Fentanyl use among street drug users in Toronto, Canada: behavioural dynamics and public health implications

Prescription opioids (POs) are playing an increasingly central role in street drug use and related harms in North America. One distinct PO substance of interest is Fentanyl (Duragesic), a potent opioid analgesic designed for transdermal time-release application. Studies from Europe and North America have documented the sizeable overdose and mortality burden associated with the non-medical use of this drug. This study explores practices and risk dynamics associated with Fentanyl abuse, also considering public health implications. Semi-structured interviews were conducted with 25 regular street-entrenched illicit PO users in Toronto, Canada, a sub-sample of which were recent Fentanyl users. Results showed that while relatively rare on the illicit PO market in Toronto, Fentanyl is a highly desired, sought after and relatively expensive PO drug among street users. In addition, the new 'matrix' patch technology implemented for Fentanyl since 2005 is a limited safeguard against abuse as simple extraction methods are utilized by street users. Finally, distinct risk behaviours relevant for public health emerge due to the high black market costs of Fentanyl and the extraction techniques applied, potentially facilitating high risks for infectious disease (e.g., HCV, HIV) transmission and/or overdose. Consequently, prevalence and practices of Fentanyl use by street users require closer monitoring, targeted interventions and further research regarding risks and outcomes.

[Illicit drug trade on the markets of Yaounde (Cameroon) and Niamey (Niger): characteristics of salesmen and quality of drugs]

This study characterizes salesmen and evaluates the drugs offer and quality of the drugs in the illicit selling network in Yaoundé (Cameroon) and Niamey (Niger). A sample of 75 and 124 drug salesmen working in these cities was questioned using a standardized questionnaire. The prescription of drugs and the advices provided by these poorly trained salesmen could have an important impact in term of public health: 32% and 67% of the salesmen in Yaoundé give systematically or occasionally advices regarding the prescription. The active substances are always present in the 153 drugs of our analysed sample, except for chloroquine-based drugs, among which 5/30 samples did not contain active substance. However, the rate of nonconformity is approximately 50% in the two cities. Complementary studies are needed to explore the origin of these nonconformities, between counterfeiting, low quality of the products provided by the factories, defects of conservation or instability of the formulations.

[Narcotics and illicit drug market. Status and 10-year development]

INTRODUCTION

A description of the illicit drug market in Denmark's second largest city is provided based upon the prevalence of narcotics and illicitly sold medicals during the years 2002 and 2003. The changes on the illicit drug market are described by comparing the results to a similar study conducted ten years earlier.

MATERIALS AND METHODS

The study is comprised of 469 cases of seized material by Aarhus Police during the period January 1st 2002-December 31st 2003. Additional information relating to the 341 persons charged is also included in the study.

RESULTS

Heroine, cocaine and amphetamine were seized in 31%, 30% and 28% of the cases, respectively, and comprise the most frequently encountered hard drugs on the market. The prevalence of cocaine in Aarhus Police District has increased more than tenfold during the past ten years. The purity of the three drugs decreased significantly during the same period, although large variations in the quality of drugs were observed. Medicals were found in 16% of the seizures (containing 32 different active substances). The most frequent group of medicals was benzodiazepines, which made up a total of 74% of the medicals in the study. Anabolic steroids, ecstasy and methamphetamine were each found in 4% of the seizures. Men with an average age of 29.1 years comprised 92% of the persons charged in the study. Persons with a foreign nationality comprised 15% of the charged, while 25% had a birthplace outside Denmark.

CONCLUSION

The prevalence of stimulants especially cocaine have increased significantly during the past ten years. Meanwhile the purity of the drugs has decreased. The benzodiazepines are still the most frequent group of medicals on the illicit market.

Social capital: implications from an investigation of illegal anabolic steroid networks

Numerous studies have linked the constructs of social capital with behaviours that are health enhancing. The factors of social trust, social cohesion, sense of belonging, civic involvement, volunteer activity, social engagement and social reciprocity are all associated with social capital and their existence is often linked with communities or settings where health enhancement is high. Utilizing an interpretive perspective, this paper demonstrates how the existence of social capital may enhance the transition into drug use, the experience of using an illegal drug and decrease the risk of detection. It highlights how social capital may contribute to behaviours which are not health enhancing. Using a variety of data, including participant observation of 147 male anabolic steroid users and 98 semi-structured in-depth interviews with male anabolic steroid users, dealers and distributors it was found that social capital facilitated the operation of the illegal anabolic steroid distribution network. The subcultural norms and social trust that existed within the network allowed anabolic steroid dealers to sell the drug to others with reduced risk of detection. It is argued that social capital facilitates the distribution of illegal anabolic steroids and that social capital is a non-discriminatory concept, that may enhance both negative and positive health-related behaviours.

