Methamphetamine injection and syringe sharing among a community-recruited sample of injection drug users in Bangkok, Thailand

The methamphetamine epidemic among persons who inject heroin in Hai Phong, Vietnam

AIMS

To describe the current methamphetamine (MA) use epidemic among persons who inject heroin (PWID) in Hai Phong, Vietnam, and consider possibilities for mitigating adverse effects of methamphetamine use.

METHODS

This study conducted surveys of PWID in 2016, 2017, and 2018 (N = 1383, 1451, and 1445, respectively). Trained interviewers administered structured interviews covering drug use histories, current drug use, and related risk behaviors. The study used urinalysis to confirm current drug use, and conducted HIV and HCV testing.

RESULTS

Participants were predominantly male (95%), mean age of 40, and all reported injecting heroin. Respondents' reports of initiating MA use were rare up through early 2000s but increased exponentially through the mid-2010s. MA use was predominantly "smoking," heating the drug and inhaling the vapor using a pipe; injecting MA was rare. Current (past 30 day) MA use appears to have plateaued in 2016-2018 with 53-58% of participants reporting no use in the last 30 days, 37-41% reporting low to moderate use (1 to 19 days in last 30 days), and 5-7% reporting very frequent use (20 or more days in last 30 days). This plateau reflects a rough balance between new users and individuals ceasing use.

CONCLUSIONS

MA use has become a substantial public health problem among PWID in Hai Phong. Initiation into MA use rose exponentially from 2005 to about 2015. Use of MA will likely continue for a substantial number of PWID. Currently, no medication is approved for treating MA disorders in Vietnam. Current psychosocial treatment requires highly trained counselors and months of treatment, so that psychosocial treatment for all PWID with MA disorders is likely beyond the resources available in a middle-income country such as Vietnam. Harm reduction programs implemented by community-based organization staff may provide a way to rapidly address aspects of the current MA epidemic. Such programs could emphasize social support for reducing use where possible and for avoiding escalation of use among persons continuing to use.

Responding to global stimulant use: challenges and opportunities

We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions (except for contingency management) had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use.

Ice parties among young men who have sex with men in Thailand: Pleasures, secrecy and risks

BACKGROUND

Crystal methamphetamine (ice) has become the substance of choice among young men who have sex with men (YMSM) in urban Thailand. Yet, there is scarce data on this phenomenon, partly due to the difficulty in accessing men who will disclose and openly discuss the social contexts, meanings and risks surrounding ice practice. We present an ethnography of ice parties, critically discussing the in-depth social meanings of ice; the sexual socialities and the secrecy surrounding its use; the transactions between older and younger men; and the role of the Internet and mobile technology.

METHODS

Forty repeated narrative interviews (life stories), ten focus group discussions, as well as systematic online and offline observations were conducted over a three-year period. Purposive sampling was used to recruit study participants in a variety of online and offline spaces and through working closely with local Thai community-based organizations serving MSM. To be eligible, participants had to be between 18 and 29 years, able to converse in Thai, had used ice, and had anal sex with another man in the past 6 months. We also strived for sample variability with respects to socio-demographic characteristics (e.g., age, educational attainment and living situation). Data analysis was conducted in Thai by two researchers using the constant comparative method based on grounded theory.

RESULTS

On surface, participants described ice parties as exclusive, in trend, luxurious, fun and pleasurable-a kind of modern camaraderie among beautiful men. In reality, however, this group phenomenon was a social hierarchy containing several important players with relational power to one another, to the ice itself and to the physical space where ice was being consumed. These players included ice suppliers, party hosts, party guests and "icetenders." The paper also discusses the sociality of secrecy that surrounds ice parties as well as the power relations between older relatively rich men who provide ice and the younger men who crave for the chemical, pointing to the risks associated with engagement at ice parties, including instances of rape, violence and unsafe sex. For some participants, ice use was part of their "everyday life," or even believed to be a "rites of passage." For others, it involved sexual silence in cases where they were forced to have (unprotected) sex with certain persons or engage in high-risk activities against their will.

CONCLUSIONS

Ice parties, where high-risk practices were common, power and agency quickly became relational and negotiable. This paper illuminated the secret sociality of ice so that public health efforts will be better equipped with understanding and reaching out to young men who may be at heightened risk for HIV, STI, violence and other health concerns. Ice parties can, for example, be seen as opportunities for harm-reduction strategies whereby young men are not judged for the activities they engage, but are instead respected and approached in a contextualized, non-judgmental way. Finally, icetenders and party hosts may be individuals where public health practitioners can target and include in the development of novel harm-reduction programs.

