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Acuff SF, Oddo LE, Johansen AN, Strickland JC. Contextual and psychosocial factors influencing drug reward in humans: The importance of non-drug reinforcement. Pharmacol Biochem Behav 2024; 241:173802. [PMID: 38866372 PMCID: PMC11284860 DOI: 10.1016/j.pbb.2024.173802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/29/2024] [Accepted: 06/01/2024] [Indexed: 06/14/2024]
Abstract
The reinforcing efficacy, or behavior-strengthening effect, of a substance is a critical determinant of substance use typically quantified by measuring behavioral allocation to the substance under schedules of reinforcement with escalating response requirements. Although responses on these tasks are often used to indicate stable reinforcing effects or trait-level abuse potential for an individual, task designs often demonstrate within-person variability across varying degrees of a constraint within experimental procedures. As a result, quantifying behavioral allocation is an effective approach for measuring the impact of contextual and psychosocial factors on substance reward. We review studies using laboratory self-administration, behavioral economic purchase tasks, and ambulatory assessments to quantify the impact of various contextual and psychosocial factors on behavioral allocation toward consumption of a substance. We selected these assessment approaches because they cover the translational spectrum from experimental control to ecological relevance, with consistent support across these approaches representing greater confidence in the effect. Conceptually, we organized factors that influence substance value into two broad categories: factors that influence the cost/benefit ratio of the substance (social context, stress and affect, cue exposure), and factors that influence the cost/benefit ratio of an alternative (alternative non-drug reinforcers, alternative drug reinforcers, and opportunity costs). We conclude with an overview of future research directions and considerations for clinical application.
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Affiliation(s)
- Samuel F Acuff
- Recovery Research Institute, Massachusetts General Hospital and Harvard Medical School, 151 Merrimac Street, Boston, MA 02114, USA.
| | - Lauren E Oddo
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA 23284-2018, USA
| | | | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
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Shen W, Li L, Liu Y, Xie X, Chen W, Liu H, Zhang W, Liu Y, Yu H, Zhou W. The motivation against change in male methamphetamine users in the compulsory detoxification setting. Front Psychiatry 2023; 14:1022926. [PMID: 36815195 PMCID: PMC9939637 DOI: 10.3389/fpsyt.2023.1022926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/06/2023] [Indexed: 02/08/2023] Open
Abstract
AIMS The study was designed to develop a measurement for the motivation for and against change in methamphetamine users in the compulsory detoxification setting. DESIGN This is a cross-sectional study. SETTING The study was carried out in a compulsory detoxification center for male drug users in China. PARTICIPANTS A total of 228 male methamphetamine users who had undergone the program for at least 30 days. MEASUREMENTS The motivation for/against change relating to compulsory detoxification was carried out using the Likert scale. A series of questionnaires were filled out by the participants, including the Egna Minnen Beträffande Uppfostran for rearing style, the Barratt Impulsiveness Scale-11, the adult ADHD self-report scale, and the Pittsburgh sleep quality index. Participants were also asked to recall the withdrawal symptoms before the program and to rate their current craving levels. FINDINGS Motivations were grouped into three factors, namely, the expectation to use drugs upon the completion of the program (factor 1), the disagreement with the compulsory setting (factor 2), and the motivation to quit drug use (factor 3). Cronbach's alpha values were 0.8037, 0.8049, and 0.6292, respectively. The structural equation model showed that the overall motivation was characterized by motivation against change rather than that for change. The overall motivation was also directly affected by the current craving level and indirectly affected by the severity of addiction, paternal authoritarian upbringing style, and ADHD traits. CONCLUSION This study provided a measurement of motivation for and against change in subjects with drug misconduct and suggested that the motivation against change may disclose more psychological barriers than the motivation for change.
