Using cohort studies to estimate mortality among injecting drug users that is not attributable to AIDS

Substance use, risk behaviours and well-being after admission to a quasi-residential abstinence-based rehabilitation programme: 4-year follow-up

BACKGROUND

Tackling Scotland's drug-related deaths and improving outcomes from substance misuse treatments, including residential rehabilitation, is a national priority.

AIMS

To analyse and report outcomes up to 4 years after attendance at a substance misuse residential rehabilitation programme (Lothians and Edinburgh Abstinence Programme).

METHOD

In total, 145 participants were recruited to this longitudinal quantitative cohort study of an abstinence-based residential rehabilitation programme based on the therapeutic community model; 87 of these participants were followed up at 4 years. Outcomes are reported for seven subsections of the Addiction Severity Index-X (ASI-X), together with frequency of alcohol use, heroin use, injecting drug use and rates of abstinence from substances of misuse.

RESULTS

Significant improvement in most outcomes at 4 years compared with admission scores were found. Completing the programme was associated with greater rates of abstinence, reduced alcohol use and improvements in alcohol status score (Mann-Whitney U = 626, P = 0.013), work satisfaction score (U = 596, P = 0.016) and psychiatric status score (U = 562, P = 0.007) on the ASI-X, in comparison with non-completion. Abstinence rates improved from 12% at baseline to 48% at 4 years, with the rate for those completing the programme increasing from 14.5% to 60.7% (χ²(2, 87) = 9.738, P = 0.002). Remaining abstinent from substances at follow-up was associated with better outcomes in the medical (U = 540, P < 0.001), psychiatric (U = 273.5, P < 0.001) and alcohol (U = 322.5, P < 0.001) subsections of the ASI-X.

CONCLUSIONS

Attending this abstinence-based rehabilitation programme was associated with positive changes in psychological and social well-being and harm reduction from substance use at 4-year follow-up, with stability of change from years 1 to 4.

Infectious diseases, comorbidities and outcomes in hospitalized people who inject drugs (PWID)

Injection drug use poses a public health challenge. Clinical experience indicates that people who inject drugs (PWID) are hospitalized frequently for infectious diseases, but little is known about outcomes when admitted. Charts were identified from local hospitals between 2013-2018 using consultation lists and hospital record searches. Included individuals injected drugs in the past six months and presented with infection. Charts were accessed using the hospital information system, undergoing primary and secondary reviews using Research Electronic Data Capture (REDCap). The Wilcoxon rank-sum test was used for comparisons between outcome categories. Categorical data were summarized as count and frequency, and compared using Fisher's exact test. Of 240 individuals, 33% were admitted to the intensive care unit, 36% underwent surgery, 12% left against medical advice (AMA), and 9% died. Infectious diagnoses included bacteremia (31%), abscess (29%), endocarditis (29%), cellulitis (20%), sepsis (10%), osteomyelitis (9%), septic arthritis (8%), pneumonia (7%), discitis (2%), meningitis/encephalitis (2%), or other (7%). Sixty-six percent had stable housing and 60% had a family physician. Fifty-four percent of patient-initiated discharges were seen in the emergency department within 30 days and 29% were readmitted. PWID are at risk for infections. Understanding their healthcare trajectory is essential to improve their care.

Internet use and uptake of a web-based prevention and risk reduction intervention for persons who use drugs in New York City - WebHealth4Us study (2013-2016)

Background: Data on Internet utilization is needed, particularly during a time when in-person services are limited or only available virtually. The purpose of this study was to identify characteristics of Internet use among persons who use drugs and assess adoption of an interactive, risk reduction informational website - WebHealth4Us. Methods: Participant recruitment occurred in pharmacies participating in the New York State pharmacy syringe access program (n = 209). ACASI surveys were conducted on-site to ascertain Internet use and related sociodemographics and risk behaviors. Internet users (use ≥ once/month) were shown a website WebHealth4Us highlighting social services and risk reduction information on four topic areas: mental health, HIV, HCV, and other STI; users could also sign-up for weekly text messages for any topic area. Follow-up ACASI occurred at four weeks to assess user experiences and website adoption. Results: Study sample (n = 196) was mostly male (60%), average age 46, black/Latinx (76%), had a history of incarceration (79%), and reported past/current injection (53%) or non-injection (51%) drug use. Internet use was high (79%), accessed >4 times/week (60%) most commonly for: housing (61%), health issues (54%), and drug treatment (45%). Over one-third accessed WebHealth4Us during follow-up, and 35% of those opted for weekly text messages (mental health most common topic selected). After adjustment, younger age (AOR = 0.96) and alcohol use (AOR = 2.26) predicted WebHealth4Us access. Conclusion: Internet use was high with considerable WebHealth4Us access, and specifically for mental health needs. Web-based interventions warrant large-scale investigation in high-risk communities, prioritizing social determinants and behavioral health.

Wounds and Skin and Soft Tissue Infections in People Who Inject Drugs and the Utility of Syringe Service Programs in Their Management

Significance: Opioid use disorder and transition to injection drug use (IDU) are an urgent, nationwide public health crisis. Wounds and skin and soft tissue infections (SSTIs) are common complications of IDU that disproportionately affect people who inject drugs (PWID) and are a major source of morbidity and mortality for this population. Critical Issues: Injections in a nonsterile environment and reusing or sharing needles facilitates bacterial inoculation, with subsequent risk of serious complications such as sepsis, gangrene, amputation, and death. PWID are susceptible to infections with a wide spectrum of organisms beyond common culprits of SSTI, including Clostridium and Bacillus spp., as well as Candida. Recent Advances: Syringe services programs (SSPs) are cost-effective and successful in reducing harms associated with IDU. SSPs provide new equipment to PWID and aid in discarding used equipment. SSPs aim to reduce the risks of unhygienic injecting practices, which are associated with transmission of infections and blood-borne pathogens. Future Directions: Concurrently run SSPs and wound care clinics are uniquely positioned to facilitate care to PWID. Providing new, sterile equipment as well as early wound care intervention can reduce morbidity and mortality as well as health care expenditures by reducing the number of SSTI and injection-related wounds that require hospital admission. Establishment of wound care clinics as part of an SSP represents an untapped potential to reduce harm.

Health programmes and services addressing the prevention and management of infectious diseases in persons who inject drugs in Canada: a systematic integrative review protocol

INTRODUCTION

Injection drug use (IDU) and intravenous drug use (IVDU) are of concern to the people using drugs, their families and health systems. One of the complications of IDU/IVDU is the risk of infection. Clinical experience has shown that persons who inject drugs (PWID) are hospitalised and re-hospitalised frequently. In Canada there are sparse data about the reasons for which PWID are admitted to hospital and their health trajectories, especially for infectious diseases. There are special concerns regarding PWID with infections who leave the hospital against medical advice and those who leave with a peripherally inserted central catheter line in place for administration of long-term antibiotics or other therapies. Improving our understanding of current programmes and services addressing the prevention and management of infectious diseases and their complications in PWID could lead to focused interventions to enhance care in this population.

