Availability of needle and syringe exchange programs and opioid substitution therapy

Via:  http://goo.gl/T673pu

“Bureaucracy & Beliefs”: Assessing the Barriers to Accessing Opioid Substitution Therapy by People Who Inject Drugs in Ukraine

Aims

Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine’s estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid dependent PWIDs have not been examined in Ukraine.

Methods

A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in 5 major Ukrainian cities in 2013 covering drug treatment attitudes and beliefs and knowledge of and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST.

Findings

A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists, and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone’s side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment.

Conclusions

Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.

Full article at:   http://goo.gl/53ASEL

By:  Martha J. Bojko,1 Alyona Mazhnaya,2 Iuliia Makarenko,3 Ruthanne Marcus,1 Sergii Dvoriak,3 Zahedul Islam,2 andFrederick L. Altice1,4

¹Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA

²ICF International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine

³Ukrainian Institute for Public Health Policy, Kyiv, Ukraine

⁴Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, Connecticut, USA

Correspondence: Martha J Bojko, PhD, Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases - AIDS Program, 135 College St., Suite 323, New Haven, CT 06510-2483, Mobile (U.S.): +1 (860) 729 04 80, Mobile (Ukraine): +38 (050) 723 15 53

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Impact of Opioid Substitution Therapy for Scotland's Prisoners on Drug‐Related Deaths Soon After Prisoner Release

Aim

To assess whether the introduction of a prison‐based opioid substitution therapy (OST) policy was associated with a reduction in drug‐related deaths (DRD) within 14 days after prison release.

Design

Linkage of Scotland's prisoner database with death registrations to compare periods before (1996–2002) and after (2003–07) prison‐based OST was introduced.

Setting

All Scottish prisons.

Participants

People released from prison between 1 January 1996 and 8 October 2007 following an imprisonment of at least 14 days and at least 14 weeks after the preceding qualifying release.

Measurements

Risk of DRD in the 12 weeks following release; percentage of these DRDs which occurred during the first 14 days.

Findings

Before prison‐based OST (1996–2002), 305 DRDs occurred in the 12 weeks after 80 200 qualifying releases, 3.8 per 1000 releases [95% confidence interval (CI) = 3.4–4.2]; of these, 175 (57%) occurred in the first 14 days. After the introduction of prison‐based OST (2003–07), 154 DRDs occurred in the 12 weeks after 70 317 qualifying releases, a significantly reduced rate of 2.2 per 1000 releases (95% CI = 1.8–2.5). However, there was no change in the proportion which occurred in the first 14 days, either for all DRDs (87: 56%) or for opioid‐related DRDs.

Conclusions

Following the introduction of a prison‐based opioid substitution therapy (OST) policy in Scotland, the rate of drug‐related deaths in the 12 weeks following release fell by two‐fifths. However, the proportion of deaths that occurred in the first 14 days did not change appreciably, suggesting that in‐prison OST does not reduce early deaths after release.

Full article at:  http://goo.gl/Zb7RcW

By:  Sheila M. Bird, 1 Colin M. Fischbacher, 2 Lesley Graham, 2 and Andrew Fraser 3

¹MRC Biostatistics Unit, Cambridge, UK

²NHS National Services Scotland, Edinburgh, UK

³NHS Health Scotland, Edinburgh, UK

Corresponding author.

^*Correspondence to: Sheila M. Bird, MRC Biostatistics Unit, Cambridge CB2 0SR, UK. E‐mail: ku.ca.mac.usb-crm@drib.aliehs

Published online 2015 Jun 8. doi:  10.1111/add.12969, Addiction. 2015 Oct; 110(10): 1617–1624.

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Differences in Polysubstance Use Patterns & Drug-Related Outcomes between People Who Inject Drugs Receiving & Not Receiving Opioid Substitution Therapies

AIMS:

To test if polysubstance use profiles and drug-related outcomes differ between those receiving and not receiving opioid substitution therapies (OST), among people who inject drugs (PWID).

DESIGN:

An annual cross-sectional, sentinel sample of PWID across Australia 

SETTING: 

Data came from three years (2011-2013) of the Illicit Drug Reporting System (IDRS).

