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

Evidence of telescoping in females across two decades of US treatment admissions for injection drug use: 2000-2020

Background

People who inject drugs (PWID) have an increased risk of soft tissue infection, drug overdose and death. Females may be particularly vulnerable due to barriers to substance use disorder (SUD) treatment entry, stigma, and telescoping, or the greater severity in substance use-related comorbidity and consequences despite a shorter history of use. We set out to identify sex differences in United States injection drug use (IDU).

Methods

The Treatment Episode Dataset-Admission (2000-2020) provided data to identify PWID undergoing their initial SUD treatment admission. Mann-Whitney U test, chi-square, and Spearman correlations were used for ordinal variables, categorical variables, and to assess similarity of male/female trends over the 21 years, respectively. The probabilistic index (PI) and Cramer's V provided effect sizes for Mann-Whitney U tests and chi-square tests, respectively.

Results

A total of 13,612,978 records existed for cases entering their initial treatment. Mapping to a history of IDU left 1,458,695 (561,793 females). Females had a higher prevalence among PWID across all 21 years; IDU trends were essentially identical between males and females (r = 0.97). Females endorsed beginning their primary substance later in life (PI = 0.47, p < 0.0001) and entered treatment after a shorter period of substance use (PI = 0.57, p < 0.0001).

Conclusions

We saw evidence of telescoping among PWID with a SUD entering their initial episode of treatment. Interventions should be implemented prior to the transition to IDU, and this window of opportunity is shortened in females. Utilizing gender-responsive treatment options may be a way to increase treatment-seeking earlier in the disease course.

Acute injection-related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management

INTRODUCTION

People who inject drugs are at risk of hospitalisation with injection-related infections (IRI). We audited the clinical features, microbiology and management of IRI at a tertiary service in Melbourne to describe the burden and identify quality improvement opportunities.

METHODS

We performed retrospective review of IRI admissions from January 2017 to April 2019. We extracted admissions where ICD-10 codes or triage text suggested injecting drug use, and the diagnosis suggested IRI. We reviewed these for eligibility and extracted data using a standardised form. We performed mixed-effects logistic regression to determine predictors of unplanned discharge.

RESULTS

From 574 extracted candidate admissions, 226 were eligible, representing 178 patients. Median age was 41 years (interquartile range 36-47), 66% (117/178) male and 49% (111/226) had unstable housing. Over 50% (96/178) had a psychiatric diagnosis and 35% (62/178) were on opioid agonist therapy (OAT) on admission. Skin and soft tissue infection was the most common IRI (119/205, 58%), followed by bacteraemia (36/205, 18%) and endocarditis (26/205, 13%). Management included addictions review (143/226, 63%), blood-borne virus screening (115/226, 51%), surgery (77/226, 34%) and OAT commencement (68/226, 30%). Aggression events (54/226, 15%) and unplanned discharge (69/226, 30%) complicated some admissions. Opioid use without OAT was associated with almost 3-fold increased odds of unplanned discharge compared to no opioid use (odds ratio 2.90, 95% confidence interval 1.23, 6.85, p = 0.015).

DISCUSSION AND CONCLUSION

Comorbidities associated with IRI may be amenable to opportunistic intervention during hospitalisation. Further research is needed to develop optimal models of care for this vulnerable patient group.

Irrational drug use and its associated factors at Debre Markos Referral Hospital's outpatient pharmacy in East Gojjam, Northwest Ethiopia

Objectives:

Half of all drugs are used irrationally around the world, and about half of patients take their medications correctly. Inappropriate use of drugs leads to antibiotic resistance, medication therapy problems, and an increase in drug costs. This study aimed to assess irrational drug use and its associated factors at the outpatient pharmacy of Debre Markos Referral Hospital.

Methods:

A hospital-based cross-sectional study was used. Systematic random sampling was used as a sampling technique. The data were collected with a structured checklist. The data were entered into EPI Data Version 3.1 and analyzed using SPSS version 20. Descriptive statistics and logistic regression analysis were used for data analysis.

Results:

The average number of drugs per patient encounter was 2.14. The prevalence of antibiotics use per encounter was 39.3%. Polypharmacy was detected in 62.2% of prescriptions, and injections were prescribed in 13% of prescriptions. The percentage of drugs prescribed with a generic name was 95.5%. In multivariable logistic regression, comorbidities, professionals’ training, and prescribers’ experience were significantly associated with polypharmacy. Patient age, comorbidity, presence of chronic disease, professionals training, and type of diseases were significantly associated with antibiotic prescribing.

Conclusion:

Our findings revealed there were practices of polypharmacy and antibiotics overuse. Continuous seminars and training on rational prescribing and periodic prescription surveys are recommended to prevent irrational drug use.

Profile and correlates of injecting-related injuries and diseases among people who inject drugs in Australia

INTRODUCTION

People who inject drugs (PWID) commonly experience harms related to their injecting, many of which are consequences of modifiable drug use practices. There is currently a gap in our understanding of how certain injecting-related injuries and diseases (IRID) cluster together, and socio-demographic and drug use characteristics associated with more complex clinical profiles.

METHOD

Surveys were conducted with 902 Australian PWID in 2019. Participants provided information regarding their drug use, and past month experience of the following IRID: artery injection, nerve damage, skin and soft tissue infection, thrombophlebitis, deep vein thrombosis, endocarditis, septic arthritis, osteomyelitis, and septicaemia. We performed a latent class analysis, grouping participants based on reported IRID and ran a class-weighted regression analysis to determine variables associated with class-membership.

RESULTS

One-third (34 %) of the sample reported any IRID. A 3-class model identified: 1) no IRID (73 %), moderate IRID (21 %), and 3) high IRID (6%) clusters. Re-using one`s own needles was associated with belonging to the high IRID versus moderate IRID class (ARRR = 2.38; 95 % CI = 1.04-5.48). Other factors, including daily injecting and past 6-month mental health problems were associated with belonging to moderate and high IRID classes versus no IRID class.

