The injection of methadone and benzodiazepines among Sydney injecting drug users 1996-2000: 5-year monitoring of trends from the Illicit Drug Reporting System

Health harms of non-medical prescription opioid use: A systematic review

ISSUES

Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken.

APPROACH

We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality.

KEY FINDINGS

Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%).

IMPLICATIONS

A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault.

DISCUSSION AND CONCLUSIONS

Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.

Electro-Acupuncture Combined Methadone for Withdrawal Symptoms of Opioid Addiction: A Protocol for Systematic Review and Meta-Analysis

Background<br/> Opioid addiction is a chronic brain disorder characterized by a series of withdrawal symptoms in behavioral, psychological, and neurobiological manifestations. Withdrawal symptoms are the main cause of relapse after periods of abstinence; thus, the treatment is focused on abstinence symptoms. Due to most of all types of opioid agonist drugs carry a potential for addiction and exacerbation of withdrawal symptoms, nondrug methods have great potentials in clinical applications. Electro-acupuncture (EA), as a novel nonpharmacological approach, combined with methadone has a long-term positive efficacy on treating addiction. Therefore, we designed a protocol to evaluate the adjuvant effect of EA for treating withdrawal symptoms of opioid addiction.<br/> Method<br/> To review reports of relevant clinical trials, we will search English language databases (EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials) and Chinese databases (Chinese Biomedical Literatures, China National Knowledge Infrastructure, Wanfang, and VIP). We will collect documents from the earliest possible date up to May 2020. We will also search online trial registries such as ClinicalTrials. gov (ClinicalTrials.gov/), the European Medicine Agency (www.ema.europa.eu/ema/), and WHO International Clinical Trials Registry Platform (www.who.int/ictrp). We will select randomized controlled trials (RCT) for withdrawal from opioid addiction involving EA-methadone and methadone alone treatment. We will use psychological assessment scales to evaluate treatment major outcomes which include numerous components such as OWS, VAS, HAMD, HAMA; then urinalysis and methadone dosage also will be measure as the additional outcomes. Finally, RevMan5 software will be used for literature quality evaluation and data analysis.<br/> Result:<br/> To evaluate the efficacy of EA in combination therapy by observing the outcomes of corresponding scale, urinalysis and decreasing methadone.<br/> Conclusion:<br/> This protocol will be used to evaluate the efficacy and safety of EA in combination with methadone in treatment of opioid addiction withdrawal symptoms.<br/> Abbreviations: Opioid dependence, OWS=Opiate Withdrawal Scale, VAS=Craving Visual Analog Scale, PWSS=Post-withdrawal symptoms Scale, HAMD=Hamilton Depression Scale, HAMA=Hamilton Anxiety Scale, RCTs=Randomized Controlled Trials, EA=Electrical Acupuncture, PRISMA=Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Prevalence and correlates of simultaneous, multiple substance injection (co-injection) among people who inject drugs in Melbourne, Australia

AIMS

To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co-injection) among a community-recruited cohort of people who inject drugs.

DESIGN

Cross-sectional study.

SETTING

Melbourne, Australia.

PARTICIPANTS

A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted.

MEASUREMENTS

We constructed two statistical models: a logistic regression model analysing correlates of co-injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin-diphenhydramine co-injection only, co-injection of other substances and no co-injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non-fatal overdose.

FINDINGS

One-third [n = 226, 31%; 95% confidence interval (CI): 28-34%] of participants reported co-injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin-diphenhydramine (n = 121, 54%; 95% CI = 48-60%) and heroin-methamphetamine (n = 121, 54%; 95% CI = 48-60%). In logistic regression analyses, reporting co-injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18-2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31-3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin-diphenhydramine co-injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80-13.56, P < 0.001] and overdose (requiring an ambulance) in the past 12 months (aRRR = 2.81, 95% CI = 1.17-6.72, P = 0.021) compared with participants reporting no co-injection or co-injection of other substances.

CONCLUSIONS

A substantial proportion of people who inject drugs report co-injection of multiple substances, which is associated with a range of socio-demographic, drug use and health service use risk factors.

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California

Background: Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). Objectives: This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. Methods: A cross-sectional sample of PWID (N = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Results: Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Conclusion: Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities

BACKGROUND

Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables.

METHODS

Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ2 tests.

RESULTS

The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives-avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one's own OST-were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment.

CONCLUSIONS

Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.

Tranquilizer misuse among active cocaine users: Predictors of initiation

INTRODUCTION AND AIMS

Tranquilizer use is associated with negative health outcomes among people who use drugs. This paper aims to estimate the incidence rate (initiation) and identify predictors of tranquilizer misuse (TM) among cocaine users.

DESIGN AND METHODS

A prospective cohort study was conducted in Montreal, Canada. Interviewer-administered questionnaires were carried out at 3-month intervals. Initiation was defined as misusing a tranquilizer for the first time during follow-up. 'Lasting-initiation', defined as reporting TM at the next visit following first use, was also examined. Cox proportional hazard regression analyses were carried out to assess predictors of initiation to TM.

RESULTS

Among the 245 participants who were eligible for the initiation analyses, 123 started TM during follow-up for an incidence rate of 40.49 per 100 person-years (95% confidence interval, CI: 33.80-48.15). Of the 123 initiates, 35.7% were still using at the interview following initiation for an incidence rate of 14.70 per 100 person-years (95% CI: 10.82-19.56). Multivariate models showed that independent predictors of initiation and 'lasting initiation' were identical as having had a criminal activity as the main source of income, having been recently in treatment for a substance use disorder (SUD) and reporting non-medical use of prescription opioids.

