Prescription Opioid Injection among HIV-Positive People Who Inject Drugs in a Canadian Setting

Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. 

We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. 

Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2% [interquartile range (IQR): 21.5-25.8 %]. 

In a multivariable generalized estimating equation model, 

• Caucasian ethnicity, 
• heroin injection, 
• and drug dealing were positively associated with PO injection, 

While older age and methadone maintenance treatment were negatively associated with PO injection (all p < 0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. 

These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.

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By:  Lake S^1,2, Kerr T^1,3, Buxton J², Guillemi S¹, Parashar S¹, Montaner J^1,3, Wood E^1,3, Milloy MJ^4,5.

¹British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

²School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada.

³Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

⁴British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-mjsm@cfenet.ubc.ca.

⁵Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-mjsm@cfenet.ubc.ca.

AIDS Behav. 2016 May 5. [Epub ahead of print] 

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The Rise of Mexican Black Tar - Video

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The impact of an automatic syringe dispensing machine in inner-city Sydney, Australia: No evidence of a 'honey-pot' effect

INTRODUCTION AND AIMS:

Needle and syringe automatic dispensing machines (ADM) aim to increase needle/syringe distribution to people who inject drugs. ADM implementation has been met with community concern about potential perceived increases in crime and drug use and that they will attract non-resident drug users-the 'honey-pot effect'. In April 2013, an ADM commenced operation in inner-city Sydney. We assessed the impact of the ADM on crime and examined its use by non-resident drug users (the honey-pot effect).

DESIGN AND METHODS:

Fixed-site needle and syringe program (n = 207) and ADM clients (n = 55) were surveyed to determine whether they lived within 1 km of the ADM. Police-recorded offences between January 2012 and March 2014 across six crime categories for the local and surrounding areas were assessed for trend to measure impact on crime.

RESULTS:

The majority (78%) of needle and syringe program clients reported residing within 1 km of the service. Most (95%) ADM users were fixed-site service clients. The 2 year trend for crime categories remained stable or decreased, except for fraud, which increased significantly (P < 0.05).

DISCUSSION AND CONCLUSION:

Automatic dispensing machine users were largely clients of the existing fixed-site service and lived locally. There was no apparent concurrent increase in crime or a honey-pot effect. It is important that services continue to be aware of community concerns and respond to them appropriate

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By:  Grau LE1, Zhan W1,2, Heimer R1.

• 1Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA.
• 2Department of Children and Families, Hartford, USA. 
• Drug Alcohol Rev. 2016 Apr 13. doi: 10.1111/dar.12396

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The Relationship Between Non-Medical Use of Prescription Opioids and Sex Work Among Adults in Residential Substance Use Treatment

Highlights

• Sex work (SW) is common among patients in residential substance use treatment.
• SW among individuals in addictions treatment is associated with more extensive substance use and greater psychiatric severity.
• Non-medical use of prescription opioids is widespread among individuals involved in SW.

High rates of substance use (e.g., alcohol, cocaine, heroin) have been documented among individuals who engage in sex work (SW), and adults seeking substance use disorder (SUD) treatment frequently report prior engagement in SW. Non-medical use of prescription opioids (NMUPO) has increased over the last decade, but little is known about the relationship between NMUPO with sex exchange. 

The purpose of this study was to describe the prevalence of recent SW among patients at a large residential SUD treatment center and examine the association between NMUPO and SW. Approximately 14% of 588 adults reported involvement in SW in the month prior to treatment. NMUPO was more common among those with a history of SW (95% of sex workers vs. 74% of non-sex-workers), and this association remained statistically significant after controlling for demographic factors, other substance use and psychiatric symptom severity (odds ratio=3.38). SW is relatively common among patients in residential SUD treatment, and is associated with greater psychiatric severity and more extensive substance use, including alarming rates of NMUPO. 

Addiction treatment for individuals involved in SW may benefit from the addition of content related to NMUPO.

