Multiple risks for HIV and hepatitis B infection among heroin users

This study investigates the extent to which heroin users are exposed to multiple forms of infection risk. Structured interviews were administered to a prospective network sample of 408 heroin users. Subjects were contracted in south London in a wide range of social settings by specially recruited privileged access interviewers. Most heroin users (74.5%) had been exposed to more than one infection risk factor and more than half of the sample had been exposed to three or more risk factors. HIV serostatus was primarily related to men having sex with men. Hepatitis B seropositive status was primarily related to the number of years injecting drugs. At this stage of the HIV epidemic in London, HIV infection among heroin users may be related more to homosexual risk behaviour than drug risk factors. Heroin injectors were at greater risk of infection than heroin chasers both through their sexual behaviour as well as through their injecting practices. Heroin users who refused to give a saliva sample for analysis were found to be more likely to engage in several health risk behaviours than those who provided samples. This finding has important methodological implications for seroprevalence surveys. Other implications of the results for prevention programmes aimed at health risk behaviours of heroin users are also discussed.

Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial

BACKGROUND

Naltrexone has considerable potential in helping to prevent relapse in heroin dependency. A longer-lasting formulation for naltrexone treatment is desirable to further reduce non-adherence and relapse during treatment of opiate dependence.

AIMS

To evaluate the safety and effectiveness of a 6-month naltrexone implant in reducing opioid use after in-patient treatment.

METHOD

A group of 56 abstinence-oriented patients who completed in-patient treatment for opioid dependence were randomly and openly assigned to receive either a 6-month naltrexone implant or their usual aftercare. Drug use and other outcomes were assessed at 6-month follow-up.

RESULTS

Patients receiving naltrexone had on average 45 days less heroin use and 60 days less opioid use than controls in the 180-day period (both P<0.05). Blood tests showed naltrexone levels above 1 ng/ml for the duration of 6 months. Two patients died, neither of whom had received an implant.

CONCLUSIONS

Naltrexone implant treatment safely and significantly reduces opioid use in a motivated population of patients.

Prevalence and clinical relevance of corrected QT interval prolongation during methadone and buprenorphine treatment: a mortality assessment study

AIMS

To determine the prevalence of corrected QT interval (QTc) prolongation among patients in opioid maintenance treatment (OMT) and to investigate mortality potentially attributable to QTc prolongation in the Norwegian OMT programme.

PARTICIPANTS AND SETTING

Two hundred OMT patients in Oslo were recruited to the QTc assessment study between October 2006 and August 2007. The Norwegian register of all patients receiving OMT in Norway (January 1997-December 2003) and the national death certificate register were used to assess mortality. Mortality records were examined for the 90 deaths that had occurred among 2382 patients with 6450 total years in OMT.

DESIGN AND MEASURES

The QTc interval was assessed by electrocardiography (ECG). All ECGs were examined by the same cardiologist, who was blind to patient history and medication. Mortality was calculated by cross-matching the OMT register and the national death certificate register: deaths that were possibly attributable to QTc prolongation were divided by the number of patient-years in OMT.

FINDINGS

In the QTc assessment sample (n = 200), 173 patients (86.5%) received methadone and 27 (13.5%) received buprenorphine. In the methadone group, 4.6% (n = 8) had a QTc above 500 milliseconds; 15% (n = 26) had a QTc interval above 470 milliseconds; and 28.9% (n = 50) had a QTc above 450 milliseconds. All patients receiving buprenorphine (n = 27) had QTc results <450 milliseconds. A positive dose-dependent association was identified between QTc length and dose of methadone, and all patients with a QTc above 500 milliseconds were taking methadone doses of 120 mg or more. OMT patient mortality, where QTc prolongation could not be excluded as the cause of death, was 0.06/100 patient-years. Only one death among 3850 OMT initiations occurred within the first month of treatment.

CONCLUSION

Of the methadone patients, 4.6% had QTc intervals above 500 milliseconds. The maximum mortality attributable to QTc prolongation was low: 0.06 per 100 patient-years.

‘Horse trading’: prescribing injectable opiates to opiate addicts. A descriptive study

The clinical audit of 40 opiate-dependent individuals who were prescribed injectable drugs (heroin or methadone) between June 1987 and June 1989 is described. These subjects were characterized by the chronicity of their injecting and dependent opiate use, and by their refusal to comply with a treatment programme involving oral-only prescribing. The key aim was to attract entrenched injectors into contact with treatment services and to promote movement away from injecting drug use and reduce HIV risk behaviour. On review 35 of the original 40 were either still receiving an injectable prescription or injecting illicit drugs. Despite this 14 (35%) were rated as making positive life changes. Nine (22.5%) had been admitted to the in-patient unit and became drug free during their stay. The stability of the lives of eight (20%) had deteriorated. The benefits and drawbacks of this form of intervention are discussed with comparison to the other studies of injectable drug prescribing.