DISCUSSION AND CONCLUSIONS

The incidence rate of TM initiation was high among a sample of cocaine users. Initiation was predicted by a problematic drug use pattern involving polydrug use, involvement in the street economy and having been in treatment for a SUD. These findings have implications for prevention and harm reduction strategies.

How does the use of multiple needles/syringes per injecting episode impact on the measurement of individual level needle and syringe program coverage?

BACKGROUND

Recent work by McCormack et al. (2016) showed that the inclusion of syringe stockpiling improves the measurement of individual-level syringe coverage. We explored whether including the use of a new parameter, multiple sterile syringes per injecting episode, further improves coverage measures.

METHODS

Data comes from 838 people who inject drugs, interviewed as part of the 2015 Illicit Drug Reporting System. Along with syringe coverage questions, the survey recorded the number of sterile syringes used on average per injecting episode. We constructed three measures of coverage: one adapted from Bluthenthal et al. (2007), the McCormack et al. measure, and a new coverage measure that included use of multiple syringes. Predictors of multiple syringe use and insufficient coverage (<100% of injecting episodes using a sterile syringe) using the new measure, were tested in logistic regression and the ability of the measures to discriminate key risk behaviours was compared using ROC curve analysis.

RESULTS

134 (16%) participants reported needing multiple syringes per injecting episode. Women showed significantly increased odds of multiple syringe use, as did those reporting injection related injuries/diseases and injecting of opioid substitution drugs or pharmaceutical opioids. Levels of insufficient coverage across the three measures were substantial (20%-28%). ROC curve analysis suggested that our new measure was no better at discriminating injecting risk behaviours than the existing measures.

CONCLUSION

Based on our findings, there appears to be little need for adding a multiple syringe use parameter to existing coverage formulae. Hence, we recommend that multiple syringe use is not included in the measurement of individual-level syringe coverage.

Benzodiazepine Use and Hepatitis C Seroconversion in a Cohort of Persons Who Inject Drugs

OBJECTIVES

To examine the relationship between benzodiazepine (BZD) use and HCV seroconversion in 2 linked prospective cohorts of persons who inject drugs (PWID).

METHODS

We examined prospective cohorts of 440 PWID (baseline BZD users: n = 102; 23.2%) from the AIDS Care Cohort to Evaluate Access to Survival Services (ACCESS) and the Vancouver Injection Drug Users Study (VIDUS) cohorts, followed-up from 1996 to 2013 in Vancouver, Canada.

RESULTS

At baseline, the prevalence of HCV was higher among those who used BZD (80.5% vs 61.5%; P < .001). After adjustment, BZD use remained independently associated with increased rates of HCV seroconversion (adjusted rate ratio = 1.67; 95% confidence interval = 1.05, 2.66).

CONCLUSIONS

BZD use is independently associated with HCV seroconversion in a population of PWID.

Health outcomes associated with illicit prescription opioid injection: A systematic review

Prescription opioid injection is a growing concern among people who use illicit drugs. Little is known about the potential health-related harms of injecting prescription opioids. Therefore, the authors undertook a systematic review to identify health outcomes associated with injecting prescription opioids. PubMed, Ovid MEDLINE®, EMBASE, Journals@Ovid, CINAHL, PsycInfo, Web of Science® Core Collection, CAB Direct, and ERIC databases were searched to identify English articles published between January 1990 and February 2015 that matched the inclusion criteria. Potentially relevant articles were those examining a clinical health outcome among people who use illicit drugs, in which a sub-group injects prescription opioids. The International Classification of Diseases (ICD-10) was used to clinically classify health outcomes. In total, 31 studies that met the inclusion criteria were identified and summarized. A modified version of the Downs and Black checklist was used to assess individual study quality and identify sources of bias. Findings supported associations between prescription opioid injection and hepatitis C infection, substance dependence and other mental health indicators, and lower general health. Associations with human immunodeficiency virus, overdose, and cutaneous infection were less consistent and varied according to prescription opioid type(s). Several potential sources of bias were identified as well as a need for more longitudinal research and more rigorous confounding adjustment. The current findings highlight a need to consider the growing popularity of prescription opioid injection in efforts to reduce drug-related harm among people who inject drugs.

Illicit use of opioid substitution drugs: prevalence, user characteristics, and the association with non-fatal overdoses

BACKGROUND AND AIMS

Diversion of opioid substitution drugs (OSD) is of public concern. This study examined the prevalence, frequency, and predictors of illicit OSD use in a group of injecting drug users (IDUs) and assessed if such use was associated with non-fatal overdoses.

METHODS

Semi-annual cross-sectional interviews conducted in Oslo, Norway (2006-2013), from 1355 street-recruited IDUs. Hurdle, logistic, and multinomial regression models were employed.

RESULTS

Overall, 27% reported illicit OSD use in the past four weeks; 16.8% methadone, 12.5% buprenorphine, and 2.9% both drugs. Almost 1/10 reported at least one non-fatal overdose in the past four weeks, and roughly 1/3 reported such experience in the past year. Use of additional drugs tended to be equally, or more prevalent among illicit OSD users than other IDUs. In terms of illicit OSD use being a risk factor for non-lethal overdoses, our results showed significant associations only for infrequent buprenorphine use (using once or less than once per week). Other factors associated with non-fatal overdoses included age, education, homelessness, as well as the benzodiazepines, stimulants, and heroin use.

CONCLUSIONS

Users of diverted OSD may represent a high-risk population, as they used more additional drugs and used them more frequently than other IDUs. However, illicit OSD use may be less harmful than previously assumed. After accounting for an extensive set of covariates, only infrequent illicit buprenorphine use, but not methadone use, was associated with non-fatal overdoses.