CONCLUSION

A meaningful proportion of PWID reported highly complex IRID presentations distinguished by the presence of thrombophlebitis and associated with greater re-use of needles. Increasing needle and syringe coverage remains critical in addressing the harms associated with injecting drug use and expanding the capacity of low-threshold services to address less severe presentations might aid in reducing IRID amongst PWID.

Contraceptive use in Appalachian women who use drugs and were recruited from rural jails

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.

Factors associated with skin and soft tissue infections among people who inject drugs in the United Kingdom: A comparative examination of data from two surveys

BACKGROUND

People who inject drugs (PWID) are at high risk of injection-related skin and soft tissue infections (SSTI). If not treated promptly, these can lead to serious health complications, which are a considerable healthcare burden. Data from two community surveys, with different approaches, were used to assess SSTI prevalence and associated factors among PWID to inform intervention implementation.

METHODS

Data were analysed from two surveys, a national surveillance survey (n=2,874; 2017-18) of infections among PWID in the United Kingdom (UK) and an in-depth survey (n=455; 2018-19) of SSTI among PWID based in London, UK. Multivariable logistic regression models were constructed to ascertain the factors associated with self-reported SSTI.

RESULTS

High prevalence of SSTI were reported in both samples: 52 % of participants from the national surveillance survey reported having SSTI within the preceding 12 months and 65 % of the London sample reported a lifetime history of SSTI. The factors associated with SSTI in both surveys were similar, including older age; number of years injecting; number of attempts required to inject into the vein; injecting into the hands, feet, groin or neck and re-using or sharing needles/syringes.

CONCLUSIONS

The number of PWID reporting SSTI in the UK is concerningly high. The two surveys used different recruitment approaches but found similar associations. We provide strong evidence of a relationship between venous access difficulty and SSTI. To stem the increase of SSTI and related complications in the UK, it is crucial that interventions attend to the underlying causes of venous damage among PWID.

Prevalence and risk factors associated with HIV-1 infection among people who inject drugs in Dar es Salaam, Tanzania: a sign of successful intervention?

Background

Prevalence of HIV infection among people who inject drugs (PWID) has been reported to be higher than that of the general population. The present study aimed to estimate the prevalence of HIV infection and associated risk factors among PWID in Dar es Salaam, Tanzania, following the introduction of a comprehensive HIV intervention package (CHIP) for PWID in the country in 2014.

Methods

We conducted an integrated bio-behavioral survey (IBBS) among PWID using respondent-driven sampling (RDS) in Dar es Salaam, Tanzania, between October and December 2017. Data on socio-demographic characteristics and risky behaviors were collected through face-to-face interviews. Blood samples were collected and tested for HIV infection. We accounted for weighting in the analyses, and logistic regression was performed to assess risk factors for HIV infection.

Results

A total of 611 PWID (94.4% males and 5.6% females) with a median age of 34 years (IQR 29–38) were recruited. The overall prevalence of HIV infection was 8.7% (95% CI 6.5–10.9). The prevalence of HIV infections for males and females were 6.8% (95% CI 4.7–8.9%) and 41.2% (95% CI 23.7–58.6%) respectively. Adjusted weighted logistic regression analysis (WLRA) showed that being a female (aOR 19.1; 95% CI 5.9–61.8), injecting drugs for more than 10 years (aOR = 7.32; 95% CI 2.1–25.5) compared to 1 year or less and being 45 years or older (aOR = 34.22; 95% CI 2.4–489.5) compared to being 25 years or younger were associated with increased odds of HIV infection. Use of a sterile needle at last injection decreased odds of HIV infection (aOR = 0.3; 95% CI 0.1–0.8).

Conclusions

The present study observed a decline in prevalence of HIV infections among PWID in Dar es Salaam (8.7%) compared to a previous estimate of 15.5% from an IBBS conducted in 2013. Despite the decrease, HIV prevalence remains high among PWID compared to the general population, and women are disproportionally affected. The decline may be possibly attributed to the on-going implementation of CHIP for PWID, highlighting the need for strengthening the existing harm reduction interventions by incorporating access to sterile needle/syringe and addressing the layered risks for women.

Estimating the number of people who inject drugs and syringe coverage in Australia, 2005-2016

BACKGROUND

Effective targeting of harm reduction programs for people who inject drugs (PWID) requires timely and robust estimates of the size of this population. This study estimated the number of people who inject drugs on a regular basis in Australia, calculated syringe coverage per person and the proportion of their injections covered by a sterile needle and syringe.

METHODS

We used trends in indicators of injection drug use to extend the 2005 estimate of the population of people who regularly inject drugs from 2005 to 2016. Included indicators were lifetime/recent injection of illicit drugs, drug-related arrests, drug-related seizures, accidental deaths due to opioids, opioid-related hospital admissions/separations and new diagnoses of hepatitis C virus infection among those aged 15-24 years. Syringe distribution and frequency of injection data were used to assess syringe coverage per PWID and the proportion of their injections covered by a sterile syringe.

RESULTS

The estimated number of people who regularly inject drugs in Australia increased by 7%, from 72,000 in 2005 to 77,270 in 2016. The annual number of syringes distributed per person increased 34%, from 470 syringes in 2005 to 640 syringes in 2016. Syringe coverage per injection first exceeded 100% in Australia in 2013.

CONCLUSIONS

Despite Australia's high syringe coverage by international standards, the number of syringes distributed is likely to be only narrowly meeting demand. It is critical that needle syringe programs be provided with sufficient resources to continue their role as the key intervention required to prevent HIV and HCV transmission among PWID.

Trends in methamphetamine and opioid use among clients of needle-syringe programs in Queensland, Australia: 2007-2015

INTRODUCTION AND AIMS

Needle-syringe programs (NSP) are an underutilized source of data on drug injection trends; these data are essential for informing public health interventions. We examine trends in NSP service occasions from 2007-2015.