Differences in risk behaviours and HIV status between primary amphetamines and opioid injectors in Estonia and Russia

BACKGROUND AND OBJECTIVE

People who inject drugs (PWID) account for over half of new HIV infections in Eastern Europe and central Asia, where opioids continue to be the dominant illicit drugs injected. Stimulants including amphetamines (ATS) have been associated with HIV infection risk in several settings. We sought to examine whether primary ATS injection was associated with greater HIV risk, compared to opioid injection in two European locales with significant HIV epidemics.

METHODS

PWID in Kohtla-Järve and St. Petersburg were recruited using respondent-driven sampling in 2012-2013. Survey data on demographic characteristics, service use, injecting and sexual risk behaviours and HIV-status (and HCV in Kohtla-Järve) were compared between primary opioid and ATS injectors using logistic regression models.

RESULTS

Of 591 injectors recruited in Kohtla-Järve and 811 in St. Petersburg, 195 (33%) and 27 (4%) primarily injected ATS in each city. In both cities, ATS injectors were younger than opioid injectors, initiated injection later, injected less frequently and were more likely to have been paid for sex. In both cities, PWID had high levels of multiple sex partners. In Kohtla-Järve, ATS-injectors had lower odds of back-loading and greater odds of polydrug use than opioid-injectors. In St. Petersburg, where over half of PWID reported unsafe sharing practices, ATS-injectors were less likely to report these practices. ATS-injection was negatively associated with being HIV positive in Kohtla-Järve (aOR = 0.6; 95%CI: 0.5-0.8) and St. Petersburg (aOR = 0.3; 95%CI: 0.1-0.7). ATS-injection was negatively associated with HCV-reactivity in Kohtla-Järve (aOR = 0.5; 95%CI: 0.3-0.6).

CONCLUSIONS

In both locations, primary ATS injection was associated with lower injecting risk behaviours, lower odds of HIV and being paid for sex compared to opioid injection. Interventions targeting the characteristics and needs of ATS injectors are needed to increase contact with services and reduce sexual and injecting risk. Harm reduction services, including sexual risk reduction, need to be expanded for all PWID in St. Petersburg.

High prevalence of syringe lending among HIV-positive people who inject drugs in Bangkok, Thailand

Background

Syringe sharing continues to be a major driver of the HIV pandemic. In light of efforts to enhance access to sterile syringes and promote secondary prevention among HIV-positive individuals, we sought to identify the prevalence and correlates of used syringe lending among self-reported HIV-positive people who inject drugs (PWID) in Bangkok, Thailand.

Findings

We used bivariable statistics to examine factors associated with self-reported syringe lending among self-reported HIV-positive PWID participating in the Mitsampan Community Research Project, a serial cross-sectional study of PWID in Bangkok, between June 2009 and October 2011. In total, 127 individuals were eligible for this analysis, including 25 (19.7 %) women. Twenty-one (16.5 %) participants reported syringe lending in the prior 6 months. Factors significantly associated with syringe lending included daily methamphetamine injection (odds ratio (OR) = 10.2, 95 % CI, 2.1–53.6), daily midazolam injection (OR = 3.1, 95 % CI, 1.1–8.7), use of drugs in combination (OR = 4.5, 95 % CI, 1.0–41.6), injecting with others on a frequent basis (OR = 4.25, 95 % CI, 1.3–18.3), and not receiving antiretroviral therapy (OR = 2.9, 95 % CI, 1.1–7.9).

Conclusions

A high prevalence of syringe lending was observed among self-reported HIV-positive PWID in Bangkok, which was associated with high intensity drug use, polysubstance use, and frequently injecting with others. It is particularly concerning that individuals who lent syringes were more likely to be untreated for HIV disease given the known benefits of antiretroviral provision on the prevention of HIV transmission. These findings underscore the need to expand access to sterile syringes and HIV treatment among HIV-positive PWID in Thailand.

Diverse HIV epidemics among people who inject drugs in Thailand: evidence from respondent-driven sampling surveys in Bangkok and Chiang Mai

BACKGROUND

Thailand's long-standing HIV sero-sentinel surveillance system for people who inject drugs (PWID) is confined to those in methadone-based drug treatment clinics and representative data are scarce, especially outside of Bangkok.