‘Over the counter’ (OTC) opiate abuse treatment

Objectives: Over the counter (OTC) medication abuse is an increasing public health concern. We studied the clinical profiles, treatment and prevalence of patients admitted with OTC opiate abuse.

Method: Using a specially designed demographic form, the records of patients admitted to St. Patrick's Hospital, a 280 bed inpatient mental health and addiction treatment facility in Dublin, with a diagnosis of harmful OTC opiate abuse or opiate dependency as defined in ICD-10 were reviewed retrospectively. All patients diagnosed with OTC opiate abuse (ICD F11.1) or dependency (ICD F11.2) on admission to our centre were included in the study. Patients with a diagnosis of primary illicit opiate misuse were excluded.

Results: Approximately 1% (n=20) of inpatients admitted in a year were diagnosed with OTC opiate abuse. The average daily codeine intake was 261.0 mg per person. Some 75% percent (n=15) of the inpatients experienced OTC opiate withdrawal and were treated with protocol driven withdrawal regimes for an average of 16.10 days. The female: male ratio was nearly 2:1 with an average age of 49.2 years. Patients tended to have co-morbid psychiatric (n=19, 95%), physical (n=17,85%) and polysubstance (n=13,65%) illness.

Conclusions: OTC opiate abuse is a significant problem which is largely covert in nature with serious co-morbidity and frequent complications including withdrawal symptoms which require treatment. Results of this study suggest that further research is warranted in this area.

High rates of midazolam injection and associated harms in Bangkok, Thailand

AIMS

To identify the prevalence and correlates of midazolam injection among injecting drug users in Thailand.

DESIGN

Serial cross-sectional mixed-methods study.

SETTING

Bangkok, Thailand.

PARTICIPANTS

  A total of 435 adults who had injected drug(s) in the past 6 months were recruited through peer outreach and word of mouth in Bangkok in 2011.

MEASUREMENTS

Multivariable logistic regression was used to analyze self-reported data collected through an interviewer-administered survey in July-October 2011 (n = 435). Additionally, qualitative data were collected in June-July 2009 (n = 10) and analyzed to explore the health problems attributable to midazolam injection.

FINDINGS

Among 435 survey participants, the prevalence of daily midazolam injection in the past 6 months was 37.0% (95% confidence interval: 32-42). While 75.8% of the daily midazolam injectors identified heroin as their drug of choice, 91.8% of these individuals reported substituting heroin with midazolam when heroin was unavailable. In multivariable analyses, daily midazolam injection was associated with femoral vein injection [adjusted odds ratio (AOR) = 4.48], polydrug use (AOR = 4.94), daily heroin injection (AOR = 3.25), binge use (AOR = 1.75) and perceived increase in policing pressure (AOR = 1.95) (all P < 0.05). Qualitative accounts indicated severe health problems associated with midazolam injection, including nerve and vascular injuries.

CONCLUSION

Midazolam misuse is increasing among injecting drug users in Bangkok and appears to be used primarily as a substitute for heroin. Midazolam injection was associated independently with various risk factors for injection-related complications. Given the many deleterious effects of midazolam injection, novel interventions for midazolam injectors are needed urgently.

The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone-experience from a medium-sized Finnish city

Providing unobserved opioid substitution treatment (OST) safely is a major challenge. This study examined whether electronic medicine dispensers (EMDs) can reduce diversion of take-home buprenorphine-naloxone (BNX) in a medium-sized Finnish city. All BNX treated OST patients in Kuopio received their take-home BNX in EMDs for 4months. EMDs' effect on diversion was investigated using questionnaires completed by patients (n=37) and treatment staff (n=19), by survey at the local needle exchange service and by systematic review of drug screen data from the Kuopio University Hospital. The majority of patients (n=21, 68%) and treatment staff (n=11, 58%) preferred to use EMDs for the safe storage of tablets. Five patients (16%) declared that EMDs had prevented them from diverting BNX. However, EMDs had no detectable effect on the availability or origin of illegal BNX or on the hospital-treated buprenorphine-related health problems. EMDs may improve the safety of storage of take-home BNX, but their ability to prevent diversion needs further research.

The needle and the damage done: clinical and behavioural markers of severe femoral vein damage among groin injectors

AIM

To identify factors associated with severe femoral vein (FV) damage among groin injectors (GIs) on oral opioid substitution treatment.

DESIGN

A cohort study.

SETTING

Drug treatment centres in South East England.

PARTICIPANTS

GIs attending an ultrasound 'health-check' clinic.

MEASURES

Femoral ultrasonography and clinical grading of venous disease in each leg.

METHOD

Comparison of 67 GIs with severely damaged FV and 86 GIs with minimal/moderate damage.

FINDINGS

The majority were men (69.3%) and the mean age was 36.2 years with mean duration of injecting drug use (IDU) of 13.3 years. There were no significant between-group differences in age, gender or duration of IDU. Severe FV damage was associated with longer duration of groin injecting (GI; P<0.005), use of thick needles (blue-hub, 23G; or green-hub, 21G; P<0.001), benzodiazepine injection (P<0.005), history of deep vein thrombosis (DVT, P<0.001) and recurrent DVT (P<0.001), presence of depressed groin scar (P<0.001) and chronic venous disease (CVD, P<0.001). Logistic regression analysis revealed needle size (β 1.2, Wald 4.9, P<0.05) and DVT (β 3.3, Wald 38.5, P<0.001) as the main predictors of severe FV damage.

CONCLUSION

Needle and syringe exchange services should consider only supplying appropriate lengths of orange-hub needle (25G) on request from GIs. Early cessation of GI, avoidance of benzodiazepine injection and prompt diagnosis and treatment of DVT might also reduce the prevalence of severe FV damage among GIs and the associated healthcare burden. Routine examination of injecting sites among these patients should include an assessment of severity of venous disease in each leg.

