Mortality among a cohort of drug users after their release from prison: an evaluation of the effectiveness of a harm reduction program in Taiwan

Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis

BACKGROUND

Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes.

METHODS

In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses.

FINDINGS

We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing.

INTERPRETATION

There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release.

FUNDING

Australian National Health and Medical Research Council.

Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration

BACKGROUND

Non-fatal overdose is a leading predictor of subsequent fatal overdose. For individuals who are incarcerated, the risk of experiencing an overdose is highest when transitioning from a correctional setting to the community. We assessed if enrollment in jail-based medications for opioid use disorder (MOUD) is associated with lower risk of non-fatal opioid overdoses after jail release among individuals with opioid use disorder (OUD).

METHODS

This was a retrospective, observational cohort study of adults with OUD who were incarcerated in New York City jails and received MOUD or did not receive any MOUD (out-of-treatment) within the last three days before release to the community in 2011-2017. The outcome was the first non-fatal opioid overdose emergency department (ED) visit within 1 year of jail release during 2011-2017. Covariates included demographic, clinical, incarceration-related, and other characteristics. We performed multivariable cause-specific Cox proportional hazards regression analysis to compare the risk of non-fatal opioid overdose ED visits within 1 year after jail release between groups.

RESULTS

MOUD group included 8660 individuals with 17,119 incarcerations; out-of-treatment group included 10,163 individuals with 14,263 incarcerations. Controlling for covariates and accounting for competing risks, in-jail MOUD was associated with lower non-fatal opioid overdose risk within 14 days after jail release (adjusted HR=0.49, 95% confidence interval=0.33-0.74). We found no significant differences 15-28, 29-56, or 57-365 days post-release.

CONCLUSION

MOUD group had lower risk of non-fatal opioid overdose immediately after jail release. Wider implementation of MOUD in US jails could potentially reduce post-release overdoses, ED utilization, and associated healthcare costs.

Record linkage studies of drug-related deaths among adults who were released from prison to the community: a scoping review

BACKGROUND

There are public health concerns about an increased risk of mortality after release from prison. The objectives of this scoping review were to investigate, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners.

METHODS

MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies (January 2011- September 2021) using keywords/index headings. Two authors independently screened all titles and abstracts using inclusion and exclusion criteria and subsequently screened full publications. Discrepancies were discussed with a third author. One author extracted data from all included publications using a data charting form. A second author independently extracted data from approximately one-third of the publications. Data were entered into Microsoft Excel sheets and cleaned for analysis. Standardised mortality ratios (SMRs) were pooled (where possible) using a random-effects DerSimonian-Laird model in STATA.

RESULTS

A total of 3680 publications were screened by title and abstract, and 109 publications were fully screened; 45 publications were included. The pooled drug-related SMR was 27.07 (95%CI 13.32- 55.02; I 2 = 93.99%) for the first two weeks (4 studies), 10.17 (95%CI 3.74-27.66; I 2 = 83.83%) for the first 3-4 weeks (3 studies) and 15.58 (95%CI 7.05-34.40; I 2 = 97.99%) for the first 1 year after release (3 studies) and 6.99 (95%CI 4.13-11.83; I 2 = 99.14%) for any time after release (5 studies). However, the estimates varied markedly between studies. There was considerable heterogeneity in terms of study design, study size, location, methodology and findings. Only four studies reported the use of a quality assessment checklist/technique.

CONCLUSIONS

This scoping review found an increased risk of drug-related death after release from prison, particularly during the first two weeks after release, though drug-related mortality risk remained elevated for the first year among former prisoners. Evidence synthesis was limited as only a small number of studies were suitable for pooled analyses for SMRs due to inconsistencies in study design and methodology.

Association between jail-based methadone or buprenorphine treatment for opioid use disorder and overdose mortality after release from New York City jails 2011-17

BACKGROUND AND AIMS

Opioid overdose is a leading cause of death during the immediate time after release from jail or prison. Most jails in the United States do not provide methadone and buprenorphine treatment for opioid use disorder (MOUD), and research in estimating its impact in jail settings is limited. We aimed to test the hypothesis that in-jail MOUD is associated with lower overdose mortality risk post-release.

DESIGN, SETTING AND PARTICIPANTS

Retrospective, observational cohort study of 15 797 adults with opioid use disorder who were released from New York City jails to the community in 2011-2017. They experienced 31 382 incarcerations and were followed up to 1 year.

MEASUREMENTS

The primary outcomes were death caused by accidental drug poisoning and all-cause death. The exposure was receipt of MOUD (17 119 events) versus out-of-treatment (14 263 events) during the last 3 days before community re-entry. Covariates included demographic, clinical, behavioral, housing, health-care utilization and legal characteristics variables. We performed a multivariable, mixed-effect Cox regression analysis to test association between in-jail MOUD and deaths.

FINDINGS

The majority were male (82%) and their average age was 42 years. Receiving MOUD was associated with misdemeanor charges, being female, injection drug use and homelessness. During 1 year post-release, 111 overdose deaths occurred and crude death rates were 0.49 and 0.83 per 100 person-years for in-jail MOUD and out-of-treatment groups, respectively. Accounting for confounding and random effects, in-jail MOUD was associated with lower overdose mortality risk [adjusted hazard ratio (aHR) = 0.20, 95% confidence interval (CI) = 0.08-0.46] and all-cause mortality risk (aHR = 0.22, 95% CI = 0.11-0.42) for the first month post-release.

CONCLUSIONS

Methadone and buprenorphine treatment for opioid use disorder during incarceration was associated with an 80% reduction in overdose mortality risk for the first month post-release.

Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia

INTRODUCTION

Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison.

METHODS

This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival.

RESULTS

Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4+ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0).

CONCLUSIONS

Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release.

TRIAL REGISTRATION

NCT02396979. Retrospectively registered 24/03/2015.

Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes

Background

The overlap between justice system involvement and drug use is well-documented. Justice-involved people who misuse opioids are at high risk for relapse and criminal recidivism. Criminal justice policymakers consider opioid-specific medication-assisted therapies (MATs) one approach for improving outcomes for this population. More research is needed that explores the impacts of opioid-specific MATs for justice-involved people.

Objectives

This study sought to assess the effects of opioid-specific MAT for reducing the frequency and likelihood of criminal justice and overdose outcomes for current or formerly justice-involved individuals.