PARTICIPANTS:

A total of 2,673 participants who injected drugs from the combined national IDRS samples of 2011 (n = 868), 2012 (n = 922), and 2013 (n = 883) 

MEASUREMENTS: 

Latent Class Analysis (LCA) was used to summarise participants' self-reported use of 18 types of substances, with the resulting polysubstance use profiles then associated with participant experience of a number of drug-related outcomes.

FINDINGS:

Polysubstance use profiles exhibiting a broad-range of substance use were generally at increased risk of negative drug-related outcomes whether participants were receiving OST or not: including thrombosis among OST receivers [odds ratio (OR)=2.13, 95% confidence intervals (CI) = 1.09-4.17], injecting with used needle among OST receivers and non-receivers respectively, and violent criminal offences among OST receivers and non-receivers respectively. An important exception was non-fatal overdose which was specifically related to a class of PWID who were not receiving OST and used morphine frequently.

CONCLUSION:

Regardless of opioid substitution therapies usage, people who inject drugs (PWID) who use a broad-range of substances experience greater levels of injecting-related injuries and poorer health outcomes and are more likely to engage in criminal activity than other groups of PWID.

Purchase full article at:   http://goo.gl/qJULgj

By:  Betts KS1, Chan G2, McIlwraith F3, Dietze P4, Whittaker E5, Burns L5, Alati R6.

• 1School of Population Health, The University of Queensland, 4th floor, Public Health Building, Herston Rd, Herston, QLD, 4006, Australia.
• 2Centre for Youth Substance Abuse, University of Queensland, Brisbane, Australia.
• 3QADREC, School of Population Health Building, University of Queensland, Brisbane.
• 4MacFarlane Burnet Institute for Medical and Public Health Research, Melbourne, Australia.
• 5National Drug and Alcohol Centre, University of New South Wales, NSW, 2052, Australia.
• 6School of Public Health and Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, Australia.
• Addiction. 2016 Feb 8. doi: 10.1111/add.13339.

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Conspicuous By Their Abstinence: The Limited Engagement of Heroin Users in English & Welsh Drug Recovery Wings`

Background

In recent years, an abstinence-focused, ‘recovery’ agenda has emerged in UK drug policy, largely in response to the perception that many opioid users had been ‘parked indefinitely’ on Opioid Substitution Therapy (OST). The introduction of ten pilot ‘Drug Recovery Wings’ (DRWs) in 2011 represents the application of this recovery agenda to prisons. This paper describes the DRWs’ operational models, the place of opiate dependent prisoners within them, and the challenges of delivering ‘recovery’ in prison.

Methods

In 2013, the implementation and operational models of all ten pilot DRWs were rapidly assessed. Up to three days were spent in each DRW, undertaking semi-structured interviews with a sample of 94 DRW staff and 102 DRW residents. Interviews were fully transcribed, and coded using grounded theory. Findings from the nine adult prisons are presented here.

Results

Four types of DRW were identified, distinguished by their size and selection criteria. Strikingly, no mid- or large-sized units regularly supported OST recipients through detoxification. Type A were large units whose residents were mostly on OST with long criminal records and few social or personal resources. Detoxification was rare, and medication reduction slow. Type B's mid-sized DRW was developed as a psychosocial support service for OST clients seeking detoxification. However, staff struggled to find such prisoners, and detoxification again proved rare. Type C DRWs focused on abstinence from all drugs, including OST. Though OST clients were not intentionally excluded, very few applied to these wings. Only Type D DRWs, offering intensive treatment on very small wings, regularly recruited OST recipients into abstinence-focused interventions.

Conclusion

Prison units wishing to support OST recipients in making greater progress towards abstinence may need to be small, intensive and take a stepped approach based on preparatory motivational work and extensive preparation for release. However, concerns about post-release deaths will remain.

Purchase full article at:   http://goo.gl/fbXIqP

By:   Geoff Page, Lorna Templeton, Sharon Grace, Paul Roberts, Neil McKeganey, Chris Russell, Alison Liebling, Zetta Kougali, Charlie Lloyd

Affiliations

Mental Health and Addictions Research Group, Department of Health Sciences, University of York, YO10 5DD

Correspondence

Corresponding author. ARC/208a, Area 4, ARRC Building, Department of Health Sciences, University of York, YO10 5DD. Tel.: +01904 321670.

