Injecting Drug Misusers Research Articles

Community pharmacists, injecting drug misusers and the reduction of HIV transmission

Abstract The role of 268 community pharmacists in reducing human immunodeficiency virus (HIV) transmission by providing advice and injecting equipment to drug addicts was investigated. Postal questionnaires were issued to proprietors or managers of all (362) community pharmacies in two family health services authorities within the North West Thames regional health authority to determine their current activities concerning the reduction of HIV transmission between injecting drug misusers (IDMs). More than half of the pharmacists supplied injecting equipment to IDMs, most frequently as 1ml disposable insulin syringes. Eleven per cent of those pharmacies from which equipment was sold provided disposal facilities. More than half of those without disposal facilities failed to provide information regarding safe disposal when supplying injecting equipment. Virtually all the pharmacists surveyed did not supply accompanying health education literature when they sold injecting equipment

Supplying injecting equipment to drug misusers: a survey of community pharmacists' attitudes, beliefs and practices

AbstractA postal survey of 888 community pharmacists in one metropolitan administrative region of southern England investigated the pharmacists' involvement in the supply of injecting equipment to injecting drug misusers (IDMs). The survey response rate was 59 per cent. Of respondents, 58 per cent sold injecting equipment and almost 10 per cent supplied it via “exchange” schemes. The respondents' attitudes and beliefs towards provision of injecting equipment were measured on a five point scale. Providers of injecting equipment were significantly more likely than non-providers to have a positive attitude towards supply, to perceive greater demand for injecting equipment, and to believe that “important others,” such as the pharmacy clientele and other health professionals, would like them to make equipment available. Certain demographic variables and specific beliefs were identified which differentiated between providers and non-providers of injecting equipment. Pharmacists who did not supply injecting equipment were significantly more likely than providers to believe in negative outcomes of supply, such as theft from the pharmacy. The strong associations identified in this study, between service provision, attitudes and beliefs, have implications for shaping attitudes and encouraging pharmacists' future involvement in HIV-prevention initiatives.

Validating estimates of problematic drug use in England

BackgroundUK Government expenditure on combatting drug abuse is based on estimates of illicit drug users, yet the validity of these estimates is unknown. This study aims to assess the face validity of problematic drug use (PDU) and injecting drug use (IDU) estimates for all English Drug Action Teams (DATs) in 2001. The estimates were derived from a statistical model using the Multiple Indicator Method (MIM).MethodsQuestionnaire study, in which the 149 English Drug Action Teams were asked to evaluate the MIM estimates for their DAT.ResultsThe response rate was 60% and there were no indications of selection bias. Of responding DATs, 64% thought the PDU estimates were about right or did not dispute them, while 27% had estimates that were too low and 9% were too high. The figures for the IDU estimates were 52% (about right), 44% (too low) and 3% (too high).ConclusionThis is the first UK study to determine the validity estimates of problematic and injecting drug misuse. The results of this paper highlight the need to consider criterion and face validity when evaluating estimates of the number of drug users.

Vascular complications of injecting drug misuse.

Drug misuse is now a significant problem in western society; many different pharmaceuticals are administered by drug abusers as intravenous preparations. This has resulted in an increasing number of complications associated with prolonged intravascular and perivascular injection of abused substances. These complications of intravenous drug abuse may lead to limb-threatening arterial injuries that present a considerable management problem in patients who often have significant comorbidity. This article provides a comprehensive review of the vascular complications that result from drug misuse by injection. It discusses the aetiology and clinical features of these complications and highlights the limited role of both the general surgeon and specialist vascular surgeon in the management of these patients.

Impact of a newly opened prison on an accident and emergency department

Objective: To determine the impact of a newly opened prison on an accident and emergency (A&E) department. Method: A new category B prison opened in April 1999, the first privately...