Search Methods

Records were searched between May 7, 2021 and June 23, 2021. We searched a total of sixteen proprietary and open access databases that included access to gray literature and conference proceedings. The bibliographies of included studies and relevant reviews were also searched.

Selection Criteria

Studies were eligible for inclusion in the review if they: (a) assessed the effects of opioid-specific MATs on individual-level criminal justice or overdose outcomes; included (b) a current or formerly justice-involved sample; and (c) a randomized or strong quasi-experimental design; and c) were published in English between January 1, 1960 and October 31, 2020.

Data Collection and Analysis

We used the standard methodological procedures as expected by The Campbell Collaboration.

Main Results

Twenty studies were included, representing 30,119 participants. The overall risk of bias for the experimental studies ranged from "some" to "high" and for quasi-experimental studies ranged from "moderate" to "serious." As such, findings must be interpreted against the backdrop of less-than-ideal methodological contexts. Of the 20 included studies, 16 included outcomes that were meta-analyzed using mean log odds ratios (which were reported as mean odds ratios). Mean effects were nonsignificant for reincarceration (odds ratio [OR] = 0.93 [0.68, 1.26], SE = .16), rearrest (OR = 1.47 [0.70, 3.07], SE = 0.38), and fatal overdose (OR = 0.82 [0.56, 1.21], SE = 0.20). For nonfatal overdose, the average effect was significant (OR = 0.41 [0.18, 0.91], SE = 0.41, p < 0.05), suggesting that those receiving MAT had nearly 60% reduced odds of a nonfatal overdose.

Implications for Policy Practice and Research

The current review supports some utility for adopting MAT for the treatment of justice-involved people with opioid addiction, however, more studies that employ rigorous methodologies are needed. Researchers should work with agencies to improve adherence to medication regimens, study design, and collect more detailed information on participants, their criminal and substance use histories, onset, and severity. This would help clarify whether treatment and control groups are indeed comparable and provide better insight into the potential reasons for participant dropout, treatment failure, and the occurrence of recidivism or overdose. Outcomes should be assessed in multiple ways, if possible (e.g., self-report and official record), as reliance on official data alone may undercount participants' degree of criminal involvement.

The state of harm reduction in prisons in 30 European countries with a focus on people who inject drugs and infectious diseases

BACKGROUND

People who inject drugs are often imprisoned, which is associated with increased levels of health risks including overdose and infectious diseases transmission, affecting not only people in prison but also the communities to which they return. This paper aims to give an up-to-date overview on availability, coverage and policy framework of prison-based harm reduction interventions in Europe.

METHODS

Available data on selected harm reduction responses in prisons were compiled from international standardised data sources and combined with a questionnaire survey among 30 National Focal Points of the European Monitoring Centre for Drugs and Drug Addiction to determine the level of availability, estimated coverage and policy framework of the interventions.

RESULTS

Information about responses to health harms in prisons is limited and heterogeneous. Cross-country comparability is hampered by diverging national data collection methods. Opioid substitution treatment (OST) is available in 29 countries, but coverage remains low (below 30% of people in need) in half of the responding countries. Needle and syringe programmes, lubricant distribution, counselling on safer injecting and tattooing/piercing are scarcely available. Testing for infectious diseases is offered but mostly upon prison entry, and uptake remains low in about half of the countries. While treatment of infections is mostly available and coverage is high for human immunodeficiency virus (HIV) and tuberculosis, hepatitis B and C treatment are less often provided. Health education as well as condom distribution is usually available, but provision remains low in nearly half of the countries. Post-release linkage to addiction care as well as to treatment of infections is available in a majority of countries, but implementation is often partial. Interventions recommended to be provided upon release, such as OST initiation, take-home naloxone and testing of infections, are rarely provided. While 21 countries address harm reduction in prison in national strategic documents, upon-release interventions appear only in 12.

CONCLUSIONS

Availability and coverage of harm reduction interventions in European prisons are limited, compared to the community. There is a gap between international recommendations and 'on-paper' availability of interventions and their actual implementation. Scaling up harm reduction in prison and throughcare can achieve important individual and public-health benefits.

Big data and predictive modelling for the opioid crisis: existing research and future potential

A need exists to accurately estimate overdose risk and improve understanding of how to deliver treatments and interventions in people with opioid use disorder in a way that reduces such risk. We consider opportunities for predictive analytics and routinely collected administrative data to evaluate how overdose could be reduced among people with opioid use disorder. Specifically, we summarise global trends in opioid use and overdoses; describe the use of big data in research into opioid overdose; consider the potential for predictive modelling, including machine learning, for prevention and monitoring of opioid overdoses; and outline the challenges and risks relating to the use of big data and machine learning in reducing harms that are related to opioid use. Future research for improving the coverage and provision of existing interventions, treatments, and resources for opioid use disorder requires collaboration of multiple agencies. Predictive modelling could transport the concept of stratified medicine to public health through novel methods, such as predictive modelling and emulated trials for evaluating diagnoses and prognoses of opioid use disorder, predicting treatment response, and providing targeted treatment recommendations.

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study

Background

In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims

Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design

Retrospective cohort study

Setting

An open prison with 120 places

Subjects

Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements

Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings

Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions

This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Estimating the impact of wide scale uptake of screening and medications for opioid use disorder in US prisons and jails

BACKGROUND

Medications for opioid use disorder (OUD) are the most effective treatment for OUD, but uptake of these life-saving medications has been extremely limited in US prisons and jail settings, and limited data are available to guide policy decisions. The objective of this study was to estimate the impact of screening and treatment with medications for OUD in US prisons and jails on post-release opioid-related mortality.

METHODS

We used data from the National Center for Vital Statistics, the Bureau of Justice Statistics, and relevant literature to construct Monte Carlo simulations of a counterfactual scenario in which wide scale uptake of screening and treatment with medications for OUD occurred in US prisons and jails in 2016.

RESULTS

Our model predicted that 1840 (95% Simulation Interval [SI]: -2757 - 4959) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated. The model also predicted that approximately 4400 (95% SI: 2675 - 5557) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated and were retained in treatment post-release. These estimates correspond to 668 (95% SI: -1008 - 1812) and 1609 (95% SI: 972 - 2037) lives saved per 10,000 persons incarcerated, respectively.