METHODS AND ANALYSIS

An integrative systematic review allows for inclusion of a variety of methodologies to understand a health issue from different viewpoints. PubMed, CINAHL, Web of Science Databases and websites of the Public Health Agency of Canada, Canadian Institute for Substance Use Research, and Canadian Centre on Substance Use and Addiction will be searched using terms for infectious diseases, drug use and geography (Canada) and limited to the last 10 years (2009-2019). The Quality Appraisal Tool in Studies with Diverse Designs will be used to appraise the quality of identified studies and documents. Quantitative, qualitative or mixed methods data synthesis will be used as needed.

ETHICS AND DISSEMINATION

This study is a secondary analysis of publicly available documents; therefore, no ethics approval is required. This information will inform a research agenda to further investigate interventions that aim to address these issues.

PROSPERO REGISTRATION NUMBER

CRD42020142947.

Suboxone Treatment and Recovery Trial (STAR-T): Study Protocol for a Randomised Controlled Trial of Opioid Medication Assisted Treatment with Adjunctive Medication Management Using Therapeutic Drug Monitoring and Contingency Management

INTRODUCTION

Opioid assisted treatment (OAT) with buprenorphine (BUP) is front-line medical maintenance intervention for illicit and prescription opioid use disorder (OUD). In many clinics, opioid medication is dispensed for several days for self-administration. This provides flexibility to the patient but may compromise the effectiveness of OAT because of nonadherence or medication diversion. OAT can be delivered as an entirely supervised intervention, but many patients discontinue treatment under this arrangement and dispensing costs may be prohibitive. An alternative is to enable patients to receive take-home doses contingent on OAT adherence guided by a medication management framework using Therapeutic Drug Monitoring (TDM) alongside negative urine drug screens (UDS) to provide evidence of abstinence. TDM is recommended to monitor adherence with BUP but it has not been applied in OAT programs and evaluation research to date.

METHODS

The Suboxone Treatment and Recovery Trial (STAR-T) is a single site, 16-week, parallel-group, randomised controlled trial. The aim of the study is to determine the effectiveness of a medication management framework including TDM and UDS to enable patients enrolled on outpatient OAT (with buprenorphine/naloxone [sublingual film formulation; BUP/NX-F; Suboxone™]) to receive stepped take-home doses. Following stabilisation during inpatient care, adult participants with illicit or prescription OUD were allocated (1:1) to receive (1) BUP/NX-F plus medication management for take-home doses based on TDM, UDS, and contingency management protocol (the experimental group) or (2) BUP/NX-F plus UDS only (treatment-as-usual, the control group). The primary outcome is the mean percentage of negative UDS over 16 weeks. The secondary outcome is treatment retention defined as completion of 16 weeks of OAT without interruption. There will be an exploratory analysis of the association between participant characteristics, clinical data, and outcomes.

CONCLUSIONS

Providing BUP/NX-F take-home doses contingent on adherence and opioid abstinence may enable OAT to be delivered flexibly and effectively.

TRIAL REGISTRATION

ISRCTN41645723 is retrospectively registered on 15/11/2015.

Intravenous buprenorphine/naloxone and concomitant oral pregabalin misuse: a case report

Opioid misuse and dependence are major medical and social concerns worldwide. Buprenorphine/naloxone combination (BNC) is a drug that has misuse potential and is used to treat opioid dependence, including buprenorphine and naloxone. Buprenorphine shows its pharmacological effects by binding to opioid receptors. Buprenorphine is a partial agonist and has smaller maximal effects compared to those of full agonists (heroin, methadone). Naloxone is a non-selective opiate antagonist added to buprenorphine for the prevention of intravenous diversion. BNC is used in the treatment of opioid dependence for detoxification and maintenance. The drug should be used as a sublingual film tablet. Pregabalin is used in the treatment of neuropathic pain, epilepsy and anxiety disorders. It is increasingly being reported as possessing a potential for misuse. In this article, we present a case of intravenous BNC and concomitant oral pregabalin misuse that developed in a monitored and treated patient for the reason of opioid dependence.

People Who Inject Drugs and Have Mood Disorders-A Brief Assessment of Health Risk Behaviors

BACKGROUND

People who inject drugs have a greater risk of infectious disease and mortality than other substance abusers and nondrug users. Variation in risk behavior among people who inject drugs is likely associated with comorbid mental health disorders.

OBJECTIVES

Examine the association between a history of mood disorder and recent risk behavior among people who inject drugs.

METHODS

With baseline data from a behavioral HIV prevention clinical trial in a population of people who inject drugs, we used logistic regression models to compare the risk behaviors of people who report a past diagnosis of bipolar disorder (n = 113) or depression (n = 237) to a comparison group with no history of diagnosed mental illness (n = 446). We also assessed differences between groups before and after adjusting for demographic characteristics and current depressive symptoms.

RESULTS

While there were no differences between groups in frequency of drug use, people who inject drugs who report a history of mood disorders reported more injection risk behaviors, drug overdoses, sex exchanges, and multiple partners than those with no history of mental illness. Adjusting the comparison for demographic characteristics and current depressive symptoms had little impact on these findings. Variation in risk between depression and bipolar disorder groups was minimal. Conclusions/Importance: People who inject drugs and have mood disorders have unique and significant social, clinical, and risk reduction needs. Despite the limited validity of self-reported mental health history, simply asking about a history of mood disorder may be effective for identifying a particularly vulnerable population of people who inject drugs.

Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis

BACKGROUND

The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP).

METHODS AND FINDINGS

We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities.

CONCLUSIONS

We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.

Chronic hepatitis C burden and care cascade in Australia in the era of interferon-based treatment

BACKGROUND AND AIM

Interferon-free direct-acting antiviral regimens for hepatitis C virus (HCV) infection have been recently available in Australia, beginning a new era in clinical and public health management of HCV infection. This study provided updated estimates of the HCV infection care cascade and burden in Australia as a reliable platform for assessing the future impact of interferon-free therapies.

METHODS

A modeling approach was applied to estimate the number of individuals living with chronic HCV infection and with various liver disease stages. Data from national registries of HCV notification and liver transplantation, literature review, and expert consensus informed the model parameters. HCV notification and Pharmaceutical Benefits Scheme data were used to estimate the number of HCV diagnosed individuals and treatment uptake.

RESULTS

In 2014, an estimated 230 470 individuals (range: 180 490-243 990) were living with HCV, among whom 75% were diagnosed (n = 172 720; range: 156 720-188 770), 20% had ever received treatment (n = 45 000; range: 39 280-50 720), and 11% had been cured (n = 24 750; range: 21 520-27 990). Among individuals with HCV infection, the proportion with hepatic fibrosis stage ≥F3 doubled during the last decade, increasing from 9% (n = 18 580) in 2004 to 19% (n = 44,730) in 2014. Individuals initiating HCV treatment increased from 1100 in 1997 to 3840 in 2007, plateaued until 2010 and decreased to 2790 in 2014.

CONCLUSIONS

The burden of HCV-related liver disease has increased markedly. Although the proportion diagnosed was high, treatment uptake remained low, with no increase over the last 7 years. Reducing the HCV burden in Australia requires scale-up of interferon-free HCV therapies.

