1
|
Mehmandoost S, Mirzazadeh A, Karamouzian M, Khezri M, Sharafi H, Shahesmaeili A, Maghsoudi SH, Ghalekhani N, Tavakoli F, Bazrafshani MS, Shokoohi M, Aghaali N, Haghdoost AA, Sharifi H. Injection cessation and relapse to injection and the associated factors among people who inject drugs in Iran: The Rostam study. Subst Abuse Treat Prev Policy 2023; 18:72. [PMID: 38031110 PMCID: PMC10687883 DOI: 10.1186/s13011-023-00583-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran. METHODS This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome. RESULTS The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation. CONCLUSION Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.
Collapse
Affiliation(s)
- Soheil Mehmandoost
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Mirzazadeh
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Mohammad Karamouzian
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mehrdad Khezri
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, USA
| | - Heidar Sharafi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Armita Shahesmaeili
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Saiedeh Haji Maghsoudi
- Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Nima Ghalekhani
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Tavakoli
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Maliheh Sadat Bazrafshani
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mostafa Shokoohi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Niloufar Aghaali
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Akbar Haghdoost
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
| |
Collapse
|
2
|
Stone J, Trickey A, Walker JG, Bivegete S, Semchuk N, Sazonova Y, Varetska O, Altice FL, Saliuk T, Vickerman P. Modelling the impact and cost-effectiveness of non-governmental organizations on HIV and HCV transmission among people who inject drugs in Ukraine. J Int AIDS Soc 2023; 26:e26073. [PMID: 37012669 PMCID: PMC10070931 DOI: 10.1002/jia2.26073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 02/23/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION People who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C virus (HCV). Non-governmental organizations (NGOs) provide PWID with needles/syringes, condoms, HIV/HCV testing and linkage to opioid agonist treatment (OAT) and antiretroviral therapy (ART). We estimated their impact and cost-effectiveness among PWID. METHODS A dynamic HIV and HCV transmission model among PWID was calibrated using data from four national PWID surveys (2011-2017). The model assumed 37-49% coverage of NGOs among community PWID, with NGO contact reducing injecting risk and increasing condom use and recruitment onto OAT and ART. We estimated the historic (1997-2021) and future (2022-2030, compared to no NGO activities from 2022) impact of NGOs in terms of the proportion of HIV/HCV infections averted and changes in HIV/HCV incidence. We estimated the future impact of scaling-up NGOs to 80% coverage with/without scale-up in OAT (5-20%) and ART (64-81%). We estimated the cost per disability-adjusted life-year (DALY) averted of current NGO provision over 2022-2041 compared to NGO activities stopping over 2022-2026, but restarting after that till 2041. We assumed average unit costs of US$80-90 per person-year of NGO contact for PWID. RESULTS With existing coverage levels of NGOs, the model projects that NGOs have averted 20.0% (95% credibility interval: 13.3-26.1) and 9.6% (5.1-14.1) of new HIV and HCV infections among PWID over 1997-2021, respectively, and will avert 31.8% (19.6-39.9) and 13.7% (7.5-18.1) of HIV and HCV infections over 2022-2030. With NGO scale-up, HIV and HCV incidence will decrease by 54.2% (43.3-63.8) and 30.2% (20.5-36.2) over 2022-2030, or 86.7% (82.9-89.3) and 39.8% (31.4-44.8) if OAT and ART are also scaled-up. Without NGOs, HIV and HCV incidence will increase by 51.6% (23.6-76.3) and 13.4% (4.8-21.9) over 2022-2030. Current NGO provision over 2022-2026 will avert 102,736 (77,611-137,512) DALYs when tracked until 2041 (discounted 3% annually), and cost US$912 (702-1222) per DALY averted; cost-effective at a willingness-to-pay threshold of US$1548/DALY averted (0.5xGDP). CONCLUSIONS NGO activities have a crucial preventative impact among PWID in Ukraine which should be scaled-up to help achieve HIV and HCV elimination. Disruptions could have a substantial detrimental impact.
Collapse
Affiliation(s)
- Jack Stone
- Population Health SciencesUniversity of BristolBristolUK
| | - Adam Trickey
- Population Health SciencesUniversity of BristolBristolUK
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Ahmad S, Zainab, Ahmad H, Khan I, Alghamdi S, Almehmadi M, Ali M, Ullah A, Hussain H, Khan NM, Ali F, Ahmad M. Green synthesis of gold nanaoparticles using Delphinium Chitralense tuber extracts, their characterization and enzyme inhibitory potential. BRAZ J BIOL 2022; 82:e257622. [PMID: 35293518 DOI: 10.1590/1519-6984.257622] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Green synthesis has been introduced as an alternative to chemical synthesis due to the serious consequences. Metal nanoparticles synthesized through green approach have different pharmaceutical, medical and agricultural applications. The present study followed a green and simple route for the preparation of potentially bioactive gold nanoparticles (Au NPs). Au NPs were prepared via green synthesis approach using crude basic alkaloidal portion of the tuber of Delphinium chitralense. The green synthesized Au NPs were characterized by transmission electron microscopy (TEM), scanning electron microscopy (SEM), X-ray diffraction (XRD) fourier transform infrared (FTIR), and UV-Visible spectrophotometer. Morphological analysis shows that Au NPs have cubic geometry with different sizes. UV-Vis spectroscopic analysis confirmed the synthesis of Au NPs while XRD proved their pure crystalline phase. The Au NPs showed promising dose dependent inhibition of both AChE and BChE as compared to the crude as well as standard drug.
Collapse
Affiliation(s)
- S Ahmad
- University of Malakand, Department of Chemistry, Chakdara, Dir (L), Khyber Pakhtunkhwa, Pakistan.,Shaheed Benazir Bhutto University Sheringal, Department of Pharmacy, Dir (Upper), Khyber Pakhtunkhwa, Pakistan
| | - Zainab
- University of Malakand, Department of Chemistry, Chakdara, Dir (L), Khyber Pakhtunkhwa, Pakistan
| | - H Ahmad
- University of Malakand, Department of Chemistry, Chakdara, Dir (L), Khyber Pakhtunkhwa, Pakistan
| | - I Khan
- Bacha Khan University Charsadda, Department of Chemistry, Khyber Pakhtunkhwa, Pakistan
| | - S Alghamdi
- Umm Al-Qura University, Faculty of Applied Medical Sciences, Laboratory Medicine Department, Makkah, Saudi Arabia
| | - M Almehmadi
- Taif University, College of Applied Medical Sciences, Department of Clinical Laboratory Sciences, Taif, Saudi Arabia
| | - M Ali
- University of Malakand, Department of Chemistry, Chakdara, Dir (L), Khyber Pakhtunkhwa, Pakistan
| | - A Ullah
- Shaheed Benazir Bhutto University Sheringal, Department of Pharmacy, Dir (Upper), Khyber Pakhtunkhwa, Pakistan
| | - H Hussain
- Shaheed Benazir Bhutto University Sheringal, Department of Pharmacy, Dir (Upper), Khyber Pakhtunkhwa, Pakistan
| | - N M Khan
- Shaheed Benazir Bhutto University Sheringal, Department of Agriculture, Dir (Upper), Khyber Pakhtunkhwa, Pakistan
| | - F Ali
- Shaheed Benazir Bhutto University Sheringal, Department of Chemistry, Dir (Upper), Khyber Pakhtunkhwa, Pakistan
| | - M Ahmad
- University of Malakand, Department of Chemistry, Chakdara, Dir (L), Khyber Pakhtunkhwa, Pakistan
| |
Collapse
|
4
|
Rudolph AE, Upton E, Young AM, Havens JR. Social network predictors of recent and sustained injection drug use cessation: findings from a longitudinal cohort study. Addiction 2021; 116:856-864. [PMID: 32812273 PMCID: PMC7889767 DOI: 10.1111/add.15218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/16/2020] [Accepted: 08/03/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The US opioid crisis has led to increases in overdose fatalities and the incidence of HIV, hepatitis C and other infections. This analysis examines social network predictors of recent (self-report injection followed by non-injection) and sustained (self-report non-injection at two consecutive visits among those who previously injected) injection cessation in Appalachian Kentucky. DESIGN Data were collected through bi-annual longitudinal assessments for Social Networks among Appalachian People (SNAP; 2008-17). Using logistic regression with generalized estimating equations that clustered on individuals, we regressed non-injection status on the number of social network members who (a) did not inject and (b) recently stopped injecting and tested for interactions between each social network exposure and prior non-injection status. Social network exposures were self-reported. SETTING Rural eastern Kentucky, USA. PARTICIPANTS Participants entered the analysis only after reporting recent injection and had to have had at least two consecutive study visits (n = 326). MEASUREMENTS Interviewer-administered surveys collected individual-level socio-demographics, recent (past 6 months) drug use behaviors and the names of recent social support, sex and drug-use partners. FINDINGS After adjusting for confounders, the number of non-injecting social network members was positively associated with recent/sustained injection cessation (adjusted odds ratio = 1.27; 95% confidence interval = 1.13-1.42) and having more social network members was associated with reduced odds of recent/sustained injection cessation. The number of previously injecting social network members who had recently stopped injecting was not statistically significantly associated with injection cessation. Neither of the interactions we tested for was statistically significant, suggesting that the relationships may be similar for those who recently stopped injecting versus had not injected for at least 1 year. CONCLUSIONS For each additional network member who did not inject drugs, there was an increased odds of recent and sustained injection cessation among people with a history of injection drug use in Appalachian Kentucky.