CONCLUSIONS

Prison and jail-based programs that comprehensively screen and provide treatment with medications for OUD have the potential to produce substantial reductions in opioid-related overdose deaths in a high-risk population; however, retention on treatment post-release is a key driver of population level impact.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

INTRODUCTION

More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance.

OBJECTIVES

To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison.

METHODS

We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology.

RESULTS

The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up.

CONCLUSIONS

The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population.

KEY WORDS

Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011-2018

BACKGROUND

People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID.

METHODS

Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age.

RESULTS

Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective.

CONCLUSION

In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.

Opioid-related treatment, interventions, and outcomes among incarcerated persons: A systematic review

BACKGROUND

Worldwide opioid-related overdose has become a major public health crisis. People with opioid use disorder (OUD) are overrepresented in the criminal justice system and at higher risk for opioid-related mortality. However, correctional facilities frequently adopt an abstinence-only approach, seldom offering the gold standard opioid agonist treatment (OAT) to incarcerated persons with OUD. In an attempt to inform adequate management of OUD among incarcerated persons, we conducted a systematic review of opioid-related interventions delivered before, during, and after incarceration.

METHODS AND FINDINGS

We systematically reviewed 8 electronic databases for original, peer-reviewed literature published between January 2008 and October 2019. Our review included studies conducted among adult participants with OUD who were incarcerated or recently released into the community (≤90 days post-incarceration). The search identified 2,356 articles, 46 of which met the inclusion criteria based on assessments by 2 independent reviewers. Thirty studies were conducted in North America, 9 in Europe, and 7 in Asia/Oceania. The systematic review included 22 randomized control trials (RCTs), 3 non-randomized clinical trials, and 21 observational studies. Eight observational studies utilized administrative data and included large sample sizes (median of 10,419 [range 2273-131,472] participants), and 13 observational studies utilized primary data, with a median of 140 (range 27-960) participants. RCTs and non-randomized clinical trials included a median of 198 (range 15-1,557) and 44 (range 27-382) participants, respectively. Twelve studies included only men, 1 study included only women, and in the remaining 33 studies, the percentage of women was below 30%. The majority of study participants were middle-aged adults (36-55 years). Participants treated at a correctional facility with methadone maintenance treatment (MMT) or buprenorphine (BPN)/naloxone (NLX) had lower rates of illicit opioid use, had higher adherence to OUD treatment, were less likely to be re-incarcerated, and were more likely to be working 1 year post-incarceration. Participants who received MMT or BPN/NLX while incarcerated had fewer nonfatal overdoses and lower mortality. The main limitation of our systematic review is the high heterogeneity of studies (different designs, settings, populations, treatments, and outcomes), precluding a meta-analysis. Other study limitations include the insufficient data about incarcerated women with OUD, and the lack of information about incarcerated populations with OUD who are not included in published research.

CONCLUSIONS

In this carefully conducted systematic review, we found that correctional facilities should scale up OAT among incarcerated persons with OUD. The strategy is likely to decrease opioid-related overdose and mortality, reduce opioid use and other risky behaviors during and after incarceration, and improve retention in addiction treatment after prison release. Immediate OAT after prison release and additional preventive strategies such as the distribution of NLX kits to at-risk individuals upon release greatly decrease the occurrence of opioid-related overdose and mortality. In an effort to mitigate the impact of the opioid-related overdose crisis, it is crucial to scale up OAT and opioid-related overdose prevention strategies (e.g., NLX) within a continuum of treatment before, during, and after incarceration.

Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis

INTRODUCTION

Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment.

OBJECTIVE

This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons.

METHODS

We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment.

RESULTS

A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider.

CONCLUSION

Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.

Opioid agonist treatment reduces losses in quality of life and quality-adjusted life expectancy in heroin users: Evidence from real world data

BACKGROUND

This study estimated the long-term changes of opioid agonist treatment (OAT) in quality of life (QOL) and quantified the quality-adjusted life years (QALY) from the loss of quality-adjusted life expectancy (QALE) in heroin users.

METHODS

A total of 1283 heroin users stratified by OAT were linked to the National Mortality Registry for 8 years (2006-2014) to obtain survival functions, which were extrapolated to lifetime by applying a rolling extrapolation algorithm to survival ratio between the sub-cohorts and age- and sex-matched referents simulated from vital statistics of Taiwan. We performed cross-sectional measurement of EQ-5D on 349 participants, including those with a valid state of OAT or non-OAT plus newly recruited consecutive patients, during 2015-2017 for utility values, while the QOL of referents were abstracted from the 2009 National Health Interview Survey. The QALE was calculated by summing the products of the mean QOL and survival rate throughout life. The QALE difference between the cohort and corresponding referents was the loss-of-QALE.

RESULTS

QOL of the OAT group was significantly better than that of the non-OAT group in every domain of the EQ-5D, which was quantified to be 0.23 for utility after controlling for other variables. After extrapolation to 70 years, the estimated QALE and loss-of-QALE were 17.8 and 18.2 QALY for OAT subjects, respectively, while those of the non-OAT group were 9.2 and 27.9 QALY.

CONCLUSIONS

Receiving OAT could reduce QALE lost by 9.7 QALYs compared with non-OAT after accounting for QOL differences along time and different age and sex distributions.

An outbreak of HIV infection among people who inject drugs linked to injection of propofol in Taiwan

INTRODUCTION

The aim of this study was to report an HIV outbreak related to propofol-injection and the impact of regulating propofol on the HIV epidemic among people who inject drugs (PWID).

METHODS

A retrospective cohort study of 252 PWID who were diagnosed with an HIV infection between 2014 and 2017 in Taiwan. The propofol information was collected by routine epidemic surveillance and interviews. We linked several national databases to collect other related factors, including methadone maintenance treatment (MMT) attendance and incarceration. The serums were tested for recent infection by the LAg-avidity EIA assay and relationship of the trains by the Phylogenetic tree analysis. Analyses were conducted using the R Surveillance package for retrospective modeling for outbreak detection. A multiple logistic regression was used to evaluate the association between propofol-injection and other related factors.