Methamphetamine in the Czech Republic

The Czech Republic has a relatively long tradition in the addictive and problem use of methamphetamine, which is called “pervitin” locally. This paper attempts to provide as complex a picture of this phenomenon as possible by analyzing what is known about the Czech methamphetamine situation through scientific monitoring and research. It begins with a brief historical overview and then utilizes five key indicators (surveys, treatment demand, problem drug use estimates, blood borne diseases, and mortality) and some of the core indicators (namely, drug related crime, price and purity data, and estimates of market value) of drug epidemiology that were developed by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). By summarizing and carefully interpreting this data, the specifics of the Czech pervitin scene are described and future research directions are identified.

Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States

BACKGROUND

The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear.

OBJECTIVE

To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID.

DESIGN

Empirically calibrated dynamic compartmental model.

DATA SOURCES

Published literature and expert opinion.

TARGET POPULATION

Adult U.S. PWID.

TIME HORIZON

20 years and lifetime.

INTERVENTION

PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage.

OUTCOME MEASURES

Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years.

RESULTS OF SENSITIVITY ANALYSIS

Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence.

LIMITATION

Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited.

CONCLUSION

PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada

BACKGROUND AND AIMS

Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods.

DESIGN

Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment.

SETTING

Toronto and Ottawa, Canada.

PARTICIPANTS

Simulated population of each city.

INTERVENTIONS

Zero to five supervised injection facilities.

MEASUREMENTS

Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios.

FINDINGS

In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million.

CONCLUSIONS

Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.

Modeling a dynamic bi-layer contact network of injection drug users and the spread of blood-borne infections

Injection drug users (IDUs) are at high risk of acquiring and spreading various blood-borne infections including human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) and a number of sexually transmitted infections. These infections can spread among IDUs via risky sexual and needle-sharing contacts. To accurately model the spread of such contagions among IDUs, we build a bi-layer network that captures both types of risky contacts. We present methodology for inferring important model parameters, such as those governing network structure and dynamics, from readily available data sources (e.g., epidemiological surveys). Such a model can be used to evaluate the efficacy of various programs that aim to combat drug addiction and contain blood-borne diseases among IDUs. The model is especially useful for evaluating interventions that exploit the structure of the contact network. To illustrate, we instantiate a network model with data collected by a needle and syringe program in Chicago. We model sexual and needle-sharing contacts and the consequent spread of HIV and HCV. We use the model to evaluate the potential effects of a peer education (PE) program under different targeting strategies. We show that a targeted PE program would avert significantly more HIV and HCV infections than an untargeted program, highlighting the importance of reaching individuals who are centrally located in contact networks when instituting prevention programs.

Are Interferon-Free Direct-Acting Antivirals for the Treatment of HCV Enough to Control the Epidemic among People Who Inject Drugs?

BACKGROUND

Widely access to interferon-free direct-acting antiviral regimens (IFN-free DAA) is poised to dramatically change the impact of the HCV epidemic among people who inject drugs (PWID). We evaluated the long-term effect of increasing HCV testing, treatment and engagement into harm-reduction activities, focused on active PWID, on the HCV epidemic in British Columbia (BC), Canada.

METHODS

We built a compartmental model of HCV disease transmission stratified by disease progression, transmission risk, and fibrosis level. We explored the effect of: (1) Increasing treatment rates from 8 to 20, 40 and 80 per 1000 infected PWID/year; (2) Increasing treatment eligibility based on fibrosis level; (3) Maximizing the effect of testing by performing it immediately upon ending the acute phase; (4) Increasing access to harm-reduction activities to reduce the risk of re-infection; (5) Different HCV antiviral regimens on the Control Reproduction Number Rc. We assessed the impact of these interventions on incidence, prevalence and mortality from 2016 to 2030.

RESULTS

Of all HCV antiviral regimens, only IFN-free DAAs offered a high chance of disease elimination (i.e. Rc < 1), but it would be necessary to substantially increase the current low testing and treatment rates. Assuming a treatment rate of 80 per 1000 infected PWID per year, coupled with a high testing rate, the incidence rate, at the end of 2030, could decrease from 92.9 per 1000 susceptible PWID per year (Status Quo) to 82.8 (by treating only PWID with fibrosis level F2 and higher) or to 65.5 (by treating PWID regardless of fibrosis level). If PWID also had access to increased harm-reduction activities, the incidence rate further decreased to 53.1 per 1000 susceptible PWID per year. We also obtained significant decreases in prevalence and mortality at the end of 2030.

CONCLUSIONS

The combination of increased access to HCV testing, highly efficacious antiviral treatment and harm-reduction programs can substantially decrease the burden of the HCV epidemic among PWID. However, unless we increase the current levels of treatment and testing, the HCV epidemic among PWID in BC, and in other parts of the world with similar epidemiological background, will remain a substantial public health concern for many years.

Modeling the Health and Economic Burden of Hepatitis C Virus in Switzerland

Background

Chronic hepatitis C virus infection is a major cause of liver disease in Switzerland and carries a significant cost burden. Currently, only conservative strategies are in place to mitigate the burden of hepatitis C in Switzerland. This study expands on previously described modeling efforts to explore the impact of: no treatment, and treatment to reduce HCC and mortality. Furthermore, the costs associated with untreated HCV were modeled.

Methods

Hepatitis C disease progression and mortality were modeled. Baseline historical assumptions were collected from the literature and expert interviews and strategies were developed to show the impact of different levels of intervention (improved drug cure rates, treatment and diagnosis) until 2030.

Results

Under the historical standard of care, the number of advanced stage cases was projected to increase until 2030, at which point the annual economic burden of untreated viremic infections was projected to reach €96.8 (95% Uncertainty Interval: €36 – €232) million. Scenarios to reduce HCV liver-related mortality by 90% by 2030 required treatment of 4,190 ≥F2 or 3,200 ≥F3 patients annually by 2018 using antivirals with a 95% efficacy rate. Delaying the implementation of these scenarios by 2 or 5 years reduced the impact on mortality to 75% and 57%, respectively.

Conclusions

With today’s treatment efficacy and uptake rates, hepatitis C disease burden is expected to increase through 2030. A substantial reduction in disease burden can be achieved by means of both higher efficacy drugs and increased treatment uptake. However, these efforts cannot be undertaken without a simultaneous effort to diagnose more infections.

High Mortality Among Non-HIV-Infected People Who Inject Drugs in Bangkok, Thailand, 2005-2012

OBJECTIVES

We examined the causes of hospitalization and death of people who inject drugs participating in the Bangkok Tenofovir Study, an HIV preexposure prophylaxis trial.

METHODS

The Bangkok Tenofovir Study was a randomized, double-blind, placebo-controlled trial conducted during 2005 to 2012 among 2413 people who inject drugs. We reviewed medical records to define the causes of hospitalization and death, examined participant characteristics and risk behaviors to determine predictors of death, and compared the participant mortality rate with the rate of the general population of Bangkok, Thailand.

RESULTS

Participants were followed an average of 4 years; 107 died: 22 (20.6%) from overdose, 13 (12.2%) from traffic accidents, and 12 (11.2%) from sepsis. In multivariable analysis, older age (40-59 years; P = .001), injecting drugs (P = .03), and injecting midazolam (P < .001) were associated with death. The standardized mortality ratio was 2.9.

