker (PB) in the sample analysis may significantly reduce errors in the back-calculation associated with population estimation and wastewater volume measurement. A number of potential PBs have been suggested but no systematic evaluation has been conducted so far. This study evaluated the eligibility of the previously suggested PB candidates (creatinine, cholesterol, coprostanol and cotinine) as well as three new ones (cortisol, androstenedione and 5-hydroxyindoleacetic acid (5-HIAA)) using five criteria. We assessed the quantification method, affinity to particulate matter and stability of candidates in wastewater, as well as the constancy of inter-day excretion and correlation between excretion and census population. All PB candidates were quantifiable in wastewater. Cholesterol and coprostanol were eliminated from further consideration due to affinity to particulate matters in the wastewater. Creatinine, cortisol and androstenedione were disqualified for stability reasons. On a population scale, both cotinine and 5-HIAA were excreted (RSD=8.01±1.13% and 10.20±0.89%, respectively) at a constant rate and concentrations of each correlated well with the census population (r=0.9809 and 0.9442, respectively). Overall, both cotinine and 5-HIAA are eligible PBs, but the neurotransmitter metabolite 5-HIAA may be more suitable for international comparisons.

Evaluation of Uncertainties Associated with the Determination of Community Drug Use through the Measurement of Sewage Drug Biomarkers

The aim of this study was to integrally address the uncertainty associated with all the steps used to estimate community drug consumption through the chemical analysis of sewage biomarkers of illicit drugs. Uncertainty has been evaluated for sampling, chemical analysis, stability of drug biomarkers in sewage, back-calculation of drug use (specific case of cocaine), and estimation of population size in a catchment using data collected from a recent Europe-wide investigation and from the available literature. The quality of sampling protocols and analytical measurements has been evaluated by analyzing standardized questionnaires collected from 19 sewage treatments plants (STPs) and the results of an interlaboratory study (ILS), respectively. Extensive reviews of the available literature have been used to evaluate stability of drug biomarkers in sewage and the uncertainty related to back-calculation of cocaine use. Different methods for estimating population size in a catchment have been compared and the variability among the collected data was very high (7-55%). A reasonable strategy to reduce uncertainty was therefore to choose the most reliable estimation case by case. In the other cases, the highest uncertainties are related to the analysis of sewage drug biomarkers (uncertainty as relative standard deviation; RSD: 6-26% from ILS) and to the back-calculation of cocaine use (uncertainty; RSD: 26%). Uncertainty can be kept below 10% in the remaining steps, if specific requirements outlined in this work are considered. For each step, a best practice protocol has been suggested and discussed to reduce and keep to a minimum the uncertainty of the entire procedure and to improve the reliability of the estimates of drug use.

Evaluation of pre‐analysis loss of dependent drugs in wastewater: stability and binding assessments

Wastewater analysis has the potential to provide objective and timely data on population drug consumption, but some crucial factors such as pre-analysis drug loss during sample storage and filtration could affect the accuracy and reliability of the method, and these uncertainties have yet to be fully assessed. This study was designed to evaluate analyte stability in wastewater stored under different conditions with the aim of optimizing the sample storage procedures for future studies. It also investigated whether there is significant analyte loss during filtration before sample extraction and storage after that. The studied substances and metabolites were: cotinine, cocaine and its metabolite benzoylecgonine, phenethylamines amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxymethamphetamine (MDMA), opioids including codeine, methadone, 6-monoacetylmorphine (MAM) and morphine. In most situations, storing samples at 4 °C is sufficient to stabilize analytes for at least 2 weeks, and refrigeration is unnecessary during sample transportation within 3 days. However, additional measures need to be taken if unstable analytes such as cocaine and MAM are to be analyzed. No significant analyte loss was observed in the filtration process or in reconstituted extract stored at 4 °C or -20 °C for 2 weeks. By choosing stable analytes and proper storage conditions, wastewater analysis has the potential to provide accurate data for estimation of community drug use.