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Affiliation(s)
- Wenwen Shen
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China
| | - Longhui Li
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China
| | - Yue Liu
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China
| | - Xiaohu Xie
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China
| | - Weisheng Chen
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China
| | - Huifen Liu
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China.,School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Wenwu Zhang
- Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China.,Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Yu Liu
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Haihang Yu
- Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China.,School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Wenhua Zhou
- Laboratory of Behavioral Neuroscience, Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, Zhejiang, China.,Ningbo Clinical Research Center for Psychiatry and Psychological Disorders, Ningbo, Zhejiang, China.,School of Medicine, Ningbo University, Ningbo, Zhejiang, China.,Ningbo Kangning Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
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Abstinence Following a Motivation-Skill-Desensitization-Mental Energy Intervention for Heroin Dependence: A Three-year Follow-up Result of a Randomized Controlled Trial. Curr Med Sci 2019; 39:472-482. [PMID: 31209821 DOI: 10.1007/s11596-019-2062-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 01/21/2019] [Indexed: 02/02/2023]
Abstract
The high rate of relapse among heroin users remains a significant public concern in China. In the present study, we utilized a Motivation-Skill-Desensitization-Mental Energy (MSDE) intervention and evaluated its effects on abstinence and mental health. Eighty-nine male heroin users in a drug rehabilitation center were enrolled in the study. The participants in the MSDE intervention group (n=46) received MSDE intervention, which included motivational interviewing, coping skills training, eye movement desensitization and reprocessing, and mindfulness-based psychotherapy. The participants in the control group (n=43) received a series of lectures on skills training. A significant increase in Contemplation Ladder score (P<0.001) and decreases in scores on the Obsessive Compulsive Drug Use Scale (P<0.001), Beck Depression Inventory (P<0.001), and Aggression Questionnaire (P=0.033) were found immediately after intervention. Compared to the control group, the MSDE intervention group reported significantly higher abstinence rates (P=0.027) and retention rates (P<0.001) at follow-up. Overall, the MSDE intervention, which uses a combined strategy for relapse prevention, could be a promising approach for preventing relapse among heroin users in China.
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Lin HC, Wang PW, Yang YH, Tsai JJ, Yen CF. Incarcerated intravenous heroin users: predictors of post-release utilization of methadone maintenance treatment. J Addict Dis 2015; 35:109-18. [PMID: 26670167 DOI: 10.1080/10550887.2015.1122467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Incarcerated intravenous heroin users have more problematic patterns of heroin use, but are less likely to access methadone maintenance treatment by their own initiative than heroin users in the community. The present study examined predictors for receiving methadone maintenance treatment post-release among incarcerated intravenous heroin users within a 24-month period. This cohort study recruited 315 incarcerated intravenous heroin users detained in 4 prisons in southern Taiwan and followed up within the 24-month period post-release. Cox proportional hazards regression analysis was applied to determine the predictive effects of sociodemographic and drug-use characteristics, attitude toward methadone maintenance treatment, human immunodeficiency virus serostatus, perceived family support, and depression for access to methadone maintenance treatment after release. There were 295 (93.7%) incarcerated intravenous heroin users released that entered the follow-up phase of the study. During the 24-month follow-up period, 50.8% of them received methadone maintenance treatment. After controlling for the effects of the detainment period before and after recruitment by Cox proportional hazards regression analysis, incarcerated intravenous heroin users who had positive human immunodeficiency virus serostatus (HR = 2.85, 95% CI = 1.80-4.52, p < .001) and had ever received methadone maintenance treatment before committal (HR = 1.94, 95% CI = 1.23-3.05, p < .01) were more likely to enter methadone maintenance treatment within the 24-month follow-up period. Positive human immunodeficiency virus serostatus with fully subsidized treatment and previous methadone maintenance treatment experiences predicted access of methadone maintenance treatment post-release. Strategies for getting familiar with methadone maintenance treatment during detainment, including providing methadone maintenance treatment prior to release and lowering the economic burden of receiving treatment, may facilitate entry of methadone maintenance treatment for incarcerated intravenous heroin users.