CONCLUSIONS

People who injected drugs were nearly 3 times as likely to die as were those in the general population of Bangkok and injecting midazolam was independently associated with death. Drug overdose and traffic accidents were the most common causes of death, and their prevention should be public health priorities.

Cost-effectiveness analysis of brief and expanded evidence-based risk reduction interventions for HIV-infected people who inject drugs in the United States

AIMS

Two behavioral HIV prevention interventions for people who inject drugs (PWID) infected with HIV include the Holistic Health Recovery Program for HIV+ (HHRP+), a comprehensive evidence-based CDC-supported program, and an abbreviated Holistic Health for HIV (3H+) Program, an adapted HHRP+ version in treatment settings. We compared the projected health benefits and cost-effectiveness of both programs, in addition to opioid substitution therapy (OST), to the status quo in the U.S.

METHODS

A dynamic HIV transmission model calibrated to epidemic data of current US populations was created. Projected outcomes include future HIV incidence, HIV prevalence, and quality-adjusted life years (QALYs) gained under alternative strategies. Total medical costs were estimated to compare the cost-effectiveness of each strategy.

RESULTS

Over 10 years, expanding HHRP+ access to 80% of PWID could avert up to 29,000 HIV infections, or 6% of the projected total, at a cost of $7,777/QALY gained. Alternatively, 3H+ could avert 19,000 infections, but is slightly more cost-effective ($7,707/QALY), and remains so under widely varying effectiveness and cost assumptions. Nearly two-thirds of infections averted with either program are among non-PWIDs, due to reduced sexual transmission from PWID to their partners. Expanding these programs with broader OST coverage could avert up to 74,000 HIV infections over 10 years and reduce HIV prevalence from 16.5% to 14.1%, but is substantially more expensive than HHRP+ or 3H+ alone.

CONCLUSIONS

Both behavioral interventions were effective and cost-effective at reducing HIV incidence among both PWID and the general adult population; however, 3H+, the economical HHRP+ version, was slightly more cost-effective than HHRP+.

Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers

Buprenorphine maintenance therapy (BMT) expands treatment access for opioid dependence and can be integrated into primary health-care settings. Treating opioid dependence, however, should ideally improve other aspects of overall health, including preventive services. Therefore, we examined how BMT affects preventive health-care outcomes, specifically nine nationally recommended primary care quality health-care indicators (QHIs), within federally qualified health centers (FQHCs) from an observational cohort study of 266 opioid-dependent patients initiating BMT between 07/01/07 and 11/30/08 within Connecticut's largest FQHC network. Nine nationally recommended preventive QHIs were collected longitudinally from electronic health records, including screening for chronic infections, metabolic conditions, and cancer. A composite QHI score (QHI-S), based on the percentage of eligible QHIs achieved, was categorized as QHI-S ≥80% (recommended) and ≥90% (optimal). The proportion of subjects achieving a composite QHI-S ≥80 and ≥90 % was 57.1 and 28.6%, respectively. Screening was highest for hypertension (91.0%), hepatitis C (80.1%), hepatitis B (76.3%), human immunodeficiency virus (71.4%), and hyperlipidemia (72.9%) and lower for syphilis (49.3%) and cervical (58.5%), breast (44.4%), and colorectal (48.7%) cancer. Achieving QHI-S ≥80% was positively and independently associated with ≥3-month BMT retention (adjusted odds ratio (AOR) = 2.19; 95% confidence interval (CI) = 1.18-4.04) and BMT prescription by primary care providers (PCPs) rather than addiction psychiatric specialists (AOR = 3.38; 95% CI = 1.78-6.37), and negatively with being female (AOR = 0.30; 95% CI = 0.16-0.55). Within primary health-care settings, achieving greater nationally recommended health-care screenings or QHIs was associated with being able to successfully retain patients on buprenorphine longer (3 months or more) and when buprenorphine was prescribed simultaneously by PCPs rather than psychiatric specialists. Decreased preventive screening for opioid-dependent women, however, may require gender-based strategies for achieving health-care parity. When patients can be retained, integrating BMT into urban FQHCs is associated with improved health outcomes including increased multiple preventive health-care screenings.

Ongoing impact of HIV infection on mortality among people who inject drugs despite free antiretroviral therapy

AIMS

To determine the impact of HIV infection on mortality over time among people who inject drugs (PWID) in settings with free HIV/AIDS care.

DESIGN AND SETTING

Prospective cohort study of PWID in Vancouver, Canada, recruited between May 1996 and December 2011. We ascertained morality rates and causes of death through a confidential linkage with the provincial vital statistics registry.

PARTICIPANTS

A total of 2283 individuals were followed for a median of 60.9 months (interquartile range: 34.4-113.1), among whom 622 (27.2%) individuals were HIV-positive at baseline, and 179 (7.8%) seroconverted during follow-up.

MEASUREMENTS

The primary and secondary outcomes of interests were all-cause mortality and cause of death, respectively. The main independent variable of interest was HIV serostatus (positive versus negative). We used Cox proportional hazards regression to determine factors associated with mortality, including socio-demographic variables, drug use behaviors and other risk behaviors.

FINDINGS

During the study period, 491 (21.5%) individuals died. In multivariate analyses, HIV infection remained associated independently with all-cause mortality (adjusted hazard ratio = 3.15; 95% CI: 2.59-3.82). While all-cause mortality rates declined markedly during the study period (P < 0.001), the independent effect of HIV infection on mortality remained unchanged over time (P = 0.640). Among HIV-positive individuals, significant changes in causes of death from infectious and AIDS-related causes to non-AIDS-related etiologies were observed.

CONCLUSIONS

HIV infection continues to have a persistent impact on mortality rates among people who inject drugs in settings with free HIV/AIDS care, although causes of death have shifted markedly from infectious and AIDS-related causes to non-AIDS-related etiologies.

Improvements in prevalence trend fitting and incidence estimation in EPP 2013

OBJECTIVE

Describe modifications to the latest version of the Joint United Nations Programme on AIDS (UNAIDS) Estimation and Projection Package component of Spectrum (EPP 2013) to improve prevalence fitting and incidence trend estimation in national epidemics and global estimates of HIV burden.

METHODS

Key changes made under the guidance of the UNAIDS Reference Group on Estimates, Modelling and Projections include: availability of a range of incidence calculation models and guidance for selecting a model; a shift to reporting the Bayesian median instead of the maximum likelihood estimate; procedures for comparison and validation against reported HIV and AIDS data; incorporation of national surveys as an integral part of the fitting and calibration procedure, allowing survey trends to inform the fit; improved antenatal clinic calibration procedures in countries without surveys; adjustment of national antiretroviral therapy reports used in the fitting to include only those aged 15-49 years; better estimates of mortality among people who inject drugs; and enhancements to speed fitting.

RESULTS

The revised models in EPP 2013 allow closer fits to observed prevalence trend data and reflect improving understanding of HIV epidemics and associated data.

