The natural history of injecting drug use: a 25-year longitudinal study of a cohort of injecting drug users in inner city Dublin

What are the risk factors of non-fatal overdose among persons who use opioids? A systematic review and meta-analysis

INTRODUCTION

Non-fatal opioid overdose (NFOD) is a concerning public health issue that is a risk factor for subsequent fatal overdose.

METHODS

This systematic review aimed to evaluate all the previous literature using a self-report method to investigate the risk factors of NFOD. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRSIMA) and its 27-item checklist guided the conduct and reporting of this systematic review. The review used the population, risk factor, and outcome (PRO) framework. The population was studies with a majority of participants that regularly used opioids. Risk factors were demographic, medical, and behavioral characteristics. The outcomes were self-reported recent (<12 months) or lifetime presence of NFOD. The study explored seven databases: PubMed, Embase, Cochrane Library, PsycINFO, CINAHL, ProQuest, and Web of Science and used Google Scholar to search for grey literature. A risk of bias assessment was carried out using ROBANS-E and meta-analysis was performed using STATA.

RESULTS

The review discovered 53 studies using the self-report experience of persons who use opioids assessing different factors associated with NFOD. Involvement in the sex trade, having a lower than typical education, previous incarceration, experiencing homelessness, unemployment, psychiatric co-morbidity, suicidal ideation or behavior, polysubstance use, especially benzodiazepine use and problematic alcohol use, needing help injecting, former opioid agonist therapy (OAT) engagement, previous treatment experiences, and a hepatitis-C diagnosis were associated with an increased likelihood of NFOD. Current engagement in OAT was protective against NFOD. Gender, relationship status, needle exchange use, symptoms of anxiety, and being HIV positive were not strongly associated with a difference in NFOD likelihood.

CONCLUSION

Using the findings from above to identify the individuals who are at high risk for NFOD, particularly those using opioids, will enable a targeted approach to outreach and education programs based on the identified risk factors- such as polysubstance use, socioeconomic associations, and psychiatric co-morbidities, which can help reduce the occurrence of NFOD.

Hepatitis C virus infection in Irish drug users and prisoners - a scoping review

BACKGROUND

Hepatitis C infection is a major public health concern globally. In Ireland, like other European countries, people who use drugs (PWUD) and prisoners carry a larger HCV disease burden than the general population. Recent advances in HCV management have made HCV elimination across Europe a realistic goal. Engaging these two marginalised and underserved populations remains a challenge. The aim of this review was to map key findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWUD and prisoners.

METHODS

A scoping review guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey & O'Malley).

RESULTS

A total of 58 studies were identified and divided into the following categories; Epidemiology, Guidelines and Policy, Treatment Outcomes, HCV-related Health Issues and qualitative research reporting on Patients' and Health Providers' Experiences. This review identified significantly higher rates of HCV infection among Irish prisoners and PWUD than the general population. There are high levels of undiagnosed and untreated HCV infection in both groups. There is poor engagement by Irish PWUD with HCV services and barriers have been identified. Prison hepatology nurse services have a positive impact on treatment uptake and outcomes. Identified gaps in the literature include; lack of accurate epidemiological data on incident infection, untreated chronic HCV infection particularly in PWUD living outside Dublin and those not engaged with OST.

CONCLUSION

Ireland like other European countries has high levels of undiagnosed and untreated HCV infection. Collecting, synthesising and identifying gaps in the available literature is timely and will inform national HCV screening, treatment and prevention strategies.

Twenty years of the methadone treatment protocol in Ireland: reflections on the role of general practice

Background

Opioid dependence, characterised by socio economic disadvantage and significant morbidity and mortality, remains a major public health problem in Ireland. Through the methadone treatment protocol (MTP), Irish general practice has been a leader in the introduction and expansion of Irish harm reduction services, including opioid substitution treatment (OST), needle and syringe programs (NSP) and naloxone provision. These services have been effective in engaging opiate users in treatment, reducing human deficiency virus (HIV) and hepatitis C virus (HCV) transmission and reducing-drug related morbidities. Challenges remain in relation to choice of substitution treatments, timely access to OST services, adequate coverage of NSP, naloxone provision and increasing drug-related deaths.

Methods

A narrative review was conducted and designed to present a broad perspective on the Irish MTP and to describe its history and development in terms of clinical care, stakeholder views and changing trends.