Temporal Analysis of the Cocaine Metabolite Benzoylecgonine in Wastewater to Estimate Community Drug Use*

Indirect estimation methods of cocaine consumption may not reflect the real extent of cocaine use. Another approach is sewage epidemiology. This direct approach is based on analysis of a stable cocaine metabolite, benzoylecgonine (BE), in wastewater. Influent to the Lubbock (Texas) Water Reclamation Plant was sampled twice a week to assess weekly variations in estimates of cocaine consumption over a 5-month period. BE was extracted from influent wastewater samples using solid phase extraction and analyzed using gas chromatography/mass spectrometry. Measured concentrations of BE were converted to cocaine equivalents; the estimated average daily consumption of cocaine during the study period was 1152 ± 147 g. Based on BE concentrations and sewage epidemiology, higher cocaine consumption was observed on weekends compared to weekdays (p < 0.0003). This method was effective in monitoring BE in wastewater and could be used to complement survey data in estimating cocaine use at a local level.

Increased Use of Community Medicine Distributors and Rational Use of Drugs in Children Less than Five Years of Age in Uganda Caused by Integrated Community Case Management of Fever

We compared use of community medicine distributors (CMDs) and drug use under integrated community case management and home-based management strategies in children 6–59 months of age in eastern Uganda. A cross-sectional study with 1,095 children was nested in a cluster randomized trial with integrated community case management (CMDs treating malaria and pneumonia) as the intervention and home-based management (CMDs treating only malaria) as the control. Care-seeking from CMDs was higher in intervention areas (31%) than in control areas (22%; P = 0.01). Prompt and appropriate treatment of malaria was higher in intervention areas (18%) than in control areas (12%; P = 0.03) and among CMD users (37%) than other health providers (9%). The mean number of drugs among CMD users compared with other health providers was 1.6 versus 2.4 in intervention areas and 1.4 versus 2.3 in control areas. Use of CMDs was low. However, integrated community case management of childhood illnesses increased use of CMDs and rational drug use.

Residential treatment for homeless female veterans with psychiatric and substance use disorders: Effect on 1-year clinical outcomes

Limited evidence shows that time-limited residential treatment (RT) is beneficial for homeless people with serious mental illness. The Department of Veterans Affairs has established 11 specialty programs for homeless female veterans. We present data comparing 1-year clinical outcomes in a group of veterans who did and did not receive at least 30 days of RT. Clients of the Homeless Women Veterans Programs were invited to participate in a follow-up study. They were interviewed every 3 months for 1 year. Those who received at least 30 days of RT in the 3 months after program entry (RT group) were compared with other program participants (no or <30 days RT [NRT] group) on measures of community functioning, psychiatric symptoms, and drug and alcohol use during the follow-up. The RT group had better outcomes on employment, social support, housing status, and psychiatric symptoms. They also had significantly increased use of drugs and alcohol compared with the NRT group. Data suggest that RT may have a beneficial effect on mental health outcomes in homeless women. This study, in conjunction with others, suggests that provision of stable housing may be an important element of recovery for homeless women with psychiatric problems, excluding substance use.

Illicit drugs in Canadian municipal wastewater and estimates of community drug use

In this study of wastewater treatment plants in three Canadian cities, selected illicit drugs, including cocaine and its major metabolite, benzoylecgonine (BE), amphetamine, methamphetamine and ecstasy (i.e. MDMA) were detected in untreated wastewater. Cocaine was the most widely used illicit drug at a median level for the 3 cities of 15.7 doses per day per 1000 people. For the other drugs, the median doses per day per 1000 people were 1.8 for amphetamine, 4.5 for methamphetamine and 0.4 for ecstasy. Methamphetamine use was highest in the largest city and cocaine use was lowest in the smallest city. Removal of the illicit drugs by wastewater treatment was generally >50%, except in a WWTP that uses primary treatment. The community consumption estimate for ecstasy in the present study is far below published estimates of the prevalence of ecstasy use among the Canadian population, which may be due to only occasional use of ecstasy.