RESULTS

There were 28 cases reported with propofol-injection, all of which were reported in Central Taiwan. A total of 11 (50%) cases among 22 propofol-injectors with serums were recent infections, which were higher than that 33 (23.4%) of non-propofol group. The phylogenetic tree indicated that 6 propofol-injectors were grouped together with the same cluster in circular. The HIV epidemic curve among PWID revealed an outbreak of 82 in 2015, which then decreased to 43 in 2016 after propofol began to be regulated as a Schedule 4 controlled drug in August 2015. In a multiple logistic regression, attendance at methadone clinics was associated with a significantly higher risk for propofol-injection (adjusted OR = 2.43, 95% CI = 0.98-5.98), and HIV reported in the year 2015 was associated with an increased risk of propofol-injection (adjusted OR = 4, 95% CI = 1.08-14.86).

CONCLUSIONS

Our data indicate that the government regulation of propofol as a controlled drug strategy was associated with significant reduction in the spread of HIV among PWID.

Acceptability of a mobile health intervention to enhance HIV care coordination for patients with substance use disorders

Background

Persons living with HIV and substance use disorders face barriers to sustained engagement in medical care, leading to suboptimal antiretroviral treatment outcomes. Innovative mobile technology tools such as customizable smartphone applications have the potential to enhance existing care coordination programs, but have not been rigorously studied.

Methods

We developed and implemented a two-component intervention consisting of peer health navigation supported by a smartphone application conducting ecologic momentary assessment (EMA) of barriers to care and medication adherence. Patients with a history of antiretroviral treatment failure and substance use were recruited to participate in the 9-month pilot intervention. Three peer health navigators were trained to provide social and logistical support while participants re-engaged in HIV care. We assessed the acceptability of the intervention components using qualitative analysis of in-depth interviews conducted with study participants and peer navigators.

Results

Of 19 patients enrolled in the study, 17 participated for at least 2 months and 15 completed the entire 9-month study protocol. The acceptability of the peer navigation intervention was rated favorably by all participants interviewed, who felt that peer support was instrumental in helping them re-engage in HIV care. Participants also responded favorably to the smartphone application, but described its usefulness mostly as providing reminders to take medications and attend appointments, rather than as a facilitator of patient navigation.

Conclusions

Peer health navigation and smartphone-based EMA are acceptable approaches to facilitating engagement in HIV care for drug using populations. Future studies to evaluate the efficacy of this approach for improving long-term retention in care and antiretroviral treatment outcomes are warranted.

ClinicalTrials.gov Identifier NCT01941108; registered on September 4, 2013

Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia

Objectives

HIV-related mortality is increasing in Indonesia, where prisons house many people living with HIV and addiction. We examined all-cause mortality in HIV-infected Indonesian prisoners within prison and up to 24 months postrelease.

Materials and methods

Randomly selected HIV-infected male prisoners (n=102) from two prisons in Jakarta, Indonesia, completed surveys in prison and were followed up for 2 years (until study completion) or until they died or were lost to follow-up. Death dates were determined from medical records and interviews with immediate family members. Kaplan–Meier and Cox proportional hazards regression models were analyzed to identify mortality predictors.

Results

During 103 person-years (PYs) of follow-up, 15 deaths occurred, including ten in prison. The crude mortality rate within prison (125.2 deaths per 1,000 PYs) was surpassed by the crude mortality rate (215.7 deaths per 1,000 PYs) in released prisoners. HIV-associated opportunistic infections were the most common probable cause of death. Predictors of within-prison and overall mortality were similar. Shorter survival overall was associated with being incarcerated within a specialized “narcotic” prison for drug offenders (hazard ratio [HR] 9.2, 95% confidence interval [CI] 1.1–76.5; P=0.03), longer incarceration (HR 1.06, 95% CI 1.01–1.1; P=0.01), and advanced HIV infection (CD4⁺ T-cell count <200/µL, HR 4.8, 95% CI 1.2–18.2; P=0.02). Addiction treatment was associated with longer survival (HR 0.1, 95% CI 0.01–0.9; P=0.03), although treatment with antiretroviral therapy (ART) or methadone was not.

Conclusion

Mortality in HIV-infected prisoners is extremely high in Indonesia, despite limited provision of ART in prisons. Interventions to restore immune function with ART and provide prophylaxis for opportunistic infections during incarceration and after release would likely reduce mortality. Narcotic prisons may be especially high-risk environments for mortality, emphasizing the need for universal access to evidence-based HIV treatments.

A Smartphone Application Supporting Recovery from Heroin Addiction: Perspectives of Patients and Providers in China, Taiwan, and the USA

Smartphone-based interventions are increasingly used to support self-monitoring, self-management, and treatment and medication compliance in order to improve overall functioning and well-being. In attempting to develop a smartphone application (S-Health) that assists heroin-dependent patients in recovery, a series of focus groups (72 patients, 22 providers) were conducted in China, Taiwan, and the USA to obtain their perspectives on its acceptance and potential adoption. Data were analyzed according to the Diffusion of Innovation (DOI) theory of characteristics important to the adoption of innovation. Important to Relative Advantage, USA participants cited S-Health's potential ability to overcome logistical barriers, while those in China and Taiwan valued its potential to supplement currently limited services. In terms of Compatibility, participants across sites reported recovery needs and goals that such an application could be helpful in supporting; however, its utility during strong craving was questioned in China and Taiwan. Important factors relevant to Complexity included concerns about smartphone access and familiarity, individualization of content, and particularly in China and Taiwan, participants wanted assurance of privacy and security. The study results suggest a general acceptance, but also indicate cultural variations in access to therapeutic and other social support systems, legal repercussions of substance use, societal perceptions of addiction, and the role of family and other social support in recovery. Taking these factors into consideration is likely to increase diffusion as well as effectiveness of these smartphone-based interventions.

Impact of opioid substitution therapy for Scotland's prisoners on drug-related deaths soon after prisoner release

AIM

To assess whether the introduction of a prison-based opioid substitution therapy (OST) policy was associated with a reduction in drug-related deaths (DRD) within 14 days after prison release.

DESIGN

Linkage of Scotland's prisoner database with death registrations to compare periods before (1996-2002) and after (2003-07) prison-based OST was introduced.

SETTING

All Scottish prisons.

PARTICIPANTS

People released from prison between 1 January 1996 and 8 October 2007 following an imprisonment of at least 14 days and at least 14 weeks after the preceding qualifying release.

MEASUREMENTS

Risk of DRD in the 12 weeks following release; percentage of these DRDs which occurred during the first 14 days.