Collapse
Affiliation(s)
- Abby E. Rudolph
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA
| | - Elizabeth Upton
- Department of Mathematics and Statistics, Williams College, Williamstown, MA, USA
| | - April M. Young
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY, USA
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky, College of Medicine, Lexington, KY, USA
- Center for Health Equity Transformation, University of Kentucky, Lexington, KY, USA
| | - Jennifer R. Havens
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky, College of Medicine, Lexington, KY, USA
| |
Collapse
|
5
|
Barati M, Bashirian S, Mohammadi Y, Moeini B, Mousali A, Afshari M. An ecological approach to exploring factors affecting substance use relapse: a systematic review. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-020-01412-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
6
|
Reddon H, DeBeck K, Socias ME, Lake S, Dong H, Karamouzian M, Hayashi K, Kerr T, Milloy MJ. Frequent Cannabis Use and Cessation of Injection of Opioids, Vancouver, Canada, 2005-2018. Am J Public Health 2020; 110:1553-1560. [PMID: 32816538 DOI: 10.2105/ajph.2020.305825] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives. To evaluate the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID).Methods. Three prospective cohorts of PWID from Vancouver, Canada, provided the data for these analyses. We used extended Cox regression analysis with time-updated covariates to analyze the association between cannabis use and injection cessation and injection relapse.Results. Between 2005 and 2018, at-least-daily cannabis use was associated with swifter rates of injection cessation (adjusted hazard ratio [AHR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). A subanalysis revealed that this association was only significant for opioid injection cessation (AHR = 1.26; 95% CI = 1.12, 1.41). At-least-daily cannabis use was not significantly associated with injection relapse (AHR = 1.08; 95% CI = 0.95, 1.23).Conclusions. We observed that at-least-daily cannabis use was associated with a 16% increase in the hazard rate of injection cessation, and this effect was restricted to the cessation of injection opioids. This finding is encouraging given the uncertainty surrounding the impact of cannabis policies on PWID during the ongoing opioid overdose crisis in many settings in the United States and Canada.
Collapse
Affiliation(s)
- Hudson Reddon
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Kora DeBeck
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - M Eugenia Socias
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Stephanie Lake
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Huiru Dong
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Mohammad Karamouzian
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Kanna Hayashi
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Thomas Kerr
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - M-J Milloy
- All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada
| |
Collapse
|
7
|
Li L, Lin C, Liang LJ, Feng N, Pham L, Hien NT. Evaluating an intervention for family members of people who use drugs in Vietnam. Soc Sci Med 2020; 261:113238. [PMID: 32736098 DOI: 10.1016/j.socscimed.2020.113238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/23/2020] [Accepted: 07/20/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA.
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA
| | - Li-Jung Liang
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA
| | - Nan Feng
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA
| | - Loc Pham
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA
| | | |
Collapse
|
8
|
Risky decision-making in individuals with substance use disorder: A meta-analysis and meta-regression review. Psychopharmacology (Berl) 2020; 237:1893-1908. [PMID: 32363438 DOI: 10.1007/s00213-020-05506-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/10/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND This review aims to identify whether risky decision-making is increased in substance users, and the impact of substance type, polysubstance use status, abstinence period, and treatment status on risky decision-making. METHODS A literature search with no date restrictions was conducted to identify case-control studies or cross-sectional studies that used behavioral tasks to measure risky decision-making in substance users. A random-effects model was performed. GRADE criteria was used to assess the quality of evidence. RESULTS 52 studies were enrolled. The result showed that the difference in risky decision-making performance between user groups and control groups was significant (SMD = - 0.590; 95%CI = - 0.849 to - 0.330; p < 0.001; I2 = 93.4%; Pheterogeneity < 0.001). Subgroup analysis showed that users in the subgroups of alcohol (p < 0.001), tobacco (p < 0.01), cocaine (p < 0.001), opioid (p < 0.001), mixed group (p < 0.01), adult users (p < 0.001), small sample size (p < 0.001), large sample size (p < 0.01), low education (p < 0.001), high education (p < 0.001), short-abstinence period (p < 0.001), long-abstinence period (p < 0.001), without current polysubstance dependence (p < 0.001), and with treatment (p < 0.001) had increased risky decision-making when compared to the controls. On the other hand, elderly substance users with short-abstinence period showed increased risky decision-making. Moreover, current treatment status and polysubstance use may not influence the level of decision-making in substance users. CONCLUSIONS The results show that substance use is associated with impaired risky decision-making, indicating that interventions targeting risky decision-making in substance users should be developed for relapse prevention and rehabilitation.
Collapse
|
9
|
Karimi SE, SoleimanvandiAzar N, Zanjari N, Ahmadi S, Mohammadi Gharehghani MA, Faez D. Social determinants of drug use among older people with HIV/AIDS in Tehran. JOURNAL OF SUBSTANCE USE 2020. [DOI: 10.1080/14659891.2020.1753832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Salah Eddin Karimi
- Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda SoleimanvandiAzar
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Nasibeh Zanjari
- Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Sina Ahmadi
- Department of Social Welfare Management, Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | | | - Diman Faez
- Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| |
Collapse
|
10
|
Abstract
Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.
Collapse
|
11
|
Fortier E, Sylvestre MP, Artenie AA, Minoyan N, Jutras-Aswad D, Roy É, Grebely J, Bruneau J. Associations between housing stability and injecting frequency fluctuations: findings from a cohort of people who inject drugs in Montréal, Canada. Drug Alcohol Depend 2020; 206:107744. [PMID: 31785537 DOI: 10.1016/j.drugalcdep.2019.107744] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 11/09/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The relationship between housing stability and drug injecting is complex, as both outcomes fluctuate over time. The objectives were to identify short-term trajectories of housing stability and injecting frequency among people who inject drugs (PWID) and examine how patterns of injecting frequency relate to those of housing stability. METHODS At three-month intervals, PWID enrolled between 2011 and 2016 in the Hepatitis Cohort completed an interviewer-administered questionnaire and were tested for hepatitis C and HIV infections. At each visit, participants reported, for each of the past three months, the accommodation they lived in the longest (stable/unstable) and the number of injecting days (0-30). Group-based dual trajectory modeling was conducted to identify housing stability and injecting frequency trajectories evolving concomitantly over 12 months and estimate the probabilities of following injecting trajectories conditional upon housing trajectories. RESULTS 386 participants were included (mean age 40.0, 82 % male). Three housing stability trajectories were identified: sustained (53 %), declining (20 %), and improving (27 %). Five injecting frequency trajectories were identified: sporadic (26 %), infrequent (34 %), increasing (15 %), decreasing (11 %), and frequent (13 %). PWID with improving housing were less likely to increase injecting (8 %) compared to those with sustained (17 %) or declining housing (17 %). CONCLUSIONS Improving housing was associated with a lower probability of increasing injecting compared to declining housing, while sustained housing stability was associated with a higher probability of increasing injecting compared to improving housing. Therefore, policies to improve PWID's access to stable housing are warranted and may reduce, to some extent, drug injecting and related harms.