The spatial epidemiology of cocaine, methamphetamine and 3,4‐methylenedioxymethamphetamine (MDMA) use: a demonstration using a population measure of community drug load derived from municipal wastewater

ABSTRACTAims To determine the utility of community‐wide drug testing with wastewater samples as a population measure of community drug use and to test the hypothesis that the association with urbanicity would vary for three different stimulant drugs of abuse.Design and participants Single‐day samples were obtained from a convenience sample of 96 municipalities representing 65% of the population of the State of Oregon.Measurements Chemical analysis of 24‐hour composite influent samples for benzoylecgonine (BZE, a cocaine metabolite), methamphetamine and 3,4‐methylenedioxymethamphetamine (MDMA). The distribution of community index drug loads accounting for total wastewater flow (i.e. dilution) and population are reported.Findings The distribution of wastewater‐derived drug index loads was found to correspond with expected epidemiological drug patterns. Index loads of BZE were significantly higher in urban areas and below detection in many rural areas. Conversely, methamphetamine was present in all municipalities, with no significant differences in index loads by urbanicity. MDMA was at quantifiable levels in fewer than half the communities, with a significant trend towards higher index loads in more urban areas.Conclusion This demonstration provides the first evidence of the utility of wastewater‐derived community drug loads for spatial analyses. Such data have the potential to improve dramatically the measurement of the true level and distribution of a range of drugs. Drug index load data provide information for all people in a community and are potentially applicable to a much larger proportion of the total population than existing measures.

Staff Perceptions of Syringe Dispensing Machines in Australia: A Pilot Study

Background/Aims: Syringe dispensing machines were introduced into needle syringe programs (NSPs) two decades ago. The few published studies on dispensing machines have focused on feedback of machine users and service providers' feedback has rarely been reported. This study obtained the feedback of health staff of NSPs, other sectors of Drug Misuse Treatment Services and of other health services adjoining dispensing machines on the role and effectiveness of dispensing machines. Methods: Between August and November 2006, questionnaires were anonymously completed by NSP and drug misuser treatment staff in an Area Health Service in Sydney, as well as by the staff of two nondrug-related health services located adjacent to needle syringe dispensing machines. The questionnaire was available in either paper or Internet based forms. Results: Almost 80% of 94 participants rated dispensing machines as either moderately successful or successful in reducing sharing of needles and syringes. Staff considered that introduction of these machines to NSPs had improved services for injecting drug users without increasing unsafe disposal of used equipment, community drug use, or vandalism. However 78% of respondents felt that dispensing machines either reduce or may reduce IDUs' opportunity for staff contact and hence opportunity for engagement or education. The study limitations were noted. Conclusion: Syringe dispensing machines are perceived to be a successful and appropriate outlet of NSPs that complement other outlets. Lack of staff-user contact was seen as their main disadvantage.

“We Do What We Think Is the Best”—A Content Analysis of Experiences of Alcohol Problem Prevention in Sweden. A Short Report

This short report describes an ongoing project whose aim was to explore how respondents from local institutions in a Swedish municipality describe their efforts in preventing alcohol consumption and related problems. Data were collected in focus group interviews, conducted during 2003 with key informants, comprising middle-ranking civil servants from different administrative sectors such as school, social welfare, and the public health office, in four Swedish municipalities: one city district, one town, and two small municipalities. We identified low knowledge of evidence-based methods for prevention of alcohol consumption–related problems and a lack of consistent focus on strategies known to be effective. The main target group for preventive efforts was identified as young people and the most common setting mentioned was the schools. Further, the key informants appeared to regard a wide range of activities as being community alcohol and drug use prevention. Generally these activities also lacked specification. Increased knowledge of alcohol and drug use prevention methods that are effective at the local level is needed within Swedish municipalities, as is greater understanding of how to implement those methods.

Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study

Problem Illicit use of injected drugs is linked with high rates of HIV infection and fatal overdose, as well as community concerns about public drug use. Supervised injecting facilities have...