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Affiliation(s)
- Huang-Chi Lin
- a Department of Psychiatry , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,b Department of Psychiatry , Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung , Taiwan
| | - Peng-Wei Wang
- a Department of Psychiatry , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,b Department of Psychiatry , Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung , Taiwan
| | - Yi-Hsin Yang
- c School of Pharmacy, Kaohsiung Medical University , Kaohsiung , Taiwan.,d Division of Medical Statistics and Bioinformatics , Department of Medical Research, Kaohsiung Medical University Hospital , Kaohsiung , Taiwan
| | - Jih-Jin Tsai
- e Department of Infectious Diseases , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,f Tropical Medicine Center, Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,g Department of Internal Medicine , Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung , Taiwan
| | - Cheng-Fang Yen
- a Department of Psychiatry , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,b Department of Psychiatry , Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung , Taiwan
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Investigation of Repeat Client Drop-Out and Re-Enrolment Cycles in Fourteen Methadone Maintenance Treatment Clinics in Guangdong, China. PLoS One 2015; 10:e0139942. [PMID: 26484772 PMCID: PMC4618733 DOI: 10.1371/journal.pone.0139942] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 09/18/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Client adherence is vital for effective methadone maintenance treatment (MMT). This study explores the pattern and associated factors of client adherence, drop-out and re-enrolment in the Chinese MMT programme over the period of 2006-2013. METHODS This retrospective study was conducted in 14 MMT clinics in Guangdong Province, China. We employed Kaplan-Meier survival analysis to estimate the rates of drop-out and re-enrolment of MMT clients and multivariate Cox regression to identify associated factors. RESULTS Among 1,512 study participants, 79% have experienced 'drop-out' during the 7-year study period. However, 82% 'dropped-out' clients resumed treatment at a later time. Low education level (junior high or below versus otherwise, HR = 1.21, 1.05-1.40), low methadone dosage in the first treatment episode (<50 ml versus ≥50 ml, HR = 1.84, 1.64-2.06) and higher proportion of positive urine test (≥50% versus<50%, HR = 3.72, 3.30-4.20) during the first treatment episode were strong predictors of subsequent drop-outs of the participants. Among the 'dropped-out' clients, being female (HR = 1.40, 1.23-1.60), being married (HR = 1.19, 1.09-1.30), and having a higher proportion of positive urine tests in the first treatment episode (≥50% versus<50%, HR = 1.35, 1.20-1.51) had greater likelihood of subsequent re-enrolment in MMT. Clients receiving lower methadone dosage (first treatment episode <50 ml versus ≥50 ml, HR = 1.12, 1.03-1.23; the last intake before drop-out <50 ml versus ≥50 ml, HR = 1.16, 1.04-1.30) were also more likely to re-enrol. CONCLUSION Persistent cycling in-and-out of clients in MMT programmes is common. Insufficient dosage and higher proportion of positive urine samples in the first treatment episode are the key determinants for subsequent client drop-out and re-enrolment. Interventions should target clients in their early stage of treatment to improve retention in the long term.
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Li J, Gu J, Lau JTF, Chen H, Mo PKH, Tang M. Prevalence of depressive symptoms and associated factors among people who inject drugs in China. Drug Alcohol Depend 2015; 151:228-35. [PMID: 25920800 DOI: 10.1016/j.drugalcdep.2015.03.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/25/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND People who inject drugs (PWID) have a high prevalence of mental health problems (e.g., depression) which compromise the effects of HIV prevention. We investigated the prevalence of depression and associated factors among PWID in Dazhou, China. METHODS Anonymous face-to-face interviews were administered to eligible participants by well-trained doctors. The Center of Epidemiological Studies Depression Scale (CES-D) was used to measure depression, using hierarchical linear regression models. RESULTS Among the 257 participants, 7.0%, 11.3%, and 75.1% were probable cases of mild (16 ≤ CES-D < 21), moderate (21 ≤ CES-D < 25), and severe (CES-D ≥ 25) depression, respectively. Hopefulness (standardized β = -0.34, p < 0.001) and emotional family support (β = -0.21, p < 0.001) were negatively associated, whereas severity of drug dependence (β = 0.12, p = 0.034) and unmet service needs (β = 0.20, p < 0.001) were positively associated, respectively, with CES-D scores. The adjusted analysis showed that resilience was negatively associated with CES-D, but it was not selected by the stepwise model containing hopefulness and emotional family support. Protective factors (i.e., hopefulness and emotional family support) and risk factors (i.e., severity of drug dependence and unmet service needs) remained significant in the same regression model. CONCLUSION Protective and risk factors were independently associated with depressive symptoms. Integrated interventions covering basic and psychosocial needs for PWID are warranted. Such interventions should strengthen emotional family support and cultivate positive factors such as hopefulness.
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Affiliation(s)
- Jinghua Li
- Division of Behavioral Health and Health Promotion, Faculty of Medicine, The School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jing Gu
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Joseph T F Lau
- Division of Behavioral Health and Health Promotion, Faculty of Medicine, The School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong; Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China; Centre for Medical Anthropology and Behavioral Health, Sun Yat-sen University, Guangzhou, China.