  

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A Cost-Effectiveness Analysis of Opioid Substitution Therapy Upon Prison Release in Reducing Mortality among People with a History of Opioid Dependence

Although opioid substitution therapy (OST) immediately after prison release reduces mortality, the cost-effectiveness of treatment has not been examined. Therefore, we undertook a cost-effectiveness analysis of OST treatment upon prison release and the prevention of death in the first 6 months post-release.

Design: Population-based, retrospective data linkage study using records of OST entrants (1985-2010), charges and court appearances (1993-2011), prison episodes (2000-11) and death notifications (1985-2011).

Participants: A cohort of 16 073 people with a history of opioid dependence released from prison for the first time between 1 January 2000 and 30 June 2011.

Intervention: OST treatment compared to no OST treatment at prison release.

Measurements: Mortality and costs (treatment, criminal justice system-court, penalties, prison-and the social costs of crime) were evaluated at 6 months post-release. Analyses included propensity score matching, bootstrapping and regression.

A total of 13 468 individuals were matched (6734 in each group). Twenty (0.3%) people released onto OST died, compared with 46 people (0.7%) not released onto OST. The final average costs were lower for the group that received OST post-release ($7206 versus $14 356). The incremental cost-effectiveness ratio showed that OST post-release was dominant, incurring lower costs and saving more lives. The probability that OST post-release is cost-effective per life-year saved is 96.7% at a willingness to pay of $500.

Opioid substitution treatment (compared with no such treatment), given on release from prison to people with a history of opioid dependence, is cost-effective in reducing mortality in the first 6 months of release.

Purchase full article at: http://goo.gl/BJ5B0g

By:  Gisev N1, Shanahan M1, Weatherburn DJ2, Mattick RP1, Larney S1,3, Burns L1, Degenhardt L1,4.

• 1National Drug and Alcohol Research Centre, UNSW Australia, Sydney, New South Wales, Australia.
• 2New South Wales Bureau of Crime Statistics and Research (BOCSAR), Sydney, New South Wales, Australia.
• 3Alpert Medical School, Brown University, Providence, Rhode Island, USA.
• 4School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia. 

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Drug-Related HIV Epidemic in Pakistan: A Review of Current Situation & Response & the Way Forward Beyond 2015

Pakistan is among four countries in Asia where the estimated number of new HIV infections has been increasing year by year ever since 1990. The Asian Epidemic Modelling (AEM), conducted in 2015, reconfirmed that the use of contaminated injection equipment among people who inject drugs (PWID) remains the main mode of HIV transmission in the country. 

The estimated number of PWID ranges from 104,804 to 420,000 PWID. HIV prevalence in this population is above 40 % in several cities, including Faisalabad (52.5 %), D.G. Khan (49.6 %), Gujrat (46.2 %), Karachi (42.2 %) and Sargodha (40.6 %), respectively. Harm reduction service delivery is being implemented through a public-private partnership led by the National and Provincial AIDS Control Programmes and Nai Zindagi with funding support from the Global Fund. Current programmatic coverage of the needle and syringe programme, HIV testing and counselling and antiretroviral treatment among PWID remain insufficient to control ongoing transmission of HIV in the country. 

While opioid substitution therapy (OST) is yet to be introduced, significant progress and coordination among various ministries have taken place recently to register buprenorphine in the dosage required for treatment of opioid dependence, and possible introduction of OST will greatly facilitate adherence to antiretroviral treatment among PWID living with HIV.

Full article at:  http://goo.gl/Qu22bC

By: Anne Bergenstrom^1*, Baseer Achakzai², Sofia Furqan², Manzoor ul Haq³, Rajwal Khan⁴and Marc Saba⁴

¹United Nations Office of Drugs and Crime (UNODC), Plot 5-11, Diplomatic Enclave-II, G-4, Islamabad 44000, Pakistan

²National AIDS Control Programme, National Institute of Health, Chak Shahzad, Park Road, Islamabad 44000, Pakistan

³United Nations Office of Drugs and Crime (UNODC), Plot 5-11, Diplomatic Enclave-II, G-4, Islamabad 44000, Pakistan

⁴UNAIDS Country Office for Pakistan & Afghanistan, Level-5, Serena Business Complex, Khyaban-e-Suhrwardy, Islamabad, Pakistan

  

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The Effects of Opioid Substitution Treatment and Highly Active Antiretroviral Therapy on the Cause-Specific Risk of Mortality among HIV-Positive People Who Inject Drugs

Prior studies indicated opioid substitution treatment (OST) reduces mortality risk and improves the odds of accessing highly active antiretroviral therapy (HAART); however, the relative effects of these treatments for human immunodeficiency virus (HIV)-positive people who inject drugs (PWID) are unclear. We determine the independent and joint effects of OST and HAART on mortality, by cause, within a population of HIV-positive PWID initiating HAART.

