Sector News

  1. 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.

  2. 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.

  3. National Day of Action on the Overdose Crisis

    On February 21, 2017, a first national Day of Action will be held across Canada to demand different levels of government take meaningful and concrete action to address the opioid overdose epidemic devastating communities across the country. The demands include an end to the war on drugs, the removal of barriers to health care including immediate improved access to naloxone and opiate substitution therapy, and the implementation of policies that are informed by real life experiences of people who use drugs. Actions are taking place in Vancouver, Victoria, Edmonton, Ottawa, Toronto, Montreal, Halifax and other communities across Canada.

    Local organizations are seeking endorsements for their lists of demands. To sign on to the demands, or to find out more information about the actions taking place closer to you, visit https://www.facebook.com/events/371308773235925/?active_tab=about or contact admin@capud.ca.

  4. Injecting Risk Behaviours after Hepatitis C Virus Treatment in Australia

    Background

    Hepatitis C virus (HCV) infection prevalence is high among people who inject drugs (PWID) and is a major cause of morbidity and mortality among this population. Due to concerns that HCV treatment may increase injecting risk behaviours among people who inject drugs (PWID) the authors compared recent (past month) injecting risk behaviours between PWID who received and did not receive HCV treatment.

    Findings

    • Of the 124 Australian participants with a history of injection drug use, 69% were male with 68% treated for HCV infection.
    • HCV treatment was not associated with an increase in recent injection drug use (adjusted odds ratio (aOR) 1.06, 95% CI 0.93, 1.21). This is consistent with previous study findings.
    • HCV treatment was not associated with recent used needle and syringe borrowing (aOR 0.99, 95% CI 0.89, 1.08).
    • Treatment was associated with a decrease in recent ancillary injecting equipment sharing (aOR 0.85, 95% CI 0.74, 0.99). This is important given that sharing of equipment contributes to HCV transmission.
    • Although a small sample, the 24 participants who remained in follow-up (24 weeks) showed a significant decrease in injecting equipment sharing during follow-up. This is at least interesting to note because the side effects of interferon-based therapy mimic opioid withdrawal, which is a concern for some physicians (they worry that treatment might lead to relapse or an increase in drug use).

    Conclusion

    Hepatitis C virus assessment and treatment for people who inject drugs should be enhanced due to its effectiveness as it does not lead to increases in injection risk behaviours and has already been shown to be safe and effective for PWID populations.

    Alavi, M.,  Spelman, T.,  & Matthews, G.V. (2015). Injecting risk behaviours following treatment for hepatitis C virus infection among people who inject drugs: The Australian Trial in Acute Hepatitis C. International Journal of Drug Policy. Vol. 26. Issue 10, pp. 976-983.

  5. 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.

  6. How does a Positive or Negative Hepatitis C Virus Test Impact Behavior?

    Background

    • Worldwide, Hepatitis C virus (HCV) prevalence among injection drug users is estimated between 50% and 90%.
    • HCV testing and counselling can be used as an opportunity to influence behaviour and transmission of HCV at the time of test notification. For example, a study conducted in Montreal showed a decrease in syringe sharing after participants were made aware of both positive and negative HCV test results in an addition to a reduction of alcohol use. However the results were limited due to a small sample size.

    Approach

    • The authors used data from the International Collaboration of Incident HIV and HCV Infection in Injecting Cohorts (InC3 Study), which is a multicohort study of pooled data from prospective studies of people who inject drugs (PWID) in Canada, USA, The Netherlands, and Australia. Participants were recruited and followed between 1985 and 2011. The sample included 829 people who inject drugs.

    Findings

    • Notification of a HCV test result showed a reduction in recent injection drug use and recent syringe sharing for both those who received a positive and negative HCV test result (5% and 3% reduction, respectively). There were no significant differences between the two groups.
    • Recent Australian and Canadian data show some sustained behavioural changes associated with the notification process.
    • The proportion of participants using alcohol increased among those who received a positive HCV test
    • Younger (under 25 years) PWID populations who received a positive HCV test significantly increased alcohol consumption in comparison to the HCV-negative group.

    Conclusion

    Timely notification of HCV test results is a key opportunity for risk behavior reduction counseling. In addition, there is need to expand post-test counseling services and monitoring in order to address post-diagnosis alcohol use.

    Spelman, T., Morris, M.D., and Zang, G. (2015). A longitudinal study of hepatitis C virus testing and infection status notification on behavior change in people who inject drugs. J Epidemiol Community Health. 69(8): 745–752.

  7. 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.

  8. Posted in:

    Targeting Hepatitis C virus Treatment ~ Who should be treated to first?

    Background

    Due to the high cost of improved Hepatitis C virus treatment, in most cases, it is not feasible to offer treatment to all injection drug users at once. In order to optimize the benefits for the overall injection population, targeting HCV treatment appropriately is vital. Previously, treatment has been withheld from active injectors because of the risk that they may become re-infected and limit the benefits to themselves and the whole population.

    Approach

    The authors of this study look at the population-level benefits of treating one chronically HCV infected injection drug user in a population of high- and low- risk users. They then compared the benefits of treating one high or low risk user to develop an optimal treatment strategy.