DESIGN AND METHODS

Using standardised data from 26 NSP outlets through the Queensland NSP Minimum Data Set (QNSPMDS), trends in service occasions among clients intending to inject methamphetamine, heroin, opioid substitution therapy (OST) medications and other pharmaceutical opioids were assessed using multilevel mixed-effects negative binomial regression, adjusting for month, year, age and clustering by site.

RESULTS

Over 1.5 million service occasions were recorded in 2007-2015. Methamphetamine was the main 'drug intended to inject' (33.7%), however cf. 2007, the incidence rate ratio decreased to 0.64 (95% CI: 0.62, 0.66) in 2009, remaining low until 2015. Among clients reporting methamphetamine injection, there was a shift in the form from base to the higher-potency crystal methamphetamine since 2012. Heroin injection (22.5% service occasions) initially increased (cf. 2007), followed by a decline to 0.77 (95% CI: 0.75, 0.79) in 2015. Significant and sustained increases in OST and other pharmaceutical opioids injection were observed throughout the study period, accounting for 7.2% and 19.8% of total visits, respectively.

DISCUSSION AND CONCLUSIONS

The QNSPMDS provides unique, routinely collected, jurisdiction-wide and standardised data on the demographics of people who inject drugs, types of drugs injected and regional variations; these data are essential in informing policy, planning and program implementation. There remains significant opportunity to enhance engagement and linkage to care alongside needle-syringe provision.

Acceptability and preferences of point-of-care finger-stick whole-blood and venepuncture hepatitis C virus testing among people who inject drugs in Australia

BACKGROUND

Uptake of hepatitis C virus (HCV) testing remains inadequate globally. Simplified point-of-care tests should enhance HCV diagnosis and elimination. We aimed to assess the acceptability of finger-stick and venepuncture HCV RNA testing among people who inject drugs (PWID).

METHODS

Participants were enrolled in an observational cohort study with recruitment at 13 sites between June 2016 and February 2018. Capillary whole-blood collected by finger-stick and plasma collected by venepuncture were performed for Xpert^® HCV viral load testing. Participants completed a questionnaire on acceptability of, and preferences for, blood collection methods.

RESULTS

Among 565 participants (mean age, 44 years; 69% male), 64% reported injecting drugs in the last month, and 63% were receiving opioid substitution treatment. Eighty three percent reported that finger-stick testing was very acceptable. Overall, 65% of participants preferred finger-stick over venepuncture testing, with 61% of these preferring to receive results in 60 min. The most common reason for preferring finger-stick over venepuncture testing was it was quick (62%) followed by venous access difficulties (21%). The main reasons for preferring venepuncture over finger-stick testing were that it was quick (61%) and accurate (29%). Females were more likely to prefer finger-stick testing than males (adjusted OR 1.96; 95% CI 1.30, 2.99; p = 0.002). Among people with recent (previous month) injecting drug use, Aboriginal and/or Torres Strait Islander people were less likely than non-Aboriginal people to prefer finger-stick testing (adjusted OR 0.57; 95% CI 0.34, 0.9; p = 0.033).

CONCLUSIONS

Finger-stick whole-blood collection is acceptable to people who inject drugs, with males and Aboriginal and/or Torres Strait Islander people with recent injecting drug use less likely to prefer finger-stick testing. Further research is needed to evaluate interventions integrating simplified point-of-care HCV testing to engage people in care in a single-visit, thereby facilitating HCV treatment scale-up.

Mortality and causes of death among people who inject amphetamine: A long-term follow-up cohort study from a needle exchange program in Sweden

BACKGROUND

Abuse of amphetamines is a worldwide problem with around 34 million users, and amphetamine is commonly used by people who inject drugs (PWID). Despite this, there is relatively little research on mortality and cause of death among people who use amphetamines primarily. The present study aimed to examine mortality and causes of death among people who inject amphetamine, and compare these results to the general population.

METHODS

This retrospective cohort study was based on data from The Malmö Needle Exchange Program in Sweden (MNEP) and on data from The Swedish National Cause of Death Register. Participants in the MNEP, between 1987 and 2011, with registered national identity number and amphetamine as their primary drug of injection use, were included in the study. Standardized mortality ratios (SMR) was calculated for overall mortality and categories of causes of death.

RESULTS

2019 individuals were included (mean follow-up-time 13.7 years [range 0.02-24.2 years], a total of 27,698 person-years). Of the 448 deceased, 428 had a registered cause of death. The most common causes of death were external causes (n = 162, 38%), followed by diseases of the circulatory system (n = 67, 16%). SMR were significantly elevated (8.3, 95% CI [7.5-9.1]) for the entire study population, and for every category of causes of death respectively.

CONCLUSIONS

People injecting amphetamine as a primary drug were found to have significantly elevated mortality compared with the general population, with high rates of both external and somatic causes of death.

Sex work, injection drug use, and abscesses: Associations in women, but not men

BACKGROUND

Abscesses commonly occur among people who inject drugs (PWID). However, whether the risks are comparable between males and females, and the impact of sex work on abscess risk is unclear. The goal of this study was to examine the contemporary associations of gender and sex work with the risk of abscesses in PWID.

METHODS

Combining data from two cross-sectional studies conducted in the Greater Boston Area with people at risk for HIV and hepatitis C virus (HCV), we used the following inclusion criteria: age 18-45 years and report of illicit or non-prescription drug injection within the 30 days prior to the survey. Information on demographics, injection-mediated risks, and sexual behaviors was collected using Audio Computer-Assisted Self-Interview Software. Multivariable logistic regressions were used to model associations.

RESULTS

The study sample included 298 people including 30% were female. Females were more likely than men to report sex work (28% vs. 16%, p = .012) and abscess during their lifetime (55% vs. 37% p = .004). Among the females, engaging in sex work increased by >5-fold the odds of reporting abscesses [Adjusted odds ratio 5.42; 95% CI: 1.27, 23.10]. There was no association between sex work and abscesses among men.

DISCUSSION

We found a female-specific association between sex work, injection drug use, and abscesses among PWID. Although the cross-sectional designs precluded causal inferences, longitudinal studies could enhance understanding of gender-associated risks for abscesses and inform the development of harm reduction interventions.

