Illicit Injection Drug Use Research Articles

The Role of Context in Integrating Buprenorphine into a Drop-In Center in Kampala, Uganda, Using the Consolidated Framework for Implementation Research.

Background: Although Africa has long borne the brunt of the human immunodeficiency virus (HIV) epidemic, until recently, the continent has been considered largely free of illicit drug use and injection drug use in particular. In Uganda, the number of people who use or inject drugs (PWUD and PWID, respectively) has increased, and PWID are a key population at high risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. However, harm reduction practices, including providing clean injection equipment and medication-assisted treatment (MAT), have only recently been piloted in the country. This project aims to integrate buprenorphine into a harm reduction drop-in center (DIC). Methods: The Consolidated Framework for Implementation Research was used to guide our preparations to integrate buprenorphine into existing practices at a harm reduction DIC. We conducted key informant interviews with members of a community advisory board and DIC staff to document this process, its successes, and its failures. Results: Results indicate that criminalization of drug use and stigmatization of PWUD challenged efforts to provide buprenorphine treatment in less regulated community settings. Conclusions: DIC staff and their commitment to harm reduction and advocacy facilitated the process of obtaining necessary approvals.

Self-reported impacts of the COVID-19 pandemic among people who use drugs: a rapid assessment study in Montreal, Canada

BackgroundPeople who use drugs (PWUD) are at high risk of experiencing indirect harms of measures implemented to curb the spread of COVID-19, given high reliance on services and social networks. This study aimed to document short-term changes in behaviours and health-related indicators among PWUD in Montreal, Canada following declaration of a provincial health emergency in Quebec.MethodsWe administered a structured rapid assessment questionnaire to members of an existing cohort of PWUD and individuals reporting past-year illicit drug use recruited via community services. Telephone and in-person interviews were conducted in May–June and September–December 2020. Participants were asked to report on events and changes since the start of the health emergency (March 13, 2020). Descriptive analyses were performed.ResultsA total of 227 participants were included (77% male, median age = 46, 81% Caucasian). 83% and 41% reported past six-month illicit drug use and injection drug use, respectively. 70% of unstably housed participants reported increased difficulty finding shelter since the start of the health emergency. 48% of opioid agonist treatment recipients had discussed strategies to avoid treatment disruptions with providers; 22% had missed at least one dose. Many participants perceived increased difficulty accessing non-addiction health care services. Adverse changes were also noted in indicators pertaining to income, drug markets, drug use frequency, and exposure to violence; however, many participants reported no changes in these areas. Among persons reporting past six-month injection drug use, 79% tried to access needle-syringe programmes during the health emergency; 93% of those obtained services. 45% tried to access supervised injection sites, of whom 71% gained entry.ConclusionsThis snapshot suggests mixed impacts of the COVID-19 pandemic on PWUD in Montreal in the months following declaration of a provincial health emergency. There were signals of increased exposure to high-risk environments as well as deteriorations in access to health services. Pandemic-related measures may have lasting impacts among vulnerable subgroups; continued monitoring is warranted.

Using actor-partner interdependence modeling to understand recent illicit opioid use and injection drug use among men in community supervision and their female partners in New York City

BackgroundThe United States’ opioid crisis disproportionately affects individuals in the criminal justice system. Intimate partners can be a source of social support that helps reduce substance use, or they can serve as a driver of continued or increased substance use. Better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions. MethodsUsing actor-partner interdependence models, we examined individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision settings in New York City (n = 229) and their female partners (n = 229). ResultsHigher levels of depression (aOR 1.98, 95% CI [1.39–2.82], p ≤ 0.01) and anxiety (aOR 1.98, 95% CI [1.42–2.75], p ≤ 0.01) were associated with recent opioid use among males in community supervision. Females with a partner having higher levels of anxiety were more likely to have recently used opioids (aOR 1.52, 95% CI [1.06–2.16], p ≤ 0.05). Males with a female partner with higher levels of anxiety (aOR 2.16, 95% CI [1.31–3.56], p ≤ 0.01) or depression (aOR 1.70, 95% CI [1.01–2.86], p ≤ 0.05) were more likely to recently inject drugs. Women with a male partner who had been in prison were more likely to have recently injected drugs (aOR 3.71, 95% CI [1.14–12.12], p ≤ 0.05), but women who had a male partner who had been arrested in the past three months were less likely to have recently injected (aOR 0.08, 95% CI [0.02–0.46], p ≤ 0.01). ConclusionsResults suggest that recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner factors, highlighting the need for couple-based approaches to address the opioid epidemic.

