Illicit Drug Injection Research Articles

Scale-up of a comprehensive harm reduction programme for people injecting opioids: lessons from north-eastern India

Harm reduction packages for people who inject illicit drugs, including those infected with human immunodeficiency virus (HIV), are cost-effective but have not been scaled up globally. In the north-eastern Indian states of Manipur and Nagaland, the epidemic of HIV infection is driven by the injection of illicit drugs, especially opioids. These states needed to scale up harm reduction programmes but faced difficulty doing so. In 2004, the Bill & Melinda Gates Foundation funded Project ORCHID to scale up a harm reduction programme in Manipur and Nagaland. In 2003, an estimated 10 000 and 16 000 people were injecting drugs in Manipur and Nagaland, respectively. The prevalence of HIV infection among people injecting drugs was 24.5% in Manipur and 8.4% in Nagaland. By 2012, the harm reduction programme had been scaled up to an average of 9011 monthly contacts outside clinics (80% of target); an average of 1709 monthly clinic visits (15% of target, well above the 5% monthly goal) and an average monthly distribution of needles and syringes of 16 each per programme participant. Opioid agonist maintenance treatment coverage was 13.7% and retention 6months after enrolment was 63%. Antiretroviral treatment coverage for HIV-positive participants was 81%. A harm reduction model consisting of community-owned, locally relevant innovations and business approaches can result in good harm reduction programme scale-up and influence harm reduction policy. Project ORCHID has influenced national harm reduction policy in India and contributed to the development of harm reduction guidelines.

Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia

ObjectivesTo assess risk for unintended pregnancy, this study describes the correlates of unprotected sexual intercourse (UPSI) among women who inject illicit drugs or who have sexual partners who inject drugs...

Methadone maintenance treatment in Spain: the success of a harm reduction approach

During the 1980s, Spain had very strict laws limiting access to opioid agonist maintenance treatment (OAMT). Because of this, mortality among people who used illicit opioids and other illicit drugs was high. Spain was also the European country with the highest number of cases of acquired immunodeficiency syndrome transmitted through illicit drug injection. The rapid spread of human immunodeficiency virus (HIV) infection among people using heroin led to a shift from a drug-free approach to the treatment of opioid dependence to one focused on harm reduction. A substantial change in legislation made it possible to meet public health needs and offer OAMT as part of harm reduction programmes in the public health system, including prisons. Legislative changes were made throughout the country, although at a different pace in different regions. Legal changes facilitated the expansion of OAMT, which has achieved a coverage of 60%. A parallel reduction in the annual incidence of HIV infection has been reported. Reductions in morbidity and mortality and improved health-related quality of life have been described in patients undergoing OAMT. The treatment of opioid dependence has been more heavily influenced by moral concepts and prejudices that hinder legislation and interfere with the implementation of OAMT than by scientific evidence. To fulfil public health needs, OAMT should be integrated in harm reduction programmes offered primarily in public facilities, including prisons. Longitudinal studies are needed to detect unmet needs and evaluate programme impact and suitability.

Viral Transmission Linked to Injecting Illicit Drugs: Finding the Best Medicine

Viral Transmission Linked to Injecting Illicit Drugs: Finding the Best Medicine

Substance Use Patterns among High‐Risk American Indians/Alaska Natives in Los Angeles County

Substance abuse among American Indians/Alaska Natives (AI/ANs) is a significant and long-standing health problem in the U.S. Two-thirds of American AIs/ANs reside in the urban setting. However, studies analyzing substance use characteristics among urban AI/ANs are very limited. Substance use patterns among a sample of AI/ANs (n = 77) and other ethnic/racial groups in Los Angeles County at high risk of substance abuse were analyzed utilizing three datasets from programs targeting individuals at high risk for substance abuse and risky sexual behaviors. Compared to all other ethnic/racial groups, AI/ANs demonstrated significantly younger age of onset of alcohol, marijuana, methamphetamine, and "other" drug use, higher correlations of age of first use of amphetamine with a measure of the drug's reinforcement, and higher mean number of illicit drug injections in the 30 days before being interviewed. Results from this study highlight a critical need for furthering our understanding of substance abuse problems among urban AI/ANs.