CONCLUSION

Spectrum and EPP continue to adapt to make better use of the existing data sources, incorporate new sources of information in their fitting and validation procedures, and correct for quantifiable biases in inputs as they are identified and understood. These adaptations provide countries with better calibrated estimates of incidence and prevalence, which increase epidemic understanding and provide a solid base for program and policy planning.

Differential long-term outcomes for voluntary and involuntary transition from injection to oral opioid maintenance treatment

Background

The most widely used maintenance treatment for opioid dependency is substitution with long-acting oral opioids. Treatment with injectable diacetylmorphine provides an opportunity for patients to stabilize and possibly transition to oral treatment, if clinically indicated. The aim of this study was to explore outcomes of individuals that received injectable diacetylmorphine and voluntarily transitioned to oral methadone.

Design and methods

The North American Opiate Medication Initiative was a randomized controlled trial that compared the effectiveness of injectable diacetylmorphine (or hydromorphone) to oral methadone for long-term opioid-dependency. Treatment was provided for 12-months with an additional 3 months for transition and weaning. Participants were followed until 24-months from randomization. Among the participants randomized to injectable treatments, a sub-group voluntarily chose to transition to oral methadone (n = 16) during the treatment period. Illicit heroin use and treatment retention were assessed at 24-months for those voluntarily and involuntarily transitioning (n = 95) to oral methadone.

Results

At 24-months, the group that voluntarily transitioned to oral methadone had higher odds of treatment retention (adjusted odds ratio = 5.55; 95% confidence interval [CI] = 1.11, 27.81; Chi-square = 4.33, df = 1, p-value = 0.037) than the involuntary transition group. At 24-months, the adjusted mean difference in prior 30 days of illicit heroin use for the voluntary, compared to the involuntary group was -5.58 (95% CI = -11.62, 0.47; t-value = -1.83, df = 97.4, p-value = 0.070).

Conclusions

Although the results of this study were based on small groups of self-selected (i.e., non-randomized) participants, our data underlines the critical importance of voluntary and patient-centered decision making. If we had continued offering treatment with diacetylmorphine, those retained to injectable medication may have sustained the achieved improvements in the first 12 months. Diversified opioid treatment should be available so patients and physicians can flexibly choose the best treatment at the time.

Trial registration

Clinical Trial Registration: NCT00175357

Does naloxone prevent seizure in tramadol intoxicated patients?

BACKGROUND

Tramadol poisoning has increased in recent years. Seizure is one of the side-effects of tramadol toxicity. There is a controversy about possible preventive effect of naloxone in tramadol poisoning induced seizure. Therefore, this study was performed to compare seizure incidence in tramadol poisoning patients who received and did not receive naloxone, as an opioid antagonist.

METHODS

This study involved prospective data collection followed by retrospective analysis on 104 tramadol poisoning patients who were admitted in a referral poisoning center. The incidences of seizure were compared between patients received naloxone and those did not. Outcome was considered as survived without or with complications and death. Logistic Regression analysis was used to determine the effects of different variables on seizure incidence.

RESULTS

70 (67.3%) of the patients were men. The mean age of the patients was 26.3 ± 9 years old. 18.3% of the patients received naloxone in their treatment period. Seizure incidence was significantly higher among tramadol poisoning patients who did not receive naloxone compare with those received naloxone (14.1% vs. 5.1%). Among different variable studied, age had a significant effect on predicting of seizure (odds ratio = 2.09; 95% of confidence interval: 1.82-2.26; P value, 0.004).

CONCLUSIONS

Although the seizure incidence was lower in patients with tramadol poisoning who received naloxone, the logistic regression did not support the preventive effect of naloxone on seizure in tramadol poisoning cases.

Mortality among people who inject drugs: a systematic review and meta-analysis

OBJECTIVE

To systematically review cohort studies of mortality among people who inject drugs, examine mortality rates and causes of death in this group, and identify participant- and study-level variables associated with a higher risk of death.

METHODS

Tailored search strings were used to search EMBASE, Medline and PsycINFO. The grey literature was identified through online grey literature databases. Experts were consulted to obtain additional studies and data. Random effects meta-analyses were performed to estimate pooled crude mortality rates (CMRs) and standardized mortality ratios (SMRs).

FINDINGS

Sixty-seven cohorts of people who inject drugs were identified, 14 of them from low- and middle-income countries. The pooled CMR was 2.35 deaths per 100 person-years (95% confidence interval, CI: 2.12-2.58). SMRs were reported for 32 cohorts; the pooled SMR was 14.68 (95% CI: 13.01-16.35). Comparison of CMRs and the calculation of CMR ratios revealed mortality to be higher in low- and middle-income country cohorts, males and people who injected drugs that were positive for human immunodeficiency virus (HIV). It was also higher during off-treatment periods. Drug overdose and acquired immunodeficiency syndrome (AIDS) were the primary causes of death across cohorts.

CONCLUSION

Compared with the general population, people who inject drugs have an elevated risk of death, although mortality rates vary across different settings. Any comprehensive approach to improving health outcomes in this group must include efforts to reduce HIV infection as well as other causes of death, particularly drug overdose.

Injecting drug use is associated with a more rapid CD4 cell decline among treatment naïve HIV-positive patients in Indonesia

Background

It remains unclear whether the natural course of human immunodeficiency virus (HIV) differs in subjects infected through injecting drug use (IDU) and no data have been published from low- or middle-income countries. We addressed this question in an urban cohort in Indonesia, which is experiencing a rapidly growing HIV epidemic strongly driven by IDU.

Methods

All antiretroviral treatment (ART) naïve HIV-positive patients who had at least two subsequent CD4 cell counts available before starting ART were included in this study. We examined the association between IDU and CD4 cell decline using a linear mixed model, with adjustment for possible confounders such as HIV viral load and hepatitis C antibodies.

Results

Among 284 HIV-positive ART naïve patients, the majority were male (56%) with a history of IDU (79% among men). People with a history of IDU had a statistically significant faster decline in CD4 cells (p<0.001). Based on our data, patients with a history of IDU would have an average 33% decline in CD4 cells after one year without ART, compared with a 22% decline among non-users. At two years, the decline would average 66 and 40%, respectively. No other factor was significantly associated with CD4 cell decline.

Conclusions

We show that a history of IDU is associated with a more rapid CD4 cell natural decline among HIV-positive individuals in Indonesia. These findings have implications for monitoring ART naïve patients with a history of IDU and for starting ART in this group.

Emerging disparity in HIV/AIDS disease progression and mortality for men who have sex with men, Jiangsu Province, China

Few data exist on HIV disease progression and antiretroviral treatment (ART) impact among men who have sex with men (MSM) in China. Using data from the national case reporting system from 2004 to 2010, we describe changes in CD4 cell count before and after ART initiation, disease progression, and mortality among MSM in Jiangsu province compared with other persons living with HIV/AIDS. Median CD4 cell count among MSM at HIV diagnosis was 432 and decreased rapidly in 12 months to below the level of heterosexuals (slope: MSM -38.0, heterosexuals -15.5, injection drug users [IDU] -8.0, blood donors -10.5). Among those initiating ART, median CD4 cell count among MSM was 157, yet the increase in count was slower than for other groups (slope: MSM 26.9, heterosexuals 31.9, IDU 29.0, blood donors 35.0). Progression to AIDS was faster among MSM than heterosexuals and IDU. For the present, the mortality rate was lower for MSM compared with heterosexuals and blood donors; however, against a backdrop of more recent infection (ie, MSM had younger age, and 93.8 % were diagnosed after 2008), findings suggest a survival rate for MSM that will fall behind other groups. Improved medical and psychosocial supportive care is needed for this stigmatized population lest disparities become greater.