Collapse
Affiliation(s)
- Emmanuel Fortier
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Marie-Pierre Sylvestre
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Andreea Adelina Artenie
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Nanor Minoyan
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Didier Jutras-Aswad
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Élise Roy
- Addiction Research and Study Program, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Longueuil, QC, Canada; Institut national de santé publique du Québec, Montréal, QC, Canada
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Julie Bruneau
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.
| |
Collapse
|
12
|
Najafi-Ghobadi S, Najafi-Ghobadi K, Tapak L, Aghaei A. Application of data mining techniques and logistic regression to model drug use transition to injection: a case study in drug use treatment centers in Kermanshah Province, Iran. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2019; 14:55. [PMID: 31831013 PMCID: PMC6909482 DOI: 10.1186/s13011-019-0242-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Drug injection has been increasing over the past decades all over the world. Hepatitis B and C viruses (HBV and HCV) are two common infections among people who inject drugs (PWID) and more than 60% of new human immunodeficiency virus (HIV) cases are PWID. Thus, investigating risk factors associated with drug use transition to injection is essential and was the aim of this research. METHODS We used a database from drug use treatment centers in Kermanshah Province (Iran) in 2013 that included 2098 records of people who use drugs (PWUD). The information of 29 potential risk factors that are commonly used in the literature on drug use was selected. We employed four classification methods (decision tree, neural network, support vector machine, and logistic regression) to determine factors affecting the decision of PWUD to transition to injection. RESULTS The average specificity of all models was over 84%. Support vector machine produced the highest specificity (0.9). Also, this model showed the highest total accuracy (0.91), sensitivity (0.94), positive likelihood ratio [1] and Kappa (0.94) and the smallest negative likelihood ratio (0). Therefore, important factors according to the support vector machine model were used for further interpretation. CONCLUSIONS Based on the support vector machine model, the use of heroin, cocaine, and hallucinogens were identified as the three most important factors associated with drug use transition injection. The results further indicated that PWUD with the history of prison or using drug due to curiosity and unemployment are at higher risks. Unemployment and unreliable sources of income were other suggested factors of transition in this research.
Collapse
Affiliation(s)
- Somayeh Najafi-Ghobadi
- Department of Industrial Engineering, Factually of Engineering, Kermanshah Branch, Islamic Azad University, Kermanshah, Iran.
| | - Khadijeh Najafi-Ghobadi
- Department of Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Lily Tapak
- Department of Biostatistics, School of Public Health, Modeling of Noncommunicable Diseases Research Center, Hamadan University of Medical Sciences, Hamadan, 65175-4171, Iran
| | - Abbas Aghaei
- PhD in Epidemiology, Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| |
Collapse
|
13
|
Rudolph AE, Upton E, McDonald MJ, Young AM, Havens JR. Peer influence of injection drug use cessation among dyads in rural eastern Kentucky. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 85:102604. [PMID: 31740176 DOI: 10.1016/j.drugpo.2019.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/30/2019] [Accepted: 11/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND This analysis aims to assess whether injection drug use cessation among peers predicts injection drug use cessation among individuals and explores whether this association varies by relationship type and strength. METHODS Data were collected through baseline and 6-month assessments for the Social Networks among Appalachian People study (2008-2011). Interviewer-administered surveys collected sociodemographic and drug use behaviors (past 6 months and lifetime). Participants also listed sex, drug use, and social support partners (past 6 months). Listed names were cross-referenced with survey participants to identify relationships between study participants. The analytic sample was further restricted to include only those relationship pairs where both individuals reported a history of injection drug use at baseline (n = 244 unique individuals and 746 dyads). We fit a generalized estimating equations logistic regression model to (1) assess the relationship between peer injection cessation and individual injection cessation and (2) determine whether the strength of this association differs by relationship-level variables (i.e., relationship role, relationship type, relationship duration, frequency of interaction, residential proximity). RESULTS Overall, those with a network member who ceased injection drug use were more likely to stop injecting over the following 6-month period (AOR=1.65). The magnitude of this association was greater for social support partners (AOR=2.95), family members (AOR=3.56), those with whom the participant interacted at least daily (AOR=2.17), and those who the participant knew longer (AOR=2.09). Further, among family members, the effect size was greater when relationships were further restricted to immediate family members (AOR=5.35). CONCLUSION Our findings suggest that in this rural community, closer, more supportive relationships, may be more influential for modeling injection cessation; however, relationship-types were not mutually exclusive so differences in effect size across strata may not be statistically significant. In this setting, social support through the recovery process (including cessation attempts with peers) may increase likelihood of injection cessation.
Collapse
Affiliation(s)
- Abby E Rudolph
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, United States.
| | - Elizabeth Upton
- Department of Mathematics and Statistics, Boston University, Boston, MA, United States; Department of Mathematics and Statistics, Williams College, Williamstown, MA, United States
| | - Madelyn J McDonald
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, United States
| | - April M Young
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY, United States; Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, United States; Center for Health Equity Transformation, University of Kentucky, Lexington, KY, United States
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, United States
| |
Collapse
|
14
|
Sijabat M, Dahlia D, Waluyo A. Experiences of palliative care nurses in providing home-based care for patient with advanced cancer. ENFERMERIA CLINICA 2019. [DOI: 10.1016/j.enfcli.2019.04.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
15
|
Islam S, Piggott DA, Moriggia A, Astemborski J, Mehta SH, Thomas DL, Kirk GD. Reducing injection intensity is associated with decreased risk for invasive bacterial infection among high-frequency injection drug users. Harm Reduct J 2019; 16:38. [PMID: 31208419 PMCID: PMC6580632 DOI: 10.1186/s12954-019-0312-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/30/2019] [Indexed: 11/23/2022] Open
Abstract
Background Bacterial infection is a major cause of morbidity and mortality for persons who inject drugs (PWID). Injection cessation may help abrogate such infections, but maintaining complete cessation is challenging. Limited data exists on the role of reduced injection intensity on invasive bacterial infection risk. We sought to evaluate decreased risk for bacterial infections following cessation and substantive reduction in the injection intensity. Methods Participants were persons in the AIDS Linked to the Intravenous Experience (ALIVE) cohort with initial high-frequency injection drug use (> 1 daily). Pooled logistic regression with generalized estimating equations was used to estimate risk for invasive bacterial infection (pneumonia, endocarditis, or sepsis) among participants achieving complete injection cessation or reduced injection intensity relative to those with sustained high-frequency use. Results Of 2247 study participants with 12,469 paired study visits, complete injection cessation was achieved at 13.5% and reduced injection intensity at 25.5% of study visits. Adjusting for sociodemographics and HIV status, injection cessation was associated with a 54% reduction of bacterial infection at 3 months (odds ratio [OR] 0.46, 95% CI 0.25–0.84) and a 46% reduction at 6 months (OR 0.54, 95% CI 0.36–0.81). Reduced injection intensity was associated with a 36% reduction of infection at 3 months (OR 0.64, 95% CI 0.43–0.96) and a 26% reduction at 6 months (OR 0.74, 95% CI 0.56–0.98). Conclusions Both complete cessation and reduced injection frequency demonstrate substantial benefit in reducing invasive bacterial infection risk among PWID. With high rates of relapse into injection use, targeting sustained reductions in drug use intensity may be a key harm reduction modality for improving clinical outcomes in this population. Electronic supplementary material The online version of this article (10.1186/s12954-019-0312-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Salequl Islam
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA. .,Department of Microbiology, Jahangirnagar University, Savar, Dhaka, 1342, Bangladesh.
| | - Damani A Piggott
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Alberto Moriggia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA.,Division of Infectious and Tropical Diseases, IRCCS San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Jacquie Astemborski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - David L Thomas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
| |
Collapse
|
16
|
Ivsins A, Marsh S. Exploring what shapes injection and non-injection among a sample of marginalized people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 57:72-78. [PMID: 29702394 DOI: 10.1016/j.drugpo.2018.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Few studies have specifically explored what influences people who use drugs to consume them in certain ways (i.e., smoking, injecting). While a great deal of research has examined the transition from non-injection to injection routes of drug administration, less is known about people who use drugs (PWUD) but have never injected or have stopped injecting. This paper draws on actor-network theory to explore what moves people to inject or not, among both people who currently smoke/sniff drugs (PWSD) and people who currently inject drugs (PWID), to better understand factors that shape/influence methods of drug consumption. METHODS Two-stage interviews (a quantitative survey followed by a qualitative interview) were conducted with 26 PWSD and 24 PWID. Interviews covered a range of topics related to drug use, including reasons for injecting drugs, never injecting, and stopping injecting. Data were analysed by drawing on actor-network theory to identify forces involved in shaping drug consumption practices. RESULTS We present three transformative drug use events to illustrate how specific methods of drug consumption are shaped by an assemblage of objects, actors, affects, spaces and processes. Rather than emphasising the role of broad socio-structural factors (i.e., poverty, drug policy) participant narratives reveal how a variety of actors, both human and non-human, assembled in unique ways produce drug consumption events that have the capacity to influence or transform drug consumption practices. CONCLUSION Actor-network theory and event analysis provide a more nuanced understanding of drug consumption practices by drawing together complex material, spatial, social and temporal aspects of drug use, which helps identify the variety of forces involved in contexts that are thought to shape substance use. By attending to events of drug consumption we can better understand how contexts shape drug use and related harms. With greater insight into the transformative capacity of drug use events, strategies may be better tailored to prevent drug use-related harms.
