Accelerated transition to injection among male heroin initiates in Hanoi, Vietnam: implications for early harm reduction interventions

Correlates of days of medication for opioid use disorder exposure among people living with HIV in Northern Vietnam

BACKGROUND

In Vietnam, access to medications for opioid use disorder (MOUD) for people living with HIV has rapidly expanded, but MOUD use over time remains low. We sought to assess factors associated with days of MOUD treatment exposure.

METHODS

From 2015 to 2019, patients with OUD in six Northern Vietnamese HIV clinics were randomized to receive HIV clinic-based buprenorphine (BUP/NX) or referral for methadone maintenance therapy (MMT) and followed for 12 months. All MOUD doses were directly observed and abstracted from dosing logs. The primary outcome was days of MOUD treatment exposure (buprenorphine or methadone) received over 12 months. Negative binomial regression modelled associations with days of MOUD exposure.

RESULTS

Of 281 participants, 264 (94%) were eligible for analysis. Participants were primarily male (97%), unmarried (61%), employed (54%), and previously arrested (83%). Participants had a mean 187 (SD 150) days of MOUD exposure with 134 (51%) having at least 180 days, and 35 (13.2%) having at least 360 days of MOUD exposure. Age (IRR 1.26, 95% CI 1.02-1.55), income (IRR 0.96, 95% CI 0.93-1.001), and methadone (IRR 1.88, 95% CI 1.51-2.42) were associated with MOUD exposure in multivariate models. Multivariate models predicted 127 (95% CL 109-147) days of MOUD exposure for HIV clinic based-buprenorphine vs 243 (95% CL 205-288) for MMT.

CONCLUSION

MOUD treatment exposure was suboptimal among patients with HIV and OUD in Northern Vietnam and was influenced by several factors. Interventions to support populations at risk of lower MOUD exposure as well programs administering MOUD should be considered in countries seeking to expand access to MOUD.

A vapor exposure method for delivering heroin alters nociception, body temperature and spontaneous activity in female and male rats

BACKGROUND

The ongoing crisis related to non-medical use of opioids makes it of continued importance to understand the risk factors for opioid addiction, the behavioral and neurobiological consequences of opioid exposure and to seek potential avenues for therapy. Pre-clinical rodent models have been critical to advancing understanding of opioid consequences for decades, but have been mostly limited to drug delivery by injection or by oral dosing. Inhalation, a significant route for many human users, has not been as well-established.

METHOD

We adapted an e-cigarette based exposure system, previously shown efficacious for delivery of other drugs to rats, to deliver heroin vapor. Effectsin vivo were assessed in male and female Sprague-Dawley rats using a warm-water assay for anti-nociception and an implanted radiotelemetry system for evaluating changes in body temperature and spontaneous activity rate.

RESULTS

Inhalation of vapor created by heroin 100 mg/mL in the propylene glycol (PG) vehicle significantly slowed tail-withdrawal from a 52 °C water bath, bi-phasically altered activity, and increased temperature in male and female rats. Inhalation of heroin 50 mg/mL for 15 min produced significant effects, as the lower bound on efficacy, whereas inhalation of heroin 100 mg/mL for 30 min produced robust effects across all endpoints and groups.

CONCLUSIONS

This work shows that e-cigarette devices deliver psychoactive doses of heroin to rats, using concentrations of ∼50-100 mg/mL and inhalation durations of 15-30 min. This technique may be useful to assess the health consequences of inhaled heroin and other opioid drugs.

Drug use generations and patterns of injection drug use: Birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California

OBJECTIVES

A robust literature documents generational trends in drug use. We examined the implications of changing national drug use patterns on drug injection histories of diverse people who inject drugs (PWID).

METHODS

Drug use histories were collected from 776 active PWID in 2011-13. Using descriptive statistics, we examine drug use initiation by year and birth cohort (BC) differences in drug first injected. A multivariate linear regression model of time to injection initiation ([TTII] (year of first injection minus year of first illicit drug use) was developed to explore BC differences.