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By:  Matusiewicz AK1, Ilgen MA2, Bonar EE3, Price A3, Bohnert AS2.

• VA Center for Clinical Management Research (CCMR), 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA; Department of Psychiatry, University of Michigan, 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor MI 48109 USA. Electronic address: amatusie@uvm.edu.
• 2VA Center for Clinical Management Research (CCMR), 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA; Department of Psychiatry, University of Michigan, 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA.
• 3Department of Psychiatry, University of Michigan, 2800 Plymouth Rd. Building 16, Ann Arbor MI 48109 USA. 
• J Subst Abuse Treat. 2016 May;64:24-8. doi: 10.1016/j.jsat.2016.01.010. Epub 2016 Feb 13.

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The Impact of Enrolment in Methadone Maintenance Therapy on Initiation of Heavy Drinking among People Who Use Heroin

BACKGROUND:

There is equivocal evidence regarding whether people who use heroin substitute heroin for alcohol upon entry to methadone maintenance therapy (MMT). We aimed to examine the impact of MMT enrolment on the onset of heavy drinking among people who use heroin.

METHODS:

We derived data from prospective, community-based cohorts of people who inject drugs in Vancouver, Canada, between December 1, 2005, and May 31, 2014. Multivariable extended Cox regression analysis examined the effect of MMT enrolment on the onset of heavy drinking among people who used heroin at baseline.

RESULTS:

In total, 357 people who use heroin were included in this study. Of these, 208 (58%) enrolled in MMT at some point during follow-up, and 115 (32%) reported initiating heavy drinking during follow-up for an incidence density of 7.8 events (95% CI 6.4-9.5) per 100 person-years. The incidence density of heavy drinking was significantly lower among those enrolled in MMT at some point during follow-up compared to those who did not (4.6 vs. 16.2). MMT enrolment was not significantly associated with time to initiate heavy drinking (adjusted relative hazard after adjustment for relevant demographic and substance-use characteristics. Age and cannabis use were the only variables that were independently associated with the time to onset of heavy drinking.

CONCLUSION:

In this study, MMT enrolment did not predict heavy drinking and may even appear to decrease the initiation of heavy drinking. Our findings suggest younger age and cannabis use may predict heavy drinking. These findings could help inform on-going discussions about the effects of opioid agonist therapy on alcohol consumption among people who use heroin.

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By:  Klimas J1, Wood E, Nguyen P, Dong H, Milloy MJ, Kerr T, Hayashi K.

• 1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, B.C., Canada.
• Eur Addict Res. 2016 Apr 6;22(4):210-214 

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Concurrent Heroin Use and Correlates among Methadone Maintenance Treatment Clients: A 12-Month Follow-up Study in Guangdong Province, China

Objective:

To assess concurrent heroin use and correlates among Methadone Maintenance Treatment (MMT) clients in Guangdong Province, China.

Method:

Demographic and drug use data were collected with a structured questionnaire, and MMT information was obtained from the MMT clinic registration system in Guangdong. Human immunodeficiency virus (HIV-) and hepatitis C virus (HCV) infected status and urine morphine results were obtained from laboratory tests. Logistic regressions were employed to investigate the factors associated with concurrent heroin use.

Results:

Among the 6848 participants, 75% continued using heroin more than once during the first 12 months after treatment initiation. Concurrent heroin use was associated with inharmonious family relationship, HIV positivity, having multiple sex partners, having ever taken intravenous drugs, higher maintenance dose and poorer MMT attendance. Among those who used heroin concurrently, the same factors, and additionally being older and female, contribute to a greater frequency of heroin use. 

Conclusions:

Concurrent heroin use was prevalent among MMT participants in Guangdong, underscoring the urgent needs for tailored interventions and health education programs for this population.