Pharmacy Syringe Purchase Test of Nonprescription Syringe Sales in San Francisco and Los Angeles in 2010

The two main legal sources of clean needles for illicit injection drug users (IDUs) in California are syringe exchange programs (SEPs) and nonprescription syringe sales (NPSS) at pharmacies. In 2004, California became one of the last states to allow NPSS. To evaluate the implementation of NPSS and the California Disease Prevention Demonstration Project (DPDP), we conducted syringe purchase tests in San Francisco (SF) and Los Angeles (LA) between March and July of 2010. Large differences in implementation were observed in the two cities. In LA, less than one-quarter of the enrolled pharmacies sold syringes to our research assistant (RA), and none sold a single syringe. The rate of successful purchase in LA is the lowest reported in any syringe purchase test. In both sites, there was notable variation among the gauge size available, and price and quantity of syringes required for a purchase. None of the DPDP pharmacies in LA or SF provided the requisite health information. The findings suggest that more outreach needs to be conducted with pharmacists and pharmacy staff. The pharmacies' failure to disseminate the educational materials may result in missed opportunities to provide needed harm reduction information to IDUs. The varied prices and required quantities may serve as a barrier to syringe access among IDUs. Future research needs to examine reasons why pharmacies do not provide the mandated information, whether the omission of disposal options is indicative of pharmacies' reluctance to serve as disposal sites, and if the dual opt-in approach of NPSS/DPDP is a barrier to pharmacy enrollment.

‘Same Ole Same Ole’ with Regard to Sterile Syringe Availability

‘Same Ole Same Ole’ with Regard to Sterile Syringe Availability Research has shown that the shared use of contaminated needles, syringes, and even drug vials is a major means of transmission for HIV and hepatitis B and C infections. However, fears persist that by allowing injecting drug users access to sterile needles and syringes sends the wrong message resulting in increased numbers of persons injecting illicit drugs and increased crime rates. And as the numbers of those injecting illicit drugs increases so do the numbers of bloodborne infections like HIV and hepatitis. Existing research and other data do not support such fears; however, there is some support for the ‘same old same old’ with regard to sterile syringe availability.

Reducing the Adverse Impact of Injection Drug Use in Canada

Reducing the Adverse Impact of Injection Drug Use in Canada

HCV Routes of Transmission: What Goes Around Comes Around

The widespread availability of injectable therapies and increase in illicit injection drug use were responsible for the rapid emergence of hepatitis C virus (HCV) infection in the latter half of the 20th century. Iatrogenic exposures and illicit injection drug use have been the predominant risk factors for HCV transmission worldwide. In developing countries, unsafe therapeutic injection practices appear to be responsible for most infections. In developed countries, donor testing has virtually eliminated transfusion-related infections, but infections transmitted to patients by unsafe injections practices is an emerging problem. Injection drug use is the major risk factor for HCV; incidence remains high among new injectors, and this behavior likely contributes to and/or confounds reported associations between HCV-positive persons and histories of noninjection drug use, tattooing, and incarceration. Increased use of illegal drugs also may play a role in the emergence of sexually transmitted HCV infections among HIV-positive men who have sex with men. Ongoing monitoring of the epidemiology of HCV infection is crucial for preventing future infections.

High HIV and hepatitis C prevalence amongst injecting drug users in Mauritius: Findings from a population size estimation and respondent driven sampling survey

Background Mauritius, an Indian Ocean Island nation of approximately 1,000,000 people, has a large number of injecting drug users (IDUs), many of whom are infected with HIV and HCV. Mauritius has been expanding harm reduction and HIV services based in the belief that HIV prevalence amongst IDUs is somewhere between 30 and 60% and the IDU population size is around 20,000. In 2009, the government of Mauritius conducted a survey to estimate the infection prevalence and risk factors and to estimate the population size of IDUs in order to more effectively expand programmes. Methods Men and women aged >15 years living in Mauritius and injecting illicit drugs in the past three months were recruited using respondent driven sampling (RDS). Consenting participants were interviewed about HIV-risk behaviours and tested for HIV, syphilis, HCV and HBV. Six multipliers were collected from service data and by the ‘unique identifier’ method in conjunction with the RDS survey. Proportions were calculated using the RDS analysis tool. Results 511 IDUs enrolled in the survey; 61.2% reported injecting 2–3 times/day and 29.3% reported past month injection with a previously used needle. Amongst the 60% of IDUs who reported having sexual intercourse in the past three months, 39.5% did so with ≥2 partners. Almost all IDUs (98.1%) reported inconsistent condom use in the past 12 months. HIV prevalence was 47.4%, HCV 97.3%, HBV 9.0%, and syphilis 2.7%; 99.7% of those infected with HIV were also infected with HCV. Our population size estimates put the number of IDUs in Mauritius at around 9500, lower than previous estimates. Conclusions We observed high rates of HCV and HIV infection amongst IDUs in Mauritius. The scale up of targeted HCV and HIV prevention, care and treatment services for IDUs should be a high priority.