Results

Three themes emerged from the analysis; The History of the Methadone Treatment Protocol, Service User and Provider Views and Challenges and Developments. Despite the initial concern about methadone maintenance treatment (MMT) in Ireland, increased participation by Irish GPs in the treatment of opioid dependence is observed over the last two decades. There are now over 10,000 people on methadone treatment in Ireland, with 40% treated in general practice. The MTP provides structure, remuneration and guidance to GPs and is underpinned by training, ongoing education and a system of quality assurance provided by the Irish College of General Practice (ICGP). Challenges include the negative views of patients around how methadone services are delivered, the stigma associated with methadone treatment, the lack of choice around substitution medication, waiting lists for treatment in certain areas and rates of fatal overdose.

Conclusion

Twenty years of the MTP has been the mainstay of harm reduction services in Ireland. It has provided a network of specially trained GPs who provide methadone to over 10,000 patients across Ireland within a structured framework of training, quality assurance and remuneration. With the ongoing commitment of Irish specialists in the field of addiction medicine, further improvements to support and treat patients can be made.

Cessation of injecting drug use: The effects of health service utilisation, drug use and demographic factors

BACKGROUND

Injecting drug use is associated with a range of harms, however cessation of injecting is rare. There is a lack of evidence on factors associated with cessation, notably those related to health services other than drug treatment. We examined the incidence and identified longitudinal correlates of first episode of cessation in a cohort of people who inject drugs (PWID).

METHODS

Using discrete-time survival analysis, we examined correlates of the first episode of cessation (no self-reported injecting drug use in the past 12 months), including the use of health services, socio-demographics and drug-related behaviour in a cohort of PWID recruited between 2008 and 2010.

RESULTS

The cohort of 467 participants contributed 1527 person-years from recruitment to 2014. Under a fifth (17.8%) of people reported cessation of 12 months or more, yielding a cessation rate of 5.4 events per 100 person-years. Younger age (25-29 compared to 30 and above) (adjusted hazard ratio (AHR) 1.79, 95% confidence interval (CI) 1.07-3.00) and male gender (AHR 1.67, 95% CI 2.01-2.76) were positively associated with cessation, while past year use of benzodiazepines (AHR 0.45, 95% CI 0.28-0.72), arrest in the past year (AHR 0.50, 95% CI 0.30-0.83) and low SF-8 physical dimension score (AHR 0.42, 95% CI 0.20-1.88) were negatively associated with cessation. Outpatient service use had the largest effect on cessation (AHR 2.28, 95% CI 0.94-5.48, p=0.067).

CONCLUSIONS

Low rates of cessation emphasise the need for sustained and comprehensive harm reduction services. The relationship between outpatient services and cessation suggests that further research into the use in health services among PWID is warranted.

Mortality and cause of death in a cohort of people who had ever injected drugs in Glasgow: 1982-2012

BACKGROUND

To describe all-cause and cause-specific mortality in a cohort of people who had ever injected drugs (PWID) with a low prevalence of HIV over 20-30 years.

METHODS

Using a retrospective study design, identifying data from a cohort of PWID recruited between 1982 and 1993 through in-patient drug treatment services were linked to National Records for Scotland deaths data using probabilistic record linkage. We report all-cause and cause-specific mortality rates; standardized mortality ratios (SMR) across time, gender and age were estimated.

RESULTS

Among 456 PWID, 139 (30.5%) died over 9024 person-years (PY) of follow-up. Mortality within the cohort was almost nine times higher than the general population, and remained elevated across all age groups. The greatest excess mortality rate was in the youngest age group, who were 15-24 years of age (SMR 31.6, 95% CI 21.2-47.1). Drug-related deaths declined over time and mortality was significantly higher among HIV positive participants. Although SMRs declined with follow-up, the SMR of the oldest age group (45-60) was 4.5 (95% CI 3.0-6.9). There were no significant differences in all-cause mortality rates between participants who were 25 years and older at cohort entry compared to younger participants.

CONCLUSION

Mortality rates remained higher than the general population across all age groups. Screening services that identify a history of injecting drug use may be an opportunity to address risk factors faced by an ageing population of PWID and potentially have implications for future health care planning.

Urban overdose hotspots: a 12-month prospective study in Dublin ambulance services

BACKGROUND

Opioid overdose (OD) is the primary cause of death among drug users globally. Personal and social determinants of overdose have been studied before, but the environmental factors lacked research attention. Area deprivation or presence of addiction clinics may contribute to overdose.

OBJECTIVES

The objective of the study is to examine the baseline incidence of all new ODs in an ambulance service and their relationship with urban deprivation and presence of addiction services.

METHODS

A prospective chart review of prehospital advanced life support patients was performed on confirmed OD calls. Demographic, geographic, and clinical information, that is, presentation, treatment, and outcomes, was collected for each call. The census data were used to calculate deprivation. Geographical information software mapped the urban deprivation and addiction services against the overdose locations.