Full article at:  http://goo.gl/r6y8ol

By:  Xiaofeng Luo,1,2 Peizhen Zhao,3 Xiao Gong,1,2 Lei Zhang,4 Weiming Tang,3 Xia Zou,1,2 Wen Chen,1,2 and Li Ling1,2,*

¹Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhongshan Road II, Guangzhou 510080, China

²Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, 74 Zhongshan Road II, Guangzhou 510080, China

³Guangdong Center for Skin Guangdong Provincial Center for Skin Diseases and STIs Control, No. 2 Lujing Road, Guangzhou 510091, China;

⁴The Kirby Institute, University of New South Wales, Sydney NSW 2052, Australia

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Lethality of Opioid Overdose in a Community Cohort of Young Heroin Users

BACKGROUND:

The aim of the study was to estimate the lethality of opioid overdose among young heroin users.

METHODS:

A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models.

RESULTS:

The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5).

CONCLUSIONS:

Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose.

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By:  Espelt A1, Barrio G, Álamo-Junquera D, Bravo MJ, Sarasa-Renedo A, Vallejo F, Molist G, Brugal MT; ITINERE Project Group.

Eur Addict Res. 2015;21(6):300-6. doi: 10.1159/000377626. Epub 2015 May 28.

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Improvements in Health-Related Quality of Life among Methadone Maintenance Clients in Dar Es Salaam, Tanzania

BACKGROUND:

Injection of heroin has become widespread in Dar es Salaam, Tanzania and is spreading throughout the country. To prevent potential bridging of HIV epidemics, the Tanzanian government established a methadone maintenance treatment (MMT) clinic in February 2011. We assess the effect of MMT on health-related quality of life (HRQOL) and examine factors, particularly HIV infection and methadone dose, associated with changes in HRQOL.

METHODS:

This study utilized routine data on clients enrolling in methadone from February 2011 to April 2012 at Muhimbili National Hospital. Change in physical (PCS) and mental health (MCS) composite scores, as measured by the SF-12 tool, were the primary outcomes. Backward stepwise linear regression, with a criterion of p<0.2 was used to identify baseline exposure variables for inclusion in multivariable models, while adjusting for baseline scores.

RESULTS:

A total of 288 MMT clients received baseline and follow-up assessments. Mean methadone dose administered was 45mg (SD±25) and 76 (27%) were confirmed HIV-positive. Significant improvements were observed in PCS and MCS, with mean increases of 15.7 and 3.3, respectively. In multivariable models, clients who had previous poly-substance use with cocaine [p=0.040] had a significantly higher mean change in PCS. Clients who were living with HIV [p=0.002]; satisfied with current marital situation [p=0.045]; had a history of suicidal thoughts [p=0.021]; and previously experienced cognitive difficulties [p=0.012] had significantly lower mean change in PCS. Clients with shorter history of heroin use [p=0.012] and who received higher methadone doses [p=0.028] had significantly higher mean change in MCS, compared to their counterparts.

CONCLUSION:

Aspects of mental and physical health, risk behaviors and quality of life among drug users are intertwined and complex. Our research revealed positive short-term effects of MMT on HRQOL and highlights the importance of sustained retention for optimal benefits. Comprehensive supportive services in addition to provision of methadone are needed to address the complex health needs of people who inject drugs.

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By:  Ubuguyu O1, Tran OC2, Bruce RD3, Masao F1, Nyandindi C1, Sabuni N4, McCurdy S5, Mbwambo J1, Lambdin BH6.

• 1Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania.
• 2Pangaea Global AIDS, 436 14th St, Suite 920, Oakland, CA 94612, USA.
• 3Yale University, New Haven, CT 06520, USA.
• 4Tanzania Ministry of Health and Social Welfare, 6 Samora Machel Ave, Dar es Salaam, Tanzania.
• 5University of Texas School of Public Health, 7000 Fannin St, Houston, TX, USA.
• 6RTI-International, 351 California St, Suite 500, San Francisco, CA 94104, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA. Electronic address: blambdin@rti.org. 
• Int J Drug Policy. 2016 Mar 11. pii: S0955-3959(16)30065-2. doi: 10.1016/j.drugpo.2016.03.005

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Years of Potential Life Lost amongst Heroin Users in the Australian Treatment Outcome Study Cohort, 2001-2015

BACKGROUND:

Heroin use carries the highest burden of disease of any drug of dependence. The study aimed to determine mortality rates of the Australian Treatment Outcome Study cohort over the period 2001-2015, and the years of potential life lost (YPLL).