METHODS

We conducted probability-based respondent-driven sampling (RDS) surveys in Bangkok (n=738) and Chiang Mai (n=309) to increase understanding of local HIV epidemics and to better inform the planning of evidence-based interventions.

RESULTS

PWID had different epidemiological profiles in these two cities. Overall HIV prevalence was higher in Bangkok (23.6% vs. 10.9%, p<0.001) but PWID in Bangkok are older and appear to have long-standing HIV infections. In Chiang Mai, HIV infections appear to be more recently acquired and PWID were younger and had higher levels of recent injecting and sexual risk behaviors with lower levels of intervention exposure. Methamphetamine was the predominant drug injected in both sites and polydrug use was common although levels and patterns of the specific drugs injected varied significantly between the sites. In multivariate analysis, recent midazolam injection was significantly associated with HIV infection in Chiang Mai (adjusted odds ratio=8.1; 95% confidence interval: 1.2-54.5) whereas in Bangkok HIV status was not associated with recent risk behaviors as infections had likely been acquired in the past.

CONCLUSION

PWID epidemics in Thailand are heterogeneous and driven by local factors. There is a need to customize intervention strategies for PWID in different settings and to integrate population-based survey methods such as RDS into routine surveillance to monitor the national response.

Cross-border activities and association with current methamphetamine use among Chinese injection drug users (IDUs) in a China-Myanmar border region

BACKGROUND

Methamphetamine has become one of the most widely used illicit substances in the world. We measured the prevalence and identified the correlates of methamphetamine use amongst current injection drug users (IDUs) in a China-Myanmar border region.

METHODS

A cross-sectional survey including interviews and serological testing was conducted in 2012. Chinese IDUs who had injected within the past six months and aged ≥ 18 years were recruited using respondent-driven sampling (RDS). Logistic regression indentified factors associated with current methamphetamine use.

RESULTS

Among 370 IDUs recruited, prevalence of lifetime and current methamphetamine use was 84.2% and 75.2% respectively. Amongst 293 current users, 18.1% ever purchased methamphetamine from Myanmar while 8.9% ever used it there during the past 6 months. IDUs who had cross-border activities, including purchasing drugs (AOR: 1.20; 95% CI: 1.10, 1.31) and visiting family/friends, doing business or odd jobs in Myanmar (AOR: 1.13; 95% CI: 1.02, 1.24) were more likely to use methamphetamine in the past six months. Other factors independently associated with current methamphetamine use included being younger (aged  ≤ 25 years, AOR: 1.24; 95% CI: 1.09, 1.41), being syphilis positive (AOR: 1.17; 95% CI: 1.03, 1.33), having used previously self-used needle/syringe (AOR: 1.20; 95% CI: 1.08, 1.34) and recently received prevention services (AOR: 1.15; 95% CI: 1.04, 1.28).

CONCLUSION

Methamphetamine has become another major drug of use and poses the serious concern among injecting drug users living in the China/Myanmar border region. The bi-national cooperation is urgently needed to develop targeted effective intervention strategies.

Drug-related harm among people who inject drugs in Thailand: summary findings from the Mitsampan Community Research Project

Background

For decades, Thailand has experienced high rates of illicit drug use and related harms. In response, the Thai government has relied on drug law enforcement to address this problem. Despite these efforts, high rates of drug use persist, and Thailand has been contending with an enduring epidemic of human immunodeficiency virus (HIV) among people who inject drugs (IDU).

Methods

In response to concerns regarding drug-related harm in Thailand and a lack of research focused on the experiences and needs of Thai IDU, the Mitsampan Community Research Project was launched in 2008. The project involved administering surveys capturing a range of behavioral and other data to community-recruited IDU in Bangkok in 2008 and 2009.

Results

In total, 468 IDU in Bangkok were enrolled in the project. Results revealed high rates of midazolam injection, non-fatal overdose and incarceration. Syringe sharing remained widespread among this population, driven primarily by problems with access to syringes and methamphetamine injection. As well, reports of police abuse were common and found to be associated with high-risk behavior. Problems with access to evidence-based drug treatment and HIV prevention programs were also documented. Although compulsory drug detention centers are widely used in Thailand, data suggested that these centers have little impact on drug use behaviors among IDU in Bangkok.