The use of alprazolam by people who inject drugs in Melbourne, Australia

INTRODUCTION AND AIMS

In Australia, people who inject drugs (PWID) commonly report the use of benzodiazepines (BZDs). This paper explores the emerging use of alprazolam among PWID in Melbourne, Australia.

DESIGN AND METHODS

This study reports on 3 years of data collected through the Victorian Illicit Drug Reporting System (2008-2010). Structured interviews were conducted with 451 PWID and analysed using odds ratios and χ(2)-tests for trends over time.

RESULTS

While the proportion of PWID reporting recent BZD use remained stable over time, the proportion reporting alprazolam to be their most commonly used BZD fluctuated, peaking in 2009. Alprazolam users were significantly more likely to report using illicit BZDs and to report recent BZD injection compared with users of other BZDs. Alprazolam use was associated with the sale of drugs for cash, but not with other criminal activities.

DISCUSSION AND CONCLUSION

The fluctuations in alprazolam use over time may be reflective of medical practitioners ceasing to prescribe alprazolam in response to reports of associated harms; however, this may in turn be driving the illicit alprazolam market. While the data do not indicate a clear association between alprazolam use and harms, considering the potential severity of associated harms and the association between alprazolam use and anterograde amnesia, patterns of alprazolam use among PWID should be closely monitored. Potential changes to prescribing practice should consider unintended consequences, such as replacement with other BZD types, or illicitly obtained BZDs.

Compliance with buprenorphine medication-assisted treatment and relapse to opioid use

Opioid dependence (OD), often characterized as a chronic relapsing disorder, affects millions of people worldwide. The purpose of this study was to examine the effect of compliance with buprenorphine on reducing relapse among a sample of patients in treatment for OD. Patients new to buprenorphine (N = 703) completed the Addiction Severity Index (ASI) at baseline, and at 1, 2, and 3 months postbaseline. The ASI is a semistructured interview designed to measure problem severity in seven functional areas known to be affected by alcohol and drug dependence. Compliance was defined as taking buprenorphine medication on at least 22 of the past 28 days (80%), while relapse classification was based on resumed use of opioids during the follow-up period (months 2 and 3). Relapse was regressed onto demographic indicators, baseline ASI composite scores, and compliance with buprenorphine. Noncompliant patients were over 10 times more likely to relapse than those who were compliant (exp β= 10.55; p < .001). Neither demographics nor baseline ASI composite scores were predictive of relapse (p's > .05). Compliance with medication-assisted treatment supports abstinence, essential for patient recovery. Understanding the factors that drive treatment compliance and noncompliance may assist providers in supporting patient compliance and recovery. 

The global diversion of pharmaceutical drugs: opiate treatment and the diversion of pharmaceutical opiates: a clinician's perspective

AIM

To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals.

METHODS

The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986-2006, Australia 1996-2008 and the United States and France from the mid-1990s.

RESULTS

Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements--including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines.

CONCLUSION

Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels.

Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland

This study examined the uses of diverted methadone and buprenorphine among opiate-addicted individuals recruited from new admissions to methadone programs and from out-of-treatment individuals recruited from the streets. Self-report data regarding diversion were obtained from surveys and semi-structured qualitative interviews. Approximately 16% (n = 84) of the total sample (N = 515) reported using diverted (street) methadone two-three times per week for six months or more, and for an average of 7.8 days (SD = 10.3) within the past month. The group reporting lifetime use of diverted methadone as compared to the group that did not report such use was less likely to use heroin and cocaine in the 30 days prior to admission (ps <.01) and had lower ASI Drug Composite scores (p <.05). Participants in our qualitative sub-sample (n = 22) indicated that street methadone was more widely used than street buprenorphine and that both drugs were largely used as self-medication for detoxification and withdrawal symptoms. Participants reported using low dosages and no injection of either medication was reported.

Gender differences among regular injecting drug users in Sydney, Australia, 1996-2003

Previous research has found that female injecting drug users (IDU) are younger and more likely to be involved in risky behaviours such as needle sharing and sex work than male IDU. Aboriginal female drug users, in particular, are over-represented in IDU and prison populations. These factors place female IDU at increased risk of health problems and complicate issues such as homelessness, unemployment and poverty. Although a substantial body of research exists, little trend analysis has been done in Australia and much of the previous literature has focused on treatment populations. Cross-sectional data from 1996 to 2003 from regular IDU in Sydney interviewed as part of Australia's drug monitoring system, the Illicit Drug Reporting System (IDRS) were examined for trends over time. The demographic characteristics, drug use patterns and self-reported risk behaviours of the most recent sample (2003) were analysed for gender differences. Female IDU were younger in all sample years. Female IDU were more likely to identify as Aboriginal or Torres Strait Islander (ATSI) and engage in sex work. There has been a steady increase in these proportions over time. Female IDU were less likely to have a prison history, although there has been an increase among both male and female IDU over time. There were no gender differences in drug use patterns or frequency of drug use. Larger proportions of females report lending needles. Reports of lending and borrowing needles have decreased over time among both male and female IDU. Female IDU may place themselves at greater risk than male IDU by being more likely to share injecting equipment and engage in sex work. Treatment and other measures to reduce harm may need to be targeted specifically at women and, in particular, indigenous women.