Elimination of HCV as a public health concern among people who inject drugs by 2030 - What will it take to get there?

INTRODUCTION

Globally, there is a considerable burden of HCV and HIV infections among people who inject drugs (PWID) and transmission of both infections continues. Needle and syringe programme (NSP) and opioid substitution therapy (OST) coverage remains low, despite evidence demonstrating their prevention benefit. Direct-acting antiviral therapies (DAA) with HCV cure >95% among PWID provide an opportunity to reverse rising trends in HCV-related morbidity and mortality and reduce incidence. However, HCV testing, linkage to care, and treatment remain low due to health system, provider, societal, and patient barriers. Between 2015 and 2030, WHO targets include reducing new HCV infections by 80% and HCV deaths by 65%, and increasing HCV diagnoses from <5% to 90% and number of eligible persons receiving HCV treatment from <1% to 80%. This commentary discusses why PWID should be considered as a priority population in these efforts, reasons why this goal could be attainable among PWID, challenges that need to be overcome, and key recommendations for action.

DISCUSSION

Challenges to HCV elimination as a global health concern among PWID include poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low HCV testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. Key recommendations for action include reforming drug policies (decriminalization of drug use and/or possession, or providing alternatives to imprisonment for PWID; decriminalization of the use and provision of sterile needles-syringes; and legalization of OST for people who are opioid dependent), scaling up and improving funding for harm reduction services, making health services accessible for PWID, supporting community empowerment and community-based programmes, improving access to affordable diagnostics and medicines, and eliminating stigma, discrimination, and violence against PWID.

CONCLUSIONS

The ambitious targets for HCV elimination set by WHO are achievable in many countries, but will require researchers, healthcare providers, policy makers, affected communities, advocates, the pharmaceutical and diagnostics industries, and governments around the world to work together to make this happen.

Correlates of Injection Drug Use Among Rural Appalachian Women

BACKGROUND

Limited research has focused on correlates of injection drug use (IDU) among high-risk subgroups of drug users, particularly women, who may be at increased risk for transmission of infectious diseases such as HIV and Hepatitis C. The purpose of this study is to better understand the contextual and health correlates of IDU among women living in rural Appalachia by examining (1) differences between injectors and noninjectors, and (2) the unique correlates of recent IDU and past IDU.

METHODS

This study involved random selection, screening, and face-to-face interviews with 400 rural Appalachian women from jails in one state. Analyses included descriptive statistics, multinomial logistic regression, and stepwise regression to identify significant correlates of recent IDU and past IDU compared to never injecting.

RESULTS

Findings indicated that 75.3% of this randomly selected sample reported lifetime injection of drugs. Contextual factors including drug use severity (RRR = 8.66, P < .001), more male sex partners (RRR = 1.01, P < .05), and having injecting partners (RRR = 7.60, P < .001) were robust correlates of recent injection practices.

CONCLUSIONS

This study makes an important contribution to understanding factors associated with IDU among rural Appalachian women drug users, which are strongly associated with both relational and health factors. Study findings on the specific factors associated with IDU risk have important implications for tailoring and targeting interventions that should include a focus on the relationship context reducing high-risk injection practices.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A systematic review of injecting-related injury and disease among people who inject drugs

BACKGROUND

Non-viral injecting-related injuries and diseases (IRID), such as abscesses and vascular damage, can result in significant morbidity and mortality if untreated. There has been no systematic assessment of the prevalence of non-viral IRID among people who inject drugs; this review aimed to address this gap, as well as identify risk factors for experience of specific IRID.

METHODS

We searched MEDLINE, Embase and CINAHL databases to identify studies on the prevalence of, or risk factors for, IRID directly linked to injecting in samples of people who inject illicit drugs.

RESULTS

We included 33 studies: 29 reported IRID prevalence in people who inject drugs, and 17 provided data on IRID risk factors. Skin and soft tissue infections at injecting sites were the most commonly reported IRID, with wide variation in lifetime prevalence (6-69%). Female sex, more frequent injecting, and intramuscular and subcutaneous injecting appear to be associated with skin and soft tissue infections at injecting sites. Cleaning injecting sites was protective against skin infections. Other IRID included infective endocarditis (lifetime prevalence ranging from 0.5-12%); sepsis (2-10%); bone and joint infections (0.5-2%); and thrombosis and emboli (3-27%).

CONCLUSIONS

There were significant gaps in the data, including a dearth of research on prevalence of IRID in low- and middle-income countries, and potential risk and protective factors for IRID. A consistent approach to measurement, including standardised definitions of IRID, is required for future research.

Drug use in business bathrooms: An exploratory study of manager encounters in New York City

BACKGROUND

Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses.

METHODS

A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches.

RESULTS

More than half of managers interviewed (58%, n=50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance.

CONCLUSION

The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.

Surveillance of injecting-related injury and diseases in people who inject drugs attending a targeted primary health care facility in Sydney's Kings Cross

OBJECTIVE

This study examined the prevalence of injecting-related injuries and diseases (IRIDs) and associated risk factors among people who inject drugs (PWID) attending a primary health care facility in Sydney's Kings Cross.

METHODS

We calculated prevalence of a wide range of IRIDs utilising data reported by 702 PWID who completed a clinician-administered survey at their first visit. Multivariable logistic regressions identified factors independently associated with at least one episode of: i) cutaneous and ii) non-cutaneous IRIDs.

RESULTS

Lifetime prevalence of cutaneous IRIDs was 23%. Forty-two per cent of PWID with a history of abscess attended hospital at their most recent episode. Female gender, lifetime receptive syringe sharing (RSS), injecting while in custody, and ever injecting in places other than the arm were independently associated with reporting at least one episode of cutaneous IRIDs. Ever injecting in sites other than the arm, injecting for five or more years and lifetime history of RSS were independently associated with at least one episode of non-cutaneous IRIDs.