Conclusions

The findings from this project highlight many ongoing health and social problems related to illicit drug use and drug policies in Bangkok. They also suggest that the emphasis on criminal justice approaches has resulted in human rights violations at the hands of police, and harms associated with compulsory drug detention and incarceration. Collectively, the findings indicate the urgent need for the implementation of evidence-based policies and programs in this setting.

The effect of exposures to policing on syringe sharing among people who inject drugs in Bangkok, Thailand

While intensive drug law enforcement is recognized as a social-structural driver of HIV epidemics among people who inject drugs (IDU), few studies have investigated the effects of direct encounters with police, particularly in Asian settings. Using multivariate log-binomial regression, we examined the relationship between syringe sharing and exposures to two types of policing practices among IDU in Bangkok, Thailand: having been beaten by police and having been tested for illicit drugs by police. Between July and October 2011, 435 IDU participated in the study, with 75 (17.2 %) participants reporting syringe sharing in the past 6 months. In multivariate analyses, exposures to the two types of policing practices had an independent effect on syringe sharing, with experiencing both practices showing the greatest effect. These findings highlight the importance of addressing the policy and social environment surrounding IDU as a means of HIV prevention.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

BACKGROUND

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

METHODS

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

RESULTS

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96).

CONCLUSIONS

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

"A costly turn on": patterns of use and perceived consequences of mephedrone based head shop products amongst Irish injectors

BACKGROUND

Mephedrone injecting has recently been reported in Romania, Slovenia, Guernsey and Ireland. The research reported here aimed to describe the experiences of a group of Irish injecting drug users, who were injecting mephedrone based headshop products prior to the introduction of legislative controls in Ireland, with particular focus on pre- and post-legislative use, effects of injecting mephedrone, settings and contexts for injecting, polydrug use and serial drug injecting, risk perceptions and harm reduction practises.

METHODS

Following a predevelopment phase with a Privileged Access Interviewer, in-depth interviews using a phenomenological approach were conducted with eleven attendees of a low threshold harm reduction service.

RESULTS

The findings describe the abuse potential of these mephedrone based headshop products when used by intravenous injection. Although participants were aware of risks and safe injecting practises, compulsive re injecting with excessive binge use over long periods of time was common. Nasal to injection route transitions, intense paranoia, violent behaviour and aggression, emergence of Parkinson type symptomatologies (in the form of spasms and 'wobbling'), and permanent numbness in lower extremities were reported. Multi and serial drug injecting with heroin was used in efforts to manage the intense rush and avoid unpleasant comedown. Participants reported limb abscesses, vein clotting, damage and recession resulting from product toxicity, crystallisation of the products when diluted and flushing practises. Seven participants were homeless, with groin and street injecting common. Following legislative changes use of mephedrone products declined due to closure of headshops, increased street prices, concerns around contamination and the emergence of new street stimulant drugs.

CONCLUSION

Continued monitoring of drug displacement patterns in post legislative time frames is advised, alongside longitudinal ethnographic research to track the diffusion of mephedrone and other cathinone derivatives within injecting networks. Further investigation of the adverse health consequences of these drugs on injection is warranted.

Injection methamphetamine use is associated with an increased risk of attempted suicide: a prospective cohort study

BACKGROUND

Methamphetamine (MA) use is a growing public health concern in many settings around the world. While some physical and mental health effects associated with injection MA use have been well described, little is known about the relationship between injecting MA and suicidal behavior. We sought to determine whether MA injection was associated with an increased risk of attempting suicide among a prospective cohort of injection drug users (IDUs) in Vancouver, Canada.

METHODS

Between 2001 and 2008, eligible participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) completed semi-annual questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems including suicidal behavior. We used Cox proportional hazards models with time-dependent covariates to determine whether self-reported MA injection was an independent predictor of attempting suicide at subsequent time points.

RESULTS

Of 1873 eligible participants, 149 (8.0%) reported a suicide attempt, resulting in an incidence density of 2.5 per 100 person-years. Participants who attempted suicide were more likely to be younger (median: 35 vs. 40, p<0.01), female (48.3% vs. 35.1%, p<0.01), and of Aboriginal ancestry (43.6% vs. 31.3%, p<0.01). In a Cox proportional hazards model, MA injection was associated with an 80% increase in the risk of attempting suicide (adjusted hazard ratio=1.80, 95% CI: 1.08-2.99, p=0.02).

CONCLUSIONS

These findings suggest that IDUs who inject MA should be monitored for suicidal behavior. Improved integration of mental health and suicide prevention interventions within harm reduction and drug treatment programs may be fruitful.