Validity of ICD-based algorithms to estimate the prevalence of injection drug use among infective endocarditis hospitalizations in the absence of a reference standard

BackgroundInternational Classification of Diseases (ICD) code algorithms are routinely used to estimate the frequency of illicit injection drug use (IDU)-associated hospitalizations in administrative health datasets despite a lack of evidence regarding their validity. We aimed to measure the sensitivity and specificity of ICD code algorithms used to estimate the prevalence of current/recent IDU among infective endocarditis (IE) hospitalizations without a reference standard. MethodsWe reviewed medical records of 321 patients aged 18–64 years old from an urban academic hospital with an IE diagnosis between 2007 and 2017. Diagnostic tests for IDU included self-reported IDU in medical records; a drug use, abuse and dependence (UAD) ICD algorithm; a Hepatitis C Virus (HCV) ICD algorithm; and a combination drug UAD/HCV ICD algorithm. Sensitivity, specificity and the misclassification error (ME)-adjusted IDU prevalence were estimated using Bayesian latent class models. ResultsThe combination algorithm had the highest sensitivity and lowest specificity. Sensitivity increased for the drug UAD algorithm in the ICD-10 period compared to the ICD-9 period. The ME-adjusted current/recent IDU prevalence estimated using the drug UAD and HCV algorithms was 23 % (95 % Bayesian credible interval: 16 %, 31 %). The unadjusted prevalence estimate from the drug UAD algorithm underestimated the ME-adjusted prevalence, while the combination algorithm overestimated it. ConclusionThe validity of ICD code algorithms for IDU among IE hospitalizations is imperfect and differs between ICD-9 and ICD-10. Commonly used ICD-based algorithms could lead to substantially biased prevalence estimates in IDU-associated hospitalizations when using administrative health data.

Effectiveness of medication assisted treatment for opioid use in prison and jail settings: A meta-analysis and systematic review

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.

Improving Hepatitis C Screening Rates in a Resident Clinic: A Quality Improvement Project

Introduction: Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the US. HCV is a viral liver disease that can result in cirrhosis, hepatocellular carcinoma, liver transplantation or death. CDC and USPSTF recommend HCV screening for all those born between 1945 and 1965- the baby boomer population. We designed a quality improvement project seeking to improve HCV screening rates in our ambulatory resident practice. Methods: We educated all residents and clinical staffs at ambulatory clinic by lectures, emails and weekly meetings about the importance of HCV screening in the baby boomers. All residents were asked to order a HCV Antibody profile as a screening test if the patient had never been tested. In case resident forgot to order it, then staff would order at the time of check out. If the test was positive, then patients were called and informed about the result and referred to hepatitis care clinic for further work up. Results: We screened 300 patients and 10 patients had a positive HCV screening test (3.3%). Only two patients had a positive viral load (20.0%). 5 out of 10 positive HCV positive patients had an intravenous drug abuse history (50.0%). No patient had undergone previous treatment for HCV infection. All 10 patients were referred to hepatitis care center for further monitoring. Conclusion: HCV screening is recommended in the baby boomer population (born between 1945-1965), history of illicit injection drug use or intranasal cocaine use and receipt of contaminated blood products or tissue. The initial screening test for chronic HCV infection in adults is an HCV antibody test. A reactive antibody test should be followed by a HCV RNA test. A nonreactive antibody test generally indicates the absence of chronic HCV infection. HCV screening can be increased by education and appropriate follow ups. Primary care clinics can successfully increase HCV screening in a relatively short time period. Incorporating a lecture about the new HCV screening guidelines to the ambulatory educational curriculum may be a more effective and sustainable strategy to increase HCV screening rates among residents.