CONCLUSIONS

IRIDs are a substantial health issue for PWID. Their ongoing surveillance is warranted particularly in primary care settings targeting PWID to inform prevention and early management, thus reducing complications that may require hospital admission.

Differences in polysubstance use patterns and drug-related outcomes between people who inject drugs receiving and not receiving opioid substitution therapies

AIMS

To test if polysubstance use profiles and drug-related outcomes differ between those receiving and not receiving opioid substitution therapies (OST) among people who inject drugs (PWID).

DESIGN

An annual cross-sectional, sentinel sample of PWID across Australia.

SETTING

Data came from 3 years (2011-13) of the Illicit Drug Reporting System (IDRS).

PARTICIPANTS

A total of 2673 participants who injected drugs from the combined national IDRS samples of 2011 (n = 868), 2012 (n = 922) and 2013 (n = 883).

MEASUREMENTS

Latent class analysis (LCA) was used to summarize participants' self-reported use of 18 types of substances, with the resulting polysubstance use profiles then associated with participant experience of a number of drug-related outcomes.

FINDINGS

Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving OST, including thrombosis among OST receivers [odds ratio (OR) = 2.13, 95% confidence intervals (CI) = 1.09-4.17], injecting with used needles among OST receivers and non-receivers, respectively (OR = 2.78, 95% CI = 1.50-5.13; OR = 2.15, 95% CI = 1.34-3.45) and violent criminal offences among OST receivers and non-receivers, respectively (OR =2.30, 95% CI = 1.16-4.58; OR = 1.87, 95% CI = 1.14-3.07). An important exception was non-fatal overdose which was related specifically to a class of PWID who were not receiving OST and used morphine frequently (OR = 1.83, 95% CI = 1.06-3.17) CONCLUSION: Regardless of opioid substitution therapies usage, people who inject drugs who use a broad-range of substances experience greater levels of injecting-related injuries and poorer health outcomes and are more likely to engage in criminal activity than other groups of people who inject drugs.

Trust and people who inject drugs: The perspectives of clients and staff of Needle Syringe Programs

AIMS

Interest in health-care related trust is growing with the recognition that trust is essential for effective therapeutic encounters. While most trust-related research has been conducted with general patient groups, the experiences of people who inject drugs cannot be understood without acknowledging the critical role social stigma plays in shaping (mis)trust, both generally and in regards to health services specifically. This study examined the experiences of trust among clients and staff of Needle and Syringe Programs (NSPs) in one area of Sydney, Australia.

METHOD

In-depth interviews with 12 NSP staff and 31 NSP clients were conducted. Analysis was informed by a five component model of trust, with particular emphasis on the notion of "global trust" as encompassing experiences of stigma and other negative social processes related to injecting drug use. Participant experiences of trust in NSPs were compared with those within other drug-related health services. Particular attention was paid to understanding the relationship between 'identity' (as a drug user) and 'legitimacy' (as a service user) and the centrality of this relationship to the experience of global trust for PWID.

RESULTS

Notions of identity and legitimacy were inextricably bound up with the stigmatisation of drug use, shaping participants' experiences and accounts of trust in NSPs and drug treatment services. Client participants reported high levels of trust in NSPs, especially when compared with drug treatment services, describing being treated like "any other person" even when negotiating 'sensitive' issues. NSP staff participants described the establishment of trust as not only underpinning their work with clients but as something that required ongoing renewal and demonstration.

CONCLUSION

"Global trust" assists us to better understand the complex experiences shaping PWID decisions to engage with and trust health services. The high levels of trust reported between client and NSP need to be recognised as a valuable resource for the delivery of effective health care for people who inject drugs, including encouraging behaviours to support the prevention of blood-borne viruses.

Can differences in the type, nature or amount of polysubstance use explain the increased risk of non-fatal overdose among psychologically distressed people who inject drugs?

BACKGROUND

This study investigates whether the type, nature or amount of polysubstance use can explain the increased risk of non-fatal overdose among people who inject drugs with severe psychological distress.

METHODS

Data came from three years (2011-2013) of the Illicit Drug Reporting System (IDRS), an annual sentinel sample of injecting drug users across Australia (n=2673). Structural Equation Modelling (SEM) was used on 14 drug types to construct five latent factors, each representing a type of polysubstance use. Tests of measurement invariance were carried out to determine if polysubstance use profiles differed between those with and without severe psychological distress. Next, we regressed non-fatal overdose on the polysubstance use factors with differences in the relationships tested between groups.

FINDINGS

Among those with severe psychological distress a polysubstance use profile characterised by heroin, oxycodone, crystal methamphetamine and cocaine use was associated with greater risk of non-fatal overdose. Among those without severe psychological distress, two polysubstance use profiles, largely characterised by opioid substitution therapies and prescription drugs, were protective against non-fatal overdose.

CONCLUSION

The types of polysubstance use profiles did not differ between people who inject drugs with and without severe psychological distress. However, the nature of use of one particular polysubstance profile placed the former group at a strongly increased risk of non-fatal overdose, while the nature of polysubstance use involving opioid substitution therapies was protective only among the latter group. The findings identify polysubstance use profiles of importance to drug-related harms among individuals with psychological problems.

HIV, HCV, and Health-Related Harms Among Women Who Inject Drugs: Implications for Prevention and Treatment

BACKGROUND

Although an estimated 3.5 million women inject drugs globally, women are outnumbered 4 to one by men who inject drugs and are often ignored or overlooked in the development and delivery of prevention and treatment services for this population. This study aimed to identify key comorbidities prevalent among women who inject drugs (WWID), consider factors that contribute to vulnerability of this population, and examine implications for prevention and treatment.

METHODS

The literature was reviewed to examine the specific challenges and needs of WWID. We searched health-related bibliographic databases and grey literature to identify studies conducted among WWID and studies conducted among people who inject drugs (PWID), where results were disaggregated by gender and policies/guidelines/reports relevant to WWID.