Interest in low-threshold employment among people who inject illicit drugs: Implications for street disorder

Background Income generation opportunities available to people who use illicit drugs have been associated with street disorder. Among a cohort of injection drug users (IDU) we sought to examine street-based income generation practices and willingness to forgo these sources of income if other low-threshold work opportunities were made available. Methods Data were derived from a prospective community recruited cohort of IDU. We assessed the prevalence of engaging in disorderly street-based income generation activities, including sex work, drug dealing, panhandling, and recycling/salvaging/vending. Using multivariate logistic regressions based on Akaike information criterion and the best subset selection procedure, we identified factors associated with disorderly income generation activities, and assessed willingness to forgo these sources of income during the period of November 2008 to July 2009. Results Among our sample of 874 IDU, 418 (48%) reported engaging in a disorderly income generation activity in the previous six months. In multivariate analyses, engaging in disorderly income generation activities was independently associated with high intensity stimulant use, as well as binge drug use, having encounters with police, being a victim of violence, sharing used syringes, and injecting in public areas. Among those engaged in disorderly income generation, 198 (47%) reported a willingness to forgo these income sources if given opportunities for low-threshold employment, with sex workers being most willing to engage in alternative employment. Conclusion Engagement in disorderly street-based income generation activities was associated with high intensity stimulant drug use and various markers of risk. We found that a high proportion of illicit drug users were willing to cease engagement in these activities if they had options for causal low-threshold employment. These findings indicate that there is a high demand for low-threshold employment that may offer important opportunities to reduce drug-related street disorder and associated harms.

P.6.012 Analysis of the impact of different forms of naltrexone on the syndrome of anhedonia and depression among heroin addicts

This study examined the state of the literature on the effectiveness of medication assisted treatment (MAT; methadone, buprenorphine, naltrexone) delivered in prisons and jails on community substance use treatment engagement, opioid use, recidivism, and health risk behaviors following release from incarceration. Randomized controlled trials (RCTs) and quasi-experimental studies published through December 2017 that examined induction to or maintenance on methadone (n = 18 studies), buprenorphine (n = 3 studies), or naltrexone (n = 3 studies) in correctional settings were identified from PsycINFO and PubMed databases. There were a sufficient number of methadone RCTs to meta-analyze; there were too few buprenorphine or naltrexone studies. All quasi-experimental studies were systematically reviewed. Data from RCTs involving 807 inmates (treatment n = 407, control n = 400) showed that methadone provided during incarceration increased community treatment engagement (n = 3 studies; OR = 8.69, 95% CI = 2.46; 30.75), reduced illicit opioid use (n = 4 studies; OR = 0.22, 95% CI = 0.15; 0.32) and injection drug use (n = 3 studies; OR = 0.26, 95% CI = 0.12; 0.56), but did not reduce recidivism (n = 4 studies; OR = 0.93, 95% CI = 0.51; 1.68). Data from observational studies of methadone showed consistent findings. Individual review of buprenorphine and naltrexone studies showed these medications were either superior to methadone or to placebo, or were as effective as methadone in reducing illicit opioid use post-release. Results provide the first meta-analytic summary of MATs delivered in correctional settings and support the use of MATs, especially with regard to community substance use treatment engagement and opioid use; additional work is needed to understand the reduction of recidivism and other health risk behaviors.