Treatment during transition from prison to community and subsequent illicit drug use

This study examined the effects of postrelease transitional therapeutic community treatment on the drug use and employment rates of drug involved prisoners in the Delaware corrections system followed for up to 5 years after release. A comparison group received standard postrelease supervision. Abstinence rates were 32.2% in the treatment group and 9.9% in the no-treatment group, and the treatment group had a higher overall proportion of time free of drug use. Time to relapse was a mean of 28.8 months in the treatment group versus 13.2 months in the no-treatment group. Relapse was defined as any use of any drug and was confirmed by urinalysis. Positive effects were seen even for those who did not complete treatment. The treatment group had a significantly higher rate of employment after leaving work release (54.6%) than did the no-treatment group (45.4%). Treatment during the transitional period between prison and community showed substantial and persistent benefits even for a cohort marked with extensive criminal history, low rates of marital bonds, and substantial unemployment.

Intensity of malaria transmission and the evolution of drug resistance

The intensity of malaria transmission varies both naturally and as a consequence of human public health intervention. The relationship between transmission intensity and the rate at which antimalarial drug resistance evolves affects the design of surveillance programmes, and the likely impact of malaria control programmes. Several theoretical studies have investigated this relationship and their key results are summarised and interpreted. The most important result is that transmission intensity does not directly affect the evolution of resistance. It exerts its influence through three clinical/epidemiological “mediators” (clonal multiplicity, the threat of infection, level of human immunity) which ultimately determine the dynamics of resistance via five “effector” variables: sexual recombination, intrahost dynamics, community drug use, proportion of malaria infections treated, and the number of parasites per host. We argue that the evolution of resistance is likely to be a two-stage process: mutations encoding drug tolerance preceding those encoding resistance. The evolution of drug tolerance is determined solely by the level of drug use in the community which is likely to have an extremely weak relationship with transmission intensity. The evolution of resistance is more complex and affected by all five effectors. The most likely scenarios are that resistance evolves faster in areas of high transmission if encoded by a single gene but if encoded by two or more genes it evolves fastest in areas of high or low transmission, with a minimum at intermediate levels of transmission.

Drug Use and Its Correlates in an Australian Prisoner Population

The prevalence of past and present tobacco, alcohol, and illicit drug use is examined in a cross sectional random sample of prisoners. 789 male and female prisoners from 27 correctional centres across New South Wales (NSW) participated in the survey. Information was collected using a face-to-face interview on community and prison drug use, and intoxication while offending. Current tobacco use was reported by 72% of the sample. Use of alcohol by females was more likely than males to be classified as 'safe' according to the Alcohol Use Disorders Identification Test (39 vs. 26%). Overall, 64% of prisoners had used illicit drugs at some time in the past with cannabis and heroin the most common. Forty four percent of prisoners had a history of injecting drug use, with injecting prevalence significantly higher in females than males (64 vs. 40%) with approximately half of both male and female injectors reporting that they had injected while in prison. 'Harmful' or 'hazardous' use of alcohol was associated with imprisonment for violent crimes. Sixty two percent of property offenders had an injecting history. Correctional authorities need to ensure that drug treatment programmes are available to prisoners and consideration should be given to piloting needle and syringe exchange programmes in NSW prisons given the high levels of sharing injecting equipment in prison.

Quality use of medicines: where does pharmacology 'end'? Invited ASCEPT Lecture. Australasian Society of Clinic and Experimental Pharmacologists and Toxicologists.

1. Pharmacology can be defined very narrowly (e.g. as solely a laboratory based specialty) or more broadly to include issues surrounding rational drug use in the community. 2. While the hypothetio-deductive approach is more clearly in evidence in laboratory and clinical pharmacological experimentation, it is no less important in the comparatively less-well charted area of drug use in the community. 3. Just as laboratory pharmacology has built new partnerships with molecular biology and genetics, the exploration of community drug use brings pharmacologists into partnership with other disciplines (epidemiology, economics, behavioural science) and other sectors (consumers, government, health professionals and industry). 4. Implementing Australia's Quality Use of Medicines Policy (1992) has led to vigorous exploration of issues and problems in medicinal drug use in the community and much scientific study of causes and potential interventions to improve the situation. 5. The Australian National Prescribing Service (1998) is attempting to bring an evidence-based approach to the many facets of prescribing and drug use, by prescribers and consumers alike. 6. Innovation commonly occurs at the interface between the boundaries of traditional disciplines.