Collapse
Affiliation(s)
- Andrew Ivsins
- Department of Sociology, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada; Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.
| | - Samona Marsh
- Vancouver Area Network of Drug Users, 380 E Hastings St, Vancouver, BC, V6A 1P4, Canada
| |
Collapse
|
17
|
Horyniak D, Strathdee SA, West BS, Meacham M, Rangel G, Gaines TL. Predictors of injecting cessation among a cohort of people who inject drugs in Tijuana, Mexico. Drug Alcohol Depend 2018; 185:298-304. [PMID: 29482055 PMCID: PMC5889739 DOI: 10.1016/j.drugalcdep.2017.12.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 12/19/2017] [Accepted: 12/20/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Little is known about the cessation of injecting drug use (IDU) among people who inject drugs (PWID) in low and middle-income settings, where access to effective interventions for reducing drug use (e.g., opioid substitution treatment; OST), may be limited. We measured the incidence and identified predictors of IDU cessation among a cohort of PWID in Tijuana, Mexico. METHODS Data were drawn from 621 participants in Proyecto El Cuete IV, a prospective cohort of PWID recruited in 2011 and interviewed biannually to 2016. A multivariable Extended Cox model was constructed to identify socio-demographic, drug use, risk environment and health-related predictors of IDU cessation (no IDU for ≥six months). RESULTS 141 participants (23%) reported at least one IDU cessation event during follow-up. The crude IDU cessation rate was 7.3 per 100 person-years (95% Confidence Interval [CI]: 6.2-8.7). IDU cessation was negatively associated with injecting at least daily on average and heroin/methamphetamine co-injection in the past six months, and positively associated with testing HIV positive at baseline, being on methadone maintenance therapy in the past six months, and recent arrest. Concern for personal safety was also independently associated with IDU cessation. CONCLUSIONS The rate of IDU cessation among PWID in Tijuana was low. These findings underscore the importance of expansion of services including OST to help reduce drug use and facilitate IDU cessation for those who wish to do so. In this setting, interventions addressing individual-level economic barriers as well as broader social and structural barriers to harm reduction services are integral.
Collapse
Affiliation(s)
- Danielle Horyniak
- Division of Global Public Health, University of California San Diego, La Jolla, CA, 92093, United States,Behaviours and Health Risks Program, Burnet Institute, Melbourne, VIC, 3004, Australia,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Steffanie A. Strathdee
- Division of Global Public Health, University of California San Diego, La Jolla, CA, 92093, United States
| | - Brooke S. West
- Division of Global Public Health, University of California San Diego, La Jolla, CA, 92093, United States
| | - Meredith Meacham
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, 94143, United States
| | - Gudelia Rangel
- United States-Mexico Border Health Commission, Tijuana, BC, 22320, Mexico
| | - Tommi L. Gaines
- Division of Global Public Health, University of California San Diego, La Jolla, CA, 92093, United States,Correspondence: Tommi L. Gaines, Division of Global Public Health, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, Phone: 858-246-0600,
| |
Collapse
|
18
|
Quinn B, Seed C, Keller A, Maher L, Wilson D, Farrell M, Caris S, Williams J, Madden A, Thompson A, Pink J, Hellard ME. Re-examining blood donor deferral criteria relating to injecting drug use. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 48:9-17. [PMID: 28666205 DOI: 10.1016/j.drugpo.2017.05.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 04/21/2017] [Accepted: 05/30/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Potential Australian blood donors are deferred indefinitely if they report a history of injecting drug use (IDU), or for 12 months if they report having engaged in sexual activity with someone who might have ever injected. Given incremental improvements in blood safety, this study sought to examine whether Australia's IDU-related eligibility criteria reflected current scientific evidence, were consistent with international best practice and, if current IDU-related policies were to be changed, how this should happen. METHODS An expert committee was formed to review relevant literature with a focus on issues including: the epidemiology of IDU in Australia and key transfusion-transmissible infections (TTIs) among Australian people who inject drugs (PWID); and, 'non-compliance' among PWID regarding IDU-related blood donation guidelines. International policies relating to blood donation and IDU were also reviewed. Modelling with available data estimated the risk of TTIs remaining undetected if the Blood Service's IDU-related guidelines were changed. RESULTS Very few (<1%) Australians engage in IDU, and IDU risk practices are reported by only a minority of PWID. However, the prevalence of HCV remains high among PWID, and IDU remains a key transmission route for various TTIs. Insufficient data were available to inform appropriate estimates of cessation and relapse among Australian PWID. Modelling findings indicated that the risk of not detecting HIV becomes greater than the reference group at a threshold of non-admission of being an active PWID of around 1.8% (0.5-5.1%). Excluding Japan, all Organisation for the Economic Co-operation and Development member countries permanently exclude individuals with a history of IDU from donating. CONCLUSION Numerous research gaps meant that the study's expert Review Committee was unable to recommend altering Australia's current IDU-related blood donation guidelines. However, having identified critical knowledge gaps and future areas of research, the review made important steps toward changing the criteria.
Collapse
Affiliation(s)
- Brendan Quinn
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Clive Seed
- Australian Red Cross Blood Service, Australia
| | | | - Lisa Maher
- Kirby Institute, University of New South Wales, Australia
| | - David Wilson
- Burnet Institute, Melbourne, Australia; Kirby Institute, University of New South Wales, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | | | | | - Annie Madden
- Australian Injecting & Illicit Drug Users League, Australia
| | | | - Joanne Pink
- Australian Red Cross Blood Service, Australia
| | | |
Collapse
|
19
|
Linton SL, Cooper HLF, Kelley ME, Karnes CC, Ross Z, Wolfe ME, Friedman SR, Jarlais DD, Semaan S, Tempalski B, Sionean C, DiNenno E, Wejnert C, Paz-Bailey G. Cross-sectional association between ZIP code-level gentrification and homelessness among a large community-based sample of people who inject drugs in 19 US cities. BMJ Open 2017; 7:e013823. [PMID: 28637724 PMCID: PMC5541298 DOI: 10.1136/bmjopen-2016-013823] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Housing instability has been associated with poor health outcomes among people who inject drugs (PWID). This study investigates the associations of local-level housing and economic conditions with homelessness among a large sample of PWID, which is an underexplored topic to date. METHODS PWID in this cross-sectional study were recruited from 19 large cities in the USA as part of National HIV Behavioral Surveillance. PWID provided self-reported information on demographics, behaviours and life events. Homelessness was defined as residing on the street, in a shelter, in a single room occupancy hotel, or in a car or temporarily residing with friends or relatives any time in the past year. Data on county-level rental housing unaffordability and demand for assisted housing units, and ZIP code-level gentrification (eg, index of percent increases in non-Hispanic white residents, household income, gross rent from 1990 to 2009) and economic deprivation were collected from the US Census Bureau and Department of Housing and Urban Development. Multilevel models evaluated the associations of local economic and housing characteristics with homelessness. RESULTS Sixty percent (5394/8992) of the participants reported homelessness in the past year. The multivariable model demonstrated that PWID living in ZIP codes with higher levels of gentrification had higher odds of homelessness in the past year (gentrification: adjusted OR=1.11, 95% CI=1.04 to 1.17). CONCLUSIONS Additional research is needed to determine the mechanisms through which gentrification increases homelessness among PWID to develop appropriate community-level interventions.
