Non-injecting Routes Of Administration Research Articles

Characteristics of fatal ‘novel’ synthetic opioid toxicity in Australia

BackgroundAims: To determine 1. The characteristics of all recorded cases of fatal drug poisoning involving novel synthetic opioids (NSOs) in Australia; 2. The toxicology of cases; and 3. The major autopsy findings. MethodsReview of all fatal poisonings related to NSOs in Australia 2000–2021 identified in the National Coronial Information System. ResultsThirty-one cases were identified, 96.8% due to unintentional drug toxicity. The mean age was 31.9 years and 87.1% were male. Only six were aged over forty. A history of substance use problems was documented in 80.6% and 58.1% had a history of injecting drug use. In 32.3% the final route of administration of a NSO was by non-injecting routes of administration. Ten NSOs were identified. Fentanyl analogues were present in 67.2%, most commonly furanylfenatyl (19.4%). Other NSO types were present in 39.7%, most commonly U-47700 (35.5%). Substances other than NSOs were present in 90.3%, most commonly benzodiazepines (67.7%) and other opioids (51.6%). A CNS depressant in addition to NSOs was present in 90.3%, and a new psychoactive substance other than a NSO in 25.8%. Pulmonary oedema was diagnosed in 82.6%, aspiration of vomitus in 30.4%, and acute bronchopneumonia in 17.4%. ConclusionsTen NSOs were identified. Case characteristics suggest a younger cohort whose profile is more typical of use of other NPS than of the established opioids. A large proportion used NSOs by non-injecting routes of administration.

From Long-Term Injecting to Long-Term Non-Injecting Heroin and Cocaine Use: The Persistence of Changed Drug Habits

ObjectivesTransitioning from injecting to non-injecting routes of drug administration can provide important individual and community health benefits. We assessed characteristics of persons who had ceased injecting while continuing to use heroin and/or cocaine in New York City. MethodsWe recruited subjects entering Mount Sinai Beth Israel detoxification and methadone maintenance programs between 2011 and 2015. Demographic information, drug use histories, sexual behaviors, and “reverse transitions” from injecting to non-injecting drug use were assessed in structured face-to-face interviews. There were 303 “former injectors,” operationally defined as persons who had injected at some time in their lives, but had not injected in at least the previous 6 months. Serum samples were collected for HIV and HCV testing. ResultsFormer injectors were 81% male, 19% female, 17% White, 43% African-American, and 38% Latino/a, with a mean age of 50 (SD=9.2), and were currently using heroin and/or cocaine. They had injected drugs for a mean of 14 (SD=12.2) years before ceasing injection, and a mean of 13 (SD=12) years had elapsed since their last injection. HIV prevalence among the sample was 13% and HCV prevalence was 66%. The former injectors reported a wide variety of reasons for ceasing injecting. Half of the group appeared to have reached a point where relapse back to injecting was no longer problematic: they had not injected for three or more years, were not deliberately using specific techniques to avoid relapse to injecting, and were not worried about relapsing to injecting. ConclusionsFormer injectors report very-long term behavior change toward reduced individual and societal harm while continuing to use heroin and cocaine. The behavior change appears to be self-sustaining, with full replacement of an injecting route of drug administration by a non-injecting route of administration. Additional research on the process of long-term cessation of injecting should be conducted within a “combined prevention and care” approach to HIV and HCV infection among persons who use drugs.

Multiple routes of drug administration and HIV risk among injecting drug users

This study assesses relationships between drug administration routes and HIV serostatus, drug use, and sexual behaviors among current injecting drug users (IDUs) in Tallinn, Estonia. We recruited 350 IDUs for a cross-sectional risk behavior survey. Adjusted odds ratios (AORs) were calculated to explore injection risk behavior, sexual behavior, and HIV serostatus associated with multiple route use. Focus groups explored reasons why injectors might use non-injecting routes of administration. Those reporting multiple drug administration routes were less likely to be HIV seropositive (AOR = 0.49, 95% confidence interval [CI] = 0.25–0.97) and had almost twice the odds of having more than one sexual partner (AOR = 1.90, 95% CI = 1.01–3.60) and of reporting having sexually transmitted diseases (AOR = 2.38, 95% CI = 1.02–5.59). IDUs who engage in noninjecting drug use may be reducing their risk of acquiring HIV though sharing injection equipment, but if infected may be a critical group for sexual transmission of HIV to people who do not inject drugs.