| | - Hongyao Chen
- Dazhou Center for Disease Control and Prevention, Sichuan, China
| | - Phoenix K H Mo
- Division of Behavioral Health and Health Promotion, Faculty of Medicine, The School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong; Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
| | - Mei Tang
- Dazhou Center for Disease Control and Prevention, Sichuan, China
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Liu Y, Li L, Zhang Y, Zhang L, Shen W, Xü H, Wang G, Lü W, Zhou W. Assessment of attitudes towards methadone maintenance treatment between heroin users at a compulsory detoxification centre and methadone maintenance clinic in Ningbo, China. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2013; 8:29. [PMID: 23915360 PMCID: PMC3750876 DOI: 10.1186/1747-597x-8-29] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 07/30/2013] [Indexed: 11/24/2022]
Abstract
Background In China, the Compulsory Detoxification Centres are the main response for people who use illegal drugs. Due to high relapse rates among people released from the Compulsory Detoxification Centres, it is likely that they may seek medical help, including Methadone Maintenance Treatment (MMT) services, at some point. Therefore, better understanding of the attitudes and beliefs of people in the Compulsory Detoxification Centres can help to provide more adequate response to opioid dependence. Methods In total, 329 detained heroin users and 112 active MMT clients were recruited from a local Compulsory Detoxification Centre and MMT clinic, respectively. The survey contained specific questions relating to attitudes and beliefs regarding MMT. Results Participants at the Compulsory Detoxification Centre and the MMT clinic expressed different opinions, regarding positive and negative attitudes and beliefs towards MMT. In addition, participants from both sites hold certain negative attitudes and beliefs about methadone despite their acknowledgement of the positive effects of MMT. Finally, participants at the Compulsory Detoxification Centre and the MMT clinic reported distinctive treatment preferences, with the former preferring community-based treatment and the latter MMT. Conclusions Developing targeted education about MMT for people at the Compulsory Detoxification Centres could help improve access to accurate and evidence-based health and treatment information. The study may also help providers understand and adjust services needed for target population in the future.
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Affiliation(s)
- Yu Liu
- Ningbo University School of Medicine, 818 Fenghua Street, Jiangbei District, Ningbo, Zhejiang, China
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Pearshouse R, Amon JJ. The ethics of research in compulsory drug detention centres in Asia. J Int AIDS Soc 2012; 15:18491. [PMID: 23237589 PMCID: PMC3516672 DOI: 10.7448/ias.15.2.18491] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 11/12/2012] [Indexed: 11/08/2022] Open
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Fu JJ, Bazazi AR, Altice FL, Mohamed MN, Kamarulzaman A. Absence of antiretroviral therapy and other risk factors for morbidity and mortality in Malaysian compulsory drug detention and rehabilitation centers. PLoS One 2012; 7:e44249. [PMID: 23028508 PMCID: PMC3445567 DOI: 10.1371/journal.pone.0044249] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 07/31/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Throughout Asia, people who use drugs are confined in facilities referred to as compulsory drug detention and rehabilitation centers. The limited transparency and accessibility of these centers has posed a significant challenge to evaluating detainees and detention conditions directly. Despite HIV being highly prevalent in this type of confined setting, direct evaluation of detainees with HIV and their access to medical care has yet to be reported in the literature. METHODS We evaluated the health status of 100 adult male detainees with HIV and their access to medical care in the two largest Malaysian compulsory drug detention and rehabilitation centers holding HIV-infected individuals. RESULTS Approximately 80% of all detainees with HIV were surveyed in each detention center. Most participants reported multiple untreated medical conditions. None reported being able to access antiretroviral therapy during detention and only 9% reported receiving any HIV-related clinical assessment or care. Nearly a quarter screened positive for symptoms indicative of active tuberculosis, yet none reported having been evaluated for tuberculosis. Although 95% of participants met criteria for opioid dependence prior to detention, none reported being able to access opioid substitution therapy during detention, with 86% reporting current cravings for opioids and 87% anticipating relapsing to drug use after release. Fourteen percent of participants reported suicidal ideation over the previous two weeks. CONCLUSION We identified a lack of access to antiretroviral therapy in two of the six compulsory drug detention and rehabilitation centers in Malaysia designated to hold HIV-infected individuals and found significant, unmet health needs among detainees with HIV. Individuals confined under such conditions are placed at considerably high risk for morbidity and mortality. Our findings underscore the urgent need for evidence-based drug policies that respect the rights of people who use drugs and seek to improve, rather than undermine, their health.
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Affiliation(s)
- Jeannia J. Fu
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, United States of America
- Centre of Excellence for Research in AIDS (CERiA), University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Alexander R. Bazazi
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, United States of America
- Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
- Centre of Excellence for Research in AIDS (CERiA), University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Frederick L. Altice
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, United States of America
- Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
- Centre of Excellence for Research in AIDS (CERiA), University Malaya Medical Centre, Kuala Lumpur, Malaysia
- * E-mail:
| | | | - Adeeba Kamarulzaman
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, United States of America
- Centre of Excellence for Research in AIDS (CERiA), University Malaya Medical Centre, Kuala Lumpur, Malaysia
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