Changing home treatment of childhood fevers by training shop keepers in rural Kenya.

Malaria control in Africa relies primarily on early effective treatment for clinical disease, but most early treatments for fever occur through self-medication with shop-bought drugs. Lack of information to community members on over-the-counter drug use has led to widespread ineffective treatment of fevers, increased risks of drug toxicity and accelerating drug resistance. We examined the feasibility and measured the likely impact of training shop keepers in rural Africa on community drug use. In a rural area of coastal Kenya, we implemented a shop keeper training programme in 23 shops serving a population of approximately 3500, based on formative research within the community. We evaluated the training by measuring changes in the proportions of drug sales where an adequate amount of chloroquine was purchased and in the percentage of home-treated childhood fevers given an adequate amount of chloroquine. The programme was assessed qualitatively in the community following the shop keeper training. The percentage of drug sales for children with fever which included an antimalarial drug rose from 34.3% (95% CI 28.9%-40.1%) before the training to a minimum of 79.3% (95% CI 71.8%-85.3%) after the training. The percentage of antimalarial drug sales where an adequate amount of drug was purchased rose from 31.8% (95% CI 26.6%-37.6%) to a minimum of 82.9% (95% CI 76.3%-87.3%). The percentage of childhood fevers where an adequate dose of chloroquine was given to the child rose from 3.7% (95% CI 1.2%-9.7%) before the training to a minimum of 65.2% (95% CI 57.7%-72.0%) afterwards, which represents an increase in the appropriate use of over-the-counter chloroquine by at least 62% (95% CI 53.7%-69.3%). Shop keepers and community members were strongly supportive of the aims and outcome of the programme. The large shifts in behaviour observed indicate that the approach of training shop keepers as a channel for information to the community is both feasible and likely to have a significant impact. Whilst some of the impact seen may be attributable to research effects in a relatively small scale pilot study, the magnitude of the changes support further investigation into this approach as a potentially important new strategy in malaria control.

The relationship of personal and community drug use to HIV/STD infection and HIV risk behaviors in an urban adolescent population

The relationship of personal and community drug use to HIV/STD infection and HIV risk behaviors in an urban adolescent population

Community structure and drug use: From a social disorganization perspective

Social disorganization theory experienced a relative resurgence in the criminological literature during the 1980s. This new generation of research has expanded the work of Shaw and McKay by testing the relationship between neighborhood structure and delinquency through the use of self-report and victimization data. Confirmation of the theory has been widespread. In this paper we investigate variables mediating between social disorganization and adolescent drug use. We thus extend the research orientation to incorporate drug use and describe a preliminary attempt to examine how neighborhood structure affects behavior. The findings suggest that in the three distinct types of socially disorganized areas that were identified, there was no difference in rates of drug use but that different “mediating factors” appear to be operating in the three different types of communities.

Community psychology, drug use, and AIDS

Intravenous drug users may hold the key to the future epidemic of AIDS in the United States. Although gay men have changed their social norms to lower the risk of AIDS, such change will be more difficult to bring about in drug users. Several intervention efforts have been developed and are being evaluated. The psychoeducational workshops developed by the authors have shown promise in random-assignment trials with drug abusers in residential treatment, methadone maintenance, and outpatient detoxification. By orientation and training, community psychologists are uniquely qualified to develop, evaluate, and disseminate AIDS prevention programs to change community norms among drug users.

Social dysfunctionality and community drug use: A regional anthropological investigation

Stepwise multiple regression was used to determine extent of association between drug use and 8 social dysfunctionality indices for a heterogeneous population of 488 drug users. Data presented indicate a moderate relationship between drug use and social dysfunctionality indices, the strongest association being with an “arrest” variable. An innovative approach to the gathering of drug use information, based on the ethnographic refinements of anthropology, was also described and suggestions given for facilitating community drug use research.