Association between depression and non-fatal overdoses among drug users: a systematic review and meta-analysis

BACKGROUND

Assessing factors associated with non-fatal overdose is important as these could be useful to identify individuals with substance use disorders at high risk of adverse outcomes and consequences. Depression may play an important role in terms of overdose risk. We aimed to test if drug users suffering from a depressive disorder might have significantly higher risk of non-fatal overdose as compared with drug users without depression.

METHODS

We conducted a systematic review and meta-analysis. PubMed, Embase and Web of Knowledge were searched. The pooled analyses were based on prevalence rates, risk difference (RD) and odds ratio (OR), reporting 95% confidence intervals (CIs). The combined estimates were obtained weighting each study according to random effects model for meta-analysis.

RESULTS

Seven articles, involving 12,019 individuals, and run in the US, Canada, Sweden, Norway, and Australia, were included. Pooled analyses comparing depressed with not depressed individuals highlighted a RD (95% CIs) for non-fatal overdose of 7.3% (4.8-9.7%) and an OR (95% CIs) of 1.45 (1.17-1.79). The subgroups analyses based on specific characteristics of included studies confirmed the association between depression and overdose.

CONCLUSIONS

Depressive disorders seem to be important factors associated to the risk of non-fatal overdose. Longitudinal studies might appropriately clarify causal inference issues. Future research should address the role of depressive disorders as predictors of subsequent non-fatal overdoses.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Improvement of quality of life in methadone treatment patients in northern Taiwan: a follow-up study

BACKGROUND

This study examined long-term improvement of quality of life amongst heroin users enrolled in methadone maintenance treatment (MMT).

METHODS

The sample contained 553 heroin-dependent individuals from 4 hospitals in northern Taiwan who enrolled in MMT for an average of 184 days. Each patient signed a consent form and was assessed prospectively 3 times semi-annually. Quality of life was measured using the WHOQOL-BREF questionnaire, 26 items of which were scored by the participants. The WHOQOL-BREF consists of four domains: physical, psychological, social, and environmental. 285 and 155 participants completed 6-month and 12-month follow-ups respectively.

RESULTS

After controlling for demographic and clinical characteristics, there were statistically significant improvements in the psychological and environmental domains between baseline and 6 months. Significant improvements were found in psychological and social domains between baseline and 12 months.

CONCLUSIONS

It is concluded that methadone maintenance treatment improves heroin users' long-term quality of life in the psychological and social relationship domains.

Establishing the Melbourne Injecting Drug User Cohort Study (MIX): rationale, methods, and baseline and twelve-month follow-up results

BACKGROUND

Cohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.

METHODS

Respondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants' demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.

RESULTS

688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years - 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months - 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.

CONCLUSIONS

Our efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.

Improved benchmark-multiplier method to estimate the prevalence of ever-injecting drug use in Belgium, 2000-10

Background

Accurate estimates of the size of the drug-using populations are essential for evidence-based policy making. However, drug users form a ‘hidden’ population, necessitating the use of indirect methods to estimate population sizes.

Methods

The benchmark-multiplier method was applied to estimate the population size of ever injecting drug users (ever-IDUs), aged 18–64 years, in Belgium using data from the national HIV/AIDS register and from a sero-behavioral study among injecting drug users. However, missing risk factor information and absence of follow-up of the HIV⁺/AIDS^– cases, limits the usefulness of the Belgian HIV/AIDS register as benchmark. To overcome these limitations, statistical corrections were required. In particular, Imputation by Chained Equations was used to correct for the missing risk factor information whereas stochastic mortality modelling was applied to account for the mortality among the HIV⁺/AIDS^– cases. Monte Carlo simulation was used to obtain confidence intervals, properly reflecting the uncertainty due to random error as well as the uncertainty associated with the two statistical corrections mentioned above.

Results

In 2010, the prevalence (/1000) of ever-IDUs was estimated to be 3.5 with 95% confidence interval [2.5;4.8]. No significant time trends were observed for the period 2000–2010.

Conclusions

To be able to estimate the ever-IDU population size using the Belgian HIV/AIDS register as benchmark, statistical corrections were required without which seriously biased estimates would result. By developing the improved methodology, Belgium is again able to provide ever-IDU population estimates, which are essential to assess the coverage of treatment and to forecast health care needs and costs.

Mortality in a large community-based cohort of inner-city residents in Vancouver, Canada

BACKGROUND

The Downtown Eastside is a robust and densely populated neighbourhood in Vancouver, Canada, that is characterized by low-income housing and drug use and a high prevalence of HIV infection. We evaluated mortality and excess mortality among the broader community of individuals living in this neighbourhood.

METHODS

The Community Health and Safety Evaluation is a community-based study of inner-city residents in the Downtown Eastside who were recruited in 2003 and 2004. Participants' data were linked with data in provincial virology and mortality databases retrospectively and prospectively for the period 1991-2009. Mortality and standardized mortality ratios (SMRs) were calculated for the period 2003-2009 to compare death rates in the study population with rates in the population of Vancouver.

RESULTS

Among 2913 participants, 374 deaths occurred, for an all-cause mortality of 223 per 10 000 person-years (95% confidence interval [CI] 201-247 per 10 000 person-years). Compared with the population of Vancouver, significant excess mortality was observed in the study population (SMR 7.1, 95% CI 6.4-7.9). Excess mortality was higher among women (SMR 15.4, 95% CI 12.8-18.5) than among men (SMR 5.8, 95% CI 5.1-6.6). Although crude mortality increased with age, excess mortality was greatest among participants less than 35 years old (SMR 13.2, 95% CI 9.4-18.5) and those 35-39 years old (SMR 13.3, 95% CI 10.3-17.1). Excess risk was also elevated among participants with hepatitis C virus (HCV), HIV and HCV/HIV infection, with SMRs of 5.9 (95% CI 4.9-7.1), 19.2 (95% CI 12.8-28.9) and 23.0 (95% CI 19.3-27.4), respectively.

INTERPRETATION

Our study showed high mortality in this inner-city population, particularly when compared with the general population of Vancouver. Excess mortality was highest among women, younger participants and those infected with either HCV or HIV or both.

Frailty, HIV infection, and mortality in an aging cohort of injection drug users

BACKGROUND

Frailty is associated with morbidity and premature mortality among elderly HIV-uninfected adults, but the determinants and consequences of frailty in HIV-infected populations remain unclear. We evaluated the correlates of frailty, and the impact of frailty on mortality in a cohort of aging injection drug users (IDUs).

