Methadone maintenance treatment and HIV risk-taking behaviour among injecting drug users in Berlin

Malmö Treatment Referral and Intervention Study-High 12-Month Retention Rates in Patients Referred from Syringe Exchange to Methadone or Buprenorphine/Naloxone Treatment

BACKGROUND

Heroin dependence is associated with high mortality. Opioid agonist treatment (OAT) with methadone or buprenorphine has strong evidence for treatment of this relapsing condition. In our setting, OAT has been associated with strict and demanding intake procedures, often with requirements of social stability, but also high, approximately 80 percent 12-month retention rates. In a recent randomized controlled trial, we demonstrated high rates of successful rapid referral from a syringe exchange programme (SEP) to treatment with methadone or buprenorphine, including actual treatment initiation. The objectives of this study were to assess 12-month retention rates, in order to assess whether a novel referral program of current drug users at a SEP would achieve retention rates comparable to more traditional intake procedures.

METHODS

The present report is a 12-month follow-up of 71 patients who successfully started treatment with methadone or buprenorphine/naloxone. Patient data from baseline and at 12 months were collected.

RESULTS

Out of the 71 patients who started treatment, 58 (82%) were still in treatment after 12 months.

CONCLUSION

This was a population, referred from a SEP, with a high drug use severity on admission and no pretreatment requirement for social stability, but there were still high retention rates at 12 months comparable to regular opioid agonist clinics in our setting.

Malmö Treatment Referral and Intervention Study (MATRIS)—effective referral from syringe exchange to treatment for heroin dependence: a pilot randomized controlled trial

AIMS

Syringe exchange has been suggested as a potential conduit to treatment for drug dependence, but this has never been documented in Europe. The primary aim was to compare the effectiveness of strength-based case management intervention (CMI) against referral only to facilitate treatment attendance in a syringe exchange programme. We also assessed the effectiveness of a syringe exchange programme for referral of heroin-dependent patients to evidence-based treatment with methadone or buprenorphine (buprenorphine-naloxone).

DESIGN

Single-site, two-group randomized controlled trial.

SETTING

The syringe exchange programme in Malmö, Sweden and an out-patient clinic (research treatment facility) for maintenance treatment, situated outside the hospital area and run by Malmö Addiction Centre.

PARTICIPANTS

Heroin-dependent patients willing to participate (n = 75) were referred to maintenance treatment and randomized to either a strength-based case management intervention aiming to facilitate referral (n = 36) or to referral-only (n = 39).

INTERVENTION

The intervention group received an appointment for maintenance treatment and a CMI adjusted to individual patient needs. The CMI was semi-structured, assessing the patients' strengths and needs and identifying what practical help they might need to get to the appointment for maintenance treatment. The control group received an appointment for maintenance treatment.

MEASURES

The primary outcome was treatment entry.

FINDINGS

Among patients who turned up for recruitment interview and randomization, the percentage of patients who started treatment was 95% in the intervention group and 94% in the control group. Treatment entry was unrelated to intervention status [unadjusted odds ratio (OR) = 0.92 (0.12–6.89), P = 1.00 and adjusted OR = 0.96 (0.12–7.83)].

CONCLUSIONS

A randomized controlled trial in a syringe exchange programme showed no evidence that a strength-based case management intervention improved attendance for treatment over referral alone. Attendance rates were high in both groups.

A Prospective Study to Investigate Predictors of Relapse among Patients with Opioid Use Disorder Treated with Methadone

INTRODUCTION

Concomitant opioid abuse is a serious problem among patients receiving methadone maintenance treatment (MMT) for opioid use disorder. This is an exploratory study that aims to identify predictors of the length of time a patient receiving MMT for opioid use disorder remains abstinent (relapse-free).

METHODS

Data were collected from 250 MMT patients enrolled in addiction treatment clinics across Southern Ontario. The impact of certain clinical and socio-demographic factors on the outcome (time until opioid relapse) was determined using a Cox proportional hazard model.

RESULTS

History of injecting drug use behavior (hazard ratio (HR): 2.26, P = 0.042), illicit benzodiazepine consumption (HR: 1.07, P = 0.002), and the age of onset of opioid abuse (HR: 1.10, P < 0.0001) are important indicators of accelerated relapse among MMT patients. Conversely, current age is positively associated with duration of abstinence from illicit opioid use, serving as a protective factor against relapse (HR: 0.93, P = 0.003).