Validity and reliability of the Severity of Dependence Scale (SDS) in a Brazilian sample of drug users

The Severity of Dependence Scale (SDS) is a short, five-item scale which provides a measure of degree of dependence upon different drugs. The present study explores the validity and reliability of a Portuguese version of the instrument with a sample of 374 Brazilian drug users. Concurrent validity of the SDS was assessed in relation to reported quantity of drugs used and to DSM-IV dependence items, and test-retest reliability was assessed with a subsample of 42 subjects. The SDS total scores for powder cocaine, crack cocaine, cannabis and alcohol were significantly and highly positively correlated with severity of dependence as measured by DSM-IV, and with the estimated quantity of drugs used in the last month. Test-retest coefficients were high for all drugs studied. Principal components analysis showed that the SDS scores lie on a single dimension with the exception of crack cocaine where scores lie on a single dimension for treatment attenders and on two dimensions for community samples. The results indicate that the Portuguese version of the SDS is a valid research tool for measuring severity of dependence upon powder cocaine (snorted), crack cocaine (smoked), cannabis and alcohol.

Training primary health care workers about drugs: a national survey of UK trainers' perceptions towards training

Reports have consistently shown that non-specialist drug workers (whose working role is not specifically concentrated on dealing with drug-related issues) are reluctant to work with drug users. A number of explanations have been offered to account for this unwillingness including attitudinal factors, occupational constraints and a lack of motivation to learn about drug-related issues. Previously, it has been shown that training affects commitment to working with substance misusers, although failure to attract particular professional groups (e.g. general practitioners) into training courses has also been reported. No previous research has examined the views of trainers about training primary health care and health-related workers. This study of a (non-probability) sample of UK drug trainers (n = 145) assessed training activity for different health care workers, and trainers' differential perceptions of training needs and methods. GPs were the group least likely to become trained about drug issues. Training in attitudes towards drug using individuals was perceived to be more important than either skills or knowledge training for GPs, practice nurses, other nurses and probation officers. Experiential training methods were perceived to be more important than a didactic approach for training all health groups except GPs for whom lecture type instruction was believed to be equally appropriate. Seventy-nine percent of subjects reported providing training across drugs in alcohol or drugs, alcohol and tobacco. Most trainers who stated that certain professions required independent training believed that GPs should be trained separately from other groups.

Heroin in the United Kingdom: different forms, different origins, and the relationship to different routes of administration

Heroin exists in the United Kingdom in several different forms, which vary not only in their country of origin and purity, but also in their suitability for use by either injecting or by 'chasing the dragon'. The availability of these different forms of heroin has varied considerably over time. A review of the characteristics and availability of these various forms of heroin in recent years is presented, accompanied by consideration of their probable intended use by injection or by 'chasing the dragon'. Samples of black market heroin in the salt form are usually used by injection, whereas the base form is usually taken by 'chasing the dragon'. The heroin yield to the drug user from samples of heroin taken by 'chasing the dragon' varies according to its base or salt format and according to the presence of other drugs in the sample. Heroin samples from different countries of production mostly conform to either base or salt form. Novel approaches at the macro level to prevention and control of heroin-related problems through influence upon this complex heroin market-place should now be considered.

Heterosexual anal intercourse, health risks and drug use: a review with special attention to drug users

Research studying HIV risk-taking behaviour has tended to focus on specific populations who are characterized by particular behaviours. Such practices include the extent of unprotected anal intercourse among homosexual men, the sharing of injecting equipment among drug users and unprotected vaginal intercourse among female sex workers. There is often a failure among both researchers and practitioners to address specific risk behaviours outside of the defined risk group. Reviewed here are studies of heterosexual anal intercourse, with special attention to drug users and female sex workers. Among the general population, the reporting of heterosexual anal intercourse varies greatly across time and cultural groups. However, a body of recent research suggests that, despite some geographical differences, rates in most countries are relatively high. Many studies have also found that associated condom usage is low. Although unprotected anal intercourse is known to be an efficient method for the transmission of HIV and other viral infections, it has rarely been addressed outside cohorts of men who have sex with men. Of particular concern is the interaction of risk behaviours among drug users and women engaging in prostitution, many studies having found high levels of unprotected anal intercourse among these groups. Harm reduction interventions must address all the health risk behaviours their target groups are engaging in, if the challenge of reducing the transmission of HIV and other viral infections is to be met.