RESULTS

The first drug injected by BC changed in tandem with national drug use trends with heroin declining from 77% for the pre-1960's BC to 58% for the 1960's BC before increasing to 71% for the 1990's BC. Multivariate linear regression modeling found that shorter TTII was associated with the 1980's/1990's BC (-3.50 years; 95% Confidence Interval [CI]=-0.79, -6.21) as compared to the 1970's BC. Longer TTII was associated with being female (1.65 years; 95% CI=0.40, 2.90), African American (1.69 years; 95% CI=0.43, 2.95), any substance use treatment prior to injection (4.22 years; 95% CI=2.65, 5.79), and prior non-injection use of drug that was first injected (3.29 years; 95% CI=2.19, 4.40).

CONCLUSION

National drug trends appear to influence injection drug use patterns. The prescription opiate drug era is associated with shorter TTII. Culturally competent, demographically and generationally-targeted prevention strategies to combat transitions to drug injection are needed to prevent or shorten upstream increases in risky drug use practices on a national level.

Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence

BACKGROUND

Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran.

METHODS

We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection.

RESULTS

A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market).

CONCLUSION

Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.

Injection and sexual risk practices among young heroin users in Hanoi, Vietnam

Epidemiological data in Vietnam shows high HIV prevalence rates among injection drug users, especially in urban centres. However, there are limited data on specific practices used to prepare and inject drugs or on sexual practices among Vietnamese injectors. A street-based cross-sectional interview was conducted with 862 heroin injectors in Hanoi, Vietnam, to collect such data. Variability was seen in both injection and sexual risk, with 12.9% of current injectors reporting at least one unsafe method of drug sharing and 57.1% reporting unsafe sex in the past 30 days. These risks were strongly associated with those who engaged in unsafe injection significantly more likely to engage in unsafe sex (69.4% vs. 55.3%) and those engaging in unsafe sex significantly more likely to engage in unsafe injection (15.7% vs. 9.2%). These findings highlight the overlap of injection and sexual risk practices among Vietnamese heroin users and suggest the need for strong, broadly targeted HIV prevention activities among this population.

Substance use among male sex workers in Vietnam: prevalence, onset, and interactions with sexual risk

BACKGROUND

HIV research in Vietnam has focused primarily on its large heroin injector population. Data on men who have sex with men [MSM], particularly the large and growing population of men who exchange sex for money or other material rewards, male sex workers [MSWs], is very limited.

METHODS

Data derive from a cross-sectional study of MSW, age 16-35, recruited using community sampling methods in three cities in 2010-2011, including Hanoi, Ho Chi Minh City [HCMC], and Nha Trang City (n=710). Assessments included demographic characteristics, substance use, sexual risk, and use of health services. A series of "event" questions were used to assess the influence of alcohol and drugs on sexual risk.

RESULTS

Both tobacco and alcohol are initiated at a young age and most participants currently use both substances overall across all three cities. While alcohol and tobacco use precede the initiation of sex work, stimulant and opiate use are initiated following the initiation of sex work. There was substantial overlap between substance use and sexual risk, and this overlap was strongest in sexual events involving male and female elective partners rather than sex work clients.

CONCLUSION

Although rates of HIV infection in this group are low, this may be an artifact of the young age of the sample. High rates of drug use, including alcohol, tobacco and illicit drugs, coupled with high rates of ulcerative STIs such as HPV, suggest the potential for rapid amplification of STI/HIV risk among MSW and their complex sex partnering networks.

Transitions from injecting to non-injecting drug use: potential protection against HCV infection

Transitions from injecting to non-injecting drug use have been reported from many different areas, particularly in areas with large human immunodeficiency virus (HIV) epidemics. The extent to which such transitions actually protect against HIV and HCV has not been determined. A cross-sectional survey with HIV and hepatitis C (HCV) testing was conducted with 322 former injectors (persons who had injected illicit drugs but permanently transitioned to non-injecting use) and 801 current injectors recruited in New York City between 2007 and 2012. There were no differences in HIV prevalence, while HCV prevalence was significantly lower among former injectors compared to current injectors. Years injecting functioned as a mediating variable linking former injector status to lower HCV prevalence. Transitions have continued well beyond the reduction in the threat of AIDS to injectors in the city. New interventions to support transitions to non-injecting drug use should be developed and supported by both drug treatment and syringe exchange programs.

