From Long-Term Injecting to Long-Term Non-Injecting Heroin and Cocaine Use: The Persistence of Changed Drug Habits

Injection cessation and relapse to injection and the associated factors among people who inject drugs in Iran: The Rostam study

BACKGROUND

Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran.

METHODS

This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome.

RESULTS

The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation.

CONCLUSION

Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.

Injecting drug use opportunities and reasons for choosing not to inject: A population-based study of Australian young adults who use stimulants

INTRODUCTION

Understanding reasons for choosing not to inject drugs, among those who have never injected before, may be helpful for reducing transitions to injecting drug use. This study examines opportunities to inject and reasons for never injecting in young adults who used stimulants.

METHODS

Data are from a population-based study of young adults who used ecstasy and methamphetamine (n = 313), recruited in Queensland, Australia in 2008/2009. At the follow-up, participants who had never injected (n = 293) completed a 13-item instrument on reasons for never injecting. We conducted a principal components analysis to identify types of reasons (scored 0-100) and multivariate regression to predict endorsement of these reasons.

RESULTS

Approximately one-in-five of all participants ever had an opportunity to inject and there was no gender difference in the propensity to accept an opportunity. Four types of reasons, labelled risk perception, subjective effects, social environment and aversion, were identified. Male gender was associated with lower endorsement of risk perception (β = -7.94; 95% confidence interval [CI] -13.37, -2.51) and social environment (β = -7.35; 95% CI -13.15, -1.54). Having friends who injected was associated with lower endorsement of the social environment (β = -8.88; 95% CI -14.83, -2.94), and higher endorsement of aversion (β = 7.67; 95% CI 1.44, 13.89).

DISCUSSION AND CONCLUSIONS

Our findings suggest that injecting drug use opportunities are common among young adults engaged in recreational drug use, with males and females equally likely to accept an opportunity. A strong aversion to injecting and a hedonic preference for non-injecting drug use may reduce the likelihood of accepting these opportunities.

Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study

BACKGROUND

Syringe services programs (SSPs) are effective venues for delivering harm-reduction services to people who inject drugs (PWID). However, SSPs often face significant barriers to implementation, particularly in the absence of known human immunodeficiency virus (HIV) outbreaks.

METHODS

Using an agent-based model, we simulated HIV transmission in Scott County, Indiana, a rural county with a 1.7% prevalence of injection drug use. We compared outcomes arising in the absence of an SSP, in the presence of a pre-existing SSP, and with implementation of an SSP after the detection of an HIV outbreak among PWID over 5 years following the introduction of a single infection into the network.

RESULTS

In the absence of an SSP, the model predicted an average of 176 infections among PWID over 5 years or an incidence rate of 12.1/100 person-years. Proactive implementation averted 154 infections and decreased incidence by 90.3%. With reactive implementation beginning operations 10 months after the first infection, an SSP would prevent 107 infections and decrease incidence by 60.8%. Reductions in incidence were also observed among people who did not inject drugs.

CONCLUSIONS

Based on model predictions, proactive implementation of an SSP in Scott County had the potential to avert more HIV infections than reactive implementation after the detection of an outbreak. The predicted impact of reactive SSP implementation was highly dependent on timely implementation after detecting the earliest infections. Consequently, there is a need for expanded proactive SSP implementation in the context of enhanced monitoring of outbreak vulnerability in Scott County and similar rural contexts.

Cocaine use in organ donors and long-term outcome after heart transplantation: An International Society for Heart and Lung Transplantation registry analysis

BACKGROUND

Cardiac allografts from donors with a history of cocaine use (DHCU) are often discarded owing to concerns regarding organ quality. We investigated long-term outcomes of de novo adult heart transplantation (HTx) using DHCU.

METHODS

Using the International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry, we identified 24,430 adult recipients of primary, deceased donor, heart-alone transplants between January 1, 2000, and June 30, 2013. Transplants were categorized on the basis of DHCU. Survival rates were compared using Kaplan-Meier curves and log-rank tests.