CONCLUSION

This study helps to identify patients at increased risk of relapse during MMT, allowing health care providers to target more aggressive adjunct therapies toward high-risk patients.

Cost-effectiveness of Methadone Maintenance Treatment in Prevention of HIV Among Drug Users in Shiraz, South of Iran

Background:

The increase in high-risk injections and unsafe sexual behaviors has led to increased HIV infection prevalence among Intravenous Drug Users (IDUs). The high costs of HIV/AIDS care and low financial resources necessitate an economic evaluation to make the best decision for the control of HIV/AIDS.

Objectives:

This study was conducted to determine the cost-effectiveness of Methadone Maintenance Treatment (MMT) centers in HIV infection prevention among drug users.

Materials and Methods:

In this interventional study, we included all the seven MMT centers and the drug users registered there (n = 694). We calculated all the costs imposed on the government, i.e. Provider of case. Mathematical models were used to estimate the number of HIV cases averted from high-risk behaviors. Sensitivity analyses were performed to show the effects of uncertainty in parameters on the number of HIV cases averted and also Incremental Cost-Effectiveness Ratio (ICER).

Results:

Based on the averted models, the selected MMT centers could prevent 128 HIV cases during 1 year. The total cost was $ 547423 and that of HIV/AIDS care in the no intervention scenario was estimated $ 14171816. ICER was $ 106382 per HIV case averted. The results of the sensitivity analysis indicated that MMT intervention was cost-effective even in the worst scenario and ICER varied from $ 39149 to $ 290004 per HIV case averted.

Conclusions:

With regard to the high prevalence of drug injection among drug users and considering the high effectiveness and cost-effectiveness of MMT centers in preventing HIV infection, establishment of MMT centers in regional and national levels seems reasonable.

Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness

BACKGROUND

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

METHODS

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

RESULTS

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.

CONCLUSION

Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

Inconsistent Condom Use among Iranian Male Drug Injectors

OBJECTIVES

The aim of this study was to determine the prevalence and associated factors of inconsistent condom use among Iranian male injecting drug users (IDUs).

MATERIALS AND METHODS

Data came from the national Iranian behavioral survey of drug dependence, which sampled 7743 individuals with drug dependence, from medical centers, prisons, and streets in 29 provinces in Iran, in 2007. This study included all individuals who were male, IDUs, and were sexually active (n = 1131). The main outcome was inconsistent condom use which was assessed using a single item. A logistic regression was used to determine the association between socio-economic data, drug use data, and high risk injection behaviors with inconsistent condom use.

RESULT

83.3% of sexually active IDUs (n = 965) reported inconsistent condom use. Based on the logistic regression, likelihood of inconsistent condom use was higher among those with a history of syringe sharing [Odds Ratio (OR); 1.63, 95% Confidence Interval (CI); 1.13-2.34], but lower among those with higher education levels (OR; 0.34, 95% CI; 0.14-0.82), those who mostly inject at home (OR; 0.09, 95% CI; 0.02-0.47), and those with a history of treatment (OR; 0.54, 95% CI; 0.31-0.94).

CONCLUSION

Because of the link between unsafe sex and risky injecting behaviors among Iranian IDUs, combined programs targeting both sexual and injection behavior may be more appropriate than programs that target sexual or injection behavior. The efficacy of combined programs should be, however, compared with traditional programs that only target sexual or injection behavior of IDUs.

Oral substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to May 2011. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion

DATA COLLECTION AND ANALYSIS

Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author.

MAIN RESULTS

Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance

We examined the impact of methadone maintenance treatment (MMT) on risk behaviors for transmission of blood-borne diseases in polydrug users who had tested positive or negative for hepatitis C virus (HCV). At intake, HCV-positive participants (n=362) engaged in more human immunodeficiency virus (HIV) risk behaviors (as measured by the HIV Risk-Taking Behavior Scale) than HCV-negative participants (n=297; p< .001). This difference was specific to injection-related behaviors and decreased significantly within the first few weeks of MMT (p< .0001). Where needles continued to be used, HCV-positive participants became more likely over time to engage in safer injecting practices. Furthermore, HCV-positive participants became more likely to use condoms than HCV-negative participants. These findings demonstrate that both drug- and sex-related risk behaviors decrease during MMT and emphasize the benefits of methadone programs for public health and HIV/HCV prevention.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to March 2007. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data from included studies, assessed quality and confirmed decisions by consulting with all other reviewers.

