Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting

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

OBJECTIVES

People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID.

DESIGN

This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada.

RESULTS

This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction.

CONCLUSIONS

These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care.

PROSPERO REGISTRATION NUMBER

CRD42020142947.

Perceptions of injectable opioid agonist treatment (iOAT) among people who regularly use opioids in Australia: findings from a cross-sectional study in three Australian cities

BACKGROUND AND AIMS

Not all people experiencing opioid dependence benefit from oral opioid agonist treatment. The aim of this study was to examine perceptions of (supervised) injectable opioid agonist treatment (iOAT) (described as 'an opioid similar to heroin self-injected at a clinic several times a day') among people who regularly use opioids and determine how common iOAT eligibility criteria accord with interest in iOAT.

DESIGN

Cross-sectional survey SETTING: Sydney, Melbourne and Hobart, Australia PARTICIPANTS: A total of 344 people (63% male) who use opioids regularly and had ever injected opioids, interviewed December 2017-March 2018. The mean age of participants was 41.5 years [standard deviation (SD) = 8.5].

MEASUREMENTS

Primary outcome measures were interest in iOAT, factors associated with interest and the proportion of participants who would be eligible using common criteria from trials and guidelines. We examined willingness to travel for iOAT, medication preferences and perspectives on whom should receive iOAT.

FINDINGS

Overall, 53% of participants (n = 182) believed that iOAT would be a good treatment option for them. Participants who believed that iOAT was a good treatment option for them were more likely to be male [adjusted odds ratio (aOR) = 1.76, 95% confidence interval (CI) = 1.10-2.82], have used heroin in the past month (aOR = 6.03, 95% CI = 2.86-12.71), currently regularly inject opioids (aOR = 1.84, 95% CI = 1.16-2.91) and have met ICD-10 criteria for opioid dependence (aOR = 3.46, 95% CI = 1.65-7.24). Those interested in iOAT had commenced more treatment episodes (aOR =1.06, 95% CI = 1.00-1.12). Among those interested in iOAT (n = 182), 26% (n = 48) met common eligibility criteria for iOAT.

CONCLUSIONS

Interest in injectable opioid agonist treatment does not appear to be universal among people who regularly use opioids. Among study participants who expressed interest in injectable opioid agonist treatment, most did not meet common eligibility criteria.

Injectable opioid agonist treatment: An evolutionary concept analysis

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under-executed and under-studied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT.

The value of harm reduction for injection drug use: A clinical and public health ethics analysis

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

The impact of OPRM1's genetic polymorphisms on methadone maintenance treatment in opioid addicts: a systematic review

Aim: Methadone is a long-acting opioid receptor agonist. It is prescribed to patients with opioid-related use disorders. The OPRM1 gene encodes for methadone's main receptor. It appears that polymorphisms in OPRM1 may affect the efficacy of methadone maintenance treatment (MMT). Objective: Our purpose was to identify all relevant published papers dealing with the impact ofOPRM1's SNPs  on MMT's efficacy and to summarize results in order to evaluate the relevance of conducting pretherapeutic genotyping in opioid addicts prior to the onset of MMT. Methods: MEDLINE, PsychINFO and Scopus databases were systematically searched up to 1 January  2018 with no year restrictions using the following keyword combination (MMT) AND (mu or OPRM or mu opioid receptors or SNP or polymorphism or gene). Endpoint of the included studies had to be the impact of OPRM1 gene polymorphisms on the efficacy of MMT and/or methadone required doses during MMT. All abstracts were reviewed to assess papers’ relevance. Studies conducted on animals and duplicate papers were excluded. Results: Our literature search identified 438 articles. Eight of them were included in our systematic review. The total number of included participants was equal to 2170, of whom 1718 underwent MMT. One study reported results of a randomized controlled trial. Three were designed as case–control studies and four as cross-sectional studies. rs1799971 (A118G) was the most studied allele. Results were divergent. Other SNPs might affect MMT's efficacy, however they were scarcely studied. Conclusion: Genotyping patients with opioid-related use disorders is a promising way to reach a better outcome in patients willing to be on MMT. Focusing on OPRM1 solely should be balanced since polymorphisms in other genes implicated in methadone pharmacodynamics and/or pharmacokinetics may conjunctly affect the efficacy of MMT. Recommendations cannot be enunciated for the moment.