FINDINGS

Before prison-based OST (1996-2002), 305 DRDs occurred in the 12 weeks after 80 200 qualifying releases, 3.8 per 1000 releases [95% confidence interval (CI) = 3.4-4.2]; of these, 175 (57%) occurred in the first 14 days. After the introduction of prison-based OST (2003-07), 154 DRDs occurred in the 12 weeks after 70 317 qualifying releases, a significantly reduced rate of 2.2 per 1000 releases (95% CI = 1.8-2.5). However, there was no change in the proportion which occurred in the first 14 days, either for all DRDs (87: 56%) or for opioid-related DRDs.

CONCLUSIONS

Following the introduction of a prison-based opioid substitution therapy (OST) policy in Scotland, the rate of drug-related deaths in the 12 weeks following release fell by two-fifths. However, the proportion of deaths that occurred in the first 14 days did not change appreciably, suggesting that in-prison OST does not reduce early deaths after release.

Estimation of life expectancy and the expected years of life lost among heroin users in the era of opioid substitution treatment (OST) in Taiwan

BACKGROUND

Opioid substitution treatment (OST) has been implemented in Taiwan since 2006. We estimated the life expectancy (LE) and expected years of life lost (EYLL) in a cohort of heroin users stratified by OST for comparison.

METHODS

A total of 1283 heroin users recruited from 2006 to 2008 were linked to the National Mortality Registry until the end of 2011. Among them, 983 received OST, while 300 did not. Kaplan-Meier estimation for survival was performed, and it was extrapolated to 50 years to obtain the LE using a semi-parametric method. We further estimated the EYLL for both cohorts by subtracting their life expectancies from the age- and sex-matched referents of the general population. Cause-specific standardized mortality ratios (SMRs) were calculated and compared with the national cohort to validate the representativeness of this sample.

RESULTS

After extrapolation to 50 years of survival, the estimated average LE and EYLL were 27.4 and 10.6 for OST subjects, respectively, while those of the non-OST were 20.2 and 18.4 years. The all-cause mortality rates (per 1000 person-years) in the observational period for the OST and non-OST group were 15.5 and 23.9, respectively, representing a 7.5- and 10.2-fold SMR compared to the general population, indicating a high representativeness for our sample. But SMR of suicide mortality elevated 16.2 and 3.1 folds in OST and non-OST group, respectively.

CONCLUSIONS

OST saves 7.8 EYLL more than non-OST after accounting for lead time bias. Effective suicide prevention programs could enhance its life-saving effect, especially among those co-morbid with depressive disorders.

Factors associated with methadone treatment duration: a Cox regression analysis

This study examined retention rates and associated predictors of methadone maintenance treatment (MMT) duration among 128 newly admitted patients in Taiwan. A semi-structured questionnaire was used to obtain demographic and drug use history. Daily records of methadone taken and test results for HIV, HCV, and morphine toxicology were taken from a computerized medical registry. Cox regression analyses were performed to examine factors associated with MMT duration. MMT retention rates were 80.5%, 68.8%, 53.9%, and 41.4% for 3, 6, 12, and 18 months, respectively. Excluding 38 patients incarcerated during the study period, retention rates were 81.1%, 73.3%, 61.1%, and 48.9% for 3 months, 6 months, 12 months, and 18 months, respectively. No participant seroconverted to HIV and 1 died during the 18-months follow-up. Results showed that being female, imprisonment, a longer distance from house to clinic, having a lower methadone dose after 30 days, being HCV positive, and in the New Taipei city program predicted early patient dropout. The findings suggest favorable MMT outcomes of HIV seroincidence and mortality. Results indicate that the need to minimize travel distance and to provide programs that meet women's requirements justify expansion of MMT clinics in Taiwan.

Register data in the evaluation and program planning of addiction treatment programs: using Sweden as an example

Data from large-scale registers is often underutilized when evaluating addiction treatment programs. Since many programs collect register data regarding clients and interventions, there is a potential to make greater use of such records for program evaluation. The purpose of this article is to discuss the value of using large-scale registers in the evaluation and program planning of addiction treatment systems and programs. Sweden is used as an example of a country where register data is both available and is starting to be used in national evaluation and program planning efforts. The article focuses on possibilities, limitations and practicalities when using large-scale register data to conduct evaluations and program planning of addiction treatment programs. Main conclusions are that using register data for evaluation provides large amounts of data at low cost, limitations associated to the use of register data may be handled statistically, register data can answer important questions in planning of addiction treatment programs, and more accurate measures are needed to account for the diversity of client populations.

The reductions in monetary cost and gains in productivity with methadone maintenance treatment: one year follow-up

While methadone maintenance treatment (MMT) is beneficial for heroin dependence, there is little information regarding the reductions in monetary cost and gains in productivity following MMT. The aim of this study was to evaluate the changes in the monetary cost of heroin addiction and productivity after one year of MMT. Twenty-nine participants from an MMT clinic were included. The monetary cost, productivity, quality of life (QOL) and mental health status were assessed at both baseline and one year follow-up. The average annual total cost was approximately US$26,485 (1.43 GDP per capita in 2010) at baseline, and decreased by 59.3% to US$10,784 (0.58 GDP) at follow-up. The mean number of months of unemployment dropped from 6.03 to 2.79, the mean income increased to exceed the basic salary, but only reached 45.3% of the national average monthly earnings. The participants׳ mental health improved, but their QOL scores did not increase significantly. After one year of MMT, the monetary cost of heroin addiction fell, both the productivity and mental health of the participants׳ improved, but limited gains were seen with regard to their QOL.

High-risk behaviors after release from incarceration among people who inject drugs in St. Petersburg, Russia

BACKGROUND

Injection drug use, infectious disease, and incarceration are inextricably linked in Russia. We aimed to identify factors associated with time to relapse (first opioid injection after release from prison) and using a non-sterile, previously used syringe at relapse in a sample of people who inject drugs in St. Petersburg.

METHODS

We collected data on time from release to relapse among individuals with a history of incarceration, a subsample of a larger study among people who inject drugs. Proportional hazards and logistic regression were used to identify factors associated with time to relapse and injection with a non-sterile previously used syringe at relapse, respectively.

RESULTS

The median time to relapse after release was 30 days. Factors that were independently associated with relapsing sooner were being a native of St. Petersburg compared to not being native (AHR: 1.64; 95% CI 1.15-2.33), unemployed at relapse compared to employed (AHR: 4.49; 95% CI 2.96-6.82) and receiving a previous diagnosis of HBV and HCV compared to no previous diagnosis (AHR: 1.49; 95% CI 1.03-2.14). Unemployment at relapse was also significant in modeling injection with a non-sterile, previously used syringe at relapse compared to those who were employed (AOR: 6.80; 95% CI 1.96-23.59).