MAIN RESULTS

Thirty-three studies, involving 10,400 participants, were included. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

A pilot survey of attitudes and knowledge about opioid substitution therapy for HIV-infected prisoners

A majority of inmates in the state of Connecticut Department of Corrections use opioids or are opioid dependent before incarceration. None of the state's prisons offer opioid substitution therapy other than for detoxification or maintenance therapy for women during pregnancy. On release to the community, most prisoners relapse to drug use and this has been associated with higher recidivism rates, and less adherence to antiretroviral medications for HIV-infected persons. Nationally and internationally, methadone (METH) and buprenorphine (BUP) have been found to decrease relapse to drug use, decrease recidivism rates, improve adherence to antiretroviral medications, decrease HIV-risk taking behaviors, and improve mortality. However, the general knowledge about opioid substitution therapy among correctionalfacility staff has been reported as substandard. This pilot study compiled results of answers to anonymous surveys from 27 individuals who work directly with inmates in a patient-care capacity for the Connecticut Department of Corrections (CT DOC) and CT DOC case-management referral program (Project TLC) in the year 2006. The surveys included questions regarding current attitudes and knowledge about opioid substitution therapy for prisoners. A minority of respondents refer released prisoners with a history of opioid dependency to METH or BUP treatment. The majority of correctional workers and case-management referral workers did not have knowledge about BUP or METH's ability to improve health and decrease HIV risk taking behaviors. This study found that more education of individuals treating and caring for HIV-infected opioid dependent prisoners is needed.

Individual and social factors associated with participation in treatment programs for drug users

Since only about one third of people who are dependent on drugs are in treatment, there is a need to promote both treatment entry and retention. Previous research has described the role of individual and social characteristics in drug user treatment participation, but little is known about the interaction of individual and social factors. Injecting and noninjecting drug users (2002-2004; N = 581) were recruited, as part of Self-Help in Eliminating Life-Threatening Diseases (SHIELD) study, in Baltimore, MD, and were administered a structured questionnaire. The mean age of participants was 43.6 years, out of which 41% were female, 50% had high school education, and 16% self-reported being HIV infected. Logistic regression analyses of interaction terms revealed that compared to those with no plans to stop and no friends encouraging them to enter treatment those who planned to cease drug use or whose friends encouraged treatment were more likely to attend a 12-step program. Furthermore, compared to those with no problems with drug use and no friends encouraging them to enter treatment those with greater perceived drug problem severity or with friends encouraging treatment were more likely to attend methadone maintenance, as were those who did not receive free drugs from others. The influence of friends may have a crucial modifying effect by getting into treatment less addicted individuals who have higher chances of successful recovery.

Factors associated with reported hepatitis C and HIV among injecting drug users in ten European cities

BACKGROUND

To analyze self-reported prevalence of HCV and HIV in a sample of socially excluded injecting drug users, as well as factors associated with the presence of these diseases.

METHODS

Cross-sectional study. Data were collected with a structured, face-to-face questionnaire by outreach workers and privileged access interviewers in 1131 participants who had injected heroin and/or cocaine over the past year (71.5% men; mean age, 30 years) from Seville and Granada, Spain; Cologne, Germany; Vienna, Austria; Brussels, Belgium; Athens, Greece; Dublin, Ireland; London, England; Lisbon, Portugal and Perugia, Italy.

RESULTS

Among the total sample, 595 (52.6%) participants reported HCV-positive status and 143 (12.6%) HIV-positive status. Multivariate analysis for HCV showed that women are at less risk than men, and that longer drug use, injecting while in prison, sharing needles, and reported positive status for tuberculosis, HBV, HIV or sexually-transmitted disease are positively associated with HCV. Participants reporting positive HIV status were generally older, had injected drugs while in prison, had completed less than 8 years of schooling, were divorced, had no regular employment, and declared infection with tuberculosis, sexually-transmitted disease and HCV.

CONCLUSIONS

The highest incidences of HCV and HIV were reported by participants in a poorer social and health situation. Drug addicts must cope not only with their addiction but also with the process of social exclusion they are immersed in. To the greatest extent possible, any course of action for this group should be built into integrated, coordinated plans that take a broad approach to the main issues involved.

Buprenorphine Use: The International Experience

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.