Determination of delta13 CV-PDB and delta15NAIR values of cocaine from a big seizure in Germany by stable isotope ratio mass spectrometry

In this study, delta(13)C(V- PDB) and delta(15)N(AIR) values of 132 cocaine samples from a big seizure in Germany in 2002 were determined using elemental analyser isotope ratio mass spectrometry. The 1.2 tons of cocaine were packed in 1 kg packages and the cocaine bricks inside these packages showed certain logos. Twenty different logos could be identified. Results show a large variability among some samples, for delta(15)N(AIR) values ranging from-17 to -2 per thousand. Furthermore, the possibility of linking samples with the same logo was checked. The results show that, in general, there is no relationship between the determined isotope ratio and a certain logo.

Symptoms experienced by law enforcement personnel during methamphetamine lab investigations

This study was conducted to determine if law enforcement personnel experience symptoms associated with methamphetamine lab investigation and to assess those factors that may result in more symptoms. A total of 258 standardized, self-administered surveys were distributed to law enforcement personnel attending national/regional training classes, between June 2004-February 2005. Ninety-three percent of the surveys were returned and used to determine symptoms experienced while investigating clandestine methamphetamine labs, as well as the job duties of the respondent and the personal protective equipment used. More than 70% of respondents reported headaches, central nervous system symptoms, respiratory symptoms, sore throat, and other symptoms. Unadjusted and adjusted risk of symptoms was higher for those who investigated more than 30 labs. Other significant risk factors included time spent in the lab, phase of investigation, presence of active chemical processes, and coexistent disease. Respirator use was not independently associated with the likelihood of reporting symptoms. It was concluded that methamphetamine lab investigation is positively associated with symptom reporting in a high percentage of law enforcement personnel involved in these tasks. For most individuals, the reported symptoms were transitory and diminished in a short time, but some individuals reported needing to seek medical attention with symptoms that persisted.

Should drugs be decriminalised? Yes

Recent government figures suggest that the UK drug treatment programmes have had limited success in rehabilitating drug users, leading to calls for decriminalisation from some parties. Kailash Chand believes that this is the best way to reduce the harm drugs cause, but Joseph Califano thinks not

Should drugs be decriminalised? No

Recent government figures suggest that the UK drug treatment programmes have had limited success in rehabilitating drug users, leading to calls for decriminalisation from some parties. Kailash Chand believes that this is the best way to reduce the harm drugs cause, but Joseph Califano thinks not

Measuring the stability of illicit drug markets: why does it matter?

Contemporary drug policy in the United States favors a balanced approach including a supply side dimension. The supply side dimension is grounded in the assumption that the disruption of illicit drug markets will result in diminished capacity of the markets to provide for consumer demand and thereby a reduction in the use of illicit drugs and a related increase in demand for treatment. In this paper we consider the disruption of methamphetamine markets in 10 cities in terms of the relative stability of those markets. We use data from the Arrestee Drug Abuse Monitoring (ADAM) program for the years 2000-2003. We conduct a comparative analysis of those markets and look at patterns of methamphetamine use and participation in treatment in those cities. Our findings demonstrate how it is possible to construct measures of market stability, and how to use those measures to assess the stability of illicit drug markets in terms of both relative value and in fluctuation over time. We also demonstrate that markets with different patterns of stability will exhibit different patterns of drug using and treatment participation. We conclude that understanding patterns of market stability will help us to understand and respond to patterns of drug using and treatment participation.

How much for a dime bag? An exploration of youth drug markets

Relatively little is known about how youth obtain marijuana and other drugs. The Drugs, Alcohol and Violence International (DAVI) study explored youthful drug markets among samples of school students, detained youth, and school dropouts (ages 14-17 years) in the greater metropolitan areas of Philadelphia, Toronto, Montreal, and Amsterdam. Students frequently reported sharing drugs, either getting them from others or giving them to others for free. Sharing was less common among the more drug-involved detainees and dropouts. Marijuana was typically obtained either outdoors or in a house or apartment. Few youth reported getting marijuana at school. In Amsterdam, where marijuana can be purchased in small quantities in coffeeshops, this was the most common place to get marijuana, even though 18 is the legal age for purchase. Alcohol was also most likely to be obtained in stores or restaurants across all the sites, even though none were of legal age except those in Amsterdam age 16 or older. Youth most often reported purchasing marijuana in nickel, dime or other small bags, which are not standardized units. The exception again was Amsterdam, where youth most often reported quantities in grams or joints, which is how it is sold in coffeeshops. The lack of standardization of units makes economic cost estimates suspect. Even standardized units such as alcohol present problems since youth report a wide range of 'typical purchases.' Survey data can, however, more aptly describe drug market characteristics such as general location of purchase, and relationship with the seller.

