Sector News

  1. Deindustrialization and Overdose Risk

    Background

    “In 2013, more Americans died from overdoses than car crashes” – Hilary Clinton in 2015 on the growing need to address the epidemic of drug overdose.

    • Opiate- and opioid-type drugs have been associated with a rising proportion of overdose deaths – from over 38% in 2004 to just under 52% in 2013 in the United States.
    • The initial rise in mortality was due to an in crease in prescription opioid (PO) abuse, but more recent data shows that heroin use has risen in popularity partly due to the attempts to control prescription drug misuse.
    • In 2008, heroin represented approximately 30% of overdose deaths. By 2014, heroin accounted for 61%, making it the most prevalent substance associated with overdose deaths.
    • Recent research has considered how the shifting dynamics of the U.S. illicit drug market have heightened overdose risk in places newly supplied with cheaper, more potent Colombian heroin.

    Study Setting

    • Small cities across the Monongahela River Valley have lost ‘‘90 percent of everything’’ – residents, jobs, and businesses – over the past three decades
    • According to the Allegheny County Medical Examiner (ACME), fatal overdoses nearly tripled from 2000 to 2014, from 109 to 307.
    • Case-level mortality data from Allegheny County shows an obvious spatial association between deadly overdose and poverty, with the highest fatality rates clustered in the region’s deindustrialized communities and Pittsburgh’s inner-city neighbourhoods.

    Risk environments =‘‘spaces – whether social or physical – in which a variety of factors interact to increase the chances of harm occurring’’ (Rhodes, 2009).

    Approach

    In a survey, participants described their own most recent overdose event and/or the last overdose they had personally witnessed. They were also asked to speculate upon the roots of the local overdose epidemic, while suggesting possible remedies.

    Findings

    • Participants viewed overdose and addiction as part of life in a poor city.
    • Participants lacked access to prevention education and free naloxone (for treating overdoses) from the county needle exchange program due to transportation barriers.
    • Several participants sold heroin in order to support their own drug use and many feared the criminal consequences of a buyer having a fatal overdose.

    Conclusion

    The authors suggest that the road into drug use is shaped by a deindustrialized context. Lack of opportunity, social support, and hope are met by the expanding illicit drug market, which offers both employment and recreation. Due to this, policy makers should be aware of the underlying factors and future overdose interventions should take into account that drug-related risks are complex and multifaceted when designing accessible programs for low/no-income individuals.

    McLean, K. (2015). ‘‘There’s nothing here’’: Deindustrialization as risk environment for overdose. International Journal of Drug Policy. Vol. 29. Pp. 19-26.

    Rhodes, T. (2009). Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy. 20: 193–201.

  2. Posted in:

    Recommendations for HCV Infection Management

    Background

    • Hepatitis C virus (HCV) infection in high income countries ranges from 50%-80% among people who inject drugs (PWID) and epidemics are also beginning to emerge in middle and low income countries among their PWID populations.
    • Among people who inject drugs, the rates of advanced liver disease complications, related healthcare costs, and liver associated morbidity and mortality are all on the rise.
    • Despite the increased burden of liver disease, treatment uptake and completion remains very low.

    Approach

    The authors make recommendations based on scientific research and expert opinion, which are updated to be in line with international guidelines.

    Summery of some of the recommendations:

    Impact of drug use on treatment adherence and sustained virologic response (SVR) 

    If one receives approximately 80% of scheduled treatments he is generally considered to be adhering to the to HCV therapy however, this does not distinguish between missed doses and the stopping of treatment.

    In addition, studies have found that lower education and unstable housing are associated with adherence and treatment completion. Other factors associated with low SVR among PWID, include low social functioning, a history of untreated depression, and continued drug use during treatment

    • Adherence assessments should consider missed doses and treatment discontinuation
    • Individuals should be counselled on the importance of adherence in attaining an SVR
    • A history of IDU and recent drug use at treatment initiation are not associated with reduced SVR and decisions to treat should be made on a case-by-case basis
    • Those with ongoing social issues, history of psychiatric disease and those with more frequent drug use during therapy are at risk of lower adherence and SVR and should be to be monitored closely.

    Treatment management recommendations

    Several models have shown that HCV treatment can be delivered successfully to PWID whether it be within a general hospital, drug detoxification clinics, opioid substitution therapy clinics, prisons or a community-based clinics.

    • HCV treatment for PWID should be looked at on a case by case basis and delivered by a multidisciplinary team
    • Access to harm reduction programs, social work and social support services should be a component of HCV clinical management
    • Peer-based support should be evaluated to improve HCV clinical management

    Conclusions

    Although there are number of barriers to care for people who inject drugs (PWID), research has shown hepatitis C virus (HCV) treatment to be safe and effective. Enhancement of HCV assessment and treatment strategies is greatly needed due to the burden of HCV-related disease.

    Grebely, J.A., Robaeys, G., Bruggmann, P., Aghemo, A, Backmund, M., and Bruneau, J. (2015).

    Recommendations for the management of hepatitis C virus infection among people who inject drugs. International Journal of Drug Policy. Vol. 26. Pp 1028-1039.

  3. Exploring the Connection between Heroin and Steroid Use

    Background

    Steroids, properly called Anabolic–androgenic steroids (AAS), are commonly used drugs in some populations of young men. Several studies have found an association between illicit drugs, such as heroin and other opiates, with steroid use.  There are various possible explanations for the connection between steroid use and illicit drug use:

    • a) Both may be associated with criminality and deprivation;
    • b) Heroin might depress certain hormones resulting in a decrease in testosterone, which may predispose a person to replacement through AAS (steroids);
    • c) Both may share similar pleasure-seeking neuropathways, which could be the reason for findings showing a high prevalence of opiate users in a group of steroid users with characteristics of dependence compared to a group of steroid users who did not show characteristics of dependence; and
    • d) An association between heroin and steroid (AAS) use may be due to social and cultural contexts.

    Approach

    In an urban area in the North East of England, the authors used several focus groups (total of 30 participants) to look at the socio-cultural links to steroid use (AAS) and the link between steroid use and heroin.

    Findings

    • Participants, including those who were heroin users, viewed heroin use with a great deal of stigma.

    Hiding weight loss

    • Due to the association of heroin with weight loss, participants associated heroin recovery with weight gain. They commented that recovery involved stopping heroin, going to the gym, eating more and becoming bigger in size and more muscular. One participant commented that he used steroids partly to make his family believe that he was recovering from heroin.

    Intimidation purposes

    • Several participants felt that in order to function well in their social environment (e.g. drug dealer or other roles) they needed steroids for intimidation purposes. The increased strength and increased physical size, helped heroin users to function well within their social context. Participants commented that they used steroids for both intimidation purposes and for progression to being a more effective drug-dealer.
    • Participants who had been in prison said that limited opportunities to do other things and boredom contributed to their focus on increasing their size and strength.

    Other studies also, have found that steroids were used for reasons such as “to feel brave” and as an attempt to hide the effects of heroin.

    Conclusion

    There are important socio-cultural reasons for the association between heroin and AAS use, which include the need to function through intimidation, and to hide the stigma associated with heroin use. It is important to note that most steroid users do not use heroin and most heroin users do not use steroids. Further research could focus on determining which heroin users are at risk of using steroids and of those who use them, investigating who is at the greatest risk for developing dependence on steroids.

    Cornforda, C.S., Keanb, J., and Nash, A. (2014). Anabolic–androgenic steroids and heroin use: A qualitative study exploring the connection. Journal of International Drug Policy. Vol. 25, Issue, 5. Pp. 928-930.