Brief report: Methadone treatment of injecting opioid users for prevention of HIV infection

OBJECTIVE

To assess the effects of oral substitution treatment for opioid-dependent injecting drug users on HIV risk behaviors and infections.

DATA SOURCES

Multiple electronic databases were searched. Reference lists of retrieved articles were checked.

METHODS

Because of varying methodologies of available studies, this systematic review was limited to a descriptive summary, looking at consistency of outcomes across studies.

RESULTS

Twenty-eight studies involving methadone treatment were included in the review. Methadone maintenance treatment is associated with statistically significant reductions in injecting use and sharing of injecting equipment. It is also associated with reductions in numbers of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviors do translate into fewer cases of HIV infection.

CONCLUSIONS

Methadone maintenance treatment for injecting drug users significantly reduces the risk of transmission of HIV and should be provided as a component of a strategic approach to the prevention and control of HIV infection. There is insufficient evidence to determine whether other forms of oral substitution treatment also reduce the risk of HIV transmission.

A syringe exchange programme in prison as prevention strategy against HIV infection and hepatitis B and C in Berlin, Germany

In two prisons in Berlin, Germany, provision of sterile injection equipment for injecting drug users (IDUs) started in 1998. To assess the programme's impact, the frequency of injecting drug use and syringe sharing, and the incidence of HIV, HBV, and HCV infection were determined in a follow-up study. Of all IDUs (n=174), 75% continued to inject. After the project start the level of syringe sharing declined from 71% during a 4-month period of previous imprisonment to 11% during the first 4 months of follow-up, and to virtually zero thereafter. Baseline seroprevalences for HIV, HBV, and HCV were 18, 53, and 82%. HIV and HCV seroprevalence at baseline was significantly associated with drug injection in prison prior to the project start. No HIV and HBV seroconversions, but four HCV seroconversions occurred. The provision of syringes for IDUs in appropriate prison settings may contribute to a substantial reduction of syringe sharing. However, the prevention of HCV infection requires additional strategies.

Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver

We identified methadone maintenance therapy (MMT) use during follow-up interviews and examined associations between MMT use and socio-demographic and drug-related variables using generalized estimating equations (GEE). Of the 1587 participants recruited into this cohort, 170 (11%) were enrolled in MMT at baseline and additional 498 (31%) initiated MMT during follow-up. Of those ever enrolled in MMT, 406 (61%) ceased MMT and re-initiated MMT on more than one occasion. The median treatment duration was 14.4 months. Factors that were negatively and significantly associated with MMT use in multivariate analyses included: Aboriginal ethnicity (adjusted odds ratio [AOR] = 0.40); recent incarceration (AOR = 0.79); sex trade involvement (AOR = 0.87); syringe lending (AOR = 0.72); heroin injection (AOR = 0.64), whereas female gender (AOR = 2.47), HIV positivity (AOR = 1.57), and crack cocaine smoking (AOR = 1.23) were positively and significantly associated with being on MMT. Unstable housing, syringe borrowing, non-fatal overdose, cocaine injection, and residence in Vancouver's Downtown Eastside were not associated with MMT use in multivariate analyses. Our study demonstrates high rates of initiation of and retention in MMT among local IDUs. While the use of MMT was associated with reductions in heroin use and HIV risk behavior, barriers to Aboriginal IDUs were evident, and the association with increased crack cocaine use deserves further study.

Buprenorphine: Its Role in Preventing HIV Transmission and Improving the Care of HIV-Infected Patients with Opioid Dependence

In the United States, approximately 25% of the 40,000 new human immunodeficiency virus (HIV) infections each year are secondary to injection drug use. Worldwide, there are an estimated 12.6 million injection drug users, and 10% of HIV infections (420,000 infections in 2003) are associated with this practice. Buprenorphine is a new medication used to treat opioid dependence that shows promise for reducing the rate of HIV transmission and improving the care of opioid-dependent patients with HIV infection. Although buprenorphine faces fewer clinical and regulatory barriers than does methadone, the optimal strategy for integration of office-based treatment of opioid dependence and HIV disease is an area of ongoing research. This review addresses the introduction of buprenorphine, in terms of public health, policy, and clinical implications for HIV-infected patients and for HIV care providers.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

Multiple electronic databases were searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched.

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered.