A pilot study of buprenorphine-naloxone combination tablet (Suboxone®) in treatment of opioid dependence

In Australia, maintenance treatment for opioid dependence involves supervised daily administration of a dose of methadone or buprenorphine. A sublingual tablet combining buprenorphine and naloxone in a 4:1 ratio (Suboxone) has been developed, designed to deter diversion and intravenous misuse, and may be suitable for unsupervised administration. The aim of this study was to investigate the tolerability of Suboxone, and investigate whether unsupervised administration can be effective in stabilized patients. Employed patients on buprenorphine maintenance, who had ceased heroin use, were switched to Suboxone and provided with weekly supplies of medication to take without supervised administration. Subjects were monitored closely with weekly clinical reviews, and research interviews at baseline, 3 and 6 months. Only 11% of people receiving buprenorphine met eligibility criteria. Seventeen subjects were recruited. Fifteen were retained for the full 6 months. No subject appeared destabilized by unsupervised dosing. Suboxone was well tolerated. The current trial demonstrated that unsupervised administration with regular clinical monitoring can be effective in selected patients. However, using access to unsupervised dosing to promote abstinence from heroin probably limits the potential benefits of unsupervised administration to a very small proportion of patients.

Trends in morphine prescriptions, illicit morphine use and associated harms among regular injecting drug users in Australia

This paper examines population trends in morphine prescriptions in Australia, and contrasts them with findings from annual surveys with regular injecting drug users (IDU). Data on morphine prescriptions from 1995 to 2003 were obtained from the Drug Monitoring System (DRUMS) run by the Australian Government Department of Health and Ageing. Data collected from regular IDU as part of the Australian Illicit Drug Reporting System (IDRS) were analysed (2001 - 2004). The rate of morphine prescription per person aged 15 - 54 years increased by 89% across Australia between 1995 and 2003 (from 46.3 to 85.9 mg per person). Almost half (46%) of IDU surveyed in 2004 reported illicit morphine use, with the highest rates in jurisdictions where heroin was less available. Recent morphine injectors were significantly more likely to be male, unemployed, out of treatment and homeless in comparison to IDU who had not injected morphine. They were also more likely to have injected other pharmaceutical drugs and to report injection related problems. Among those who had injected morphine recently, the most commonly reported injecting harms were morphine dependence (38%), difficulty finding veins into which to inject (36%) and scarring or bruising (27%). Morphine use and injection is a common practice among regular IDU in Australia. In some cases, morphine may be a substitute for illicit heroin; in others, it may be being used to treat heroin dependence where other pharmacotherapies, such as methadone and buprenorphine, are perceived as being unavailable or undesirable by IDU. Morphine injection appears to be associated with polydrug use, and with it, a range of problems related to drug injection. Further research is required to monitor and reduce morphine diversion and related harms by such polydrug injectors.

Injecting-related injury and disease among clients of a supervised injecting facility

BACKGROUND

The process of drug injection may give rise to vascular and soft tissue injuries and infections. The social and physical environments in which drugs are injected play a significant role in these and other morbidities. Supervised injecting facilities (SIFs) seek to address such issues associated with public injecting drug use.

AIMS

Estimate lifetime prevalence of injecting-related problems, injury and disease and explore the socio-demographic and behavioral characteristics associated with the more serious complications.

DESIGN, SETTING, PARTICIPANTS

Self-report data from 9552 injecting drug users (IDUs) registering to use the Sydney Medically Supervised Injecting Centre (MSIC).

FINDINGS

Lifetime history of either injecting-related problems (IRP) or injecting-related injury and disease (IRID) was reported by 29% of the 9552 IDUs; 26% (n=2469) reported ever experiencing IRP and 10% (n=972) reported IRID. Prevalence of IRP included difficulties finding a vein (18%), prominent scarring or bruising (14%) and swelling of hands or feet (7%). Prevalence of IRID included abscesses or skin infection (6%), thrombosis (4%), septicaemia (2%) and endocarditis (1%). Females, those who mainly injected drugs other than heroin, and those who reported a history of drug treatment, drug overdose, and/or sex work, were more likely to report lifetime IRID. Frequency and duration of injecting, recent public injecting, and sharing of needles and/or syringes were also independently associated with IRID.

CONCLUSIONS

IRPs and IRIDs were common. Findings support the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes. Through provision of hygienic environments and advice on venous access, safer injecting techniques and wound care, SIFs have the potential to address a number of risk factors for IRID.

Prevalences and correlates of non-viral injecting-related injuries and diseases in a convenience sample of Australian injecting drug users

BACKGROUND

The prevalences and correlates of non-viral injecting-related injuries and diseases (IRIDs) in Australian injecting drug users (IDUs) remain unknown.

METHODS

A cross-sectional survey of IDUs was conducted in six sites across Australia's eastern states to investigate IRID experience among Australian IDU. Correlates of IRIDs were explored using logistic and negative binomial regression analyses.

RESULTS

393 IDUs were recruited. Lifetime experience of non-serious IRIDs was common (e.g., 'dirty hit' 68%); potentially serious and serious IRIDs were less commonly experienced (e.g., abscess 16%; gangrene <1%). Factors independently associated with potentially serious or serious IRIDs in the previous 12 months were: injecting in sites other than arms (Adjusted Odds Ratio 3.0, 95% confidence interval 1.7-5.4), injecting non-powder drug forms (5.0, 2.2-11.2), unstable accommodation (2.0, 1.1-3.5), being aged 25 years or older (4.3, 1.7-10.6) and not always washing hands before injection (9.3, 2.1-41.8). Factors independently associated with multiple IRIDs in the preceding 12 months were using three or more injecting sites (Adjusted Incidence Rate Ratio 1.5, 95% CI 1.1-2.0), injecting in sites other than arms (1.7, 1.3-2.2), using non-powder drug forms (1.9, 1.4-2.5), injecting daily or more often (1.7, 1.3-2.2), current pharmacotherapy experience (1.5, 1.1-1.9), and not always washing hands before injecting (1.9, 1.2-2.9).