High rates of transitions to injecting drug use among Mexican American non-injecting heroin users in San Antonio, Texas (never and former injectors)

Objective To assess the incidence and rate of transition to injecting among Mexican American noninjecting heroin users. Methods In a prospective cohort study of street-recruited MA-NIU in San Antonio, Texas, 2002–2005, participants were administered structured interviews and tested for Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). The analysis sample comprised former injection drug users (last injected >6 months ago, n = 47) and those who had never injected drugs and tested HCV negative ( n = 219). A transition to injecting was defined as the first injection of illicit drugs since baseline interview. Transition rates were based on person-years at-risk (PYAR). Proportional hazards regression was used to estimate crude and adjusted (for significant differences between former and never injectors) hazard ratios and 95% confidence intervals of injecting history on transitioning to injecting. Results Sixty-three (24%) participants transitioned to injecting at a rate of 22.3/100 PYAR (95% CI: 17.2–28.2). Former-injectors were significantly more likely to transition than never injectors (43% or 20/47 vs. 20% or 43/219; p < 0.001), and did so at a faster rate (40.4/100 PYAR, 95% CI: 24.6–60.0 vs. 18.5/100 PYAR, 95% CI: 13.4–24.4), with the crude HR = 1.931 (95% CI: 1.116, 3.341) and adjusted HR = 2.263 (95% CI: 1.192–4.294). Conclusions The rate of transitioning to injecting was high and greater among former injectors. Of particular concern is the high rate of injecting initiation among never injectors. Future analyses will examine factors associated with injecting initiation, including individual susceptibility and behaviors, social networks, and the cultural and drug market context.

The Beginning of a New Era in Understanding Hepatitis C Virus Prevention

The Beginning of a New Era in Understanding Hepatitis C Virus Prevention

A devastating complication of ‘skin popping’

A 40-year-old gentleman presented with a 7-day history of a painful ulcer over the lateral aspect of his right lower leg. He was an intravenous drug user for the last 15 years and on a methadone programme for the previous 12 months. He admitted to the practice of “skin popping” (injecting drugs subcutaneously) over his right leg as he had exhausted all of the venous access sites. The ulcer had been present for the last 2 years and he did not seek any medical attention as this area was used as a “shooters patch” to inject illicit drugs. Clinical examination revealed a 22 15 cm ulcer over the lateral aspect of his right lower leg with a central area of necrosis approximating 12 8 cm (Fig. 1). The base of the ulcer extended down to the fibula. Radiographic examination

Social structural factors that shape assisted injecting practices among injection drug users in Vancouver, Canada: a qualitative study

BackgroundInjection drug users (IDU) commonly seek manual assistance with illicit drug injections, a practice known to be associated with various health-related harms. We investigated the social structural factors that shape risks related to assisted injection and the harms that may result.MethodsTwenty semi-structured qualitative interviews were conducted with IDU enrolled in the ACCESS or Vancouver Injection Drug Users Study (VIDUS) who reported requiring assistance injecting in the past six months. Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted.ResultsBarriers to self-injecting included a lack of knowledge of proper injecting technique, a loss of accessible veins, and drug withdrawal. The exchange of money or drugs for assistance with injecting was common. Harms experienced by IDU requiring assistance injecting included theft of the drug, missed injections, overdose, and risk of blood-borne disease transmission. Increased vulnerability to HIV/HCV infection within the context of intimate relationships was represented in participant narratives. IDU identified a lack of services available for those who require assistance injecting, with notable mention of restricted use of Vancouver's supervised injection facility.ConclusionsThis study documents numerous severe harms that arise from assisted injecting. Social structural factors that shape the risks related to assisted injection in the Vancouver context included intimate partner relations and social conventions requiring an exchange of goods for provision of injecting assistance. Health services for IDU who need help injecting should include targeted interventions, and supervised injection facilities should attempt to accommodate individuals who require assistance with injecting.

Gender differences in hepatitis C antibody prevalence and risk behaviours amongst people who inject drugs in Australia 1998–2008