METHODS

Frailty was assessed using standard criteria among HIV-infected and uninfected IDUs in 6-month intervals from 2005 to 2008. Generalized linear mixed-model analyses assessed correlates of frailty. Cox proportional hazards models estimated risk for all-cause mortality.

RESULTS

Of 1230 participants at baseline, the median age was 48 years and 29% were HIV-infected; the frailty prevalence was 12.3%. In multivariable analysis of 3,365 frailty measures, HIV-infected IDUs had an increased likelihood of frailty (OR, 1.66; 95% CI, 1.24-2.21) compared to HIV-uninfected IDUs; the association was strongest (OR, 2.37; 95% CI, 1.62-3.48) among HIV-infected IDUs with advanced HIV disease (CD4<350 cells/mm3 and detectable HIV RNA). No significant association was seen with less advanced disease. Sociodemographic factors, comorbidity, depressive symptoms, and prescription drug abuse were also independently associated with frailty. Mortality risk was increased with frailty alone (HR 2.63, 95% CI, 1.23-5.66), HIV infection alone (HR 3.29, 95% CI, 1.85-5.88), and being both HIV-infected and frail (HR, 7.06; 95%CI 3.49-14.3).

CONCLUSION

Frailty was strongly associated with advanced HIV disease, but IDUs with well-controlled HIV had a similar prevalence to HIV-uninfected IDUs. Frailty was independently associated with mortality, with a marked increase in mortality risk for IDUs with both frailty and HIV infection.

HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy

BACKGROUND AND OBJECTIVES

HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live.

DESIGN

A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of 'enabling' environment described the policy environments in which they are implemented.

STUDIES REVIEWED

Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID.

RESULTS

HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies.

CONCLUSIONS

The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.

Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users

OBJECTIVE

To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).

DESIGN

Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).

METHODS

We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.

DISCUSSION

Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

The natural history of injecting drug use: a 25-year longitudinal study of a cohort of injecting drug users in inner city Dublin

BACKGROUND

Injecting drug use is associated with increased morbidity and mortality. This is the first longitudinal study of a community-based population of injecting drug users (IDUs) in the Republic of Ireland.

AIM

To establish the natural history of IDUs in a deprived Dublin community.

METHODS

Eighty-two IDUs (heroin) were recruited over the summer months of 1985. The prevalence of drug use in this district electoral area was established in 1985 and followed-up over a 25-year period with two formal interviews in 1995 and 2010.

RESULTS

It is a descriptive study of a cohort of IDUs established in 1985 prior to human immunodeficiency virus (HIV) testing being available. The majority of the cohort recruited included single, unemployed males aged 20 to 29 years, who had served a prison sentence. Fifty-one (63 %) of the cohort had died by 2010, of which 26 were attributed to HIV disease. The mean age of death was 35.9 years of age (standard deviation 4.1 years). Fifty-two (63 %) of the cohort tested positive for HIV and 58 (71 %) for hepatitis B between 1985 and 2010. The median survival time for those with a positive HIV status was 17 years (95 % CI 14.0-20.0) and for those with a positive hepatitis C status, 21 years (95 % CI 15.5-26.5).

CONCLUSIONS

The lifestyle of IDUs, as demonstrated by the experience of this cohort, has hazardous consequences resulting in high levels of morbidity and mortality. A relatively stable picture of HIV associated with IDUs is now emerging in Ireland, as is the case throughout most of the EU. HIV is a more manageable chronic disease, posing challenges for primary care in its treatment of former and existing IDUs who are ageing and now have other chronic diseases.

Mortality among young injection drug users in San Francisco: a 10-year follow-up of the UFO study

This study examined associations between mortality and demographic and risk characteristics among young injection drug users in San Francisco, California, and compared the mortality rate with that of the population. A total of 644 young (<30 years) injection drug users completed a baseline interview and were enrolled in a prospective cohort study, known as the UFO ("U Find Out") Study, from November 1997 to December 2007. Using the National Death Index, the authors identified 38 deaths over 4,167 person-years of follow-up, yielding a mortality rate of 9.1 (95% confidence interval: 6.6, 12.5) per 1,000 person-years. This mortality rate was 10 times that of the general population. The leading causes of death were overdose (57.9%), self-inflicted injury (13.2%), trauma/accidents (10.5%), and injection drug user-related medical conditions (13.1%). Mortality incidence was significantly higher among those who reported injecting heroin most days in the past month (adjusted hazard ratio = 5.8, 95% confidence interval: 1.4, 24.3). The leading cause of death in this group was overdose, and primary use of heroin was the only significant risk factor for death observed in the study. These findings highlight the continued need for public health interventions that address the risk of overdose in this population in order to reduce premature deaths.

Extent of illicit drug use and dependence, and their contribution to the global burden of disease

This paper summarises data for the prevalence, correlates, and probable adverse health consequences of problem use of amphetamines, cannabis, cocaine, and opioids. We discuss findings from systematic reviews of the prevalence of illicit drug use and dependence, remission from dependence, and mortality in illicit drug users, and evidence for acute and chronic effects of illicit drug use. We outline the regional and global distribution of use and estimated health burden from illicit drugs. These distributions are likely to be underestimates because they have not included all adverse outcomes of drug use and exclude those of cannabis--the mostly widely used illicit drug. In high-income countries, illicit drug use contributes less to the burden of disease than does tobacco but a substantial proportion of that due to alcohol. The major adverse health effects of cannabis use are dependence and probably psychotic disorders and other mental disorders. The health-related harms of cannabis use differ from those of amphetamine, cocaine, and opioid use, in that cannabis contributes little to mortality. Intelligent policy responses to drug problems need better data for the prevalence of different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas.

What data are available on the extent of illicit drug use and dependence globally? Results of four systematic reviews

BACKGROUND

We systematically reviewed availability and quality of data on the prevalence of use and dependence on meth/amphetamine, cannabis, cocaine and opioids.

METHODS

Multiple search strategies: (a) peer-reviewed literature searches (1990-2008) using methods recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; (b) systematic searches of online databases; (c) Internet searches to find other published evidence of drug use; (d) repeated consultation and feedback from experts around the globe; (e) a viral email sent to lists of researchers in the illicit drug and HIV fields. Data were extracted and graded according to predefined variables reflecting quality of data source.

RESULTS

Qualitative evidence of illicit drug use and dependence was found for most countries, which hold over 98% of the world's population aged 15-64 years. Countries where use was identified but prevalence estimates had not been made (evidence of drug supply, trafficking, reports of use, treatment data) were mainly from Asia, Africa, the Middle East, and Oceania. Estimates of the prevalence of use were located in 77 countries for meth/amphetamine, 95 for cannabis, 86 for cocaine and 89 for opioids. Dependence prevalence estimates existed in very few countries; 9 meth/amphetamine dependence estimates, 7 cannabis dependence estimates, 5 cocaine dependence estimates, and 25 opioid dependence estimates were located.

CONCLUSIONS

Data on the extent of meth/amphetamine, cannabis, cocaine and opioid use and dependence must be improved in quality and coverage. Dependence estimates are lacking even in high income countries that have required resources. Responses to illicit drug dependence require better estimates of its scale.