Substance abuse professionals’ attitudes regarding harm reduction versus traditional interventions for injecting drug users

Investigations of attitudes regarding harm reduction have usually assessed the acceptance of specific interventions, but investigators have rarely compared the ratings of harm reduction interventions to the ratings of traditional interventions or tested whether the perceived value of harm reduction interventions varies as a function of client characteristics. Therefore, using a vignette describing an injecting drug user, we tested whether clinical administrators of substance abuse treatment agencies and licensed chemical dependency counselors rated the beneficence (on a 7-point scale from “Extremely Harmful” to “Extremely Beneficial”) of injection-related harm reduction interventions (e.g., cleaning needles with bleach, muscling, non-injecting routes of administration) differently from the beneficence of traditional treatment interventions (e.g., self-help group, individual and group counseling), and whether client gender and human immunodeficiency virus (HIV) status impacted such ratings. In Study One, a set of traditional interventions was rated as more beneficial than a set of harm reduction interventions. Study Two showed that a subset of harm reduction interventions designed to prevent transmission of blood-borne diseases was seen as more beneficial than a subset designed to prevent overdose fatalities. Clinical administrators rated harm reduction as more beneficial for HIV-negative clients than for those whose HIV status was described as unknown (Study One), but there was no impact of HIV status on perceived beneficence of harm reduction among licensed chemical dependency counselors (Study Two). Gender of the vignette client did not influence the beneficence ratings in either sample.

Route transition interventions: Potential public health gains from reducing or preventing injecting

Multiple factors are implicated in the diffusion of injecting drug use (IDU), including individual and demographic characteristics, drug markets, economics, social networks and political and cultural environments. However, studies show that individual transitions away from injecting are possible, and that a recent diffusion of non-injecting routes of administration (NIROA) has occurred in several countries. Injecting is more risk-laden than other routes of drug administration, yet relatively little attention has been paid to reducing or preventing injecting drug use by promoting NIROA. This commentary reviews the case for, and examples of, ‘route transition interventions’ which seek to do this. These include: prescribing oral substitutes; providing non-injecting equipment; providing safer smoking facilities; and training individuals to prevent transitions to injecting, promote NIROA, or prevent the initiation of new injectors. These initiatives have the potential—as yet largely unrealised—to offer public health gains and empower people to control and manage their drug use. Further research is needed to secure commitments at all levels to support this approach.

Transitions to Injecting and Risk of Hepatitis C Transmission among Ethnic Vietnamese Heroin Smokers in Melbourne, Australia

Background and Aims: To examine factors associated with transition from non-injecting to injecting routes of drug administration and testing antibody positive to hepatitis C virus (HCV) among ethnic Vietnamese heroin users in Melbourne, Australia. Methods: In a cross-sectional convenience survey, sample recruited by peer-workers using snowball sampling technique with a finger prick blood collection. Two-hundred ethnic Vietnamese heroin users were recruited and interviews conducted mainly in Footscray, an area of high ethnic Vietnamese residency with a prominent street based drug market. A structured questionnaire was administered. Measures included patterns of drug use, transition from smoking to injecting and vice versa, injection related risk behaviours and HCV sero-status. Results: Ninety-three percent of the sample commenced drug use by non-injecting routes of administration. More than a half had made the transition from smoking to injecting and almost two thirds of participants had ever injected. The factors associated with making this transition included being male and a longer duration of use. Prevalence of exposure to HCV among injectors was over 50%. Factors associated with being HCV positive were longer duration of injecting, sharing injecting equipment and being older. Conclusions: Smoking heroin is a common route of drug administration among heroin users of Vietnamese ethnicity in this study. The transition from smoking to injecting was very common in the sample. The need for targeted harm reduction initiatives is indicated, and these must take into account patterns of heroin use as well as the social context

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

The Threat of Hepatitis C as an Influence on Injecting Amphetamine Users' Change Towards Non-Injecting

ABSTRACT Young injecting drug users are a particularly vulnerable group for Hepatitis C (HCV) infection. One method for minimising the risk of contraction of Hepatitis C for amphetamine users (not widely explored in the research to date) is through encouraging non-injecting routes of administration (NIROA). Self-report data from 150 young injecting amphetamine users was analysed to investigate the influence of Hepatitis C threat on the decision to cease injecting and the worth of promoting the use of NIROA. Application of the Transtheoretical Model of Behaviour Change and the Expanded Health Belief Model showed that threat of Hepatitis C was not perceived as reason to cease injecting at any stage in the injecting career. Cessation was a result of personal choice, rather than response to any type of threat. This supports the promotion of harm reduction rather than abstinence campaigns. Furthermore, the deficits in knowledge of Hepatitis C threat are worthy of campaign attention.

