Sector News

  1. Posted in:

    International Harm Reduction Awareness Day, May 7th

    This year’s theme is YOU, Harm-reductionist Heroes:
    Peer Drug Users, Professional, Volunteers.
    Get communicating: Tweet using the hashtag #IHRD18 & #HarmReductionHeroes to help build momentum for the day and add a Twibbon to your Facebook & Twitter profile picture

    The Yellow Cross was created in Denmark by a civil society and indicates a drug consumption room and that harm reduction is practiced here.

  2. Methadone Injection in a Canadian Context

    Background

    • According to the Substance Abuse and Mental Health Services Administration (2012), 669,000 people used heroin in the previous year in the United States. As well, the number of heroin users increased every year for five years in a row.

    • Although methadone is an effective treatment for patients with opioid use disorder and chronic pain, fatalities have continued to rise due to illicit methadone use.

    • The authors aimed to look at the factors associated with methadone injection in an urban Canadian setting where access to methadone prescribed through primary care physicians is common.

    Approach

    The authors used two prospective cohorts of individuals who use drugs in Vancouver (Vancouver Injection Drug Users Study (VIDUS), and AIDS Care Cohort).

    Findings

    • Approximately 7% of participants injected methadone over the study period. The authors found this behaviour to be associated with socioeconomic vulnerability and other addictions.

    • Methadone injection was not associated with enrolment in a methadone program. Interestingly, the findings of this study contrast with other studies, which propose that enrolment in a methadone maintenance program is associated with injection of methadone. Due to this, the authors suggest that these individuals may represent a sub-population of PWID “for whom evidence-based addiction treatment services remain out of reach.”

    • The rates of diversion (transfer of legally prescribed drugs from the patient to another person for illicit use) show a need to implement tools that enhance the flexibility of program rules for patients at low risk of diversion. , while at the same time ensuring that patients at risk of selling their medication ingest their medication at the time it is provided.

    • However, the authors also note that PWID may be purchasing and using street methadone as a means to reduce their heroin consumption and self-treat opioid withdrawal symptoms.

    Conclusion

    The injection of methadone is associated with several other high-risk behaviors. Due to this, access to methadone programs should be optimized while also making efforts to limit diversion of methadone to the street.

    Tucker, D., Milloy, M.J., Hayashi, K., Nguyen, P., Kerr, T., and Wood, K. (2015). Factors Associated with Illicit Methadone Injecting in a Canadian Setting. The American Journal on Addictions. 24:532-537.

  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.

  4. Cost-effectiveness of Harm Reduction Strategies

    Background

    Health care providers and governments across the globe are faced with an urgent task to improve health outcomes for PWID, specifically reducing increasing rates of HIV and HCV transmission.

    Approach

    The authors assess needle exchange programs (NSPs), opioid substitution therapy (ORT), and antiretroviral therapy (ART) in isolation and then in combination.

    Findings

    Effectiveness and Cost-effectiveness of needle syringe programs (NSPs)

    • NSPs are generally the least expensive at $23 -$71 (US) per person each year. This variation is cost depends on region of the world and the delivery system (e.g. pharmacies, mobile outreach).

    Effectiveness and Cost effectiveness of opioid substitution therapy (OST)

    • OST is a structural intervention with other societal benefits. Although it is more expensive than NSP, the largest benefits relate to a reduction in the number and severity of relapses due to opiate use, as well as, lower rates of criminal activity and incarceration for drug related crimes. OSTs are particularly more cost effective when these factors are included in economic analyses.

    Effectiveness and Cost effectiveness of antiretroviral therapy ART

    • Several studies have shown that ART is cost-effective for both keeping people alive and for the prevention benefits it offers.
    • A Russian study found that ART would cost approximately $1501 (US) per QALY gained when targeted to PWID. This is considered good value for money.
    • ART costs are expected to decline by 2020

    Effectiveness and Cost effectiveness of combination strategies

    • Comprehensive strategies appear to be a better approach because generally no single harm reduction strategy is sufficient.
    • Research shows that needle syringe programs (NSPs), opioid substitution programs, and antiretroviral therapy (ART) together have shown to be effective to reduce drug dependency, reduce injection equipment sharing, improve quality of life, and avoid HIV infections.
    • Overall, the unit cost of harm reduction interventions is low, but it can vary based on type of provider, delivery model, and region.

    Conclusion

    Harm reduction interventions are good value for the money invested and improve health outcomes for PWID, as well as, the broader population. Currently, coverage of harm reduction programs is too low across almost all global regions. Although scaling up is costly, it is worthwhile not only for the societal benefits, but also for the significant returns on investment for governments.

    Wilson, D.P., Donald, B., Shattock, A.J., Wilson, D., and Fraser-Hunt, N. (2015). The cost-effectiveness of harm reduction. International Journal of Drug Policy. Vol. 26, pp. S5-S11.