DATA COLLECTION AND ANALYSIS

Each potentially relevant study was independently assessed by two reviewers. For studies that met the inclusion criteria, key information was extracted by one reviewer and confirmed by consultation between all four reviewers.

MAIN RESULTS

Twenty-eight studies, involving 7900 participants, were included. The majority were not randomised controlled studies. Issues of confounding and bias are discussed. The studies varied in several aspects limiting the extent of quantitative analysis.

REVIEWERS' CONCLUSIONS

Oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review. However, these findings add to the stronger evidence of effectiveness of substitution treatment on drug use, and treatment retention outcomes shown by other systematic reviews. On this basis, the provision of substitution treatment for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users should be supported.

Overdose deaths attributed to methadone and heroin in New York City, 1990-1998

AIMS

Methadone treatment has been shown to be an effective intervention that can lower the risk of heroin-induced overdose death. Recent reports have suggested increases in methadone-induced overdose deaths in several locations in the USA and in Europe. This study investigated the role of methadone and opiates in accidental overdose deaths in New York City.

DESIGN

We analysed data from the Office of the Chief Medical Examiner to examine all accidental drug overdose deaths in New York City between 1990 and 1998.

FINDINGS

Of 7451 total overdose deaths during this period, there were 1024 methadone-induced overdose deaths, 4627 heroin-induced overdose deaths and 408 overdose deaths attributed to both methadone and heroin. Fewer than a third as many accidental overdose deaths were attributed to methadone than were attributed to heroin during this period. The proportion of accidental overdose deaths attributed to methadone did not change appreciably (12.6-15.8% of total overdose mortality), while the proportion of overdose deaths attributed to heroin increased significantly (53.5-64.2%) during the period of study.

CONCLUSIONS

There was no appreciable increase in methadone-induced overdose mortality in New York City during the 1990s. Both heroin-induced overdose mortality and prescriptions of methadone increased during the same interval.

The urgent need for HIV and hepatitis prevention in drug treatment programs in Hungary

We assess HIV and hepatitis testing and counseling in drug treatment programs in Hungary, a country with low rates of HIV but high rates of hepatitis C among injection drug users. The official context of drug treatment programs is described, and using key informants from representative drug treatment programs, the practice of HIV and hepatitis testing and counseling in such programs is assessed. Although HIV testing and counseling occurs, testing and counseling for hepatitis B and C are rare, especially in outpatient settings, and sexual risk in the drug use context is ineffectively addressed by treatment programs. Drug treatment centers are not adequately addressing the need to provide either HIV or hepatitis prevention services. There is an urgent need for preventing HIV and related infections among drug users by integrating HIV and hepatitis B and C prevention with drug treatment.

Drug user treatment referrals and entry among participants of a needle exchange program

OBJECTIVE

To compare characteristics of needle exchange program (NEP) participants who requested methadone treatment to those who did not, compare participants who subsequently enrolled into treatment to those who did not enroll, and suggest possible barriers to treatment among NEP participants.

METHODS AND MATERIALS

Between 8/94 and 2/97, data pertaining to demographics and drug use were collected from Baltimore NEP participants upon registration. Participants were made aware that referrals to off-site methadone maintenance were available upon request. Odds ratios and multiple logistic regression models were used to compare those who requested treatment to those who did not and those who entered treatment to those who did not enter.

RESULTS

Among 2659 NEP participants, 86% were African-American, 28% were female, 9% were employed, and the median age was 38 years. Requesting a drug user treatment referral was associated with female gender [Adjusted Odds Ratio (AOR) = 2.02], age > 38 years (AOR = 1.96), use of speedballs during the past 6 months (AOR = 3.38), and age > 20 years at time of first injection (AOR = 1.59). Among 139 individuals who requested treatment, males were twice as likely as females to enter treatment (OR = 2.45). In an open-ended survey, health insurance (p = .02) and not living with children (p = .01) were associated with drug user treatment entry.

CONCLUSIONS

Even though female NEP participants were more likely to request methadone treatment, they were less likely than males to enter treatment. Although NEPs can be a bridge to drug user treatment, these data suggest that barriers to utilizing treatment referrals are important issues to resolve, especially for women who use community needle exchange programs.

Sex, drugs, and HIV: does methadone maintenance reduce drug use and risky sexual behavior?