DISCUSSION

Some IRIDs are widespread among Australian IDUs. Observed associations, particularly the protective effect of handwashing, have useful public health implications.

Clinical characteristics of treatment-seeking adolescents with opioid versus cannabis/alcohol use disorders

OBJECTIVES

To assess the clinical characteristics of adolescents with DSM-IV opioid use disorder (OUD) and compare them to adolescents with cannabis/alcohol use disorders.

METHOD

94 adolescents (ages 14-18 years) with a current OUD and 74 adolescents with a current non-OUD cannabis/alcohol use disorders were recruited from admissions, predominantly residential, to a substance abuse treatment program in Baltimore, ML. Participants were assessed cross-sectionally using standardized interviews and self-reports. Chi-square, t-tests and ANCOVA (adjusting for age, gender and treatment setting, race and residence) were performed to determine group differences on demographic, substance use, psychiatric and HIV-risk behaviors; logistic regression analyses, both unadjusted and adjusted for the above five factors were conducted to assess the strength of associations.

RESULTS

The OUD group was more likely to be Caucasian, to have dropped out of school and to live in the suburbs (trend). They also had greater substance use severity with higher proportion of current sedative and multiple substance use disorders (SUD). There were generally no differences in rates of criminal behaviors. Both groups had high rates of current psychiatric disorders (83% vs. 78%, n.s.) but the OUD adolescents reported higher depressive symptoms, mostly in the moderate range. Injection drug use (IDU) and needle sharing was almost exclusive to the OUD group, while both groups reported similar high rates of risky sexual behaviors.

CONCLUSIONS

While there were similarities between the two groups, OUD adolescents evidenced greater impairment in academic, substance use, depressive symptom and IDU-related HIV-risk areas. Findings suggest poorer long-term prognosis and highlight the need for specialized interventions for treatment-seeking OUD adolescents.

Infrequent illicit methadone use among stimulant-using patients in methadone maintenance treatment programs: a national drug abuse treatment clinical trials network study

We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. We obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use.

Prevalence and predictors of injecting-related injury and disease among clients of Australia's needle and syringe programs

OBJECTIVE

To identify lifetime prevalence and predictors of self-reported injecting-related injuries and diseases (IRID) and/or injecting-related problems (IRP) among a national cross-sectional sample of injecting drug users.

METHODS

1,961 clients of 45 needle and syringe programs (NSPs) who participated in the 2006 Australian NSP Survey self-completed an item regarding lifetime experience of eight separate IRIDs and IRPs.

RESULTS

Sixty-nine per cent of participants reported a history of IRID/IRP, with a mean of 1.9 injuries/problems (range 0-8). Lifetime prevalence of specific injuries/problems ranged from problems finding a vein (43%) to endocarditis (4%). Factors independently associated with IRID/IRP included bisexual identity; daily or more frequent injecting; injection of pharmaceutical preparations; female gender; longer injecting history; and hepatitis C antibody-positive serostatus.

CONCLUSIONS

Consistent with existing literature, results suggest that vascular injury and localised infections are common among IDUs; and that treatment-seeking is often delayed until serious complications arise.

IMPLICATIONS

Findings support the imperative for co-ordinated and timely treatment and prevention activities to reduce the severity and burden of these prevalent injecting outcomes.

Pharmacodynamics of diazepam co-administered with methadone or buprenorphine under high dose conditions in opioid dependent patients

BACKGROUND

Benzodiazepine abuse is common among methadone- and buprenorphine-maintained patients; however interactions between these drugs under high dose conditions have not been adequately examined under controlled conditions.

OBJECTIVE

To investigate the effects of co-administering diazepam with methadone or buprenorphine under high dose conditions.

DESIGN

Double-blind, randomly ordered, 2 x 2 cross-over design in which the effects of diazepam dose (0mg versus 40 mg) and opioid dose (100% versus 150% normal dose) were examined over four sessions in methadone- and buprenorphine-maintained patients.

PARTICIPANTS

Four methadone- and seven buprenorphine-prescribed patients without concurrent dependence on other substances or significant medical co-morbidity.

MEASURES

Physiological (pulse rate, blood pressure, pupil size, respiratory rate and peripheral SpO2), subjective (ARCI, VAS ratings) and performance (reaction time, cancellation task and Digit Symbol Substitution Test, DSST) measures were taken prior to and for 6h post-dosing.

RESULTS

High dose diazepam was associated with time-dependent increases in the intensity of subjective drug effects (strength of drug effect, sedation) and decreases in psychological performance (reaction time, DSST) for both methadone and buprenorphine patients. These effects were generally independent of the opioid dose administered. High dose opioid administration (150% normal dose) was associated with reductions in overall SpO2 levels and performance (reaction time, DSST) in the methadone patients, but had virtually no impact on pharmacodynamic responses in the buprenorphine group.

CONCLUSION

High dose diazepam significantly alters subjective drug responses and psychological performance in patients maintained on methadone and buprenorphine.

The injection of methadone syrup in New South Wales: patterns of use and increased harm after partial banning of injecting equipment

OBJECTIVE

To describe methadone injectors and the risk practices associated with injecting methadone in New South Wales, Australia. To assess the impact on injecting drug use and risk behaviour of the withdrawal of methadone injecting equipment from government-funded needle and syringe programs.

METHOD

Cross-sectional survey, conducted in 1999, of 206 people who had injected methadone at least once in the previous month. Participants were from Central Sydney, West Sydney and rural New South Wales.