RESULTS

WWID face a range of unique, gender-specific, and often additional challenges and barriers. The lack of a targeted focus on WWID by prevention and treatment services and harm-reduction programs increases women's vulnerability to a range of health-related harms, including blood-borne viral and sexually transmitted infections, injection-related injuries, mental health issues, physical and sexual violence, poor sexual and reproductive health, issues in relation to childbearing and child care, and pervasive stigma and discrimination.

CONCLUSIONS

There is a need to improve the collection and reporting of gender-disaggregated data on prevalence of key infections and prevention and treatment service access and program coverage. Women-focussed services and integrating gender equity and human rights into the harm-reduction programming will be a prerequisite if improvements in the health, safety, and well-being of this often invisible and highly vulnerable population are to be achieved.

Patterns of, and Factors Associated With, Illicit Pharmaceutical Opioid Analgesic Use in a Prospective Cohort of People Who Inject Drugs in Melbourne, Australia

BACKGROUND

People who inject drugs (PWID) are a key population engaging in pharmaceutical opioid analgesic (PO) use, yet little is known about patterns of illicit PO use among this group.

OBJECTIVES

The aims of this research were to measure the prevalence and frequency of lifetime and past-month illicit PO use and injection in a sample of regular PWID, to examine patterns of past-month illicit PO use within individuals over time, and to identify factors independently associated with past-month illicit PO use.

METHODS

Data were drawn from a prospective cohort study of regular PWID (N = 666) in Melbourne, Australia. Data from five waves of annual data collection (including baseline) were analyzed descriptively and using generalized estimating equations (GEE).

RESULTS

At baseline, 59% of participants reported lifetime illicit PO use and 20% reported past-month use, predominantly through injecting. Most illicit PO users at baseline transitioned to nonuse of illicit POs across the study period. In multivariable GEE analysis, factors associated with past-month illicit PO use included past-year arrest [adjusted odds ratio (AOR): 1.39], opioids other than heroin as drug of choice (AOR: 5.14), experiencing poorer physical health (AOR: 0.98) and a range of other drug use variables.

CONCLUSIONS

We found little evidence of ongoing illicit PO use among those followed up, with illicit PO use linked to polydrug use more broadly. Nonetheless, trends in illicit PO use among PWID should continue to be monitored and harm reduction interventions implemented to reduce the associated public health risks.

Correlates of Skin and Soft Tissue Infections in Injection Drug Users in a Syringe-Exchange Program in Malmö, Sweden

BACKGROUND

Injection drug users (IDUs) are at increased risk of various medical conditions, including bacterial skin and soft tissue infections (SSTIs). SSTIs, which are painful and can lead to life-threatening complications, are common but scarcely studied.

OBJECTIVES

To investigate life time, past 12 month and past 30-day prevalence for SSTI related to injection drug use, in IDUs at Malmö syringe exchange program (Malmö SEP). To investigate factors associated with having ever had an SSTI.

METHODS

IDUs were recruited from Malmö SEP (N = 80). They participated in a survey with questions about demographics, drug use, and experience of SSTIs. Factors independently associated with self-reported SSTI ever were assessed using logistic regression analysis.

RESULTS

The lifetime reported prevalence of SSTI was 58%, past 12 months 30%, and past 30 days 14%. Factors independently associated with SSTI ever were age (adjusted odds ratio [AOR] = 1.09; 95% confidence interval [CI] = 1.01-1.18), female sex (AOR = 6.75; 95% CI = 1.40-32.47), having ever injected prescribed drugs (AOR = 52.15; 95% CI = 5.17-525.67), and having ever injected in the neck (AOR = 8.08; 95% CI = 1.16-56.08).

CONCLUSIONS/IMPORTANCE

SSTI is common among IDUs in Malmö. Women and those injecting in the neck or injecting prescribed drugs (crushed tablets/liquids), are more likely to have had an SSTI.

Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England

People who inject drugs (PWID) are vulnerable to infections and injuries at injection sites. The factors associated with reporting symptoms of these, seeking related advice, and hospital admission are examined. PWID were recruited in Birmingham, Bristol and Leeds using respondent-driven sampling (N = 855). During the preceding year, 48% reported having redness, swelling and tenderness (RST), 19% an abscess, and 10% an open wound at an injection site. Overall, 54% reported ⩾1 symptoms, with 45% of these seeking medical advice (main sources emergency departments and General Practitioners). Advice was often sought ⩾5 days after the symptom first appeared (44% of those seeking advice about an abscess, 45% about an open wound, and 35% for RST); the majority received antibiotics. Overall, 9·5% reported hospital admission during the preceding year. Ever being diagnosed with septicaemia and endocarditis were reported by 8·8% and 2·9%, respectively. Interventions are needed to reduce morbidity, healthcare burden and delays in accessing treatment.

Predicting biopsychosocial outcomes for heroin users in primary care treatment: a prospective longitudinal cohort study

BACKGROUND

Opiate substitution treatment for heroin users reduces mortality, illicit drug use, crime, and risk-taking behaviour, and improves physical, mental and social functioning. Few extended studies have been carried out in UK primary care to study factors predicting recovery.

AIM

To establish whether primary care opiate substitution treatment is associated with improvements in outcomes over 11 years, in delivering recovery, and to identify predictive factors.

DESIGN AND SETTING

A prospective longitudinal cohort study, with repeated measures in the Primary Care Addiction Service, Sheffield, 1999-2011.

METHOD

A total of 123 eligible patients were assessed using the Opiate Treatment Index at entry to treatment and at 1, 5, and 11 years. Clinical records were used to assess factors including employment and discharge status.

RESULTS

At 11 years, there was a high rate of drug-free discharge (22.0%) and medically-assisted recovery (30.9%), and low mortality (6.5%). Continuous treatment was associated with being discharged drug free (P = 0.005). For those still in treatment, there were highly significant reductions in heroin use and injecting, and significantly improved psychosocial functioning. There were strong positive correlations between mental health, physical health, and social functioning. Patients in employment had significantly better psychological and social functioning (P = 0.017, P = 0.007, respectively).