CONCLUSIONS

Unemployment was an important correlate for both resuming opioid injection after release and using a non-sterile previously used syringe at relapse. Linkage to medical, harm reduction, and employment services should be developed for incarcerated Russian people who inject drugs prior to release.

The health of female prisoners in Indonesia

Purpose

– Indonesian law provides prisoners with basic rights, including access to education, health care and nutrition. Yet, structural and institutional limitations, notably overcrowding and under-resourcing, prohibits penal institutions from fulfilling these commitments for female prisoners. The purpose of this paper is to explore their health concerns.

Design/methodology/approach

– Six prisons and one detention centre were researched, comprising: female prisoners (n=69); clinical officers (six); clinic heads (seven); wardens (seven); heads of prisons (seven); and a Directorate representative. Data were collected through observation, focus group discussions, in-depth interviews and a semi-structured questionnaire. Raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory.

Findings

– Both “formal” and “informal” health-coping strategies were dependent upon a range of factors which determined access to treatment, medicines and other items procured both inside and outside of the prison, as well as referral services. Informal systems of support existed for women, especially in regard to pregnancy and raising of babies born in detention. Systems that maintain harmony within cell blocks were identified as an important informal coping strategy.

Originality/value

– This research is important in informing policy and practice. There is a clear need for gender-sensitive legislative frameworks, penal policies and prison rules to ensure women's needs are addressed. The identified coping strategies were considered viable, but do not replace the need for a health system providing women prisoners with levels of care as available in the community, including commensurate budgeting, personnel, access and referral to more specialised external health services.

Excessive suicide mortality and risk factors for suicide among patients with heroin dependence

BACKGROUND

The mortality risk is high among individuals dependent on heroin, and suicide is a severe consequence of long-term heroin use. We estimated the incidence of suicide mortality and its risk factors in a large Asian cohort with heroin dependence.

METHODS

A consecutive series of 2750 inpatients dependent on heroin admitted to a psychiatric center in northern Taiwan between 1990 and 2010 were retrospectively enrolled as the study cohort. These patients were linked to the Taiwan National Mortality Database to obtain each mortality event. We determined the Standardized Mortality Ratio (SMR) for each cause of death. Among the deceased, 69 deaths were due to suicide (cases); 138 controls were randomly selected using risk-set density sampling based on a nested case-control design. We collected clinical information from subjects' medical records. Multivariate conditional logistic regression was employed to explore the correlates of suicide mortality.

RESULTS

The findings showed a 7.9-fold SMR for all-cause mortality among heroin users compared to the general population while the SMR for suicide mortality was 16.2. Multivariate analysis showed that suicide attempt as the reason for the index admission (adjusted risk ratio [RR] = 4.29, p = 0.035) and depressive syndrome anytime during life (adjusted RR = 2.61, p = 0.019) were associated with the risk of suicide mortality.

CONCLUSIONS

Individuals dependent on heroin are more likely to die of suicide compared to the general population. We recommend that clinical psychiatric staff carefully gather information related to the identified risk factors to prevent suicide among heroin users.

Coverage of overdose prevention programs for opiate users and injectors: a cross-sectional study

Background

The use of opiates, particularly heroin, remains an important cause of morbidity and mortality. Half of the deaths among heroin consumers are attributed to overdose. In response to this problem, overdose prevention programs (OPPs) were designed. The objective of our study was to assess coverage of OPPs among the target population in a specific Spanish region (Catalonia) and to identify characteristics related to attendance.

Methods

A cross-sectional survey recruited individuals from outpatient treatment centers (OTCs), therapeutic communities (ThCs), and harm reduction facilities (HRFs) in Catalonia. From 513 participants, 306 opiate users and/or injectors were selected for this study. Coverage was calculated as the proportion of subjects who declared having participated in an OPP. A Poisson regression with robust variance was used to assess factors (socio-demographic aspects and psychoactive substance use patterns) associated to OPP participation, taking into account recruitment strategy.

Results

Average age of the 306 subjects was 39.7 years (s.d.: 7.7); 79% were male; 79.2% lived in urban areas and 56.3% were unemployed or had never worked. Overall OPP coverage was 43.5% (95% CI: 37%–49%). Training was received mostly in HRF (60%), followed by OTC (24.4%), prison (19%), and ThC (16%). OPP sessions were attended by 41% of Spanish-born study participants and by 63.3% of foreigners; 92.2% of the participants lived in urban areas. The Poisson regression analysis adjusted by age, sex, and type of recruitment center showed that OPP participation rates were higher for individuals with foreign nationality (PR = 1.3; 95% CI: 1.04–1.72), for those living in municipalities with more than 100,000 inhabitants (PR = 2.0; 95% CI: 1.37–2.81) or the Barcelona conurbation (PR = 2.5; 95% CI: 1.68–3.77), and for those having ever been in prison (PR = 1.6; 95% CI: 1.41–1.81) and had first consumption when they were less than 12 years old (PR = 1.2; 95% CI: 1.06–1.45).

Conclusion

Coverage as a whole can be considered high. However, in Catalonia, new strategies ought to be developed in order to attract opiate users and injectors not currently participating, by expanding OPP offer to services and regions where coverage is poor.

Examining non-AIDS mortality among people who inject drugs

Objective:

To systematically review and analyse data from cohorts of people who inject drugs (PWID) to improve existing estimates of non-AIDS mortality used to calculate mortality among PWID in the Spectrum Estimates and Projection Package.

Design:

Systematic review and meta-analysis.

Methods:

We conducted an update of an earlier systematic review of mortality among PWID, searching specifically for studies providing data on non-AIDS-related deaths. Random-effects meta-analyses were performed to derive pooled estimates of non-AIDS crude mortality rates across cohorts disaggregated by sex, HIV status and periods in and out of opioid substitution therapy (OST). Within each cohort, ratios of non-AIDS CMRs were calculated and then pooled across studies for the following paired sub-groups: HIV-negative versus HIV-positive PWID; male versus female PWID; periods in OST versus out of OST. For each analysis, pooled estimates by country income group and by geographic region were also calculated.