Using a linked population-level database for British Columbia, Canada, we used time-to-event analytic methods, including competing risks models, proportional hazards models with time-varying covariates, and marginal structural models, to identify the independent and joint effects of OST and HAART on all-cause as well as drug- and HIV-related mortality, controlling for covariates.

Among 1727 HIV-positive PWID, 493 (28.5%) died during a median 5.1 years of follow-up: 

• 18.7% due to drug-related causes, 
• 55.8% due to HIV-related causes, 
• and 25.6% due to other causes. 

Standardized mortality ratios were 12.2 during OST and 30.0 during periods out of OST. Both OST and HAART decreased the hazard of all-cause mortality; however, individuals were at lowest risk of death when these medications were used jointly. Both OST and HAART independently protected against HIV-related death, drug-related death and death due to other causes.

While both OST and HAART are life-saving treatments, joint administration is urgently needed to protect against both drug- and HIV-related mortality.

Via:  http://ht.ly/SpmkD 

By: Nosyk B1, Min JE2, Evans E3, Li L3, Liu L4, Lima VD5, Wood E5, Montaner JS5.

• 1BC Centre for Excellence in HIV/AIDS, Vancouver Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
• 2BC Centre for Excellence in HIV/AIDS, Vancouver.
• 3University of California-Los Angeles Integrated Substance Abuse Programs.
• 4Department of Preventative Medicine, Northwestern University, Chicago, Illinois.
• 5BC Centre for Excellence in HIV/AIDS, Vancouver Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
• 
  
  
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Incidence & Predictors of Non-Fatal Drug Overdose After Release from Prison among People Who Inject Drugs in Queensland, Australia

The incidence of reported overdose was highest between 1 and 3 months post-release (37.8 per 100 person-years (PY) among PWID; 24.5/100 PY among all ex-prisoners). In adjusted analyses, the risk of post-release non-fatal overdose was higher for PWID who reported: being unemployed for >6 months before prison, having been removed from family as a child, at least weekly use of benzodiazepines and/or pharmaceutical opiates in the 3 months prior to prison, and ever receiving opioid substitution therapy (OST). Pre-release psychological distress and a lifetime history of mental disorder also predicted overdose, whereas risky alcohol use in the year before prison was protective.

PWID have a high risk of overdose following release from prison. Imprisonment is an opportunity to initiate targeted preventive interventions such as OST, overdose prevention training and peer-delivered naloxone for those with a high risk profile

Via: http://ht.ly/SiRWf 

By: Winter RJ1, Stoové M2, Degenhardt L3, Hellard ME2, Spelman T4, Jenkinson R5, McCarthy DR6, Kinner SA7.

• 1Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia
• 2Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia.
• 3National Drug and Alcohol Research Centre, University of New South Wales, Australia; Melbourne School of Population and Global Health, University of Melbourne, Australia.
• 4Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia; Victorian Infectious Diseases Service, Doherty Institute, Australia.
• 5Centre for Population Health, Burnet Institute, Australia; Australian Institute of Family Studies, Australia.
• 6Centre for Population Health, Burnet Institute, Australia.
• 7School of Public Health and Preventive Medicine, Monash University, Australia; Melbourne School of Population and Global Health, University of Melbourne, Australia; School of Medicine, University of Queensland, Australia.

Impact of Opioid Substitution Therapy for Scotland's Prisoners on Drug-Related Deaths Soon After Prisoner Release

To assess whether the introduction of a prison-based opioid substitution therapy (OST) policy was associated with a reduction in drug-related deaths (DRD) within 14 days after prison release.