RESULTS

A total of 3,246 (13.3%) HTx were performed using DHCU during the study period. Of these, 1,477 (45.5%) were classified as current users. Organs from DHCU were transplanted at a later sequence number (data from a sub-group of patients transplanted in the United States) than those from the non-cocaine use group (mean sequence number 16.1 ± 55.6 vs 11.5 ± 38.2; p < 0.001), suggesting higher decline rates by centers. Kaplan-Meier estimates of survival were not different between groups (p = 0.16), with post-transplant survival rates at 1, 5, and 10 years of 88.1%, 75.8%, and 58.5%, respectively, in the non-cocaine use group and 90.0%, 76.7%, and 59.7%, respectively, in the DHCU group. On multivariate analysis, DHCU were not associated with mortality (hazard ratio [HR]: 0.94; 95% CI: 0.88-1.00; p = 0.050), cardiac allograft vasculopathy (HR: 1.02; 95% CI: 0.94-1.11; p = 0.56), or allograft rejection (HR: 0.98; 95% CI: 0.92-1.05; p = 0.61).

CONCLUSIONS

Our findings demonstrate that adult HTx performed using DHCU is not associated with an adverse impact on long-term clinical outcomes. These findings should spur efforts to reduce discard rates of organs from DHCU.

Risk of hepatitis C virus infection in injecting and noninjecting drug users receiving opioid substitution therapy

BACKGROUND

Hepatitis C virus (HCV) is the most common viral infection among illicit drug users in the world. Although intervention of needle and syringe program and opioid substitution therapy had engaged to prevent HCV infection, the prevalence of HCV infection does not seem to decline. The aim of this study was to estimate the risk of HCV infection in injecting drug users (IDUs) and noninjecting drug users (NIDUs) receiving opioid substitution therapy.

METHODS

We recruited 1179 heroin-dependent patients (age: 20-66 years) under opioid substitution therapy from 2012 to 2015 in a Psychiatric Center, Southern Taiwan. The data of HCV, hepatitis B virus and HIV infection and liver biochemical examination were obtained. We used multivariate logistic regression analysis to predict the risk of HCV infection.

RESULTS

There were 93.1% of IDUs and 68.1% of NIDUs positive for HCV infection. In IDUs, HIV infection, age of heroin initiation, duration and dose of heroin use, frequency of detoxification, and number of criminal conviction were significantly associated with HCV infection. In NIDUs, snort/sniff heroin exhibited a significantly increased risk of HCV infection. Intravenous injecting (odds ratio [OR] = 23.10, 95% CI = 8.04-66.40, p < 0.001), intravenous injecting combined snort/sniff (OR = 12.95, 95% CI = 3.90-42.97, p < 0.001), and snort/sniff (OR = 4.14, 95% CI = 1.30-13.18, p = 0.016) were significantly associated with increased risk of HCV infection compared with smoking. The trend was significant (p for trend <0.001).

CONCLUSION

In Taiwan, IDUs had harmful characteristics compared with NIDUs and both had extremely high prevalence of HCV infection. We provided evidence that snort/sniff is a possible way of leak in HCV infection despite needle-syringes supplement program been provided. Opioid substitution therapy program should include HCV assessment and treatment in the new direct-acting antiviral therapy era.

Short and sporadic injecting cessation episodes as predictors of incident hepatitis C virus infection: findings from a cohort study of people who inject drugs in Montréal, Canada

BACKGROUND AND AIMS

For most people who inject drugs (PWID), drug injecting follows a dynamic process characterized by transitions in and out of injecting. The objective of this investigation was to examine injecting cessation episodes of 1-3-month duration as predictors of hepatitis C virus (HCV) acquisition.

DESIGN

Cohort study.

SETTING

Montréal, Canada.

PARTICIPANTS

A total of 372 HCV-uninfected (HCV RNA-negative, HCV antibody-positive or -negative) PWID (mean age = 39.3 years, 82% male, 45% HCV antibody-positive) enrolled between March 2011 and June 2016.

MEASUREMENTS

At 3-month intervals, participants completed an interviewer-administered questionnaire and were tested for HCV particles (HCV RNA). At each visit, participants indicated whether they injected in each of the past 3 months (defined as three consecutive 30-day periods). Injecting cessation patterns were evaluated on a categorical scale: persistent injecting (no injecting cessation in the past 3 months), sporadic injecting cessation (injecting cessation in 1 of 3 or 2 of 3 months) and short injecting cessation (injecting cessation in 3 of 3 months). Their association with HCV infection risk was examined using Cox regression analyses with time-dependent covariates, including age, gender, incarceration, opioid agonist treatment and other addiction treatments.