RESULTS

There were 469 overdoses, 13 of which were fatal; most were male (80%), of a young age (32 years), with a high rate of repeated overdoses (26%) and common polydrug use (9.6%). Most occurred in daytime (275) and on the streets (212). Overdoses were more likely in more affluent areas (r = .15; P < .05) and in a 1000-m radius of addiction services. Residential overdoses were in more deprived areas than street overdoses (mean difference, 7.8; t170 = 3.99; P < .001). Street overdoses were more common in the city center than suburbs (χ(2)(1) = 33.04; P < .001).

CONCLUSIONS

The identified clusters of increased incidence-urban overdose hotspots-suggest a link between environment characteristics and overdoses. This highlights a need to establish overdose education and naloxone distribution in the overdose hotspots.

Primary care and youth mental health in Ireland: qualitative study in deprived urban areas

Background

Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15–24 years. However, healthcare professionals are faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people’s unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals’ experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16–25 years) in primary care in deprived urban settings in Ireland.

Methods

The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres.

Results

We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care’s longitudinal nature as a key asset in promoting treatment engagement.

Conclusions

Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people’s experience and developing complex interventions that promote early intervention are priorities. (350 words)

Mortality in a large community-based cohort of inner-city residents in Vancouver, Canada

BACKGROUND

The Downtown Eastside is a robust and densely populated neighbourhood in Vancouver, Canada, that is characterized by low-income housing and drug use and a high prevalence of HIV infection. We evaluated mortality and excess mortality among the broader community of individuals living in this neighbourhood.

METHODS

The Community Health and Safety Evaluation is a community-based study of inner-city residents in the Downtown Eastside who were recruited in 2003 and 2004. Participants' data were linked with data in provincial virology and mortality databases retrospectively and prospectively for the period 1991-2009. Mortality and standardized mortality ratios (SMRs) were calculated for the period 2003-2009 to compare death rates in the study population with rates in the population of Vancouver.

RESULTS

Among 2913 participants, 374 deaths occurred, for an all-cause mortality of 223 per 10 000 person-years (95% confidence interval [CI] 201-247 per 10 000 person-years). Compared with the population of Vancouver, significant excess mortality was observed in the study population (SMR 7.1, 95% CI 6.4-7.9). Excess mortality was higher among women (SMR 15.4, 95% CI 12.8-18.5) than among men (SMR 5.8, 95% CI 5.1-6.6). Although crude mortality increased with age, excess mortality was greatest among participants less than 35 years old (SMR 13.2, 95% CI 9.4-18.5) and those 35-39 years old (SMR 13.3, 95% CI 10.3-17.1). Excess risk was also elevated among participants with hepatitis C virus (HCV), HIV and HCV/HIV infection, with SMRs of 5.9 (95% CI 4.9-7.1), 19.2 (95% CI 12.8-28.9) and 23.0 (95% CI 19.3-27.4), respectively.

INTERPRETATION

Our study showed high mortality in this inner-city population, particularly when compared with the general population of Vancouver. Excess mortality was highest among women, younger participants and those infected with either HCV or HIV or both.

Cross-sectional study of the characteristics, healthcare usage, morbidity and mortality of injecting drug users attending an inner city emergency department

BACKGROUND

The affliction of injecting drug use (IDU) has resulted in the emergence of a subgroup of people with a unique set of medical issues. We aimed to describe the emergency department (ED) presentations of IDUs.

METHODS

In a prospective observational study over a 3-month period, we identified characteristics of patients with a history of active IDU presenting to the ED.

RESULTS

From 1 January 2010 to 31 March 2010, 146 patients with a history of IDU were identified. These contributed to 222 acute presentations to the ED. Baseline characteristics revealed that patients were predominantly male, of Irish nationality, with high levels of homelessness, unemployment and lack of stable family or intimate partner relationships. 45% of presentations occurred as a result of infection (95% CI 38.5% to 51.5%). Trauma, pure toxicological issues, thromboembolic phenomena and psychiatric issues comprised the other common acute diagnoses. The burden of comorbid medical illness was substantial with high rates of hepatitis C infection (74%) and HIV infection (13.8%). Healthcare utilisation indices for this cohort are extreme on multiple measures. We found an ED attendance rate of 445 per 100 patient-years, an admission rate of 68.8 per 100 patient-years and mortality rate of 4.86 per 100 patient-years.

CONCLUSIONS

Our study characterises the emergency presentations of active IDUs. We describe considerable acute and chronic medical consequences and high healthcare utilisation associated with IDU. This study is of particular relevance to any institution that provides acute medical care to this group of patients.