Health Care Use and Health Behaviors Among Young Adults With History of Parental Incarceration.

To determine if longitudinal associations exist between parental incarceration (PI) and health care use or health behaviors among a national sample of young adults. We used the National Longitudinal Survey of Adolescent to Adult Health to examine associations between history of mother incarceration (MI) and father incarceration (FI), health care use, and 3 dimensions of health behaviors (eg, general health behaviors, substance use, and other risky behaviors) (N = 13 084). Multivariable logistic regression models accounted for individual, family, and geographic factors and generated adjusted odds ratios (aORs). Over 10% of the sample had a history of PI before the age of 18. History of MI and FI were both associated with forgone health care (aOR = 1.65 [95% confidence interval (CI), 1.20-2.27], aOR = 1.22 [95% CI, 1.02-1.47], respectively), prescription drug abuse (MI aOR = 1.61 [95% CI, 1.02-2.55], FI aOR = 1.46 [95% CI, 1.20-1.79]), and 10 or more lifetime sexual partners (MI aOR = 1.55 [95% CI, 1.08-2.22], FI aOR = 1.19 [95% CI, 1.01-1.41]). MI was associated with higher likelihood of emergency department use (aOR = 2.36 [95% CI, 1.51-3.68]), and FI was associated with illicit injection drug use (aOR = 2.54 [95% CI, 1.27-5.12]). The effects of incarceration extend beyond incarcerated individuals. PI histories are associated with lower health care use and unhealthy behaviors in young adulthood. By addressing barriers to health care and health-harming behaviors, health care providers and policy makers may reduce health disparities among this population.

Hepatitis C virus cure does not impact kidney function decline in HIV co-infected patients

To examine the impact of sustained virologic response (SVR) and illicit (injection and noninjection) drug use on kidney function among hepatitis C virus (HCV) and HIV co-infected individuals. Longitudinal observational cohort study of HCV-HIV co-infected patients. Data from 1631 patients enrolled in the Canadian Co-Infection Cohort between 2003 and 2016 were analyzed. Patients who achieved SVR were matched 1 : 2 with chronically infected patients using time-dependent propensity scores. Linear regression with generalized estimating equations was used to model differences in estimated glomerular filtration rates (eGFR) between chronic HCV-infected patients and those achieving SVR. The relationship between illicit drug use and eGFR was explored in patients who achieved SVR. We identified 384 co-infected patients who achieved SVR (53% treated with interferon-free antiviral regimens) and 768 propensity-score matched patients with chronic HCV infection. Most patients were men (78%) and white (87%), with a median age of 51 years (interquartile range: 45-56). During 1767 person-years of follow-up, 4041 eGFR measurements were available for analysis. Annual rates of decline in eGFR were similar between patients with SVR [-1.32 (ml/min per 1.73 m)/year, 95% confidence interval (CI) -1.75 to -0.90] and chronic infection [-1.19 (ml/min per 1.73 m) per year, 95% CI -1.55 to -0.84]. Among SVR patients, recent injection cocaine use was associated with rapid eGFR decline [-2.16 (ml/min per 1.73 m)/year, 95% CI -4.17 to -0.16]. SVR did not reduce the rate of kidney function decline among HCV-HIV co-infected patients. Increased risk of chronic kidney disease in co-infection may not be related to persistent HCV replication but to ongoing injection cocaine use.

Illicit Injection Drug Use as A Risk Factor for Hospital Onset Central Line-Associated Bloodstream Infection

Illicit Injection Drug Use as A Risk Factor for Hospital Onset Central Line-Associated Bloodstream Infection

The Long-Term Effectiveness of Methadone Maintenance Treatment in Prevention of Hepatitis C Virus: A Modeling Study