METHODS:

The cohort consisted of 615 heroin users. Crude mortality rates per 1000 person years (PY) and Standardised Mortality Ratios (SMR) were calculated. YPLL were calculated using two criteria: years lost prior to age 65, and years lost prior to average life expectancy.

RESULTS:

The cohort was followed for 7,790.9 PY. At 2015, 72 (11.7%) of the cohort were deceased, with a crude mortality rate of 9.2 per 1000 PYs. Neither age nor gender associated with mortality. The SMR was 10.2 (males 7.3, females 17.2), matched for age, gender and year of death. The most common mortality cause was opioid overdose (52.8%). Using the<65 years criterion, there were 1988.3 YPLL, with a mean of 27.6 (males 27.6, females 27.7). Using the average life expectancy criterion, there were 3135.1 YPLL, with a mean of 43.5 (males 41.9, females 46.3). Accidental overdose (<65yr 63.0%, average life expectancy 63.7%) and suicide (<65yr 12.8%, average life expectancy 13.3%) accounted for three quarters of YPLL where cause of death was known.

CONCLUSIONS:

YPLL associated with heroin use was a quarter of a century, or close to half a century, depending on the criteria used. Given the prominent role of overdose and suicide, the majority of these fatalities, and the associated YPLL, appear preventable.

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By:  Darke S1, Marel C2, Mills KL2, Ross J2, Slade T2, Tessson M2.

• 1National Drug and Alcohol Research Centre, University of New South Wales, Australia. Electronic address: s.darke@unsw.edu.au.
• 2National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia 
• Drug Alcohol Depend. 2016 Mar 18. pii: S0376-8716(16)00152-6. doi: 10.1016/j.drugalcdep.2016.03.010. 

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Ecological Momentary Assessment of Illicit Drug Use Compared to Biological and Self-Reported Methods

BACKGROUND:

The use of mHealth methods for capturing illicit drug use and associated behaviors have become more widely used in research settings, yet there is little research as to how valid these methods are compared to known measures of capturing and quantifying drug use.

OBJECTIVE:

We examined the concordance of ecological momentary assessment (EMA) of drug use to previously validated biological and audio-computer assisted self-interview (ACASI) methods.

METHODS:

The Exposure Assessment in Current Time (EXACT) study utilized EMA methods to assess drug use in real-time in participants' natural environments. Utilizing mobile devices, participants self-reported each time they used heroin or cocaine over a 4-week period. Each week, PharmChek sweat patch samples were collected for measurement of heroin and cocaine and participants answered an ACASI-based questionnaire to report behaviors and drug using events during the prior week. Reports of cocaine and heroin use captured through EMA were compared to weekly biological or self-report measures through percent agreement and concordance correlation coefficients to account for repeated measures. Correlates of discordance were obtained from logistic regression models.

RESULTS:

A total of 109 participants were a median of 48.5 years old, 90% African American, and 52% male. During 436 person-weeks of observation, we recorded 212 (49%) cocaine and 103 (24%) heroin sweat patches, 192 (44%) cocaine and 161 (37%) heroin ACASI surveys, and 163 (37%) cocaine and 145 (33%) heroin EMA reports. The percent agreement between EMA and sweat patch methods was 70% for cocaine use and 72% for heroin use, while the percent agreement between EMA and ACASI methods was 77% for cocaine use and 79% for heroin use. Misreporting of drug use by EMA compared to sweat patch and ACASI methods were different by illicit drug type.

CONCLUSIONS:

Our work demonstrates moderate to good agreement of EMA to biological and standard self-report methods in capturing illicit drug use. Limitations occur with each method and accuracy may differ by type of illicit drugs used.