RESULTS

Of participants who had injected both methadone and other drugs in the previous month (n=162), significantly more reused their methadone injecting equipment compared with those who reused their other drug injecting equipment (60% vs. 28%, p<0.01). There was no significant difference in terms of sharing injecting equipment, with 19% reporting sharing methadone injecting equipment and 14% sharing other drug injecting equipment. However, women were more likely than men to share methadone injecting equipment. Over half of the participants had accessed diverted methadone and a substantial minority reported the use of public spaces for injecting methadone.

CONCLUSIONS

Our results suggest that the current policy has led to increased reuse of equipment for injecting methadone.

IMPLICATIONS

A range of other possible policy options, such as closer monitoring and dilution of take-home doses, increasing oral doses and implementing trials of injected methadone, may assist to reduce the prevalence of methadone syrup injection and related harms.

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.

Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue?

AIMS

To examine indicators of buprenorphine diversion and injection among injecting drug users in Melbourne, Australia and to determine the factors associated with buprenorphine injection.

DESIGN

Melbourne arm of the 2002 Illicit Drug Reporting System (IDRS) cross-sectional study.

SETTING

Five Needle and Syringe Programme sites in Melbourne, Australia.

PARTICIPANTS

A total of 156 current injecting drug users (IDU). Study eligibility criteria were at least monthly injection during the previous 6 months, and Melbourne residence for at least the preceding 12 months.

MEASUREMENTS

Structured questionnaire covering demographic characteristics, drug use history, the price, purity and availability of drugs, criminal activity, risk-taking behaviours, health-related issues and general drug use trends.

FINDINGS

Over one-third (37%) of the study sample reported injecting buprenorphine in their life-time and 33% reported injecting the drug in the last 6 months. Recent buprenorphine injection was associated with the injection of other drug types (i.e. polydrug injectors), opioid substitution treatment, injection-related health problems and involvement in crime. Almost half (47%) of those who reported recent buprenorphine injection reported obtaining the drug illicitly at least once during that time.

CONCLUSIONS

Given the significant health harms associated with intravenous buprenorphine use (e.g. vein damage, abscesses and infections, precipitated withdrawal, blood-borne virus transmission, hospitalization and death), routine monitoring of the misuse of buprenorphine in Melbourne is warranted. These results suggest the need for development of effective countermeasures to address diversion and injection of buprenorphine in this setting.

Adapting the Illicit Drug Reporting System (IDRS) to examine the feasibility of monitoring trends in the markets for 'party drugs'

Since 1996, the Illicit Drug Reporting System (IDRS), Australia's strategic early warning system for illicit drug trends, has monitored annual trends in the markets for the four main illicit drug classes, cannabis, methamphetamine, cocaine and heroin. In 2000, a 2-year trial was implemented to examine the feasibility of using similar methodology to monitor trends in the markets for 'party drugs'. A triangulation of three data sources was sought: (1) quantitative interviews with a 'sentinel' population of drug users; (2) qualitative interviews with key informants (KIs), or those who have contact with drug users through their work; (3) extant indicator data sources such as the purity of illicit drugs seized by law enforcement agencies. The results suggested that the feasibility of collecting detailed, reliable and valid data about party drug markets is a direct function of the size of those markets. The trial demonstrated that the system would allow the successful monitoring of markets for party drugs that are relatively widely used, such as ecstasy, but would be less sensitive in monitoring markets for party drugs that are used by small proportions of the total population, such as gamma-hydroxy-butyrate (GHB) and ketamine. Methodological issues encountered during the conduct of this trial are discussed, including defining the appropriate sentinel population of drug users, identifying relevant key informants, and the relative absence of extant indicator data sources that could inform our understanding of party drug markets.

Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence and risk factors

AIMS

To determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with a recent history of attempted suicide.

DESIGN

Cross-sectional structured interview.

SETTING

Sydney, Australia.

PARTICIPANTS

Six hundred and fifteen current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT).

FINDINGS

A lifetime history of attempted suicide was reported by 34% of subjects, 13% had attempted suicide in the preceding year and 5% had done so in the preceding month. Females were more likely to have lifetime (44% versus 28%) and 12 month (21% versus 9%) suicide attempt histories. The 12 month prevalence of attempted suicide among treatment groups ranged between 11% (MT, NT) and 17% (RR). Factors associated with recent suicide attempts were: being an RR entrant, female gender, younger age, less education, more extensive polydrug use, benzodiazepine use, recent heroin overdose, Major Depression, current suicidal ideation, Borderline Personality Disorder (BPD)and Post-Traumatic Stress Disorder.

CONCLUSIONS

Recent suicidal behaviour is a major clinical problem for heroin users, and for females and RR entrants in particular. An essential adjunct to treatment for heroin dependence is routine screening for depression and suicidal ideation, with the provision of appropriate treatment where needed.

Health service utilization and benzodiazepine use among heroin users: findings from the Australian Treatment Outcome Study (ATOS)

AIMS

To determine levels of health service utilization among heroin users, the types of prescription drugs obtained by heroin users and the contribution of benzodiazepine use in health service utilization and prescribed drug use.

DESIGN

Cross-sectional survey.

SETTING

Sydney, Australia.

PARTICIPANTS

A total of 615 current heroin users recruited for the Australian Treatment Outcome Study (ATOS).

FINDINGS

Sixty per cent of subjects had consulted a general practitioner (GP) and 7% a specialist in the preceding month. An ambulance had attended 11% of subjects in the preceding month. Forty-eight per cent of subjects had prescriptions dispensed for medication in the preceding month. Thirty-nine per cent of participants had prescriptions dispensed for psychotropic medications, representing 80% of all prescriptions. Twenty per cent of subjects had prescriptions dispensed for non-psychotropic medications (20% of prescriptions). The most commonly prescribed drugs were benzodiazepines (59% of prescriptions), which had been obtained by 30% of subjects. Benzodiazepine users had more GP and psychiatrist visits, were more likely to have had an ambulance attendance and had significantly more dispensed prescriptions.