This study examined differences in drug use, sexual behavior, attitudes, and perceptions of vulnerability for AIDS between injection drug users who received methadone treatment in the previous 6 months and those who did not. Of the 123 participants assessed, 62 (50%) received methadone treatment. Methadone patients reported fewer sexual partners and greater use of condoms compared to nonmethadone patients. Methadone patients also reported fewer high-risk sexual partners than those not in treatment. Women reported more high-risk partners than men. Methadone patients reported drinking alcohol less, but smoking marijuana more than nonmethadone users. Methadone users had more positive beliefs about the efficacy of condoms for preventing AIDS and expressed less anger than nonmethadone users in situations related to condom usage. These findings have important implications for using methadone maintenance to reduce the dual risk for HIV in injection drug users.

Methadone treatment and HIV and hepatitis B and C risk reduction among injectors in the Seattle area

Drug treatment has the potential to reduce incidence of blood-borne infections by helping injection drug users (IDUs) achieve abstinence or by decreasing the frequency of injection and sharing practices. We studied the associations between retention in methadone treatment and drug use behaviors and incidence of hepatitis B and C in a cohort of IDUs in the Seattle, Washington, area. Data on IDUs entering methadone treatment at four centers in King County, Washington, were collected through face-to-face interviews using a standardized questionnaire at baseline and 12-month follow-up between October 1994 and January 1998. Blood specimens were obtained and tested for human immunodeficiency virus (HIV) and hepatitis B and C. Drug treatment status at follow-up was analyzed in relation to study enrollment characteristics and potential treatment outcomes, including injection risk behaviors, cessation or reduced frequency of injection, and incidence of hepatitis B and C. Of 716 IDUs, 292 (41%) left treatment, 198 (28%) disrupted (left and returned) treatment, and 226 (32%) continued treatment throughout the 1-year follow-up period. Compared to those who left treatment, subjects who disrupted or continued were less likely to inject at follow-up (odds ratio [OR] = 0.5, 95% CI 0.3-0.7; and OR = 0.1, 95% CI 0.1-0.2, respectively). Among the 468 (65%) subjects who continued injecting, those who continued treatment injected less frequently, were less likely to pool money to buy drugs (OR = 0.5, 95% CI 0.3-0.8) and inject with used needles (OR = 0.5, 95% CI 0.2-0.8) compared to those who left treatment. Cooker or cotton sharing was not associated with retention in treatment, but hepatitis B incidence was lowest among those who continued treatment. The results of this study suggest drug use risk reduction is more likely to be achieved by those who remain in drug treatment and by those who stop injecting, but that those who drop out and return and those who continue to inject while in treatment may also benefit. This supports the role of consistent drug treatment in an overall harm-reduction strategy.

Drug abuse treatment as an HIV prevention strategy: a review

We review drug abuse treatment as a means of preventing infection with HIV. Thirty-three studies, with an aggregate of over seventeen thousand subjects, were published in peer-reviewed journals from 1988-1998. Research on the utility of drug abuse treatment as an HIV prevention strategy has focused primarily on methadone maintenance treatment (MMT) rather than other modalities such as residential or outpatient drug-free treatment. Recent research provides clear evidence that MMT reduces HIV risk behaviors, particularly needle-use, and strong evidence that MMT prevents HIV infection. There is less definitive evidence that MMT reduces needle-sharing and unsafe sexual behavior, or that other treatment modalities prevent HIV infection. Future research should take into account patient self-selection processes and investigate other treatment modalities for heroin and stimulant abuse to determine their effects on HIV risk behaviors and HIV infection.

Understanding condom use among heroin addicts in methadone maintenance using the information-motivation-behavioral skills model

The current study represents the application of a health behavior model to account for unsafe sexual behavior (as opposed to unsafe needle use) among heroin addicts in methadone treatment. The Information-Motivation-Behavioral Skills (IMB) model of HIV preventive behavior asserts that HIV prevention information, motivation, and behavioral skills are fundamental determinants of HIV preventive behavior. Participants (N = 156 heroin-addicted individuals in methadone treatment) completed assessments of their levels of HIV prevention information, motivation, behavioral skills, and safer sexual behavior. Overall measures of fit generated via structural equation modeling indicate that the IMB model adequately fits the data obtained. The constructs of the model accounted for a substantial proportion of the variance in safer sexual behavior, and tests of parameter estimates indicate that while information and motivation had direct and reliable associations with safer sexual behavior in this population, behavioral skills did not. Discussion focuses on the primary roles of HIV prevention information and motivation as determinants of safer sexual behavior in this population, on the lack of a significant contribution of HIV prevention behavioral skills, and on the implications for intervention of this pattern of findings.