Background Global prevalence of hepatitis C virus (HCV) is estimated to be around 3% with approximately 170 million people affected. In Australia, and in many other resource rich countries, injecting drug use is the single most important risk factor for acquiring HCV, with around a third of diagnoses occurring in women. This study aims to assess gender differences in hepatitis C antibody prevalence and associated risk behaviours amongst a large sample of PWID in Australia. Methods During a one to two week period in October, PWID attending selected NSP sites are invited to participate in the Australian NSP Survey. Between 1998 and 2008, approximately 16,000 individuals completed a self-administered questionnaire and provided a capillary blood sample for HIV and HCV antibody testing. We stratified our sample by time since onset of injecting and analysed the demographic characteristics, injecting behaviours and antibody test results to determine gender differences. Results Women were found to be at increased risk of exposure to hepatitis C in all duration of injection categories except those injecting for 17 or more years. In the early years of injecting, women also reported higher rates of receptive sharing of needles and syringe and ancillary equipment when compared to men. Last injecting heroin, methadone or buprenorphine was significantly associated with HCV antibody prevalence amongst both males and females injecting for less than 5 years. Conclusion Findings indicate that women are at greater risk than men of HCV infection during the early years of injection through higher rates of receptive sharing of needles and syringes and/or ancillary equipment. Our results suggest that women who are new to injecting, and Indigenous women in particular, should be identified as priority populations when developing and implementing harm reduction strategies that target people who inject illicit drugs.

Public injecting and HIV risk behaviour among street-involved youth

Background Although street-involved youth who inject illicit drugs are known to be at an increased risk of HIV and other adverse health outcomes, little is known about public injecting among this population and how injecting in public environments may impact HIV risk behaviour. Methods We used data derived from a study of 560 street-involved youth in Vancouver, Canada to examine the factors associated with injecting in public environments among youth who reported injecting drugs in the past 6 months. Results At baseline, 162 (28.9%) reported injecting drugs in the past 6 months. Among injectors, the 124 (76.5%) participants who reported injecting in public were more likely to be homeless (odds ratio [OR] = 6.39, p < 0.001), engage in unprotected intercourse (OR = 3.09, p = 0.004), deal drugs (OR = 2.26, p = 0.032), smoke crack cocaine (OR = 3.00, p = 0.005), inject heroin (OR = 3.48, p = 0.001), drop used syringes outdoors (OR = 8.44, p < 0.001), share syringes (OR = 4.43, p = 0.004), and were less likely to clean injection sites >75% of the time (OR = 0.36, p = 0.008). The majority (62.1%) reported feeling rushed while injecting in public. Conclusions Youth who inject in public are significantly more likely to engage in sexual and injection-related risk behaviour. Given the known elevated rates of HIV infection and other harms among this population, youth-focused interventions that target both sexual and drug-related risks associated with public drug-using environments are in urgent need of evaluation.

Scaling up methadone maintenance treatment for opioid-dependent prisoners in Iran

Background Research evidence indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions including methadone maintenance treatment (MMT) have been introduced into prisons in Iran. Methods This report reviews and presents some important information extracted from published articles, and available documents on HIV sentinel surveillance and provision of MMT inside correctional settings in Iran. Results Biological surveillance data in 2005 showed that on average about 3% of prisoners in the country tested positive for HIV infection. MTT that constitutes a main component of the Prison Organisation's HIV prevention package is becoming increasingly accessible to opioid-dependent prisoners. Between 2002 and 2008, the number of opioid-dependent prisoners receiving MMT increased steadily from 100 to more than 25000. Conclusion Experiences in Iran suggest that access to MMT would be helpful for reducing illicit drug injection in a prison setting and can be considered as a major intervention for preventing the transmission of blood-borne infections among prisoners.

Injecting Illicit Substances Epidemic and Infective Endocarditis

Infective endocarditis (IE) is not the most frequent infection acquainted in intravenous drug abusers (IVDAs). On the other hand, all physicians should keep a high index of suspicion and always consider this possibility when they are dealing with an infectious process in this special population group. Since Sir William Osler, at the turn of the previous century, first described IE, there have been tremendous alterations in the very nature of this serious and possibly fatal disease. Right-sided endocarditis accounts for almost 10% of all IE episodes and has been correlated most commonly with injection of illicit drugs. However, recent reports have proposed that left-sided valves' participation is seen more often now than in the past. Although, the advances in medicine and especially modern imaging techniques have expanded our capacity to identify IE, there are still some gray areas in our ability to fully comprehend right-sided IE. Hussey et al. [1] were the first to distinguish IE as a distinct impediment of IV narcotics abuse in 1950. Although, many reports have been published since then arguing about the aspects of this medical entity, we will try here to comprehensively review the epidemiology and predisposing factors, clinical features and complications, diagnosis, treatment and prognosis of this disease, emphasizing on those distinctive or exclusive features seen in IE patients who are injecting illicit substances.