Collapse
Affiliation(s)
- Sabriya L Linton
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Hannah LF Cooper
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mary E Kelley
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Conny C Karnes
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Zev Ross
- ZevRoss Spatial Analysis, Ithaca, New York, USA
| | - Mary E Wolfe
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Samuel R Friedman
- Institute for Infectious Disease Research, National Development and Research Institutes, New York, New York, USA
| | - Don Des Jarlais
- Baron Edmond de Rothschild Chemical Dependency Institute, Mount Sinai Beth Israel, New York, USA
| | - Salaam Semaan
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Barbara Tempalski
- Institute for Infectious Disease Research, National Development and Research Institutes, New York, New York, USA
| | - Catlainn Sionean
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Cyprian Wejnert
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | |
Collapse
|
20
|
Boyd J, Fast D, Hobbins M, McNeil R, Small W. Social-structural factors influencing periods of injection cessation among marginalized youth who inject drugs in Vancouver, Canada: an ethno-epidemiological study. Harm Reduct J 2017; 14:31. [PMID: 28583136 PMCID: PMC5460503 DOI: 10.1186/s12954-017-0159-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/24/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Injection drug use is associated with HIV and hepatitis C transmission, overdose, and other preventable harms. These harms are heightened for structurally vulnerable injection drug-using populations, as their social conditions pose barriers to safer injecting. Previous research on injection cessation has largely focused on adult drug-using populations. Little qualitative work has examined the social, structural, and environmental factors that shape periods of injection cessation among youth and young adults. Such research is essential to understanding how we can best reduce harms among this vulnerable population as they move in and out of periods of injection cessation. METHODS We conducted 22 semi-structured, qualitative interviews with street-involved young people who use drugs (SY), focused on characterizing their transitions into periods of injection cessation and perceived barriers to injection cessation. Adopting an ethno-epidemiological approach, participants who had experienced at least 6 months of injection cessation were purposively recruited from an ongoing prospective cohort study of SY in Vancouver, Canada to participate in qualitative interviews. Qualitative interview findings were triangulated with the findings of a longitudinal program of ethnographic research with SY in this setting. This ethno-epidemiological approach allowed for a more robust exploration of contextual factors surrounding drug use patterns than would be possible through traditional epidemiological methods alone. RESULTS Findings indicate that periods of injection cessation were influenced by access to harm reduction-informed youth-focused services, transitions in route of administration (e.g., from injecting methamphetamine to the smoking of methamphetamine), and the provision of housing and social supports (e.g., from friends, family, and care providers). Conversely, participants indicated that inadequate social supports and, for some, abstinence-focused treatment methods (e.g., 12-step programs), impeded efforts to cease injecting. CONCLUSIONS To reduce harms, it is imperative to reorient attention toward the social, structural, and spatial contexts that surround injection drug use and shape periods of injection cessation for SY. There is an urgent need for more comprehensive youth-focused services for those engaged in injection drug use, and further study of innovative means of engaging youth.
Collapse
Affiliation(s)
- Jade Boyd
- British Columbia Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Danya Fast
- British Columbia Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Megan Hobbins
- Faculty of Health Sciences, Simon Fraser University, 8888 University Dr, Burnaby, V5A 1S6, BC, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Will Small
- British Columbia Centre on Substance Use, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Faculty of Health Sciences, Simon Fraser University, 8888 University Dr, Burnaby, V5A 1S6, BC, Canada.
| |
Collapse
|
21
|
Bluthenthal RN, Wenger L, Chu D, Bourgois P, Kral AH. Drug use generations and patterns of injection drug use: Birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California. Drug Alcohol Depend 2017; 175:210-218. [PMID: 28448905 PMCID: PMC5494991 DOI: 10.1016/j.drugalcdep.2017.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/24/2017] [Accepted: 04/05/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVES A robust literature documents generational trends in drug use. We examined the implications of changing national drug use patterns on drug injection histories of diverse people who inject drugs (PWID). METHODS Drug use histories were collected from 776 active PWID in 2011-13. Using descriptive statistics, we examine drug use initiation by year and birth cohort (BC) differences in drug first injected. A multivariate linear regression model of time to injection initiation ([TTII] (year of first injection minus year of first illicit drug use) was developed to explore BC differences. RESULTS The first drug injected by BC changed in tandem with national drug use trends with heroin declining from 77% for the pre-1960's BC to 58% for the 1960's BC before increasing to 71% for the 1990's BC. Multivariate linear regression modeling found that shorter TTII was associated with the 1980's/1990's BC (-3.50 years; 95% Confidence Interval [CI]=-0.79, -6.21) as compared to the 1970's BC. Longer TTII was associated with being female (1.65 years; 95% CI=0.40, 2.90), African American (1.69 years; 95% CI=0.43, 2.95), any substance use treatment prior to injection (4.22 years; 95% CI=2.65, 5.79), and prior non-injection use of drug that was first injected (3.29 years; 95% CI=2.19, 4.40). CONCLUSION National drug trends appear to influence injection drug use patterns. The prescription opiate drug era is associated with shorter TTII. Culturally competent, demographically and generationally-targeted prevention strategies to combat transitions to drug injection are needed to prevent or shorten upstream increases in risky drug use practices on a national level.
Collapse
Affiliation(s)
- Ricky N. Bluthenthal
- Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90033, USA
| | - Lynn Wenger
- Behavioral and Urban Health Program, RTI International, 351 California St., San Francisco, CA 94104, USA
| | - Daniel Chu
- Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90033, USA
| | - Philippe Bourgois
- Department of Psychiatry and Biobehavioral Sciences, UCLA Center for Social Medicine and the Humanities, Semel Institute, 760 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Alex H. Kral
- Behavioral and Urban Health Program, RTI International, 351 California St., San Francisco, CA 94104, USA
| |
Collapse
|
22
|
Hickman M, De Angelis D, Vickerman P, Hutchinson S, Martin NK. Hepatitis C virus treatment as prevention in people who inject drugs: testing the evidence. Curr Opin Infect Dis 2015; 28:576-82. [PMID: 26524330 PMCID: PMC4659818 DOI: 10.1097/qco.0000000000000216] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The majority of hepatitis C virus (HCV) infections in the United Kingdom and many developing countries were acquired through injecting. New clinical guidance suggests that HCV treatment should be offered to people with a transmission risk - such as people who inject drugs (PWID) - irrespective of severity of liver disease. We consider the strength of the evidence base and potential problems in evaluating HCV treatment as prevention among PWID. RECENT FINDINGS There is good theoretical evidence from dynamic models that HCV treatment for PWID could reduce HCV chronic prevalence and incidence among PWID. Economic evaluations from high-income settings have suggested HCV treatment for PWID is cost-effective, and that in many settings HCV treatment of PWID could be more cost-effective than treating those at an equivalent stage with no ongoing transmission risk. Epidemiological studies of older interferon treatments have suggested that PWID can achieve similar treatment outcomes to other patient groups treated for chronic HCV. Impact and cost-effectiveness of HCV treatment is driven by the potential 'prevention benefit' of treating PWID. Model projections suggest that more future infections, end stage liver disease, and HCV-related deaths will be averted than lost through reinfection of PWID treated successfully for HCV. However, there is to date no empirical evidence from trials or observational studies that test the model projections and 'prevention benefit' hypothesis. In part this is because of uncertainty in the evidence base but also there is unlikely to have been a change in HCV prevalence due to HCV treatment because PWID HCV treatment rates historically in most sites have been low, and any scale-up and switch to the new direct acting antiviral has not yet occurred. There are a number of key uncertainties in the data available on PWID that need to be improved and addressed to evaluate treatment as prevention. These include estimates of the prevalence of PWID, measurements of HCV chronic prevalence and incidence among PWID, and how to interpret reinfection rates as potential outcome measures. SUMMARY Eliminating HCV through scaling up treatment is a theoretical possibility. But empirical data are required to demonstrate that HCV treatment can reduce HCV transmission, which will require an improved evidence base and analytic framework for measuring PWID and HCV prevalence.