Background:Chronic infection with hepatitis C virus (HCV) is increasingly recognized as a major global health problem. Illicit injection drug use is an important risk factor for the rising hepatitis C virus (HCV) prevalence in IR Iran.Objectives:The objective of this study was to determine the long-term effectiveness (total quality adjusted life years (QALYs) gained) of methadone maintenance treatment (MMT program) in prevention of HCV infection among injecting drug users (IDUs).Materials and Methods:A number of Markov models were developed to model morbidity and mortality among IDUs. The input data used in modeling were collected by a self-reported method from 259 IDUs before registration and one year after MMT and also from previous studies. One way and probabilistic sensitivity analyses were done to show the effects of uncertainty in parameters on number of life years and QALYs saved. The expected consequences were estimated using a life-time time horizon for the two strategies including implementation and not implementation of the MMT program.Results:Our model estimated that total number of discounted life years lived per IDU with and without the MMT program would be 5.15 (5.05 - 5.25) and 4.63 (4.42 - 4.81), respectively. The model also estimated that total number of discounted QALYs lived per IDU with and without the MMT program would be 4.11 (3.86 - 4.41) and 2.45 (2.17 - 2.84). Simulation results indicated that all differences in life years and QALYs lived between the two strategies were statistically significant (p < 0.001). Based on our model, total discounted life years and QALYs saved in a cohort of 1000 IDUs were 1790 (1520 - 2090) and 1590 (1090- 2090), respectively.Conclusions:Considering the high prevalence of illicit injecting drug use in Iran and MMT effectiveness in prevention of HCV infection, it is necessary to develop MMT centers at regional and national levels.

Neighborhood of residence and risk of initiation into injection drug use among street-involved youth in a Canadian setting

BackgroundWhile research has suggested that exposure to environments where drug use is prevalent may be a key determinant of drug-related risk, little is known regarding the impact of such exposure on the initiation of illicit injection drug use. We assessed whether neighborhood of residence predicted rates of injecting initiation among a cohort of street-involved youth in Vancouver, British Columbia. MethodsWe followed street-involved injecting naïve youth aged 14–26 and compared rates of injecting initiation between youth residing in Vancouver's Downtown Eastside (DTES) neighborhood (the site of a large street-based illicit drug market) to those living in other parts of the city. Univariate and multivariate Cox regression analyses were employed to determine whether residence in the DTES was independently associated with increased risk of initiation of injection drug use. ResultsBetween September, 2005 and November, 2011, 422 injection-naïve individuals were followed, among whom 77 initiated injecting for an incidence density of injecting of 10.3 (95% confidence interval [CI] 5.0–18.8) per 100 person years. In a multivariate model, residence in the DTES was independently associated with initiating injection drug use (adjusted hazard ratio [AHR]=2.16, 95% CI: 1.33–3.52, p=0.002). ConclusionsThese results suggest neighborhood of residence affects the risk of initiation into injection drug use among street-involved youth. The development of prevention interventions should target high-risk neighborhoods where risk of initiating into injecting drug use may be greatest.

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.

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.

Resilience from the perspective of the illicit injection drug user: An exploratory descriptive study

Background Illicit injection drug use and its attendant harms are a key health and social concern. Resilience-based strategies have the potential to complement existing approaches, but there is a paucity of research on resilience. This study identifies and explores manifestations of resilience among illicit drug users (IDUs), including indicators of cognitive transformation at key turning points, and protective factors associated with enhanced resilience. Method A secondary analysis was conducted on data collected from a larger qualitative study involving 41 injection drug users and 45 service providers and community leaders. A conceptualization of resilience as a relative and dynamic process manifesting at key ‘turning points’ provided a lens to frame the analysis, which was also informed by the resilience models of Garmezy [Garmezy, N. (1991). Resiliency and vulnerability to adverse developmental outcomes associated with poverty. American Behavioral Scientist, 34, 6–430.] and Werner and Smith [Werner, E., & Smith, R. (1982). Vulnerable but invincible: A longitudinal study of resilient children and youth. New York: McGraw-Hill.]; instances of cognitive transformation [Tebes, J. K., Irish, J. T., Vasquez, M. J. P., & Perkins, D. V. (2004). Cognitive transformation as a marker of resilience. Substance Use & Misuse, 39, 769–788.] were also identified. Analytic techniques of constant comparison and open coding [Morse, J. M., & Field, P. A. (1995). Qualitative research methods health professionals (2nd ed). Thousand Oaks, CA: Sage.] were used. Results Key turning points reflecting resilience were captured by two themes. First, participants described how “Getting to the Point of Change” involved particular cognitive and emotional mechanisms encompassed within this theme: “Recognizing it's not Worth it”, “Getting Scared” and “Recognizing an Inner Desire to Quit”. The second manifestation of resilience centred on the enactment of hope in goal-setting, and entailed “Envisioning a Better Future.” In contrast, descriptions of the need to dull past and present hopelessness and pain suggested the suppression of resilience. Hope and a sense of control were particular manifestations of resilience. Other factors (physical or emotional pain, frightening experiences, witnessing or experiencing negative costs) were protective for some individuals but suppressed resilience in others. Conclusion The findings support the usefulness of the concept of resilience in understanding cognitive and behavioural change among IDUs, and provide a promising direction for future research.