CONCLUSION

Opiate substitution treatment is associated over 11 years with full recovery, drug-free discharge and medically-assisted recovery. There is a strong association between the psychosocial variables, suggesting that intervention in any one of these areas may have extended benefits, by impacting on related variables and employment. The best predictor of a drug-free discharge was continuous uninterrupted treatment.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

BACKGROUND

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

METHODS

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

RESULTS

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96).

CONCLUSIONS

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

Injection drug use and HIV antiretroviral therapy discontinuation in a Canadian setting

We investigated whether drug-related behaviors predicted antiretroviral therapy (ART) discontinuation among a cohort of injection drug users (IDU) in a Canadian setting. Cox regression analyses were used to investigate the impact of drug use patterns on rates of ART discontinuation among a sample of HIV-positive IDU in Vancouver, Canada between May 1996 and April 2008. In total, 408 HIV-positive IDU initiated ART during the study period, among whom 257 (63.0%) discontinued ART at least once. Rates of ART discontinuation were not significantly elevated among those who reported ongoing injection of heroin, cocaine, or other illicit drugs in comparison to those who reported not injecting drugs. However, public drug use was significantly predictive of ART discontinuation. Our findings may contribute to a reconsideration of the role of active drug use in determining retention in ART programs among IDU.

The cost of providing primary health-care services from a needle and syringe program: a case study

INTRODUCTION AND AIMS

Targeted primary health-care services for injecting drug users have been established in several countries to reduce barriers to health care, subsequent poor health outcomes and the considerable costs of emergency treatment. The long-term sustainability of such services depends on the resources required and the coverage provided. This study assesses the additional cost required to operate a nurse-led primary health care in an existing needle syringe program setting, estimates the costs per occasion of service and identifies key factors influencing improved service utilisation.

DESIGN AND METHODS

Using standard costing methods and the funder perspective, this study estimates costs using the 'ingredients' approach where the costs of inputs are based on quantities and unit prices (the ingredients).

RESULTS

During the 2009-2010 fiscal year, the primary health-care clinic provided 1252 occasions of service to 220 individuals, who each made an average of 3.9 presentations. A total cost of AU$250,626 was incurred, 69% of which was for personnel and 22% for pathology. During the study period the average cost per occasion of service was AU$199.96, which could be as low as AU$93.32 if the clinic reached its full utilisation level.

DISCUSSION AND CONCLUSIONS

Although the average number of presentations per client was satisfactory, the clinic was underutilised during the study period. Proactive engagement of clients at the needle syringe program shopfront and an increased range of services offered by the clinic may help to attract more clients.

Individual-level syringe coverage among Needle and Syringe Program attendees in Australia

BACKGROUND

Harm associated with injecting drug use is a significant public health issue and a major cause of morbidity and mortality, with global estimates of 3 million injectors infected with HIV and 8 million living with chronic hepatitis C virus (HCV) infection. Estimates of program coverage are widely used in the context of HIV prevention and are critical in determining the effectiveness of interventions such as Needle and Syringe Programs (NSPs).

METHODS

Data from a national cross-sectional study of NSP attendees in Australia were used to estimate individual-level syringe coverage as a proportion of monthly injections covered by a new syringe. Univariate and multivariate logistic regressions modelled associations between demographics, injecting risk, anti-HIV and HCV prevalence and syringe coverage. The median number of syringes retained per NSP attendee per annum was also estimated.

RESULTS

Twenty percent of participants had insufficient new syringes for all injections. Syringe reuse (including reuse of one's own syringe) was independently associated with syringe coverage of <100%. Conversely, procurement of syringes from an NSP was independently associated with syringe coverage ≥100%, with a greater protective effect occurring when NSP utilisation was combined with current engagement in opiate substitution therapy. The median number of syringes retained per participant per annum was 720, equivalent to 2 per day.

CONCLUSIONS

While Australian NSP attendees report high syringe coverage by international standards, prevention efforts could be scaled up. Syringe reuse was associated with syringe coverage of <100%, suggesting the utility of reuse as a proxy for individual-level syringe coverage.

Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney, Australia

INTRODUCTION AND AIMS

Cleaning needles/syringes is an important second-line harm reduction strategy, yet there is limited information on practices employed by people who inject drugs in Australia. This study attempts to identify and assess cleaning practices in terms of the techniques involved and the social contexts in which cleaning takes place.

DESIGN AND METHODS

As part of an exploratory qualitative study in south-west Sydney, in-depth interviews and simulated cleaning exercises were conducted with 12 people who inject drugs. Interviews were digitally recorded and transcribed verbatim. Open coding was used to inductively classify data into themes, and data were examined for patterns and variations in the relationships within and between themes.

RESULTS

Data indicate that cleaning and reuse of needles/syringes was common in this small sample. The most frequently utilised reagent was cool water. While all participants reported cleaning and reusing only their own equipment, none of the techniques demonstrated would have been sufficient to deactivate human immunodeficiency virus or hepatitis C virus.

DISCUSSION AND CONCLUSIONS

Results suggest that even where cleaning of needles and syringes is widespread, people who inject drugs may not engage in efficacious cleaning. The combination of the complexity of current cleaning messages and a lack of accurate information about efficacious techniques are likely to contribute to poor cleaning practice. Australia could benefit from the development of a nationally consistent cleaning message; however, the evidence would suggest that this would need to be accompanied by strategies designed to simplify and disseminate this information in order to increase the uptake of efficacious cleaning methods by people who inject drugs.

High prevalence of abscesses and self-treatment among injection drug users in Tijuana, Mexico

BACKGROUND

Soft tissue infections are common among injection drug users (IDUs), but information on correlates and treatment in this highly marginalized population is lacking.

METHODS

Six hundred twenty-three community-recruited IDUs in Tijuana, Mexico, completed a detailed interview on abscess history and treatment. Univariate and multiple logistic regressions were used to identify factors independently associated with having an abscess in the prior 6 months.