Substance use disorders and HIV in Vietnam since Doi Moi (Renovation): an overview

Drawing from published and gray literature, this manuscript focuses on the following topics: (1) changing patterns of substance use and abuse in Vietnam since the early 1990s; (2) the roles of substance use in the HIV epidemic; (3) the responses of the Vietnamese government and other entities (both domestic and international) to substance use disorders (SUDs) and HIV; and (4) the current research capacity in Vietnam and ways in which furthering research in Vietnam could enrich our knowledge of the linkages between SUDs and HIV and of effective measures to reduce their public health consequences. A growing number of studies during the past two decades show dynamic and still evolving twin epidemics of SUDs and HIV in Vietnam, including a shift from consumption of opium to heroin and amphetamine-type stimulants, the concurrent use of drugs, and the increasing embrace by the government of internationally recognized effective responses (including harm reduction and methadone substitution therapy). And yet, remaining issues, such as the rapid ascendance of amphetamine-type stimulant use among the country's most vulnerable populations, the lack of effective integration of SUD and HIV services for HIV-infected drug users, and the reliance on international resources for maintaining quality services, among others, are posing challenges for building sustainable Vietnamese responses. Therefore, building local research and training capacity is a crucial foundation to meet these challenges.

Drug users in Hanoi, Vietnam: factors associated with membership in community-based drug user groups

Background

A syndemic conjoins injection drug use, incarceration, and HIV in Vietnam, where there is a need for programs that empower people who use drugs to minimize the harms thereby produced. Here we present a post-hoc evaluation of the organizing efforts of the Centre for Supporting Community Development Initiatives (SCDI) with two community-based drug user groups (CBGs) in Hanoi.

Methods

Members (n = 188) of the CBGs were compared to non-member peers (n = 184) on demographic, psychosocial, behavioral and knowledge variables using a face-to-face structured interview that focused on issues of quality of life and harm reduction. Bivariate analyses were conducted, and variables significantly associated with membership at p < 0.10 were included in a multivariate model.

Results

Variables associated with membership in the CBGs in the multivariate model included increased self-efficacy to get drug-related health care (OR 1.59, 1.24-2.04), increased quality of life in the psychological (OR 2.04, 1.07-3.93) and environmental (OR 2.54, 1.31-4.93) domains, and greater history of interactions with police about drugs (OR 3.15, 1.79-5.52). There was little difference between members and non-members on injection-related harms except in the domain of knowledge about opioid overdose. Among the 114 current injectors (30.6% of the sample), low rates of unsafe injection practices were reported, and low statistical power limited the ability to conclusively assess association with membership.

Conclusions

Although the CBG members displayed higher levels of well-being and access to healthcare than non-members, further longitudinal study is required to determine if these are a result of membership. The CBGs should pay more attention towards meeting challenges in responding to specific health issues of those who continue to use drugs including HIV, hepatitis, and drug overdose.

Mental health and family relations among people who inject drugs and their family members in Vietnam

BACKGROUND

This article explores the association of people who inject drugs and their family members in terms of mental health and family relations. The objective was to understand the family context and its impact on people who inject drugs in a family-oriented culture in Vietnam.

METHODS

Cross-sectional assessment data were gathered from 83 people who inject drugs and 83 of their family members recruited from four communes in Phú Thọ province, Vietnam. Depressive symptoms and family relations were measured for both people who inject drugs and family members. Internalized shame and drug-using behavior were reported by people who inject drugs, and caregiver burden was reported by family members.

RESULTS

We found that higher level of drug using behavior of people who inject drugs was significantly associated with higher depressive symptoms and lower family relations reported by themselves as well as their family members. Family relations reported by people who inject drugs and their family members were positively correlated.

CONCLUSION

The findings highlight the need for interventions that address psychological distress and the related challenges faced by family members of people who inject drugs. The article has policy implication which concludes with an argument for developing strategies that enhance the role of families in supporting behavioral change among people who inject drugs.