Price and purity analysis for illicit drug: data and conceptual issues

Data on illicit drug purity and prices are invaluable but challenging. Academic purists argue they are unsuitable for economic analysis [Manski, C.F., Pepper, J.V., Petrie, C.V., 2001. Informing America's Policy on Illegal Drugs: What We Don't Know Keeps Hurting Us. National Academy Press, Washington, DC], but in practice they are used frequently [ONDCP, 2001a. What America's Users Spend on Illegal Drugs. Office of National Drug Control Policy, The White House, Washington, DC; ONDCP, 2001b. The Price of Illicit Drugs: 1981 Through the Second Quarter of 2000. Office of National Drug Control Policy, The White House, Washington, DC; ONDCP, 2004. The Price and Purity of Illicit Drugs: 1981 Through the Second Quarter of 2003. Office of National Drug Control Policy, The White House, Washington, DC; Grossman, M., 2004. Individual behaviors and substance use: the role of price. Plenary Address for the 24th Arne Ryde Symposium on Economics of Substance Abuse at Lund University, Lund, Sweden, August 13-14, 2004]. This paper reviews data and conceptual issues that people producing, analyzing, and consuming drug price and purity series should understand in order to reduce the likelihood of misinterpretation. It also identifies aspects of drug markets that are both poorly understood and relevant to some of these issues. They constitute a useful research agenda for health and law enforcement communities who would benefit from better data on the supply, availability, and use of illicit drugs.

An evaluation of retail outlets as part of a community prevention trial to reduce sales of harmful legal products to youth

Communities across the nation have become increasingly concerned about inhalant use and use of harmful legal products among youth because of increasing prevalence rates and deleterious health consequences from abusing these products. The increasing concern of communities about inhaling and ingesting legal products has been coupled with increasing awareness and concern about ability of youth to access and abuse a variety of other legal retail products. There are few examples of scientifically designed community prevention projects that seek to reduce youth abuse of such legal products. This article describes a community prevention trial that is designed to reduce sales of inhalants and other harmful legal products to youth and demonstrates how the retailer component of the trial can be rigorously evaluated. It also shows how data from youth purchase attempts can complement survey data from retailers.

The economics of drug abuse: a quantitative assessment of drug demand

Behavioral economic concepts have proven useful for an overall understanding of the regulation of behavior by environmental commodities and complements a pharmacological perspective on drug abuse in several ways. First, a quantitative assessment of drug demand, equated in terms of drug potency, allows meaningful comparisons to be made among drug reinforcers within and across pharmacological classes. Second, behavioral economics provides a conceptual framework for understanding key factors, both pharmacological and environmental, that contribute to reductions in consumption of illicit drugs. Finally, behavioral economics provides a basis for generalization from laboratory and clinical studies to the development of novel behavioral and pharmacological therapies.

Longitudinal modeling of genetic and environmental influences on self-reported availability of psychoactive substances: alcohol, cigarettes, marijuana, cocaine and stimulants

BACKGROUND

Although an obvious environmental factor influencing drug use, the sources of individual differences in drug availability (DA) are unknown.

METHOD

This report is based on 1788 adult males from the Mid-Atlantic Twin Registry who participated in a structured telephone interview that included retrospective assessments of DA (cigarette, alcohol, marijuana, cocaine and stimulants) between ages 8 and 25. We fitted a biometric dual change score (DCS) model, adapted for ordinal data, to model latent growth and estimate the genetic and environmental components of variance over time.

RESULTS

DA, despite being considered an environmental risk factor, is under both genetic and environmental control. For cigarette, alcohol, marijuana and cocaine availability, there was an overall increase in additive genetic variance and a decline in shared environmental variance over time. Non-shared environmental variance remained steady. Stimulant availability did not follow this pattern. Instead, there was an upswing in shared environmental effects with increasing age.

CONCLUSION

We have modeled the genetic and environmental architecture of changes in DA across adolescence. The rise in additive genetic variance over time coincides with acceleration in the expression of individual differences, probably brought on by an increase in personal freedom and a reduction in social constraints. Understanding the etiology of DA is likely to reveal key components, acting directly or indirectly, in the pathway(s) leading to drug initiation, abuse and dependence.