Trends in HIV/AIDS Diagnoses Among Men Who Have Sex With Men—33 States, 2001-2006

In 2008, CDC conducted an analysis of trends in diagnoses of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) among men who have sex with men (MSM) in the 33 states that have had confidential, name-based HIV case reporting since at least 2001. This report summarizes the results of that analysis, which indicated that the number of HIV/AIDS diagnoses among MSM overall during 2001-2006 increased 8.6% (estimated annual percentage change [EAPC] = 1.5). During 2001-2006, an estimated 214,379 persons had HIV/AIDS diagnosed in the 33 states. Of these diagnoses, 46% were in MSM, and 4% were in MSM who engaged in illicit injection-drug use (IDU) (i.e., MSM and IDU). To reduce the impact of HIV/AIDS in the United States, HIV prevention services that aim to reduce the risk for acquiring and transmitting infection among MSM and link infected MSM to treatment must be expanded.

A 54-year-old man with slowness of movement and confusion

This patient’s history dated back to 1 year prior to presentation. He had acute pancreatitis of uncertain cause. He did not drink alcohol and no gallstones were identified. He did develop a pancreatic pseudocyst following which was followed by CT and thought to be diminishing in size. He was in his normal state of health prior to this with no significant past medical history. He became fatigued after the pancreatitis. His wife then noticed reduced facial expression and some confusion, such as misplacing his billfold and being unable to find it. Clear episodes of amnesia or memory loss were difficult to specify. He discontinued driving because of these problems and being bothered by the movements of cars and the car lights bothering his eyes. The patient reported slowness of movement, trouble with balance, rare twitching of muscles, and mild stooped posture, photosensitivity, mild lightheadedness on standing, and hypophonia. He reported increased startle and a few jerks occurring during sleep. He also reported a few screams at night but there was no strong suggestion of REM sleep behavior disorder. He denied tremors, micrographia, muscle stiffness, trouble with eye movements, neck stiffness, motor weakness, dysphagia, dysarthria, shuffling, reduced arm swing, involuntary wandering of arm or leg, excessive drooling, erectile dysfunction, tinnitus, tongue biting, anhidrosis, repeating himself, forgetfulness during mid-sentence, fluctuating cognition, difficulty falling asleep, trouble recognizing familiar faces, hallucinations, problems reading, writing, or spelling, problems with language, deja vu, loss of emotion, or behavioral dyscontrol. His past medical history was remarkable for hypertension, possible depression, and the episode of pancreatitis. His medications on presentation were venlafaxine 75 mg once daily and metoprolol 25 mg twice daily. He was a lifetime nonsmoker, did not drink alcohol, and had no history of illicit injection drug use or significant travel history. His paternal grandfather had …

Nationwide Increase in the Number of Hospitalizations for Illicit Injection Drug Use-Related Infective Endocarditis

Infective endocarditis is a potentially fatal consequence of illicit injection drug use. We estimate that the number of hospitalization for injection drug use-related infective endocarditis increased by 38%-66% in the United States between 2000-2001 and 2002-2003, a period during which the number of at-risk persons (i.e., injection drug users) remained stable. Increasing methamphetamine use and/or drug injection frequency may have increased the incidence of infective endocarditis among active injection drug users.