RESULTS

Overall, 46% had ever had an abscess and 20% had had an abscess in the past 6 months. Only 12% had sought medical care for their most recent abscess; 60% treated the abscess themselves. The most common self-treatment method was to apply heated (24%) or unheated (23%) Aloe vera leaf. Other methods included draining the wound with a syringe (19%) or knife (11%). Factors independently associated with recent abscess were having income from sex work (adjusted odds ratio (aOR) 4.56, 95% confidence interval (CI) 2.08-10.00), smoking methamphetamine (aOR 1.65, 95% CI 1.05-2.62), seeking someone to help with injection (aOR 2.06, 95% CI 1.18-3.61), and reporting that police affected where they used drugs (aOR 2.14, 95% CI 1.15-3.96).

CONCLUSIONS

Abscesses are common among IDUs in this setting, but appropriate treatment is rare. Interventions to reduce barriers to medical care in this population are needed. Research on the effectiveness of Aloe vera application in this setting is also needed, as are interventions to provide IDU sex workers, methamphetamine smokers, and those who assist with injection with the information and equipment necessary to reduce abscess risk.

Community-associated methicillin-resistant Staphylococcus aureus is prevalent in wounds of community-based injection drug users

Injection drug users (IDUs) have an elevated risk for carriage of Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA). Cutaneous injection-related infections are common in IDUs but detailed studies are few. Based on a subsample of 218 individuals from a community-recruited cohort of IDUs at a supervised injection facility, we investigated the microbiology and related antibiotic susceptibility profiles of isolates from 59 wounds. Twenty-seven percent of subjects had at least one wound and 25 (43%) were culture positive for S. aureus alone [14 MRSA and 11 (19%) methicillin-susceptible (MSSA) isolates]. Sixteen of 18 MRSA isolates were classified as community associated (CA) by the presence of genes encoding for PVL. MRSA and MSSA occurred in mixed infection with other organisms on three and six occasions, respectively. All CA-MRSA isolates were susceptible to tetracycline, vancomycin and linezolid but only 13% were susceptible to clindamycin compared to 63% of MSSA isolates. The frequency of CA-MRSA is a cause for concern in wound infection in the IDU setting.

The extent of injection site infection in injecting drug users: findings from a national surveillance study

Injection site infections in injecting drug users (IDUs) are associated with serious morbidity and healthcare costs. Factors associated with symptoms of these were examined through annual (2006–2008) unlinked-anonymous survey of IDUs in England, Wales and Northern Ireland. Overall 36% (1863/5209) self-reported having a symptom with no trend over time (35% 2006, 37% 2007, 34% 2008). Symptoms were less common in the North East of England; increased with years injecting; and were higher in women, those recently homeless, those recently using a needle exchange, and those injecting both opiates and stimulants. Of those injecting during the previous 4 weeks (n=3733) symptoms were associated with: injecting daily; injecting ⩾10 times a day; injecting into hands, groin, or legs; sharing filters; and reusing water to flush syringes. Symptoms of injection site infections are common in IDUs. Better-targeted preventive interventions are needed, and continued surveillance should assist with assessing the impact of new initiatives.

Determinants of cutaneous injection-related infection care at a supervised injecting facility

PURPOSE

To evaluate the factors associated with receiving cutaneous injection-related infection (CIRI) care among a representative cohort of supervised injecting facility (SIF) users.

METHODS

Data were collected biannually as part of a prospective cohort, the Scientific Evaluation of Supervised Injection study. Kaplan-Meier methods and Cox proportional hazards regression with recurrent events were used to examine incidence and factors associated with CIRI care, respectively.

RESULTS

One thousand eighty individuals were recruited between December 1, 2003 and January 31, 2008. The incidence density of participants receiving CIRI care was 22.0 per 100 person-years (95% confidence interval [CI]: 19.6-24.6). In the adjusted Cox proportional hazard model, female sex (adjusted hazard ratio [AHR]=1.87 [95% CI: 1.32-2.64]), unstable housing (AHR=1.39 [95% CI: 1.02-1.88]), and daily heroin injection (AHR=1.52 [95% CI: 1.13-2.04]) were independently associated with receiving CIRI care at the SIF.

CONCLUSIONS

These results describe who is more likely to receive CIRI care, which is of use to those engaged with policy and practice of treatment regimens involving this population.

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

BACKGROUND

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

AIMS

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

DESIGN, SETTING, PARTICIPANTS

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

FINDINGS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Frequency, factors and costs associated with injection site infections: findings from a national multi-site survey of injecting drug users in England

BACKGROUND

Injection site infections among injecting drug users (IDUs) have been associated with serious morbidity and health service costs in North America. This study explores the frequency, factors and costs associated with injection site infections among IDUs in England.

METHODS

Unlinked-anonymous survey during 2003/05 recruiting IDUs from community settings at seven locations across England. Self-reported injecting practice, symptoms of injection site infections (abscess or open wound) and health service utilisation data were collected using a questionnaire, participants also provided dried blood spot samples (tested for markers blood borne virus infections). Cost estimates were obtained by combining questionnaire data with information from national databases and the scientific literature.

RESULTS

36% of the 1,058 participants reported an injection site infection in the last year. Those reporting an injection site infection were more likely to be female and aged over 24, and to have: injected into legs, groin, and hands in last year; injected on 14 or more days during the last four weeks; cleaned needles/syringes for reuse; injected crack-cocaine; antibodies to hepatitis C; and previously received prescribed substitute drug. Two-thirds of those with an injection site infection reported seeking medical advice; half attended an emergency department and three-quarters of these reported hospital admission. Simple conservative estimates of associated healthcare costs range from pound 15.5 million per year to as high as pound 30 million; though if less conservative unit costs assumptions are made the total may be much higher (pound 47 million). The vast majority of these costs are due to hospital admissions and the uncertainty is due to little data on length of hospital stays.

CONCLUSION

Symptoms of injection site infections are common among IDUs in England. The potential costs to the health service are substantial, but these costs need more accurate determination. Better-targeted interventions to support safer injection need to be developed and evaluated. The validity of self-reported symptoms, and the relationship between symptoms, infection severity, and health seeking behaviour require further research.