Before prison-based OST (1996-2002), 305 DRDs occurred in the 12 weeks after 80 200 qualifying releases, 3.8 per 1000 releases [95% confidence interval (CI) = 3.4-4.2]; of these, 175 (57%) occurred in the first 14 days. After the introduction of prison-based OST (2003-07), 154 DRDs occurred in the 12 weeks after 70 317 qualifying releases, a significantly reduced rate of 2.2 per 1000 releases (95% CI = 1.8-2.5). However, there was no change in the proportion which occurred in the first 14 days, either for all DRDs (87: 56%) or for opioid-related DRDs.

Following the introduction of a prison-based opioid substitution therapy (OST) policy in Scotland, the rate of drug-related deaths in the 12 weeks following release fell by two-fifths. However, the proportion of deaths that occurred in the first 14 days did not change appreciably, suggesting that in-prison OST does not reduce early deaths after release.

Read more at: http://ht.ly/ScVe0

By: Bird SM1, Fischbacher CM2, Graham L2, Fraser A3.

• 1MRC Biostatistics Unit, Cambridge, UK.
• 2NHS National Services Scotland, Edinburgh, UK.
• 3NHS Health Scotland, Edinburgh, UK.

The Extramedical Use & Diversion of Opioid Substitution Medications & Other Medications in Prison Settings in Australia Following the Introduction of Buprenorphine-Naloxone Film

INTRODUCTION AND AIMS:

Around 65% of people incarcerated in prisons in Australia, America and Europe have a history of drug dependence, sometimes treated with opioid substitution treatment (OST) medications. Studies report that those in treatment in prison do engage in some level of diversion to others, whether on a voluntary or coerced basis. We aimed to examine the use of prescribed and non-prescribed OST medications by those in prisons, especially buprenorphine-naloxone film (BNX-F); the extent of non-adherence and diversion and reasons for such practices; and the impact of the introduction of BNX-F into the prison system.

DESIGN AND METHODS:

Mixed methods study drawing on: (i) structured interviews with current OST clients (n = 60) who reported being incarcerated in the 12 months prior to being interviewed and (ii) qualitative interviews with key experts working in corrections and prison (or justice) health settings.

RESULTS:

The majority were prescribed OST medications in prison, with 25% removing all or part of their supervised dose on at least one occasion, and 44% reporting use of non-prescribed medications. Some reported intravenous use (14% injected). One-third of OST recipients reported selling/sharing OST medications with others in prison. The introduction of BNX-F into the prison system saw different diversion methods used and removal from dosing within prison.

DISCUSSION AND CONCLUSIONS:

Despite prison being a highly regulated and controlled environment, some level of diversion and sharing of psychoactive medication occurs among prisoners. The buprenorphine formulations used in OST present particular challenges with respect to supervised dosing in this setting. [White N, Ali R, Larance B, Zador D, Mattick RP, Degenhardt L]. The extramedical use and diversion of opioid substitution medications and other medications in prison settings in Australia following the introduction of buprenorphine-naloxone film.

Via: http://ht.ly/RRnma

By: White N1, Ali R1, Larance B2, Zador D2, Mattick RP2, Degenhardt L2.

• 1Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, Australia.
• 2National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
  
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Cross-Sectional Assessments of Participants’ Characteristics & Loss To Follow-Up in the First Opioid Substitution Therapy Pilot Program in Kabul, Afghanistan

Below: Participants enrolled and surveyed in the OSTPP between February 2010 and May 2012. Eighty-three participants were initially enrolled and surveyed by MdM, 38 dropped-out, and 45 were retained. After 18 months, 57 clients were surveyed by JHU

Two cross-sectional surveys evaluated participants attending the OSTPP at baseline (n = 83) and 18 months after (n = 57). Questionnaires assessed socio-demographic, drug use behavior, and general and mental health factors. After 18 months, 57 participants remained in the OSTPP. Participants lost to follow-up were younger (p < 0.01) and married (p < 0.01) and had no family contact (p < 0.01). Participants at 18 months reported no criminal activity in the last month and only two (3.5 %) reported heroin use in the last month, constituting significant decreases from baseline.

While preliminary results are promising, further evaluation is needed to determine the feasibility of implementing OSTPP in this setting and effectiveness in reducing injection risk behaviors in Afghanistan.

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