Seroprevalence of hepatitis C in a sample of middle class substance abusers

Hepatitis C (HCV) is an indolent and often fatal disease affecting four million Americans commonly associated with low socioeconomic status. We assessed its prevalence in a sample of 334 consecutively admitted middle class substance abusers in a private urban hospital, and ascertained risk factors for its transmission. We found that the point prevalence rate for HCV was 27.7% among all substance abusers, and 76.7% among intravenous drug users. Using logistic regression, we found risk factors associated with HCV were intravenous drug use, needle sharing, prior liver disease, opioid dependence, HIV infection, and benzodiazepine dependence. Not found to increase infective risk were lower social class, male gender, African-American race, male homosexuality, unemployment, and the absence of private health insurance. Multiple viral genotype types were identified in this sample, suggesting diverse sources of transmission in the sample. This study documents an epidemic of HCV in an American middle class sample.

Methadone maintenance treatment modalities in relation to incidence of HIV: results of the Amsterdam cohort study

STUDY OBJECTIVE

To evaluate methadone maintenance treatment modalities, prescribed within the concept of harm reduction, in relation to incidence of HIV infection among drug users with a history of methadone treatment in Amsterdam, The Netherlands.

DESIGN

Prospective observational cohort study among 582 HIV-negative drug users. To ensure valid and detailed assessment of methadone treatment, data from the Central Methadone Register in Amsterdam were linked to the Amsterdam cohort study among drug users.

METHODS

Poisson regression analysis was used to identify independent and significant predictors of incidence of HIV.

MAIN RESULTS

During 1906 person years, 58 drug users seroconverted, the overall incidence of HIV being 3.0 per 100 person years with a declining trend for current injectors. An increase in frequency of methadone programme attendance [relative risk (RR), 2.4; 95% confidence interval (CI), 1.2-4.6, compared with no change] and increase in methadone dosage (RR, 0.8; 95% CI, 0.6-1.0, per category of change of 10 mg/day) were significantly associated with incidence of HIV in multivariate analysis. Methadone dosage and frequency of programme attendance in itself were not significant predictors. Other multivariate significant risk factors were homelessness, current injecting and in-patient hospital care.

CONCLUSIONS

Among drug users who receive methadone maintenance treatment in a harm-reduction setting, which includes ancillary services such as needle-exchange programmes and HIV testing and counselling, prescription of high methadone dosages is not sufficient to stop the spread of HIV. However, an individual increase of the methadone dosage and measures to achieve high treatment retention could contribute to the prevention of HIV among drug users.

[The persistence of risky conduct for HIV transmission among intravenous drug users in Madrid, Seville, and Valencia. The Working Group of the Médicos del Mundo for the Monitoring of HIV Infection and the Risk Practices of Intravenous Drug Users]

OBJECTIVE

To determine the prevalence of HIV infection and risk-taking behavior for infection among intravenous drug users in Madrid, Seville, and Valencia (Spain). To study the main factors associated with such behavior.

MATERIAL AND METHODS

Personal interviews were carried out with 821 intravenous drug users recruited in 1994 and 1995 among recent participants in three needle-exchange programs. Subjects were asked about their risk-taking behavior in the 30 days preceding the interview. Bivariate statistical methods and logistical regression techniques were used.

RESULTS

In the month before the interview, 13.8% of the subjects in Valencia, 18.1% in Madrid, and 26.9% in Seville used needles that had been used by other people, usually (73-88%) without disinfecting them effectively. Condom use during the reference period was 50% in Seville, 42.5% in Madrid, and 34.2% in Valencia. The prevalence of HIV infection ranged from 30.1% in Seville to 43. 2% in Madrid. Multivariate analysis showed that the factors most closely associated with accepting used needles were: needle sharing (OR = 12.2), residence in Seville (OR = 6.6), and HIV positivity (OR = 4.6). The factors most closely associated with not using condoms systematically were: ignorance of personal HIV serological state (OR = 4.1), needle sharing (OR = 3.7), and HIV negativity (OR = 3.3).

CONCLUSIONS

The risk of HIV transmission among intra-venous drug users in Spain is high (infection and risk-taking behavior have a high prevalence), so programs designed to reduce this risk should be increased quickly.