'Meeting people where they're at': experiences of family physicians engaging women who use illicit drugs

PURPOSE

There is little research exploring the experiences of family physicians caring for women who use illicit drugs. This study explores the experiences of these physicians in order to better understand the process of engaging these women in the patient-physician relationship.

METHODS

We conducted a phenomenologic, qualitative study using individual, in-depth interviews with 10 family physicians working in inner-city Toronto and Ottawa, Ontario. An iterative and interpretive analysis was used.

RESULTS

Three broad themes emerged from the analysis. The predominant theme was that of the patient-physician relationship, which consisted of 2 phases: the engagement phase and the maintenance phase. During the engagement phase, issues such as access and women's experiences of trauma and violence were evident and impeded participants' ability to engage with this population. As such, the patient-physician relationship during the engagement phase was tenuous. Trust and presence were paramount during this phase. Once a family physician engaged a woman, the transition to the maintenance phase was made. Within the maintenance phase, 2 subthemes were identified: continuity of care and "meeting people where they're at" (finding common ground).

CONCLUSIONS

This study identified a 2-phase process of the patient-physician relationship from the perspective of family physicians caring for women using illicit drugs: the engagement and maintenance phases. Our findings identified strategies to support the patient-physician relationship during each of these phases that have implications for improving the health of these women.

Individual and network factors associated with non-fatal overdose among rural Appalachian drug users

BACKGROUND

Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States--especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users.

METHODS

Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses.

RESULTS

Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network.

CONCLUSIONS

Rural drug users with history of overdose were more likely to have injected with prescription opioids--which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.

Mortality and HIV transmission among male Vietnamese injection drug users

AIMS

To estimate all-cause mortality rate and to assess predictors of all-cause mortality among injection drug users (IDUs) in Thai Nguyen province, Vietnam between 2005 and 2007.

DESIGN

Prospective cohort study.

SETTING

Community-dwelling IDUs were enrolled and followed at 3-month intervals for up to 2 years.

PARTICIPANTS

A total of 894 male IDUs (median age of 32 years, 22.8% HIV-positive, all having injected opioids).

MEASUREMENTS

Deaths were confirmed by family members and by reviewing government records. Marginal Cox proportional hazards models for clustered data were constructed to determine the independent predictors of all-cause mortality, using both fixed baseline measurements and time-dependent repeated measurements.

FINDINGS

During 710.1 person-years of follow-up, 45 (5.0%) drug injectors died. The causes of deaths were AIDS-related (14 cases, 31%), drug overdose (12, 27%), suicide (three, 7%), traffic accident (three, 7%), violence (two, 4%), pneumonia (two, 4%), non-traffic accident (one, 2%) and unknown causes (eight, 18%). The all-cause mortality rate was 6.3% (95% CI = 4.6-8.5) per 100 person-years. The standardized mortality ratio was 13.4. The HIV incidence rate was 5.2 (95% CI = 3.5-7.6) per 100 person-years. In multi-factorial analysis, HIV infection [hazard ratio (HR) = 3.5, 95% CI = 1.9-6.3] and previous diagnosis of tuberculosis (HR = 10.0, 95% CI = 4.1-24.3) were associated significantly with increased hazard of death.

CONCLUSIONS

The all-cause, age- and sex-standardized mortality among Vietnamese IDUs is 13-fold higher than the general population and substantially higher than IDUs studied in developed countries. Effective prevention and control of HIV infection and tuberculosis are needed urgently.

Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review

The diversion, misuse, and non-medically supervised use of buprenorphine and buprenorphine/naloxone by opioid users are reviewed. Buprenorphine and buprenorphine/naloxone are used globally as opioid analgesics and in the treatment of opioid dependency. Diversion of buprenorphine and buprenorphine/naloxone represents a complex medical and social issue, and has been widely documented in various geographical regions throughout the world. We first discuss the clinical properties of buprenorphine and its abuse potential. Second, we discuss its diversion and illicit use on an international level, as well as motivations for those activities. Third, we examine the medical risks and benefits of buprenorphine's non-medically supervised use and misuse. These risks and benefits include the effect of buprenorphine's use on HIV risk and the risk of its concomitant use with other medications and drugs of abuse. Finally, we discuss the implications of diversion, misuse, and non-medically supervised use (including potential measures to address issues of diversion); and potential areas for further research.

The relationship between injection and noninjection drug use and HIV disease progression

BACKGROUND

Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression.

METHODS

We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005.

RESULTS

There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43-2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92-1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period (n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09-3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81-1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use.

CONCLUSIONS

This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.

Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies

AIMS

To review the literature on mortality among dependent or regular users of opioids across regions, according to specific causes, and related to a number of demographic and clinical variables.

METHODS

Multiple search strategies included searches of Medline, EMBASE and PsycINFO, consistent with the methodology recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; grey literature searches; and contact of experts for any additional unpublished data from studies meeting inclusion criteria. Random-effects meta-analyses were conducted for crude mortality rates (CMRs) and standardized mortality ratios (SMRs), with stratified analyses where possible. Meta-regressions examined potentially important sources of heterogeneity across studies.

RESULTS

Fifty-eight prospective studies reported mortality rates from opioid-dependent samples. Very high heterogeneity across studies was observed; pooled all-cause CMR was 2.09 per 100 person-years (PY; 95% CI; 1.93, 2.26), and the pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out-of-treatment periods had higher mortality risk than in-treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). Causes of death varied across studies, but overdose was the most common cause. Multivariable regressions found the following predictors of mortality rates: country of origin; the proportion of sample injecting; the extent to which populations were recruited from an entire country (versus subnational); and year of publication.

CONCLUSIONS

Mortality among opioid-dependent users varies across countries and populations. Treatment is clearly protective against mortality even in non-randomized observational studies. Study characteristics predict mortality levels; these should be taken into account in future studies.

Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment

OBJECTIVES

To examine survival and long term cessation of injecting in a cohort of drug users and to assess the influence of opiate substitution treatment on these outcomes.

DESIGN

Prospective open cohort study.

SETTING

A single primary care facility in Edinburgh.

PARTICIPANTS

794 patients with a history of injecting drug use presenting between 1980 and 2007; 655 (82%) were followed up by interview or linkage to primary care records and mortality register, or both, and contributed 10,390 person years at risk; 557 (85%) had received opiate substitution treatment.

MAIN OUTCOME MEASURES

Duration of injecting: years from first injection to long term cessation, defined as last injection before period of five years of non-injecting; mortality before cessation; overall survival.

RESULTS

In the entire cohort 277 participants achieved long term cessation of injecting, and 228 died. Half of the survivors had poor health related quality of life. Median duration from first injection to death was 24 years for participants with HIV and 41 years for those without HIV. For each additional year of opiate substitution treatment the hazard of death before long term cessation fell 13% (95% confidence interval 17% to 9%) after adjustment for HIV, sex, calendar period, age at first injection, and history of prison and overdose. Conversely exposure to opiate substitution treatment was inversely related to the chances of achieving long term cessation.

CONCLUSIONS

Opiate substitution treatment in injecting drug users in primary care reduces this risk of mortality, with survival benefits increasing with cumulative exposure to treatment. Treatment does not reduce the overall duration of injecting.