Results:

Thirty-seven eligible studies from high-income countries and five from low and middle-income countries were found. Non-AIDS mortality was significantly higher in low and middle-income countries [2.74 per 100 person-years; 95% confidence interval (CI) 1.76–3.72] than in high-income countries (1.56 per 100 person-years; 95% CI 1.38–1.74). Non-AIDS CMRs were 1.34 times greater among men than women (95% CI 1.14–1.57; N = 19 studies); 1.50 times greater among HIV-positive than HIV-negative PWID (95% CI 1.15, 1.96; N = 16 studies); and more than three times greater during periods out of OST than for periods on OST (N = 7 studies).

Conclusions:

A comprehensive response to injecting drug must include efforts to reduce the high levels of non-AIDS mortality among PWID. Due to limitations of currently available data, including substantial heterogeneity between studies, estimates of non-AIDS mortality specific to geographic regions, country income level, or the availability of OST should be interpreted with caution.

Prevalence and factors associated with HIV infection among injection drug users at methadone clinics in Taipei, Taiwan

BACKGROUND

Methadone treatment was introduced in Taiwan in 2006 as a harm-reduction program for injection drug users (IDUs), among whom HIV was endemic. We examined the association of HIV serostatus with demographic characteristics, substance use, and sexual behaviors among IDUs at methadone clinics in Taipei, Taiwan.

METHODS

During 2012-2013, IDUs at methadone clinics in Taipei were recruited to complete a risk assessment interview and undergo serologic testing for HIV infection. Correlates of HIV infection were identified by multivariate logistic regression.

RESULTS

Of the 827 eligible participants, 85.9% were male, median age was 45 years, and mean years of injecting was 18.0 (range 1-56). The prevalence of HIV infection was 17.7%. In multivariate analysis, HIV infection was significantly associated with age ≤ 45 years (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI] 1.01-2.62), being divorced (AOR = 1.67, 95% CI 1.06-2.62), deriving the majority of income during the previous 6 months from temporary jobs or other noncriminal sources (AOR = 1.53, 95% CI 1.02-2.30), unstable housing during the previous 6 months (AOR = 1.47, 95% CI 1.003-2.15), higher number of incarcerations (AOR = 1.14, 95% CI 1.03-1.26), and a history of overdose (AOR = 1.51, 95% CI 1.01-2.28).

CONCLUSIONS

Taiwanese IDUs at methadone clinics have a relatively high HIV prevalence, which was associated with younger age and history of overdose. It is imperative to educate IDUs' about HIV transmission, particularly for the younger and overdosed IDUs.

Changes in HIV incidence among people who inject drugs in Taiwan following introduction of a harm reduction program: a study of two cohorts

BACKGROUND

Harm reduction strategies for combating HIV epidemics among people who inject drugs (PWID) have been implemented in several countries. However, large-scale studies using sensitive measurements of HIV incidence and intervention exposures in defined cohorts are rare. The aim of this study was to determine the association between harm reduction programs and HIV incidence among PWID.

METHODS AND FINDINGS

The study included two populations. For 3,851 PWID who entered prison between 2004 and 2010 and tested HIV positive upon incarceration, we tested their sera using a BED HIV-1 capture enzyme immunoassay to estimate HIV incidence. Also, we enrolled in a prospective study a cohort of 4,357 individuals who were released from prison via an amnesty on July 16, 2007. We followed them with interviews at intervals of 6-12 mo and by linking several databases. A total of 2,473 participants who were HIV negative in January 2006 had interviews between then and 2010 to evaluate the association between use of harm reduction programs and HIV incidence. We used survival methods with attendance at methadone clinics as a time-varying covariate to measure the association with HIV incidence. We used a Poisson regression model and calculated the HIV incidence rate to evaluate the association between needle/syringe program use and HIV incidence. Among the population of PWID who were imprisoned, the implementation of comprehensive harm reduction programs and a lower mean community HIV viral load were associated with a reduced HIV incidence among PWID. The HIV incidence in this population of PWID decreased from 18.2% in 2005 to 0.3% in 2010. In an individual-level analysis of the amnesty cohort, attendance at methadone clinics was associated with a significantly lower HIV incidence (adjusted hazard ratio: 0.20, 95% CI: 0.06-0.67), and frequent users of needle/syringe program services had lower HIV incidence (0% in high NSP users, 0.5% in non NSP users). In addition, no HIV seroconversions were detected among prison inmates.

CONCLUSIONS

Although our data are affected by participation bias, they strongly suggest that comprehensive harm- reduction services and free treatment were associated with reversal of a rapidly emerging epidemic of HIV among PWID. Please see later in the article for the Editors' Summary.

Temporal trends in the survival of drug and alcohol abusers according to the primary drug of admission to treatment in Spain

BACKGROUND

Mortality of alcohol and drug abusers is much higher than the general population. We aimed to characterize the role of the primary substance of abuse on the survival of patients admitted to treatment and to analyze changes in mortality over time.

METHODS

Longitudinal study analyzing demographic, drug use, and biological data of 5023 patients admitted to three hospital-based treatment units in Barcelona, Spain, between 1985 and 2006. Vital status and causes of death were ascertained from clinical charts and the mortality register. Piecewise regression models were used to analyze changes in mortality.

RESULTS

The primary substances of dependence were heroin, cocaine, and alcohol in 3388 (67.5%), 945 (18.8%), and 690 patients (13.7%), respectively. The median follow-up after admission to treatment was 11.6 years (IQR: 6.6-16.1), 6.5 years (IQR: 3.9-10.6), and 4.8 years (IQR: 3.1-7.8) for the heroin-, cocaine-, and alcohol-dependent patients, respectively. For heroin-dependent patients, mortality rate decreased from 7.3×100person-years (p-y) in 1985 to 1.8×100p-y in 2008. For cocaine-dependent patients, mortality rate decreased from 10.7×100p-y in 1985 to <2.5×100p-y after 2004. The annual average decrease was 2% for alcohol-dependent patients, with the lowest mortality rate (3.3×100p-y) in 2008.

CONCLUSIONS

Significant reductions in mortality of alcohol and drug dependent patients are observed in recent years in Spain. Preventive interventions, treatment of substance dependence and antiretroviral therapy may have contributed to improve survival in this population.