Aggregating indices of risk and protection for adolescent behavior problems: the Communities That Care Youth Survey

PURPOSE

To facilitate research on adolescent risk and protection regarding behavior problems, and to facilitate community decision-making regarding resource allocation for intervention programs, by creating a reduced set of coherent aggregate indices of adolescent risk and protection.

METHODS

We examined the 31 risk and protective factor scales in the Communities That Care Youth Survey (CTC-YS). Data came from two waves of the CTC-YS administered to sixth through 12th graders in Pennsylvania (2001 n = 43,842; 2003 n =101,988). Factor analysis and calculation of internal reliability were used to create aggregate indices of risk/protective factor domains. Correlations of aggregate indices with each other and with problem behaviors (antisocial behavior, substance use) were examined.

RESULTS

Theory and empirical results led to the creation of seven coherent indices: Community Cohesion, Family Cohesion, Family Risk, School Support for Prosocial Activities, Antisocial Peer Domain, Attitudes toward Risky Behavior, Risky Behavioral Tendencies. Four scales were not included in the aggregate index (Religiosity, Academic Performance, Personal Transitions and Mobility, and Early Initiation of Drug Use and Antisocial Behavior). The indices were related to each other and to adolescent problem behaviors (antisocial behavior and substance use) in expected ways. Results were consistent across waves of data.

CONCLUSIONS

The construction of theoretically meaningful and empirically defensible aggregate measures of adolescent risk and protective factors is possible, although analyses of other data sets and further discussion are warranted. The use of aggregate indices by researchers and communities is recommended as a way to facilitate research and decision-making.

Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users

BACKGROUND

Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined.

OBJECTIVE

To estimate the frequency and risk factors for use of street methadone.

METHODS

Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression.

RESULTS

Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment.

CONCLUSION

The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.

Drug trafficking routes and hepatitis B in injection drug users, Manipur, India

Prevalence of hepatitis B genotype C in injection drug users in the northeastern Indian state of Manipur, neighboring the "Golden Triangle," correlates well with overland drug-trafficking routes, the injection drug use epidemic, and the spread of HIV. Further spread to other regions of India through mobile populations is possible.

Shooting gallery operation in the context of establishing a medically supervised injecting center: Sydney, Australia

Shooting galleries (SGs) are illicit off-street spaces close to drug markets used for drug injection. Supervised injecting facilities (SIFs) are low threshold health services where injecting drug users (IDUs) can inject pre-obtained drugs under supervision. This study describes SG use in Kings Cross, Sydney before and after the opening of the Sydney Medically Supervised Injecting Centre (MSIC), Australia's first SIF. Operational and environmental characteristics of SGs, reasons for SG use, and willingness to use MSIC were also examined. An exploratory survey of SG users (n = 31), interviews with SG users (n = 17), and drug workers (n = 8), and counts of used needles routinely collected from SGs (6 months before and after MSIC) and visits to the MSIC (6 months after MSIC) were triangulated. We found five SGs operated during the study period. Key operational characteristics were 24-h operation, AUS $10 entry fee, 30-min time limit, and dual use for sex work. Key reasons for SG use were to avoid police, a preference not to inject in public, and assistance from SG operators in case of overdose. SG users reported high levels of willingness to use the MSIC. The number of used needles collected from SGs decreased by 69% (41,819 vs. 12,935) in the 6 months after MSIC opened, while MSIC visits increased incrementally. We conclude that injections were transferred from SGs to the MSIC, but SGs continued to accommodate injections and harm reduction outreach should be maintained.

Risk, citizenship, and public discourse: coeval dialogues on war and health in Vancouver's Downtown Eastside

This article is about September 11, 2001, and its narrated effects on the lives of nine street-involved women in Vancouver's Downtown Eastside. I outline the locations from which they spoke about war and health: as consumers and economic agents whose bodies are linked to transnational economic processes; as residents in a local community of shared knowledge and practices; and as marginalized citizens of a nation-state. I hope to emphasize the value of engaging research subjects in coeval dialogues that work against essentializing, state-sanctioned discourses narrated in the context of armed conflict and a public health crisis. To women drug users in Vancouver's Downtown Eastside, the "War against Terror" evokes particular sites of knowledge: the body, the local community, and transnational processes. Their repertoires of war stimulate questions about citizenship and perceptions of risk, challenging dominating medical and political discourses that tend to temporally and spatially localize their engagement with the world.