Sector News

  1. Perceived Risk of Opioid Overdose

    Background

    Globally, opioid use is on the rise. Opioid dependence is estimated as the largest contributor to the global burden of disease from drug dependence. In the United Stated, over 25 million people began using nonmedical opioids between 2002 and 2011. During this time, the drug-poisoning mortality rate more than doubled.

    Method

    The authors surveyed 172 opioid users in San Francisco to assess predictors of risk perception for opioid overdose.

    Findings

    • Older individuals and those who injected more frequently were less likely to see themselves at a high risk for opioid overdose. However, the literature indicates that those who are older are actually more likely to die from overdose.
    • Those who injected more frequently were less likely to perceive themselves as high risk for overdose.
    • Interestingly, although concurrent use of opioids and alcohol was associated with a high-perceived risk of overdose, concurrent use of opioids and benzodiazepines or cocaine was not. Yet previous research shows that concurrent use of these substances is linked to opioid overdose.
    • Participants who experienced a past overdose, used heroin and mixed opioids and alcohol more frequently were more likely to see themselves as high risk for overdose. This finding is consistent with the literature, which shows previous overdose to be the strongest predictor of overdose and overdose death.
    • HCV positive participants were more likely perceive themselves at high risk for overdose. However this association was not found amongst HIV positive participants, despite the risks. This suggests a gap in risk perception amongst this particular population.

    Conclusion

    There are gaps in awareness between real overdose risk factors and perceived overdose risk amongst opioid users. The authors highlight the need for educational interventions.

    Rowena, C., Santos, G.M., Behar, E., and Coffin P.O. (2016). Correlates of overdose risk perception among illicit opioid users. Drug and Alcohol Dependence. 159: 234-239.

  2. Posted in:

    HCV Among People Who Inject Drugs in Rural Puerto Rico

    Background

    Although we know that the microbial differences between HIV and HCV have an impact on prevalence, how drugs are obtained and used may also influence prevalence. Recent studies show Puerto Rico has one of the highest HCV prevalence rates in the world.

    Aim

    The authors looked risk factors of 315 rural Puerto Rican people who inject drugs (PWID) and also compared the behaviours of HCV negative and HCV positive participants.

    Method

    INSTI Rapid HIV and OraQuick Rapid tests were used to determine HIV and HCV status. Additional data was acquired through questionnaires.

    Findings

    • Over three quarters (78.4%) of the participants were positive for HCV and significantly fewer (6.0%) were HIV positive.
    • All HIV positive individuals were also infected with HCV.
    • Both HCV positive and HCV negative reported the same frequency of injection drug use during the last year.
    • Each additional person who used equipment before the participant was associated with an increase 18% increase in the odds of being HCV + positive.
    • Frequency of injection with a used cooker was over twice as common as injection with a used needle.

    HCV + (pos) Characteristics

    • 3 years older (than HCV negative)
    • Began injecting at a younger age (20.7 vs 26.3)
    • Injected for 9.4 more years than HCV negative group
    • Used cookers, cotton and water after an average of 2 or more people

    Conclusion

    This adds to current research showing that a notable proportion of HCV infections are due to cooker or cotton sharing.

    Abadie, R., Welch-Lazoritz, M., Gelepi-Acosta, C., Reyes, J.C., and Dombrowski, K. (2016). Understanding differences in HIV/HCV prevalence according to differentiated risk behaviors in a sample of PWID in rural Puerto Rico. Harm Reduction Journal. 13:10-13.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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.