  5. Crack-Cocaine Abuse: Overview of Interventions

    Background

    • Globally, approximately 14-21 million (0.3-0.5%) are cocaine users.
    • The prevalence of cocaine use is estimated to be highest in the Americas as it is the second most common illicit drug used.
    • Crack-cocaine makes up an extensive proportion of cocaine use and is the most commonly used non-injection drug among street drug user populations.
    • Psychiatric problems, HCV, HIV, and tuberculosis are higher among crack-users. Also, mortality rates are 4-8 times higher when compared to the general population.
    • Many crack users are socially and economically marginalized, which results in limited social, health, and/or treatment services.
    • Due to a lack of targeted prevention and treatment specifically for crack use, the authors provide a comprehensive overview of secondary prevention and treatment interventions with a specific focus on crack-cocaine misuse.

    Findings

    Diverse Psycho-social treatment

    • A large body of evidence shows that psycho-social treatment (e.g. cognitive/behavioural therapy, peer-delivered interventions) can reduce drug use, as well as the negative health impacts associated with it. Though limited, it may, be the best treatment currently available for cocaine/crack.
    • Psycho-social treatment that incorporates Contingency Management (e.g. housing contingent on drug abstinence, vouchers for cocaine-free urine samples) may be the primary reason for the effectiveness of psycho-social treatment. Contingency Management shows greater efficacy in achieving periods of drug abstinence in crack user populations.

    Pharmaceutical treatment

    • Many studies explored pharmacotherapy treatment options for cocaine/crack-dependence, however, despite the multiple drugs tested, studies have shown no pharmacological treatments to be overall effective. At this point, the most promising options are glutamatergic and GABA (e.g. topiramate) as well as dexamphetine formulations.
    • Immunotherapy is considered a promising preventative-therapeutic approach, however so far the effects appear to be short lived and only in very specific populations. A new vaccine compound shows a reduction in cocaine seeking in animal studies, but it has not yet been studied in humans.

    Conclusion

    Even though crack use is as common as opioid and injection drug use, currently, there is no  ‘gold standard’ prevention and treatment intervention for crack abuse.  Further research is vital in order to develop treatments for crack/cocaine comparative to the effectiveness of other interventions such as needle exchange services and opioid maintenance treatment.

    Fischer, B., Blanken, P. and Da Silveira, D. et al. (2015). Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: A comprehensive narrative overview of English-language studies. International Journal of Drug Policy. Vol. 26. Pp. 352-363.

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    Encounters with Security Guards in Vancouver’s Eastside

    Background

    The number of licensed security guards in British Columbia has doubled in the last decade. Currently, there are 17,000 licensed security guards in the province, which is twice the number of police officers. Security guards are often hired to patrol areas frequented by people who inject drugs (PWID) such as Vancouver’s Eastside. Recent qualitative research found that people who use drugs in this area are often subject to discriminatory surveillance and abuse by security guards. As well, previous findings suggest that security guard presence may prevent access to health care services.

    Findings:

    • One third of the sample reported at least one encounter with a security guard in the course of the 8-year study.
    • Of the 1172 reported encounters with security guards, participants most commonly reported that they were told to move on (70.6%); verbally abused (15.6%); assaulted (7.6%); detained (5.4%); or chased (5.1%) by security guards.
    • People who inject drugs (PWID) who have encounters with security guards were generally marginalized on several markers of vulnerability and drug related harm such as unstable housing, experiencing violence, non-fatal overdose, syringe sharing, public injection and inability to access addiction treatment.
    • Security guards may be overstepping their legal authority when interacting with people who inject drugs, such as controlling access to public space and using excessive force.
    • The authors found an association between security guard contact and high-risk drug use behaviours, which aligns with previous research. For example, intensified police presence has been shown to promote rushed injections, hinder access to sterile injection equipment from harm reduction services, which could contribute to syringe sharing.
    • Interaction with security guards was positively associated with inability to access addiction treatment, which was also found in a previous study.

    Conclusion

    Accounts of specific interactions with security guards suggest that reforms need to be made to ensure that security guards do to not overstep their legal boundaries in their interactions with people who inject drugs. Broader structural interventions are required to assess risk and harm for people who inject drugs in public spaces.

    Kennedy, M.C., Milloy, M.-J., Markwik, N. et al. (2016). Encounters with private security guards among people who inject drugs in a Canadian setting. International Journal of Drug Policy. 28:124-127.

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    Opiate Substitution Programs and Needle and Syringe Programs can Reduce Injection Risk Behaviour

    Systematic Review of Reviews finds that Opiate Substitution Programs and Needle and Syringe Programs can Reduce Injection Risk Behaviour, However a Stronger Evidence Base for Interventions is needed to Prevent HIV and HCV Infection in People Who Inject Drugs.