Which drugs cause overdose among opiate misusers? Study of personal and witnessed overdoses

AbstractConcern has been expressed at the widespread prescribing of methadone in view of its inherent toxicity. Commentators have opined that methadone is more toxic than heroin and causes more overdose deaths. However, data deficiencies and flawed analyses leave continuing uncertainty about this crucial policy issue. The relative contributions of heroin, other opiates (e.g. methadone) and non‐opiate drugs to overdose and overdose deaths among drug misusers were examined in a community‐recruited sample of 312 injecting drug misusers in London. Data were collected on last personal overdose (n=117), last witnessed overdose (n=167) and last witnessed fatal overdose (n=55), and on the different drugs that had been involved with these overdoses. Heroin was involved in 83% of last personal overdoses, 90% of last witnessed overdoses and 80% of last witnessed fatal overdoses, while other opiates were involved in only 18%, 8% and 26%, respectively. Methadone accounted for about half of these “other opiate” overdoses. Overdoses involving a combination of heroin and a non‐opiate were common − 29%, 21% and 39%, respectively. Heroin was the drug most frequently involved in overdose across all three areas of study. However, combinations of heroin and a non‐opiate were surprisingly frequent, especially in witnessed fatal overdoses (as reported recently by other investigators using different methodologies). Considering the wide extent of methadone prescribing to this group, methadone was remarkably infrequently reported as responsible (solely or in combination) for either personal overdoses, witnessed overdoses or witnessed fatal overdoses.

Preventing opiate overdose fatalities with take-home naloxone: pre-launch study of possible impact and acceptability.

Before proceeding with the introduction of an overdose fatality prevention programme including teaching in cardio-pulmonary resuscitation and distribution of naloxone, a pre-launch study of treatment and community samples of injecting drug misusers has been undertaken to establish (i) the extent of witnessing overdoses, (ii) the acceptability of naloxone distribution and training; and (iii) the likely impact of such measures. Structured interview of two samples: (a) a community sample of injecting drug misusers recruited by selected privileged access interviewers (PAI) and interviewed by them in community settings and (b) a treatment sample of opiate addicts recruited from our methadone maintenance clinic (interviewed by in-house research staff). (a) Three hundred and twelve injecting drug misusers with a history of having injected and currently still using injectable drugs; and (b) 142 opiate addicts in treatment at our local catchment area methadone maintenance clinic in South London. History of personal overdose was found with 38% of the community sample and 55% of the treatment sample--mainly involving opiates and in the company of friends. Most (54% and 92%, respectively) had witnessed at least one overdose (again mostly involving opiates), of whom a third had witnessed a fatal overdose. Only a few (35%) already knew of the existence and effects of naloxone. After explanation to the treatment sample, 70% considered naloxone distribution to be a good proposal. Of the 13% opposed to the proposal, half thought it may lead them to use more drugs. Eighty-nine per cent of those who had witnessed an overdose fatality would have administered naloxone if it had been available. We estimate that at least two-thirds of witnessed overdose fatalities could be prevented by administration of home-based supplies of naloxone. Substantial proportions of both community and treatment samples of drug misusers have witnessed an overdose death which could have been prevented through prior training in resuscitation techniques and administration of home-based supplies of naloxone. Such a new approach would be supported by most drug misusers. On the basis of these findings, we conclude that it is appropriate to proceed to a carefully constructed trial of naloxone distribution.

Heroin overdose among a treatment sample of injecting drug misusers: accident or suicidal behaviour?

Overdose is a common cause of premature death in opiate misusers. Substance misuse is known to increase the risk of completed suicide. The relationship between ‘non-intentional overdoses’ and ‘intentional overdoses’ or suicides is unclear. In order to investigate this relationship a semi-structured interview investigating the history of heroin overdose and suicidal thoughts and behaviour was undertaken with 48 injecting drug misusers attending a South London community-based treatment centre. Fifty-four percent had previously overdosed on heroin, and 35% had made a suicide attempt. A history of suicide attempts and history of heroin overdose were significantly associated. However, heroin overdose as a means of attempting suicide was uncommon, with the majority reporting overdose by use of other drugs. It is concluded that heroin overdose and history of suicide attempts were both common. Although heroin overdose was seldom chosen as a suicide method, the findings suggest that the risks of non-intentional heroin overdose and of suicide overlap. Non-intentional overdoses and suicide attempts should be regarded as risk markers for each other.