Below:   Reported drug use as assessed by sweat patch (green bars), EMA (orange bars) or ACASI (blue bars) methods

Below:  Figure 2. Percent agreement by drug type and week comparing EMA, sweat patch, and ACASI methods. Panel A: Percent agreement between EMA/Sweat Patch methods (blue bars) and EMA/ACASI methods (green bars) by week for cocaine use. Panel B: Percent agreement between EMA/Sweat Patch methods (orange bars) and EMA/ACASI methods (yellow bars) by week for heroin use.

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By:  Linas BS1, Genz A, Westergaard RP, Chang LW, Bollinger RC, Latkin C, Kirk GD.

• 1Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA. Blinas@jhu.edu.
• JMIR Mhealth Uhealth. 2016 Mar 15;4(1):e27. doi: 10.2196/mhealth.4470. 

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Substance Use Patterns of HIV-Infected Russian Women With and Without Hepatitis C Virus Co-infection

Individuals with HIV and hepatitis C virus (HCV) co-infection may experience substance use related health complications. This study characterized substance use patterns between HIV/HCV co-infected and HIV mono-infected Russian women. HIV-infected women (N = 247; M age = 30.0) in St. Petersburg, Russia, completed a survey assessing substance use, problematic substance use, and the co-occurrence of substance use and sexual behaviors. 

Covariate adjusted logistic and linear regression analyses indicated that HIV/HCV co-infected participants (57.1 %) reported more lifetime drug use (e.g., heroin), problem drinking, substance use problems, and increased likelihood of past injection drug use relative to HIV mono-infected individuals. HIV/HCV co-infection was prevalent and associated with increased substance use and problematic drug use. 

Findings highlight the need for ongoing substance use and HIV/HCV risk behavior assessment and treatment among HIV/HCV co-infected Russian women.

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By:  Brown JL1, DiClemente RJ2,3,4, Sales JM2,3, Rose ES2, Safonova P5, Levina OS6, Belyakov N7, Rassokhin VV5.

• 1Addiction Sciences Division, Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Suite 104, Cincinnati, OH, 45229, USA. jennifer.brown2@uc.edu.
• 2Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
• 3Centers for AIDS Research, Emory University, Atlanta, GA, USA.
• 4Department of Pediatrics, Division of Infectious Diseases, Epidemiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA.
• 5St. Petersburg AIDS Center, St. Petersburg, Russia.
• 6Stellit, St. Petersburg, Russia.
• 7North-West Regional Center for Control and Prevention of AIDS, St. Petersburg, Russia. 
• AIDS Behav. 2016 Mar 19.

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High Prevalence of Assisted Injection among Street-Involved Youth in a Canadian Setting

Many people who inject illicit drugs receive manual assistance when injecting, and this practice has been linked to increased risk of HIV infection and other harms. Little is known, however, about this practice among youth. 

This study uses a multivariate generalized estimating equation to identify factors associated with receiving assistance with injecting among a cohort of street-involved youth aged 14-26 in Vancouver, Canada. 

A total of 253 participants reported injecting drugs during the study period, and 49 % (n = 125) of these youth reported receiving assistance with injecting in the past 6 months. In multivariate analysis, younger age, female gender, binge drug use, heroin injecting, cocaine injecting, crystal methamphetamine injecting, and syringe sharing were positively and independently associated with assisted injection (all p < 0.05). 

These findings underscore the need for expanding substance abuse treatment alongside HIV prevention and health promotion interventions to empower youth to enact safer injection practices.

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By:  Cheng T1,2, Kerr T1,3, Small W1,2, Dong H1, Montaner J1,3, Wood E1,3, DeBeck K4,5.

• 1Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
• 2Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
• 3Faculty of Medicine, University of British Columbia, Vancouver, Canada.
• 4Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-kd@cfenet.ubc.ca.
• 5School of Public Policy, Simon Fraser University, Burnaby, Canada. uhri-kd@cfenet.ubc.ca. 

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