Collapse
Affiliation(s)
- Matthew Hickman
- aSchool of Social and Community Medicine, University of Bristol bMRC Biostatistics Unit, University of Cambridge and Public Health England cGlasgow Caledonian University and Health Protection Scotland, UK dDivision of Global Public Health, University of California San Diego, California, USA
| | | | | | | | | |
Collapse
|
23
|
Defining populations and injecting parameters among people who inject drugs: Implications for the assessment of hepatitis C treatment programs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:950-7. [DOI: 10.1016/j.drugpo.2015.07.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/12/2015] [Accepted: 07/13/2015] [Indexed: 01/19/2023]
|
24
|
Nambiar D, Agius PA, Stoové M, Hickman M, Dietze P. Cessation of injecting drug use: The effects of health service utilisation, drug use and demographic factors. Drug Alcohol Depend 2015; 154:208-13. [PMID: 26154480 DOI: 10.1016/j.drugalcdep.2015.06.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/10/2015] [Accepted: 06/23/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Injecting drug use is associated with a range of harms, however cessation of injecting is rare. There is a lack of evidence on factors associated with cessation, notably those related to health services other than drug treatment. We examined the incidence and identified longitudinal correlates of first episode of cessation in a cohort of people who inject drugs (PWID). METHODS Using discrete-time survival analysis, we examined correlates of the first episode of cessation (no self-reported injecting drug use in the past 12 months), including the use of health services, socio-demographics and drug-related behaviour in a cohort of PWID recruited between 2008 and 2010. RESULTS The cohort of 467 participants contributed 1527 person-years from recruitment to 2014. Under a fifth (17.8%) of people reported cessation of 12 months or more, yielding a cessation rate of 5.4 events per 100 person-years. Younger age (25-29 compared to 30 and above) (adjusted hazard ratio (AHR) 1.79, 95% confidence interval (CI) 1.07-3.00) and male gender (AHR 1.67, 95% CI 2.01-2.76) were positively associated with cessation, while past year use of benzodiazepines (AHR 0.45, 95% CI 0.28-0.72), arrest in the past year (AHR 0.50, 95% CI 0.30-0.83) and low SF-8 physical dimension score (AHR 0.42, 95% CI 0.20-1.88) were negatively associated with cessation. Outpatient service use had the largest effect on cessation (AHR 2.28, 95% CI 0.94-5.48, p=0.067). CONCLUSIONS Low rates of cessation emphasise the need for sustained and comprehensive harm reduction services. The relationship between outpatient services and cessation suggests that further research into the use in health services among PWID is warranted.
Collapse
Affiliation(s)
- Dhanya Nambiar
- Centre for Population Health, Burnet Institute, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia.
| | - Paul A Agius
- Centre for Population Health, Burnet Institute, Australia; Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Mark Stoové
- Centre for Population Health, Burnet Institute, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Canynge Hall, United Kingdom
| | - Paul Dietze
- Centre for Population Health, Burnet Institute, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia
| |
Collapse
|
25
|
Rahimi-Movaghar A, Amin-Esmaeili M, Shadloo B, Malekinejad M. Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:808-19. [PMID: 26210009 PMCID: PMC4625838 DOI: 10.1016/j.drugpo.2015.04.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 02/19/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran. METHODS We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection. RESULTS A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market). CONCLUSION Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.
Collapse
Affiliation(s)
- Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Address: Address: No. 669, South Karegar Ave., Tehran, Iran, Postal Code: 1336616357
| | - Masoumeh Amin-Esmaeili
- Iranian Research Center for HIV/AIDS (IRCHA), Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Address: Imam Khomeini Hospital, Keshavarz Blvd., Tehran, Iran, Postal code: 14197-33141
| | - Behrang Shadloo
- Iranian Research Center for HIV/AIDS (IRCHA), Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Address: Imam Khomeini Hospital, Keshavarz Blvd., Tehran, Iran, Postal code: 14197-33141
| | - Mohsen Malekinejad
- Depaertment of Epidemiology and Biostatistics, Global Health Sciences, University of California San Francisco, Address: 3333 California Street, Suite 265, San Francisco, CA 94118, USA
| |
Collapse
|
26
|
Girotto E, de Andrade SM, Mesas AE, González AD, Guidoni CM. Working conditions and illicit psychoactive substance use among truck drivers in Brazil. Occup Environ Med 2015; 72:764-9. [PMID: 26304775 DOI: 10.1136/oemed-2015-102868] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 07/22/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND The aim of this study was to identify the role that working conditions play in predicting the consumption of illicit psychoactive substances (IPS) among truck drivers. METHODS This cross-sectional study was conducted with truck drivers who transport grains to Paranaguá Port, PR, Brazil. The truck drivers were interviewed, and they completed a self-administered questionnaire regarding their sociodemographics, lifestyles, working conditions, and consumption of IPS over the past 30 days. The statistical analysis included logistic regression models progressively adjusted for sociodemographic and lifestyle variables. RESULTS A total of 670 male drivers with a mean age of 41.9 (±11.1) years were assessed. The prevalence of IPS consumption over the past 30 days was 10.9% (n=73). The drugs used primarily consisted of amphetamines (n=61). After adjusting for working characteristics, sociodemographic and lifestyle variables, the following working conditions were associated with the consumption of IPS: driving mostly at night (OR=3.91; 95% CI 1.75 to 8.74), driving while tired (OR=2.26; 95% CI 1.31 to 3.89), and earning a higher monthly income (OR=2.08; 95% CI 1.16 to 3.72). Drivers who were 39 years old or younger (OR=2.11; 95% CI 1.05 to 4.25) and not living with a partner (OR=2.22; 95% CI 1.17 to 4.22) were also more likely to consume IPS. CONCLUSIONS Driving mostly at night, being tired, and earning more increase the use of IPS among truck drivers, regardless of other working characteristics, sociodemographic, and lifestyle variables.
Collapse
Affiliation(s)
- Edmarlon Girotto
- Department of Pharmaceutical Sciences, Health Sciences Center, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil
| | - Selma Maffei de Andrade
- Department of Public Health, Postgraduate Program in Public Health, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil
| | - Arthur Eumann Mesas
- Department of Public Health, Postgraduate Program in Public Health, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil
| | - Alberto Durán González
- Department of Public Health, Postgraduate Program in Public Health, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil
| | - Camilo Molino Guidoni
- Department of Pharmaceutical Sciences, Health Sciences Center, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil
| |
Collapse
|
27
|
Abstract
BACKGROUND Injecting drug use has historically been the principal driver of the HIV epidemic in the northeast states of India. However, recent data indicate growing numbers of people who inject drugs (PWIDs) in north and central Indian cities. METHODS We conducted face-to-face surveys among PWIDs in seven northeast and eight north/central Indian cities using respondent-driven sampling. We used a rapid HIV-testing protocol to identify seropositive individuals and multiassay algorithm to identify those with recent infection. We used multilevel regression models that incorporated sampling weights and had random intercepts for site to assess risk factors for prevalent and incident (recent) HIV infection. RESULTS We surveyed 14 481 PWIDs from 15 Indian cities between January and December 2013. Participants reported high rates of needle/syringe sharing. The median (site range) estimated HIV prevalence and incidence were 18.1% (5.9, 44.9) and 2.9 per 100 person-years (0, 12.4), respectively. HIV prevalence was higher in northeast sites, whereas HIV incidence was higher in north/central sites. The odds of prevalent HIV were over three-fold higher in women than in men. Other factors associated with HIV prevalence or incidence included duration since first injection, injection of pharmaceutical drugs, and needle/syringe sharing. CONCLUSIONS The burden of HIV infection is high among PWIDs in India, and may be increasing in cities where injecting drug use is emerging. Women who inject drugs were at substantially higher risk for HIV than men - a situation that may be mediated by dual injection-related and sexual risks.
Collapse
|
28
|
Abstract
Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.