Amphetamine use and co-occurring psychological problems: Review of the literature and implications for treatment

There has been a substantial increase in the use of amphetamine in Australia in recent years, with many users presenting with a range of psychological symptoms including those associated with mood, anxiety and psychotic disorders. Many of these symptoms are due to the direct effect of amphetamine or occur during withdrawal and resolve rapidly. However, determining whether there is a pre-existing disorder requires a careful assessment of the temporal relationship between the onset of regular drug use and symptoms, and ideally ongoing monitoring of symptoms in the absence of drug use. Treatment options need to match the diagnostic presentation, and drawing from the limited literature in this area it is recommended that amphetamine use be targeted in the first instance and other more intensive treatments follow as the diagnostic picture becomes clearer. Many people use psychostimulants and, although the majority who use occasionally by non-injecting routes of administration do not experience problems (Hall, Darke, Ross, & Wodak, 1993), it appears that as many as 30% of amphetamine users develop a psychostimulant use disorder (Hall, Teesson, Lynskey, & Degenhardt, 1998). Of particular concern is the recent increase in the use of methamphetamine across Australia (Topp, Day, & Degenhardt, 2003), a synthetic drug closely related to amphetamine but with higher abuse potential. It produces euphoric effects that are similar to, but longer lasting than those of, cocaine (Dean, 2004), with some evidence suggesting that the progression from initial use to regular and problematic use occurs more rapidly than with cocaine use (Castro, Barrington, Walton, & Rawson, 2000). There are many indications (e.g., increased availability of methamphetamine, an increasing trend towards injection, an increase in demand for treatment and reports of additional demands for emergency services) that the increase in methamphetamine use in Australia in the last 5 years will continue (Jenner & McKetin, 2004). There are now a number of studies in which the range of psychological symptoms have been documented among amphetamine users including depressed mood, anxiety, irritability, paranoia, mood swings, difficulty concentrating, aggression, hallucinations and psychosis (Topp et al., 2003). It would appear that many of these symptoms are related to the use of amphetamine and abate on cessation of use. Cross-sectional studies have suggested that perhaps up to half of regular amphetamine users report that these symptoms emerge after the commencement of regular amphetamine use (Baker et al., submitted; Hall, Hando, Darke, & Ross, 1996). However, it is possible that some symptoms may have pre-dated the use of amphetamine and may be related to the initial use of the substance. The risk of experiencing adverse effects of amphetamine appears to be related to dose, with the risk of harm reduced with less than twice weekly use and the use of small amounts (Hall & Hando, 1994). In this paper we review the literature describing the prevalence and course of the most common co-occurring psychological problems among amphetamine users. A review of treatments currently considered to be best practice will be provided and recommendations for further research suggested.

Injecting and non‐injecting cocaine use in Sydney, Australia: physical and psychological morbidity

This study aimed to examine the physical and psychological harms of cocaine use and investigate the role of injecting versus non-injecting routes of administration in the severity of such harms. Two hundred and twelve cocaine users from inner-city and south-western Sydney were administered a structured interview containing sections on demographics, drug treatment history, drug use history, cocaine use patterns, cocaine dependence and physical and psychological problems associated with cocaine use. Serious physical and psychological symptoms were prevalent among both injecting and non-injecting cocaine users. The prevalence and extent of symptoms was greater among injecting cocaine users, however route of administration did not prove to be a significant independent predictor of harm when other factors, such as frequency of use and level of dependence, were taken into account. While the level of physical and psychological harm was greater among cocaine injectors, it would appear that factors engendered by injecting, such as more frequent use and higher levels of dependence, result in higher levels of harm, rather than the route of administration per se. Physical and psychological problems were also reported among infrequent users, suggesting that cocaine can cause harm irrespective of frequency or method of use. Harm reduction initiatives should be targeted towards all cocaine users, not just those who seek treatment for dependence or present with acute medical complications.

Non-injecting routes of administration among entrants to three treatment modalities for heroin dependence.

A sample of 535 entrants to opioid dependence treatments across three treatment modalities were administered a structured interview to ascertain the prevalence of non-injecting heroin use. Ten per cent of participants had used heroin primarily by smoking/inhaling in the month preceding interview, and 9% had used heroin and other drugs exclusively by non-injecting routes. Non-injectors were younger (25.3 vs. 29.5 years), had higher levels of education (10.6 vs. 10.0 years), were more likely to be employed (33 vs. 18%) and had lower levels of recent crime (31 vs. 56%). They also had shorter heroin using careers (5.1 vs. 9.9 years), fewer symptoms of dependence (5.1 vs. 5.6), had been enrolled in fewer previous treatment episodes (3.3 vs. 11.5) and had less extensive lifetime (8.0 vs. 9.1 drug classes) and recent (3.6 vs. 4.9) polydrug use. Non-injectors were substantially less likely to report lifetime (13% vs. 58%) or recent (2% vs. 29%) heroin overdoses. There were no differences between the general physical and psychological health of the two groups. While non-injectors had a lower level of post-traumatic stress disorder (29% vs. 34%), there were no differences in levels of major depression, attempted suicide, antisocial personality disorder, or borderline personality disorder. A substantial minority of Australian treatment entrants are now using heroin exclusively by non-injecting routes. While this group is younger, and has substantially reduced risk of overdose and blood borne virus transmission, the physical and psychological health of non-injectors mirrors that of injectors.