    Findings

    • High-risk injectors share injecting equipment approximately 7 times more frequently than low-risk injectors.
    • When approximately 32% of injectors are infected with Hepatitis C, the preventative impact of treating high and low risk injectors is equivalent

    (1 high-risk injector = 1 low-risk injector).

    • When Hepatitis C Virus is rare, the benefits of preventing high-risk injectors spreading it to larger numbers outweighs the risk that they will become re-infected.
    • When the virus is already very common, fewer injectors can be infected, which reduces the spreading potential of high-risk users. At this point, it is better to focus efforts toward treating lower risk injectors who are less likely to become re-infected.

    Conclusion

    To enhance the preventative impact of hepatitis C virus treatment, interventions should be targeted based on how often the patient shares injecting equipment. When Hepatitis C virus is relatively uncommon among injectors, it is best to cure infected high-risk injectors. When the virus is relatively common, low-risk injectors should be targeted.

    De Vos, A.S., Prins, M., and Kretzschmar, M.E.E. (2015). Hepatitis C virus treatment as prevention among injecting drug users: who should we cure first? Addiction. Vol.110, pp. 975-983.

  9. Exploring Health Services Access to Non-active Injectors

    Background

    It is important for former injectors to maintain connections with syringe exchange programs (SEPs) in order to access general social and health services that will help them to maintain sobriety. This study looked at walking distance to needle exchange programs for both current and former people who inject drugs (PWID).

    Approach

    The study surveyed 137 people who inject drugs who presented for services at syringe exchange program (SEP) mobile distribution sites in Washington DC.

    Findings

    • Active and non-active injectors do not have equal access to syringe exchange program (SEP) services.
    • Those who are not actively injecting may have less motivation to travel to access services compared to when they were actively injecting and seeking sterile equipment.
    • Non-active injectors may also be seeking healthcare services elsewhere.
    • Challenges to enhancing access to SEP services include policies that restrict where needle exchange programs can legally operate (e.g. certain proximity to schools). Future work should explore enhancing access in areas of greatest need.

    Conclusion

    Providing comprehensive services for former/non-active substance users, a vulnerable population, is important for addressing their complex medical and social health care needs such as addiction treatment and support and housing.

    Allen, S., Ruiz, M., and O’Rourk, A. (2015).How far will they go?: assessing the travel distance of current and former drug users to access harm reduction services. Harm Reduction Journal. Vol. 12. Issue 3.

  10. Challenges faced by Peer Helpers

    Background

    • The role of peer helpers came out of a need to address the limitations of the traditional “provider-client model.”
    • Mediators or Peer Helpers act as both secondary distribution agents and advocates. They have become a valuable component of the most successful strategies aimed at injection drug using communities as they bring the reality of the lives of marginalized populations into strategic discussions.
    • This study aimed to explore the difficult situations peer helpers may find themselves in when they attempt to implement harm reduction practices and balance potential serious health problems and even death against anticipated backlash from users, medical staff, and the community.

    Approach

    A series of focus group sessions were conducted with peer helpers over a two-year time frame in Cape Breton, Canada.

    Findings/Key Themes

    Officially sanctioned peer helper practices

    • Overall, few moral dilemmas arose with the official distribution part of the peer helper role unless there was a shortage of supply.
    • Peer helpers viewed education of new users as a very important part of their harm reduction role. They felt that the hidden nature of injecting left them responsible for “how to” training.
    • Contrary to public discourse, peer helpers attempt to dissuade individuals from taking that first hit. However, they were exposed to threats from others such as neighbours and child protection workers because of how their role is perceived by the general public.
    • Peer helpers can be credited with the high rates of safe needle disposal. They play a key role in developing and reinforcing return practices.

    Unofficial peer helper practices

    • Given that peer helpers are viewed as authorities on safe injection within their community, one of the first ways they can be drawn into an unofficial role is through requests for assistance.
    • The imminent threat of death from overdose is on the top of the minds of peer helpers, not the threat of blood-borne pathogens.
    • Peer helpers are the ones who typically step in to deal with overdose and will usually make the call to emergency services despite repercussions from health professionals and police as well as the users themselves. As a result, peer helpers find themselves caught in the middle of competing courses of action – do they call the police or not?
    • Due to users’ hesitation to seek medical treatment, peer helpers find themselves treating wounds and abscesses. Some helpers find themselves saving and sharing antibiotics (even though they know it’s problematic) to help those who refuse to seek medical attention.
    • Many peer helpers also take on the role of counselor
    • Peer helpers lived experience enables them to empathize with those struggling with addiction – “they almost never give up on people.” They let people who were homeless come to their homes for food, a shower and a night’s sleep.

    Conclusion

    Peer helpers find themselves in difficult situations with user populations often because people who inject drugs feel undeserving of services and discriminated against when they do seek services. This adversely impacts users, and particularly the peer helpers seeking to assist them. In an effort to keep users alive, peer helpers engage in practices that extend far beyond their roles of disseminating sterile syringes and safe injection materials.

    Dechman, M.K. (2015). Peer helpers’ struggles to care for “others” who inject drugs. International Journal of Drug Policy. Vol. 26. Pp. 492-500.