Route of drug use and its implications for drug effect, risk of dependence and health consequences

Route of administration has a profound, but often overlooked, influence on the actual experience of the drug use itself, on the risk of resulting development of dependence, and on the nature of the harms to which drug users are exposing themselves. These three areas are reviewed. The influence of route of administration on drug effect is considered first with regard to overall effectiveness of absorption, and also with regard to speed of onset of effect. The implications for risk of dependence cover animal and human laboratory studies of reinforcement schedules, epidemiological studies, the attitudes of drug users themselves to the different routes of possible drug use and associated dependence risk and the postulated influences on progression to dependence. Finally, the relationship between route of drug use and health sequelae is explored for the three most widely used routes of administration of illicit drugs-snorting, smoking and injecting.

Cannabis use in adolescents: the impact of risk and protective factors and social functioning

The study uses a school-based sample to test the social and familial risk and protective factors relating to cannabis use. Based on a self-completion survey of 2078 14-16-year-olds (mean age of 15 years) attending seven standard state-run secondary schools in south London, an assessment was made of rates and risk factors for cannabis use. Twenty-four per cent of the total sample had ever used cannabis, with 15% having done so in the month prior to assessment. In addition to greater likelihood of illicit drug use, lifetime cannabis users were less likely to spend time regularly with both their mothers and fathers, but more likely to spend free time with friends who smoked, drank alcohol and used illicit drugs, and with friends involved in criminal activities. Among those who had ever used cannabis, frequency of cannabis use was predicted (using linear regression) by two onset factors (earlier initiation of drinking and cannabis use were both linked to more frequent use) and two social factors (more time spent with drug-using friends and less time spent with the mother). Overall, the study showed that early onset, itself predicted by social networks, is linked to more frequent use of cannabis and that this appears to be sustained by less time spent with parents and more with drug-using peers.

Severity of heroin dependence in Taiwan: reliability and validity of the Chinese version of the Severity of Dependence Scale (SDS[Ch])

The development of instruments to assess substance use that are easy to use, valid and reliable across cultures is an important task. The present study investigates the reliability and validity of the Chinese language version of the SDS (SDS([Ch])) when used to measure severity of dependence among heroin users in Taiwan (n=522). Data were collected on demographic data, heroin use behaviours, and criminal convictions. Taiwanese heroin users recorded high SDS([Ch]) scores and the results support the validity and reliability of the Chinese version of the SDS. A positive correlation was found between SDS([Ch]) scores and DSM-IV criteria for heroin dependence. SDS([Ch]) scores were positively related to heroin injection, frequency of heroin injection, spending on heroin, earlier age of onset of heroin use and more drug-related criminal convictions. The findings support the suggestion that the concept of dependence as assessed by the SDS has cross-cultural validity.

Changes in neuropsychological functioning during alcohol detoxification

This study investigates changes in neuropsychological functioning during early abstinence from alcohol. 30 alcohol-dependent inpatients were tested at intake (day 4 of admission) and post detoxification (day 26), using a test-retest design. The neuropsychological battery included measures of pre-morbid IQ, full-scale IQ, verbal and non-verbal measures of memory and executive function. IQ was within the normal range at intake and comparable with age-adjusted normative values and there were some impairments in memory and executive function. There were significant increases in performance scores post detoxification in working memory, verbal fluency and verbal inhibition but not in non-verbal executive function tasks (mental flexibility and planning ability). Despite increased scores on tests of verbal and memory skills after 3 weeks of abstinence, complex executive abilities showed little change. These may have a negative impact on engagement and response to treatment and compromise clinical outcomes, heightening the risk of relapse.

Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study

AIMS

This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes.

METHODS

Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients (n = 142) at intake to residential treatment, and at 1 year, 2 years and 4-5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers.

FINDINGS

Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders.

CONCLUSIONS

NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups.

Influence of the dose on the severity of opiate withdrawal symptoms during methadone detoxification

AIM

This study investigates factors influencing the severity of opiate withdrawal symptoms, focusing on the relationship between methadone dose and withdrawal severity among opiate-dependent in-patients receiving methadone detoxification.

METHODS

The sample comprised 48 opiate-dependent patients admitted to a specialist in-patient drug treatment service and withdrawn from opiates, using a 10-day methadone reduction schedule. The severity of withdrawal symptoms was assessed daily using the Short Opiate Withdrawal Scale.

RESULTS

Patients withdrawn from higher doses of methadone and those reporting higher levels of anxiety reported more severe withdrawal symptoms. No relationship was found between methadone dose and completion of detoxification or length of hospital stay.

CONCLUSIONS

Although patients on higher doses of methadone reported more severe opiate withdrawal symptoms than patients on lower doses, the dose effect accounted for only a small percentage of the total variance. Nonetheless, the finding of a dose-response effect supports one of the basic principles of clinical practice during detoxification, namely the matching of the medication withdrawal schedule to the pre-admission opiate dose.