AIDS and Drug Misuse in the UK-10 Years on: Achievements, failings and new harm reduction opportunities

The year 1988 saw the publication of the influential first AIDS and Drug Misuse report from the Advisory Council on the Misuse of Drugs (ACMD, 1988) in the UK. Most of the policy documents and developments of practice in the intervening years can be seen as merely following through on the recommendations from this seminal 1988 report. Ten years on, it is appropriate to take stock of the situation and to describe some of the successes, reflect on the failures, and speculate on possible new areas of development in the harm reduction field. This paper comprises four parts. Firstly, what was new about the health risk facing the broader population of drug injectors—and how did this lead lo the public health approach that was adopted to dealing with the problems of HIV amongst injecting drug misusers? Secondly, an examination is required as to how concerns about HIV transmission have brought a new focus to the work of existing treatment services, as well as being the birthright of the new services established in the wake of HIV awareness. Thirdly, the spotlight should be shone on those areas in which we have failed to respond adequately, and a consideration should be made of the reasons underlying these disappointing failures of policy and practice. Fourthly, an exploration is necessary in order to chart some of the new areas in which it may be possible for new harm reduction opportunities to be developed.

Screening asymptomatic people at high risk for hepatitis C. The case for.

In some respects hepatitis C is hepatitis B revisited. Years after the discovery of hepatitis B virus and 11 years after development of a safe, efficacious vaccine, consensus has emerged in the international health community that decisive global action against hepatitis B is a necessity.1 Those who doubt that a similar approach will be needed towards hepatitis C point to a relative lack of knowledge of the clinical course of hepatitis C and the efficacy of treatment. In 1989 hepatitis C virus was cloned and characterised as a positive sense, single stranded RNA genome containing 9400 nucleotides. It is a major cause of post-transfusion hepatitis2; up to 50% of patients commonly progress to chronic hepatitis and 20% to cirrhosis with secondary complications such as hepatocellular carcinoma.3 A problem arises because hepatitis C may have a progressive course to chronic disease occurring over decades, during which time the individual may be symptom free and the disease remain undiagnosed until the patient presents with liver disease or its complications.2 3 In the United States 3.5 million people are estimated to have chronic hepatitis C; of these, 8000-10000 die of liver related complications and 1000 undergo liver transplantation.4 Around 23% of patients given a transplant had hepatitis C virus, and 19% of those given transplants for seronegative cryptogenic cirrhosis developed hepatitis C after transplantation.4 5 Prevalence is similar in Europe and higher in Japan and other eastern countries. The hepatitis C virus is transmitted parenterally through blood, blood products, injecting drug misuse, and tattooing, as well as by sexual6 and household transmission. Serological identification of hepatitis C virus by second and …

HIV subtype may explain sexual transmission

A subtype of HIV that spreads more easily in heterosexual than homosexual men or injecting drug misusers may explain different patterns of transmission of the disease worldwide. In Thailand, India, and sub-Saharan Africa about 90% of HIV-1 infections are acquired through heterosexual contact compared with 10% in the US and western Europe. So far scientists have identified nine subtypes of HIV-1 from A through to I. Subtypes A, C, and D predominate in Africa, E and B are common in Thailand, and C is the main type in India. In the US and western …

The development of healthcare services for drug misusers and prostitutes.

With the advent of human immunodeficiency virus (HIV) and the increase of drug misuse in the UK, the Government wishes primary care to play a greater part in treating drug problems in the hope of preventing the spread of HIV. Drug misusers do not avail themselves of traditional services and many are not registered with general practitioners. In response to this Liverpool Health Authority and Family Health Service Authority commenced a new salaried post to provide primary care services to special groups such as injecting drug misusers and prostitutes. Judgemental attitudes towards drug misusers, their high mobility and being a transient population play a part in the reasons why drug misusers find it difficult to access primary healthcare. Drug misusers have high morbidity related to their drug misuse. Many of these conditions, if treated early, can prevent the need for more intensive intervention. Although drug misusers may present with a condition requiring immediate treatment, the opportunity is used to provide other healthcare such as hepatitis B vaccinations, sexually transmitted infection screening, contraception and HIV/hepatitis B testing. The sero prevalence of anti-HBc in injecting drug misusers is 45.5%. Due to their high morbidity and associated costs, the requirements of these groups may conflict with the objectives of budget-holding practices. If general practitioners are unable to respond to their problems, then health care providers and purchasers will have to consider similar schemes in areas which have a higher prevalence of drug misuse in order to provide appropriate healthcare for these vulnerable groups.