Namibian prisoners describe barriers to HIV antiretroviral therapy adherence

Little is available in scholarly literature about how HIV-positive prisoners, especially in low-income countries, access antiretroviral therapy (ART) medication. We interviewed 18 prisoners at a large prison in Namibia to identify barriers to medication adherence. The lead nurse researcher was a long-standing clinic employee at the prison, which afforded her access to the population. We identified six significant barriers to adherence, including (1) the desire for privacy and anonymity in a setting where HIV is strongly stigmatized; (2) the lack of simple supports for adherence, such as availability of clocks; (3) insufficient access to food to support the toll on the body of ingesting taxing ART medications; (4) commodification of ART medication; (5) the brutality and despair in the prison setting, generally leading to discouragement and a lack of motivation to strive for optimum health; and (6) the lack of understanding about HIV, how it is transmitted, and how it is best managed. Because most prisoners eventually transition back to communitysettings when their sentences are served, investments in prison health represent important investments in public health.

Mortality among methadone maintenance clients in China: a six-year cohort study

Objective

To assess the overall mortality of methadone maintenance treatment (MMT) clients in China and its associated factors.

Methods

A total of 1,511 MMT clients, all of whom enrolled in China's first eight MMT clinics between March and December 2004, were included in this cohort study and followed for approximately six years, until June 2010. Mortality and its predictors were examined using Cox proportional hazards regression models.

Results

A total of 154 deaths were observed within 5,391 person-years (PY) of follow-up for an all-cause mortality rate of 28.6 per 1,000 PY. The leading causes of death were drug overdose (33.8%), HIV/AIDS-unrelated disease (21.4%), and HIV/AIDS (16.9%). The all-cause mortality rate of clients engaged in MMT for one year or less was roughly three times that of clients who stayed in MMT for four years or more (14.0 vs. 4.6, p<0.0001), HIV-positive subjects was nearly four times mortality rate than that of HIV-negative individuals (28.1 vs.6.8, p<0.0001). ART-naive HIV-positive subjects had approximately two times higher mortality rate than those receiving ART (31.2 vs. 17.3, <0.0001). After adjusting for confounding variables, we found that being male (HR = 1.63, CI: 1.03–2.57, p = 0.0355) and being HIV-positive (HR = 5.16, CI: 3.70–7.10, p<0.0001) were both associated with higher risk of death whereas increased durations of methadone treatment were associated with a lower risk of death (HR = 0.26, CI: 0.18–0.38, p<0.0001 for two to three years, HR = 0.08, CI: 0.05–0.14, p<0.0001 for four or more years).

Conclusion

Overall mortality was high among MMT clients in China. Specific interventions aimed at decreasing mortality among MMT clients are needed. Our study supports the need for keeping client at MMT longer and for expanding ART coverage and suggests the potential benefits of integrated MMT and ART services for drug users in China.

Higher methadone doses are associated with lower mortality in patients of opioid dependence in Taiwan

Optimal methadone dosage and service profile is challenging in treatment of opioid dependence. This study explores the impact of methadone dosage on the mortality of opioid-dependent patients in methadone maintenance therapy by using a large-scale and continual supervised dosing registry information system. Database of nationwide enrolled opioid-dependent patients at methadone clinics in Taiwan during 2006-2008 was assessed. The relative risk of age, sex, marital status, HIV infection and methadone dosage were analyzed by Cox regression analysis. Among all of the 33,549 recruited patients, the crude mortality rate was 134.78/10,000 person-years, and the standardized mortality ratio was 4.68. A dose-response relationship of higher- vs. lower-dosage groups on the risk of mortality risk was observed (adjusted HR = 0.68, P = 0.016). In further sub-grouping analysis, this trend was more significant in HIV positive patients, in subgroup of patients who continuously staying in MMT, and in subgroup of patients who re-enter MMT. This dosage effect is not significantly seen in patients receiving MMT more than 365 days. Further exploration of other treatment-related factors may be important for understanding the long-term treatment outcome of opioid addiction patients.

Systematic review of record linkage studies of mortality in ex-prisoners: why (good) methods matter

AIMS

World-wide, more than 30 million people move through prisons annually. Record linkage studies have identified an increased risk of death in ex-prisoners. In order to inform preventive interventions it is necessary to understand who is most at risk, when and why. Limitations of existing studies have rendered synthesis and interpretation of this literature difficult. The aim of this study was to describe methodological characteristics of existing studies and make recommendations for the design, analysis and reporting of future studies.

METHODS

Systematic review of studies using record linkage to explore mortality in ex-prisoners. Based on analysis of these studies we illustrate how methodological limitations and heterogeneity of design, analysis and reporting both hamper data synthesis and create potential for misinterpretation of findings. Using data from a recent Australian study involving 42,015 ex-prisoners and 2329 observed deaths, we quantify the variation in findings associated with various approaches.

RESULTS

We identified 29 publications based on 25 separate studies published 1998-2011, mainly from the United Kingdom, United States and Australia. Mortality estimates varied systematically according to features of study design and data analysis. A number of common, avoidable and significant methodological limitations were identified. Substantial heterogeneity in study design, methods of data analysis and reporting of findings was observed.

CONCLUSIONS

Record linkage studies examining mortality in ex-prisoners show widely varying estimates that are influenced substantially by avoidable methodological limitations and reducible heterogeneity. Future studies should adopt best practice methods and more consistent methods of analysis and reporting, to maximize policy relevance and impact.

Adapting an Evidence-Based Intervention Targeting HIV-Infected Prisoners in Malaysia

HIV-infected prisoners in Malaysia represent a critical target population for secondary HIV risk reduction interventions and care. We report on the process and outcome of our formative research aimed at systematically selecting and adapting an EBI designed to reduce secondary HIV risk and improve adherence to antiretroviral therapy among soon-to-be-released HIV-infected prisoners. Our formative work involved a critical examination of established EBIs and associated published reports complemented by data elicited through structured interviews and focus groups with key stakeholders, members of the target population, and their family members. Based on all information, we adapted the Holistic Health Recovery Program targeting people living with HIV (HHRP+), an EBI, to consist of eight 2-hour sessions that cover a range of specified topics so that participants may individually apply intervention content as needed to accommodate their particular substance abuse, HIV risk, and antiretroviral adherence issues. This study provides a complete example of the process of selecting and adapting an EBI-taking into account both empirical evidence and input from target organization stakeholders and target population members and their families-for use in real world prison settings where high-risk populations are concentrated.