CONCLUSIONS

There were high levels of health utilization among heroin users. Prescription drug use was common, and dominated by psychotropic drugs. Benzodiazepine use was a dominant factor in the use of services and in prescriptions dispensed. Despite increased awareness of the harms associated with benzodiazepines, they continue to be prescribed widely to heroin users.

Changes in patterns of drug injection concurrent with a sustained reduction in the availability of heroin in Australia

Between 1996 and 2000, heroin was the drug most frequently injected in Australia, and viable heroin markets existed in six of Australia's eight jurisdictions. In 2001, there was a dramatic and sustained reduction in the availability of heroin that was accompanied by a substantial increase in its price, and a 14% decline in the average purity of seizures analysed by forensic laboratories. The shortage of heroin constitutes a unique natural experiment within which to examine the impact of supply reduction. This paper reviews one important correlate of the shortage, namely changes in patterns of illicit drug injection. A number of studies have consistently suggested that between 2000 and 2001, there was a sizeable decrease in both prevalence and frequency of heroin injection among injecting drug users. These changes were accompanied by increased prevalence and frequency of stimulant injection. Cocaine was favoured in NSW, the sole jurisdiction in which a cocaine market was established prior to the heroin shortage; whereas methamphetamine predominated in other jurisdictions. Some data suggest that, at least in the short-term, some drug injectors left the market altogether subsequent to the reduced heroin availability. However, the findings that (1) some former heroin users switched their drug preference to a stimulant; and (2) subsequently attributed this change to the reduced availability of heroin, suggests that reducing the supply of one drug may serve to increase the use of others. Given the differential harms associated with the use of stimulants and opiates, this possibility has grave implications for Australia, where the intervention and treatment system is designed primarily to accommodate opiate use and dependence.

In-patient benzodiazepine withdrawal: comparison of fixed and symptom-triggered taper methods

Fixed and symptom-triggered taper methods during in-patient benzodiazepine withdrawal treatment were compared using a randomized controlled design. Forty-four benzodiazepine users seeking in-patient withdrawal treatment at two substance use treatment clinics in Adelaide, Australia were recruited. Measurements included the Severity of Dependence Scale and the SF-36. A scale comprising six items from the Clinical Institute Withdrawal Assessment Scale--Benzodiazepines (CIWA-B) was used to measure withdrawal symptoms. Participants were randomized to receive a fixed diazepam tapering regime or diazepam only in response to withdrawal symptoms (symptom-triggered group). Results showed that there were no significant differences between treatment groups in terms of withdrawal severity, duration of in-patient treatment, amount of diazepam administered, treatment attrition and benzodiazepine use at follow-up. Both groups showed a reduction in benzodiazepine dosage of 86% over the first 8 days which was maintained at 1 month post-discharge. Although there were improvements in some subscales of the SF-36 between baseline and follow-up, values were significantly below age-matched norms at both time-points. This study showed that benzodiazepine users entering treatment have relatively poor health and that symptom-triggered taper methods incorporating flexible dosing and flexible treatment duration are as effective as fixed dose taper methods for in-patient benzodiazepine withdrawal treatment.

Prevalence and correlates of intravenous methadone syrup administration in Adelaide, Australia

AIMS

The aims of this study were to determine the prevalence of methadone syrup injecting in Adelaide, South Australia and to characterize methadone injectors, including their heroin use and risk behaviours associated with heroin overdose.

DESIGN

Cross-sectional design.

SETTING

Community setting, principally metropolitan Adelaide.

PARTICIPANTS

Current heroin users (used heroin in the last 6 months), recruited through snowballing.

MEASUREMENTS

Structured questionnaire.

FINDINGS

Of 365 participants, 18.4% reported having ever injected methadone syrup and 11.0% had injected methadone in the last 6 months. Those that had injected methadone were more likely to be male, and were more likely to be receiving methadone maintenance. They were also maintained on higher doses of methadone than subjects not injecting methadone. A history of methadone injection was associated with more heroin overdose experiences and greater dependence on heroin. Methadone injectors were also more likely to engage in risky behaviours associated with heroin overdose, including using heroin when no other people were present, not trial-tasting new batches of heroin and polydrug use.

CONCLUSIONS

Methadone syrup injectors appear to be at greater risk of a series of harms than subjects not injecting methadone. The prevalence of methadone syrup injecting in Adelaide, South Australia was 11%, which was lower than prevalence in Sydney, New South Wales, but higher than in Melbourne, Victoria. Jurisdictional differences concerning the prevalence of methadone syrup injecting may reflect differing policies by each state to methadone dispensing.

The monitoring of drug trends in Australia

Recently, there has been increased recognition of the importance of drug information systems (DIS), highlighting the need for an internationally coordinated approach to data collection and advocating the regular assessment of a range of areas. Accurate information provides policy makers with the evidence to evaluate current strategies and to plan future strategies. An effective drug information system (DIS) must collect comprehensive, detailed and in-depth data, while also being sensitive to emergent trends and placing these changes into the context of longer-term trends. An integrated and comprehensive system combines both sensitive (or lead) and slower but more reliable lag indicators. This article reviews conceptual frameworks for DIS and developments in international systems. It then considers the range of DIS in Australia and then describes two integrated monitoring systems with an early warning function: the Illicit Drug Reporting System (IDRS) and the Drug Use Monitoring Australia (DUMA) Programme. Both systems collate sensitive lead indicators, and provide timely information about emerging drug trends in Australia. Together, these two systems are best-placed to provide effective early warning of new trends in illicit drug markets, and constitute an important component of the overall approach to the monitoring of drug use and associated harms in Australia.