US: Injecting drug misuse is rare in prisons

US: Injecting drug misuse is rare in prisons

Building a city wide service for exchanging needles and syringes.

How best can injecting drug misusers obtain clean injecting equipment in a city where drug injecting is widespread? An exchange service for needles and syringes throughout Glasgow has been established in health centres and clinics in the evening. Over the past four years seven new exchanges have been opened and over 2700 injecting drug misusers have attended. Attendances rose from under 1000 in 1988 to 28,000 in 1992. The exchanges also provide a wide range of other health and social services. Public hostility to the exchanges has abated. During the same period equipment sharing in the city diminished and the observed prevalence of HIV among injecting drug misusers stabilised at around 1%.

The health of the nation: responses. Injecting drug misuse.

The health of the nation: responses. Injecting drug misuse.

Progression of HIV infection in misusers of injected drugs who stop injecting or follow a programme of maintenance treatment with methadone.

To see whether misusers of injected drugs who stop injecting or switch to a programme of maintenance treatment with methadone have a reduced risk of progression of HIV infection when compared with a group of persistent misusers. Observational cohort study in HIV seropositive subjects with a current or past history of misusing injected drugs. HIV outpatient clinic at the University Hospital of Zurich, Switzerland. 297 Current and former parenteral drug misusers (median age 27) with asymptomatic HIV infection. During the observation period 80 subjects adhered to a programme of maintenance treatment with methadone, 124 continued with parenteral drug misuse, and 93 former misusers remained free of illicit drugs. No antiretroviral treatment was given during the study. Probability of progression of HIV infection from asymptomatic to symptomatic (Centers for Disease Control stage IV) as calculated by life table analysis and compared in the three groups of patients by means of a log rank test, and predictors of disease progression as analysed with a Cox proportional hazards regression model. The 297 patients were followed up for a median of 16 months. The median duration of injecting drug misuse before enrollment was 7.1 years. There were no significant differences among the three groups with respect to CD4+ counts at the beginning of the study (median 0.44 x 10(9)/l). Life table analysis showed a significantly lower probability of progression of HIV disease in both the methadone treated group and former drug misusers than in persistent injecting drug misusers. Multivariate regression analysis showed a relative risk of progression of the disease of 1.78 (95% confidence interval 1.20 to 2.67; p less than 0.01) in persistent injecting drug misusers, 0.48 (0.29 to 0.77; p less than 0.01) in the methadone treated group, and 0.66 (0.41 to 1.06; p = 0.085) in former drug misusers. Stopping the misuse of injected drugs slows the progression of HIV disease in infected subjects. Drug treatment programmes are effective in secondary prevention of HIV associated morbidity.

Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales.

To determine the current and potential roles of community pharmacists in the prevention of AIDS among misusers of injected drugs. Cross sectional postal survey of a one in four random sample of registered pharmacies in England and Wales. Project conducted in the addiction research unit of the Institute of Psychiatry, London. 2469 Community pharmacies in the 15 regional health authorities in England and Wales. Willingness of pharmacists to sell injecting equipment to known or suspected misusers of drugs; pharmacists' attitudes to syringe exchange schemes, keeping a "sharps" box for use by misusers of drugs, and offering face to face advice and leaflets; and opinions of community pharmacists on their role in AIDS prevention and drug misuse. 1946 Questionnaires were returned, representing a response rate of 79%. This fell short of the target of one in four pharmacies in each family practitioner committee area in England and Wales, and total numbers of respondents were therefore weighted in inverse proportion to the response rate in each area. The findings disclosed a substantial demand for injecting equipment by drug misusers. After weighting of numbers of respondents an estimated 676 of 2434 pharmacies were currently selling injecting equipment and 65 of 2415 (3%) were participating in local syringe exchange schemes; only 94 of 2410 pharmacies (4%) had a sharps box for used equipment. There was a high degree of concern among pharmacists about particular consequences of drug misusers visiting their premises, along with a widespread acceptance that the community pharmacist had an important part to play. Promoting the participation of community pharmacists in the prevention of AIDS among misusers of injected drugs is a viable policy, but several problems would need to be overcome before it was implemented.