    Background
    It is estimated that worldwide approximately 3 million people who inject drugs (PWID) may be living with HIV and 10 million may have HCV. Preventing initial infection of HIV and HCV is therefore critical to reduce long-term morbidity amongst people who inject drugs.

    Approach
    Authors categorized/rated reviews according to a set of criterion in order to assess the quality of the evidence.

    Findings
    Needle Syringe Programs (NSP)
    Thirty-nine of 43 studies found a reduction of injection risk behavior (IBR) associated with needle syringe programs (NSP). However, the effectiveness of NSP programs in the prevention of HIV was tentative and evidence for the prevention of HCV was considered insufficient by the authors.
    Opiate Replacement Therapy (OSP)
    Thirteen studies assessed prevalence of injecting drug use before and after OST and all found a decrease in injection risk behavior (IRB)
    Drug Preparation Equipment
    One study addressed the effect of provision of drug preparation equipment on HCV. This study found a positive impact, however was not considered sufficient evidence to support nor negate to show effectiveness.
    Provision of Foils
    No reviews were found on the provisions of foil to stimulate route transition, however this is not surprising given the recent introduction of this intervention. Primary studies may not yet be published.
    Information, Education and Counseling (IEC) and Outreach
    Five out of six core reviews found tentative of conclusive evidence in support of effectiveness of IEC in reducing IRB.
    Supervised Injection Facilities
    Authors concluded that there is tentative review level evidence to support the effectiveness of SIFs in reducing IRB and improving injecting hygiene.

    Conclusions
    – Interestingly, evidence for the effectiveness of NSP (needle syringe provision) and OST (opiate substitution treatment) was strongest in relation to IRB and HIV, yet the authors found little review-level evidence to support the impact of NSP and OST on HCV transmission.
    Possible reasons for lack of evidence for HCV interventions
    o A lack of recent reviews.
    o Reductions observed in IRB studies may not be sufficient to reduce risk of incidence in HCV infection since HCV has greater transmissibility via syringe sharing or needle-stick injury compared to HIV.
    o Very low levels of sharing, such as a few times per month, may be required to have an impact on HCV transmission between people who inject drugs.

    – Interventions need to target both recent and longer-term injectors to have an impact of HCV incidence.
    – A recent meta-analysis found a synergistic impact of NSP and OST in relation to HCV incidence. Those receiving OST and at least one sterile needle from NSP per injection had a 79% reduction in risk of HCV seroconversion as compared to those not receiving OST and with less than one sterile needle per injection. In addition, a cohort study found greater benefit of participation in NSP and OST compared to NSP or OST alone in relation to both HCV and HIV transmission.
    – Combinations of harm reduction interventions provided with sufficient coverage is needed to impact on HCV and HIV transmission. Globally, only 6-12% of people who inject drugs (PWID) receive OST and only 1 to 4 needles are distributed per PWID per month.
    – Identification of insufficient review level evidence relating to particular interventions does not infer a lack of effectiveness but rather a gap in the evidence base, inappropriate study designs, findings that have yet to be published, variability in prevalence and incidence of HIV or HCV and the inclusion of high risk populations.

    Summary
    Although interventions such as OST, NSO, or IEC can be effective in reducing HIV or HCV transmission and IRB, the evidence base regarding the impact of the range of harm reduction interventions on HIV and HCV transmission remains limited. Emerging evidence suggests that interventions need to be provided at high coverage and in combination to minimize risk of HCV and HIV infection amongst people who inject drugs.

    MacArthur, G.J., Velzen, E., Palmateer, N. et al. (2014). Interventions to prevent HIV and Hepatitis C in People who inject drugs: A review of reviews to assess evidence of effectiveness. International Journal of Drug Policy. Vol, 25. Pp. 34-52.

  8. Support. Don’t Punish

    SUPPORT. DON’T PUNISH is a global advocacy campaign to raise awareness of the harms being caused by the war on drugs. The campaign aims to promote drug policies that respect human rights and protect public health, to change laws and policies which impede access to harm reduction interventions and other evidence-based services, and to end the criminalisation of people who use drug
    For more information on all of this, please visit www.supportdontpunish.org

    A global advocacy campaign calling for drug policies based on health and human rights.

  9. International Harm Reduction Day – May 7, 2015

    May 7th, 2015  is International Harm Reduction Day .

    To learn more about how you can get involved, CLICK HERE.

  10. World Health Organization has a new guideline on HIV prevention, diagnosis, and treatment

    This new HIV guideline by the WHO consolidates guidelines relevant to men who have sex with men, people who use drugs, people in prison, sex workers, and transgender people. The hope is that this new guideline will act as one comprehensive package for all key populations. To learn more CLICK HERE