Collapse
|
29
|
Fairbairn N, Hayashi K, Ti L, Kaplan K, Suwannawong P, Wood E, Kerr T. Compulsory drug detention and injection drug use cessation and relapse in Bangkok, Thailand. Drug Alcohol Rev 2014; 34:74-81. [PMID: 25302711 DOI: 10.1111/dar.12206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/14/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND AIMS Strategies to promote the reduction and cessation of injection drug use are central to human immunodeficiency virus prevention and treatment efforts globally. Though drug use cessation is a major focus of drug policy in Thailand, little is known about factors associated with injection cessation and relapse in this setting. DESIGN AND METHODS A cross-sectional study was conducted between July and October 2011 of a community-recruited sample of people who inject drugs in Bangkok, Thailand. Using multivariate logistic regression, we examined the prevalence and correlates of injection drug use cessation with subsequent relapse. RESULTS Among 422 participants, 209 (49.5%) reported a period of injection drug use cessation of at least one year. In multivariate analyses, incarceration (adjusted odds ratio [AOR] 13.07), voluntary drug treatment (AOR 2.75), midazolam injection (AOR 2.48) and number of years since first injection (AOR 1.07) were positively associated with injection cessation of duration greater than a year (all P < 0.05). Exposure to compulsory drug detention was positively associated (AOR 2.61) and methadone treatment was negatively associated (AOR 0.38) with short-term cessation only. Injection drug use cessation was most often due to incarceration (74%), and relapse was associated with release from prison (66%). DISCUSSION AND CONCLUSION Half of the study participants had previously stopped injecting drugs for more than a year, and this was strongly associated with incarceration. Compulsory drug detention was associated with short-term cessation and relapse. A range of evidence-based strategies should be made available to facilitate sustained cessation of injection drug use in Thailand.
Collapse
Affiliation(s)
- Nadia Fairbairn
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
| | | | | | | | | | | | | |
Collapse
|
30
|
Ti L, Richardson L, DeBeck K, Nguyen P, Montaner J, Wood E, Kerr T. The impact of engagement in street-based income generation activities on stimulant drug use cessation among people who inject drugs. Drug Alcohol Depend 2014; 141:58-64. [PMID: 24909853 PMCID: PMC4090016 DOI: 10.1016/j.drugalcdep.2014.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/05/2014] [Accepted: 05/06/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Despite the growing prevalence of illicit stimulant drug use internationally, and the widespread involvement of people who inject drugs (IDU) within street-based drug markets, little is known about the impact of different types of street-based income generation activities on the cessation of stimulant use among IDU. METHODS Data were derived from an open prospective cohort of IDU in Vancouver, Canada. We used Kaplan-Meier methods and Cox proportional hazards regression to examine the effect of different types of street-based income generation activities (e.g., sex work, drug dealing, and scavenging) on time to cessation of stimulant use. RESULTS Between December, 2005 and November, 2012, 887 IDU who use stimulant drugs (cocaine, crack cocaine, or crystal methamphetamine) were prospectively followed-up for a median duration of 47 months. In Kaplan-Meier analyses, compared to those who did not engage in street-based income generation activities, participants who reported sex work, drug dealing, scavenging, or more than one of these activities were significantly less likely to report stimulant drug use cessation (all p<0.001). When considered as time-updated variables and adjusted for potential confounders in a multivariable model, each type of street-based income generation activity remained significantly associated with a slower time to stimulant drug cessation (all p<0.005). CONCLUSIONS Our findings highlight the urgent need for strategies to address stimulant dependence, including novel pharmacotherapies. Also important, structural interventions, such as low-threshold employment opportunities, availability of supportive housing, legal reforms regarding drug use, and evidence-based approaches that reduce harm among IDU are urgently required.
Collapse
Affiliation(s)
- Lianping Ti
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, Canada V6T 1Z3
| | - Lindsey Richardson
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6
| | - Kora DeBeck
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; School of Public Policy, Simon Fraser University, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
| | - Paul Nguyen
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, Canada V5Z 1M9.
| |
Collapse
|
31
|
The association between neighborhood residential rehabilitation and injection drug use in Baltimore, Maryland, 2000-2011. Health Place 2014; 28:142-9. [PMID: 24840154 DOI: 10.1016/j.healthplace.2014.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 04/13/2014] [Accepted: 04/17/2014] [Indexed: 02/05/2023]
Abstract
This study utilized multilevel cross-classified models to longitudinally assess the association between neighborhood residential rehabilitation and injection drug use. We also assessed whether relocating between neighborhoods of varying levels of residential rehabilitation was associated with injection drug use. Residential rehabilitation was categorized into three groups (e.g. low, moderate, high), and lagged one visit to ensure temporality. After adjusting for neighborhood and individual-level factors, residence in a neighborhood with moderate residential rehabilitation was associated with a 23% reduction in injection drug use [AOR=0.77; 95% CI (0.67,0.87)]; residence in a neighborhood with high residential rehabilitation was associated with a 26% reduction in injection drug use [AOR=0.74; 95% CI (0.61,0.91)]. Continuous residence within neighborhoods with moderate/high rehabilitation, and relocating to neighborhoods with moderate/high rehabilitation, were associated with a lower likelihood of injection drug use. Additional studies are needed to understand the mechanisms behind these relationships.
Collapse
|
32
|
Correlates of drug use cessation among participants in the Canadian HIV-HCV Co-infection Cohort. Drug Alcohol Depend 2014; 137:121-8. [PMID: 24559606 DOI: 10.1016/j.drugalcdep.2014.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 01/21/2014] [Accepted: 01/22/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Ongoing drug use remains a barrier to HIV and HCV treatment. We examined the occurrence and correlates of drug use cessation among HIV-HCV co-infected drug users participating in HIV care. METHODS Participants from the Canadian Co-infection Cohort reporting drug use (injecting drugs and/or smoking crack) with at least two follow-up visits were included (n=521 (43%), 1832 visits). Socio-demographics, behavioural, and health information were collected at each six-month visit. Associations with cessation (no drug use since last visit) were examined using non-linear mixed effects logistic regression models with random intercepts. RESULTS During follow-up, 361 (69%) participants ceased using drugs. Having a fixed address (aOR [adjusted odds ratio] 1.73, CI [95% confidence interval] 1.02-2.96) and smoking crack without injecting drugs (aOR 3.10, CI 2.05-4.71) were positively associated. Living alone (aOR 0.47, CI 0.35-0.63), current tobacco use (aOR 0.41, CI 0.26-0.64), hazardous alcohol drinking (aOR 0.67, CI 0.49-0.91), snorting drugs (aOR 0.52, CI 0.37-0.74), having a greater exposure to addiction programmes (aOR 0.88, CI 0.81-0.94), having been recruited in Quebec or Nova Scotia (aOR 0.41, CI 0.25-0.66), and British Columbia or Alberta (aOR 0.51, CI 0.32-0.82) were negatively associated. Various socio-demographic (age, education) and health-related (HIV duration, care adherence) factors were not associated. CONCLUSION Drug use cessation among HIV-HCV co-infected persons is relatively common in this cohort. Stable housing and supportive living situations seem to be important facilitators for drug use cessation in this population. Greater efforts should be made to retain patients in addiction treatment programmes.
Collapse
|
33
|
Lijffijt M, Hu K, Swann AC. Stress modulates illness-course of substance use disorders: a translational review. Front Psychiatry 2014; 5:83. [PMID: 25101007 PMCID: PMC4101973 DOI: 10.3389/fpsyt.2014.00083] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 06/30/2014] [Indexed: 11/21/2022] Open
Abstract
Childhood trauma and post-childhood chronic/repeated stress could increase the risk of a substance use disorder by affecting five stages of addiction illness-course: (a) initial experimentation with substances; (b) shifting from experimental to regular use; (c) escalation from regular use to abuse or dependence; (d) motivation to quit; and (e) risk of (re-)lapse. We reviewed the human literature on relationships between stress and addiction illness-course. We explored per illness-course stage: (i) whether childhood trauma and post-childhood chronic/repeated stress have comparable effects and (ii) whether effects cut across classes of substances of abuse. We further discuss potential underlying mechanisms by which stressors may affect illness-course stages for which we relied on evidence from studies in animals and humans. Stress and substances of abuse both activate stress and dopaminergic motivation systems, and childhood trauma and post-childhood stressful events are more chronic and occur more frequently in people who use substances. Stressors increase risk to initiate early use potentially by affecting trait-like factors of risk-taking, decision making, and behavioral control. Stressors also accelerate transition to regular use potentially due to prior effects of stress on sensitization of dopaminergic motivation systems, cross-sensitizing with substances of abuse, especially in people with high trait impulsivity who are more prone to sensitization. Finally, stressors increase risk for abuse and dependence, attenuate motivation to quit, and increase relapse risk potentially by intensified sensitization of motivational systems, by a shift from positive to negative reinforcement due to sensitization of the amygdala by corticotropin releasing factor, and by increased sensitization of noradrenergic systems. Stress generally affects addiction illness-course across stressor types and across classes of substances of abuse.