Fatal heroin overdoses resulting from non-injecting routes of administration, NSW, Australia, 1992-1996.

To document cases of fatal heroin overdose in New South Wales by non-injecting routes of administration, and to compare the characteristics and toxicology of these cases with injecting fatalities. Examination of coronial files. New South Wales, Australia. All fatal heroin overdose cases in NSW between 1992 and 1996. There were 10 cases of death resulting from non-injecting routes of heroin administration between 1992 and 1996, representing 1% of cases. In three cases the route of administration was by inhalation, in five cases by nasal administration and in two cases by swallowing. The mean age of cases was 29.6 years, and nine of the cases were male. The median blood morphine concentration of non-injectors was 0.31 mg/l (range 0.06-0.99 mg/l). Drugs other than morphine were also detected in seven cases. Heroin overdose deaths are not restricted to the injection of heroin. While injection may constitute a greater overdose risk-factor, there is no safe, overdose-free way to use heroin.

Injecting Equipment Provision in Australia: The State of Play

Injecting equipment provision measures in Australia can be judged reasonably successful as HIV prevention measures. In the capital cities of all Australian States and Territories, access to needles and syringes is easy, at least during the day in at least some areas. In conjunction with peer education and other activities, needle and syringe supply appears to have led to a change in norms away from the sharing of needles and other injecting equipment among at least older heroin injectors in large population centers. However, in many other areas, and in many subpopulations-particularly further marginalized groups such as Aboriginal and Vietnamese-Australian injectors-messages about HIV/AIDS risk are either not penetrating or are being ignored, and needle and other equipment sharing still appears to be common. The strategy of providing access to needles and syringes as a separate activity from peer education among injecting drug users (IDUs) needs to be reconsidered in the light of the widespread epidemic of hepatitis C among Australian IDUs. The level of supply of all injecting equipment also needs to be increased to assist all IDUs in learning and carrying out an aseptic injecting technique given the lack of an effective disinfection technique to prevent the spread of hepatitis C, and me problems surrounding both the promotion of disinfection and the promotion of noninjecting routes of administration.

Injecting nation: achieving control of hepatitis C in Australia

Since Australia banned heroin in 1953 consumption of illicit drugs, deaths, crime and corruption related to drugs have steadily increased. Injecting drug use (IDU) in Australia is now a significant public health problem linked each year to approximately 500 overdose deaths and more than 6000 hepatitis C infections. At least 85% of prevalent and incident hepatitis C cases in Australia are injecting drug users (IDUs) with annual incidence estimated at 15%. Although poorly documented, increasing numbers of patients with end-stage liver disease from hepatitis C now appear to present in Australia. This reflects a heroin-injecting epidemic commencing a quarter of a century ago, the close association between drug injecting and hepatitis C and the long delay between hepatitis C infection and complications. The overall health and economic burden of hepatitis C may soon exceed HIV. Control is far more difficult to achieve for hepatitis C than HIV because of much higher baseline prevalence levels and far greater infectiousness by blood to blood spread. Transmission appears to follow minimal breaches of infection control guidelines. Hepatitis C has not yet become a priority public health issue in Australia. No national prevention strategy has been proposed. Prevention strategies (such as needle exchange or methadone) which controlled HIV among IDUs should be expanded, with the expectation of some useful reduction of spread but without achieving control of hepatitis C. Other options for control must be considered. Eradicating illicit drug use in Australia is unachievable. Virtually eradicating injecting drug use by facilitating a switch to non-injecting routes of administration (NIROA) is achievable (although difficult) and this could control hepatitis C. NIROA will have the probable additional benefit of reducing drug overdose deaths. NIROA has begun recently to replace injecting in several countries without government intervention. Powerful cultural, pharmacological and economic factors strongly reinforce drug injecting. Economic impediments to NIROA could be reduced by drug policy reform. Facilitating a switch to NIROA carries some risk of increased discrimination directed against an already marginalized population. A major obstacle to harm reduction is the common assumption that any relaxation of drug policy invariably leads to increased consumption. Switching the predominant route of administration of illicit drugs from IDU to NIROA should be the major focus of national efforts to control hepatitis C and overdose deaths in Australia.