Therapie der chronischen Hepatitis C im Rahmen einer heroingestützten Behandlung

A 37-year-old man with a 19-years history of injection drug use (IDU) who had acquired a chronic hepatitis C virus (HCV-) infection 9 years ago, entered the German clinical study on heroine assisted treatment ("Modellprojekt zur heroingestützten Behandlung Opiatabhängiger"). Before study onset he received buprenorphine maintainance treatment, while at the same time engaging in illicit IDU (heroine, cocaine). He lived in a caravan and was on social welfare. PCR revealed a genotype 2 and an HCV-viral load of 310,000 IU/ml. Liver biopsy showed a moderate chronic active hepatitis and a mild portal fibrosis without signs of liver cirrhosis. Within the heroine-assisted treatment program the patient injected heroine under medical supervision several times a day and attended the standardized psychosocial program that comprised an intensive education on HCV-infection. Within a period of ten months of physical and social stabilization he managed to stop illicit drug use, found stable housing and started to work. We then initiated treatment of HCV-infection. Subcutaneous pegylated interferon alpha-2a, peroral ribavirin and intravenous heroine were administered as directly observed therapy. Based on the close mashed care of the heroine assisted treatment setting, side effects were well controllable and reversible after the end of antiviral therapy. A sustained response was obtained. After careful indication, heroine-assisted treatment with particularly intensive medical and psychological care can offer appropriate conditions for a save and successful treatment of hepatitis C as well as for a sustained result.

Hepatitis C virus reinfection in injection drug users

Spontaneous clearance of hepatitis C (HCV) may provide protection against reinfection. In a large community-based cohort study of 3,553 inner-city residents (mainly injection drug users), we identified HCV-infected individuals in whom virological clearance had occurred and compared the rate of reinfection in this group with that observed in previously uninfected members of the same cohort. We identified 926 HCV-uninfected and 658 HCV-infected viremic subjects at baseline, with 152 of 658 (23.1%) spontaneously clearing viremia over a median follow-up of 5.2 years (IQR, 2.8-7.4). At baseline, individuals with HCV clearance were more likely to be HIV coinfected (P < .001) and to be engaged in frequent illicit drug use (P = .004) and injection drug use (P < .001). The occurrence of HCV infection was lower in individuals with previous infection (14/152, 9.2%) compared with that in those without previous infection (172/926, 18.6%), with incidence rates of 1.8 (95% CI, 0.9-3.0 cases/100 person-years) and 8.1 (95% CI, 6.9-9.4 cases/100 person-years) cases/100 person-years, respectively, after accounting for follow-up. In a logistic regression analysis, with previous HCV infection assessed as a covariate with other potential confounding variables (age, sex, ethnicity, HIV infection, housing status, and illicit and injection drug use), individuals with previous HCV infection and viral clearance were 4 times less likely to develop infection than those infected for the first time (adjusted odds ratio, 0.23; 95% CI, 0.10-0.51, P < .001). In conclusion, individuals with clearance of HCV infection may have a lower risk of acquiring HCV than individuals who have never been infected, despite ongoing exposure to HCV.

The public health and social impacts of drug market enforcement: A review of the evidence

The primary response to the harms associated with illicit injection drug use in most settings has involved intensifying law enforcement in an effort to limit the supply and use of drugs. Policing approaches have been increasingly applied within illicit drug markets since the 1980s despite limited scientific confirmation of their efficacy. On the contrary, a growing body of research indicates that these approaches have substantial potential to produce harmful health and social impacts, including disrupting the provision of health care to injection drug users (IDU), increasing risk behaviour associated with infectious disease transmission and overdose, and exposing previously unaffected communities to the harms associated illicit with drug use. There are, however, alternatives to traditional targeted enforcement approaches that may have substantially less potential for negative health and social consequences and greater potential for net community benefit. Some of these approaches involve modifying policing practices, fostering partnerships between policing and public health agencies, and developing systems to monitor policing practices. Other alternatives involve the provision of harm reduction services, such as safer injecting facilities, that help to minimize drug-related harms, and addiction treatment services which ultimately help to reduce the demand for illicit drugs.