Collapse
Affiliation(s)
- Marijn Lijffijt
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX , USA
| | - Kesong Hu
- Human Neuroscience Institute, Department of Human Development, Cornell University , Ithaca, NY , USA
| | - Alan C Swann
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX , USA ; Mental Health Care Line, Michael E. DeBakey VA Medical Center , Houston, TX , USA
| |
Collapse
|
34
|
Li L, Hien NT, Liang LJ, Lin C, Tuan NA. Correlated outcomes of a pilot intervention for people injecting drugs and their family members in Vietnam. Drug Alcohol Depend 2014; 134:348-354. [PMID: 24305572 PMCID: PMC3881285 DOI: 10.1016/j.drugalcdep.2013.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 11/01/2013] [Accepted: 11/02/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The interrelationship between the well-being of injecting drug users (IDUs) and their family environment has been widely documented. However, few intervention programs have addressed the needs of both IDUs and their family members. METHODS This study describes a randomized intervention pilot targeting 83 IDUs and 83 of their family members from four communes in Phú Thọ province, Vietnam. The IDUs and family members in the intervention condition received multiple group sessions, with the intent to improve psychological well-being and family relationships. The intervention outcomes (depressive symptoms and family relations) were evaluated at baseline, 3-month and 6-month follow-up assessments. RESULTS Depressive symptoms and family relations reported by IDUs were found to be correlated to those reported by their family members. Overall, significant intervention effects on depressive symptoms and family relations were observed for both IDUs and family members. A similar improvement pattern in family relations emerged for both the IDU and family member samples, although the intervention effect of reducing depressive symptoms was more sustainable for family members at the 6-month assessment when compared to the IDU sample. CONCLUSION The intervention pilot addressed challenges faced by IDUs and their family members and revealed correlated outcomes for the two groups. Findings suggest a vital need to include family members in future drug prevention and harm reduction intervention efforts.
Collapse
Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA.
| | - Nguyen Tran Hien
- National Institute of Hygiene and Epidemiology, 1 Yersin, Hanoi 10000, Vietnam
| | - Li-Jung Liang
- Department of Medicine Statistics Core, University of California, 911 Broxton Ave., Los Angeles, CA 90095, U.S.A
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, U.S.A
| | - Nguyen Anh Tuan
- National Institute of Hygiene and Epidemiology, 1 Yersin, Hanoi 10000, Vietnam
| |
Collapse
|
35
|
Linton SL, Celentano DD, Kirk GD, Mehta SH. The longitudinal association between homelessness, injection drug use, and injection-related risk behavior among persons with a history of injection drug use in Baltimore, MD. Drug Alcohol Depend 2013; 132:457-65. [PMID: 23578590 PMCID: PMC3926693 DOI: 10.1016/j.drugalcdep.2013.03.009] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 03/04/2013] [Accepted: 03/09/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Few studies have assessed the temporal association between homelessness and injection drug use, and injection-related risk behavior. METHODS Among a cohort of 1405 current and former injection drug users in follow-up from 2005 to 2009, we used random intercept models to assess the temporal association between homelessness and subsequent injection drug use, and to determine whether the association between homelessness and sustained injection drug use among active injectors differed from the association between homelessness and relapse among those who stopped injecting. We also assessed the association between homelessness and subsequent injection-related risk behavior among participants who injected drugs consecutively across two visits. Homelessness was categorized by duration: none, <1 month, and ≥1 month. RESULTS Homelessness was reported on at least one occasion by 532 (38%) participants. The relationship between homelessness and subsequent injection drug use was different for active injectors and those who stopped injecting. Among those who stopped injecting, homelessness was associated with relapse [<1 month: AOR=1.67, 95% CI (1.01, 2.74); ≥1 month: AOR=1.34 95% CI (0.77, 2.33)]. Among active injectors, homelessness was not associated with sustained injection drug use [<1 month: AOR=1.03, 95% CI (0.71, 1.49); ≥1 month: AOR=0.81 95% CI (0.56, 1.17)]. Among those injecting drugs across two consecutive visits, homelessness ≥1 month was associated with subsequent injection-related risk behavior [AOR=1.61, 95% CI (1.06, 2.45)]. CONCLUSION Homelessness appears to be associated with relapse and injection-related risk behavior. Strengthening policies and interventions that prevent homelessness may reduce injection drug use and injection-related risk behaviors.
Collapse
Affiliation(s)
- Sabriya L. Linton
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - David D. Celentano
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Gregory D. Kirk
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Shruti H. Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, USA
| |
Collapse
|
36
|
Li L, Tuan NA, Liang LJ, Lin C, Farmer SC, Flore M. Mental health and family relations among people who inject drugs and their family members in Vietnam. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 24:545-9. [PMID: 23910167 DOI: 10.1016/j.drugpo.2013.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/18/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND This article explores the association of people who inject drugs and their family members in terms of mental health and family relations. The objective was to understand the family context and its impact on people who inject drugs in a family-oriented culture in Vietnam. METHODS Cross-sectional assessment data were gathered from 83 people who inject drugs and 83 of their family members recruited from four communes in Phú Thọ province, Vietnam. Depressive symptoms and family relations were measured for both people who inject drugs and family members. Internalized shame and drug-using behavior were reported by people who inject drugs, and caregiver burden was reported by family members. RESULTS We found that higher level of drug using behavior of people who inject drugs was significantly associated with higher depressive symptoms and lower family relations reported by themselves as well as their family members. Family relations reported by people who inject drugs and their family members were positively correlated. CONCLUSION The findings highlight the need for interventions that address psychological distress and the related challenges faced by family members of people who inject drugs. The article has policy implication which concludes with an argument for developing strategies that enhance the role of families in supporting behavioral change among people who inject drugs.
Collapse
Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA.
| | - Nguyen Anh Tuan
- National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam
| | - Li-Jung Liang
- Department of Medicine Statistics Core, University of California at Los Angeles, Los Angeles, CA, USA
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA
| | - Shu C Farmer
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA, USA
| | - Martin Flore
- Department of Medicine Statistics Core, University of California at Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
37
|
Sarkar S, Nebhinani N, Kaur J, Kaur K, Ghai S, Basu D. Relationship of reasons and fears of treatment with outcome in substance using population attending a de-addiction centre. Ind Psychiatry J 2013; 22:143-8. [PMID: 25013316 PMCID: PMC4085807 DOI: 10.4103/0972-6748.132929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Substance users approach a treatment facility for a variety of reasons as well as avoid or delay in help seeking due to perceived fears with treatment facilities. Sometimes these factors might be associated with treatment outcomes. OBJECTIVES We studied the relationship of reasons and fears of treatment seeking with treatment outcome in substance users. MATERIALS AND METHODS One hundred subjects, attending the Drug Deaddiction and Treatment Centre, PGIMER, were prospectively recruited by purposive sampling. A semistructured proforma was used to gather sociodemographic and clinical data. Reasons of help-seeking and fear questionnaire, social support scale, and PGI locus of control scale were then applied. Followup data were available for 69 patients, which were classified into good or poor outcome based on relapse status. RESULTS At 6 months followup, 22 patients had relapsed, while 47 patients did not relapse. A higher degree of dysfunction due to substance at baseline was associated with relapsed status at followup. Parents or guardians coming to know about resuming substance and being unemployed for a long time were the reasons associated with relapsed status, while needing to consult a doctor immediately was significantly related to abstinent status at followup. Fear of not being able to meet substance using friends was associated with a poorer outcome in the form of relapse. CONCLUSIONS Reasons for treatment seeking as well as fears related to treatment have significant implications on the clinical outcome of substance abusing patients. Addressing these could help in better patient outcomes.
Collapse
Affiliation(s)
- Siddharth Sarkar
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Nebhinani
- Postgraduate Institute of Medical Science, Rohtak, Haryana, India
| | - Jasveen Kaur
- National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamalpreet Kaur
- National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandhya Ghai
- National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Debasish Basu
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
38
|
Hickman M, Vickerman P, Degenhardt L. Commentary on Mehta et al. (2012): Natural history of injecting drug use. Addiction 2012; 107:359-60. [PMID: 22248140 DOI: 10.1111/j.1360-0443.2011.03741.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Matt Hickman
- University of Bristol-Department of Social Medicine, UK.
| | | | | |
Collapse
|