FINDINGS

At baseline, 61, 26 and 13% of participants reported persistent injecting, sporadic injecting cessation and short injecting cessation, respectively. HCV incidence was 7.5 per 100 person-years [95% confidence interval (CI) = 5.9-9.5; 916 person-years of follow-up]. In adjusted Cox models, sporadic injecting cessation and short injecting cessation were associated with lower risks of incident HCV infection compared to persistent injecting (adjusted hazard ratios = 0.56, 95% CI = 0.30-1.04 and 0.24, 95% CI = 0.09-0.61), respectively.

CONCLUSION

Short and sporadic injecting cessation episodes were common among a cohort of people who inject drugs in Montréal, Canada. Injecting cessation episodes appear to be protective against hepatitis C virus acquisition, particularly when maintained for at least 3 months.

Do risk factors increase measurement of hepatitis B, C signs and HIV-AIDS among middle-aged and older IDUs in southwest Iran?

Purpose

Injecting drug use addiction is a main factor in hepatitis B, C infection and HIV–AIDS infection. The purpose of this paper is to measure seroprevalence of hepatitis B, C virus and HIV–AIDS amongst injecting drug users (IDUs) and its influencing factors.

Design/methodology/approach

The cross-sectional method was used in mid-2017 in Ahwaz city, southwest Iran. In total, 133 IDUs, aged 29–71 years (mean age=48.21 ± 10.4), were chosen from Aria addiction treatment centre. The data were collected on demographic and behavioural characteristics. In addition, serum samples were screened for those diseases.

Findings

In a total of 131 IDUs, 2 (1.5 per cent) were HIV+, 16 (11.7 per cent) HCV+ and 8 (6.1 per cent) HBV+. There was a significant correlation between diseases and IDU. Results of multiple regression stated that IDU was a more predicting variable as β=0.76 and the model was able to predict 74.1 per cent of the variance, F (3, 35)=12.42, ρ<0.001, R2=0.741, OR=3.01, 95% CI [1.44, 3.83]. The synchronised pairwise effect of age, imprisonment and IDU with GLM analysis was significant, F (2, 114)=20.433, ρ<0.000, η HCV + 2 = 0.609 , η HBV + 2 = 0.616 , and η HCV + 2 = 0.612 , λWilks’=0.056. The infection rate among IDUs was significant and the most important risk factor for these infections has been intravenous drug use, together with age of misusing and imprisonment.

Research limitations/implications

The non-cooperation of two samples, lack of participation of three addiction rehabilitation centres in Ahwaz city, the end of cooperation in the first two months of the implementation of the plan, and the lack of consistency of the three serum samples in the cases (two cases) were limitations of the study.

Practical implications

Based on the results, the following suggestions could be presented: establishing “Intervention Clubs” for treatment in the peripheral urban areas for the participation of women drug users – the responsible organisation is Cultural and Social Deputy of Ahwaz Municipality Organisation. Integration of “Small Self-caring Groups” in Sepidar Women’s Penitentiary in the East Ahwaz region – the responsible organisation is Khuzistan Province Prisons Organisation (the southwestern Iranian prisons authority); constructing “Community-based Committees” to increase the level of social intervention – the responsible organisation is the Iran Drug Control Headquarters at Iranian Presidential Office; screening of injecting drug use in the populations at risk, especially girls and women in marginalised areas – the responsible organisation is Deputy Director of Prevention and Treatment of Addiction in the Iran Welfare and Rehabilitation Organisation; establishing an “Patient Treatment Center” in high-risk areas along with directing drug users and supervising the relevant authorities – the responsible organisation is Deputy Police Commander on Social Assistance; providing education to families involved with addiction in the “Neighborhood Parks” – the responsible organisation is Deputy for Health Affairs.

Social implications

They are mixed with practical implications as well.

Originality/value

The comprehensive harm reduction plan and prison-related issues of IDUs with shared syringe along with the pairwise age and imprisonment need to consider the above factors.