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1.  Evaluation of California's Alcohol and Drug Screening and Brief Intervention Project for Emergency Department Patients 
Introduction: Visits to settings such as emergency departments (EDs) may present a “teachable moment” in that a patient may be more open to feedback and suggestions regarding their risky alcohol and illicit drug-use behaviors. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an 'opportunistic' public health approach that targets low-risk users, in addition to those already dependent on alcohol and/or drugs. SBIRT programs provide patients with comprehensive screening and assessments, and deliver interventions of appropriate intensity to reduce risks related to alcohol and drug use.
Methods: This study used a single group pre-post test design to assess the effect of the California SBIRT service program (i.e., CASBIRT) on 6 substance-use outcomes (past-month prevalence and number of days of binge drinking, illegal drug use, and marijuana use). Trained bilingual/bicultural Health Educators attempted to screen all adult patients in 12 EDs/trauma centers (regardless of the reason for the patient's visit) using a short instrument, and then delivered a brief motivational intervention matched to the patient's risk level. A total of 2,436 randomly selected patients who screened positive for alcohol and/or drug use consented to be in a 6-month telephone follow-up interview. Because of the high loss to follow-up rate, we used an intention-to-treat approach for the data analysis.
Results: Results of generalized linear mixed models showed modest reductions in all 6 drug-and alcohol-use outcomes. Men (versus women), those at relatively higher risk status (versus lower risk), and those with only one substance of misuse (versus both alcohol and illicit drug misuse) tended to show more positive change.
Conclusion: These results suggest that SBIRT services provided in acute care settings are associated with modest changes in self-reported recent alcohol and illicit drug use.
doi:10.5811/westjem.2012.9.11551
PMCID: PMC3656708  PMID: 23687546
2.  Substance Use and PTSD Symptoms in Trauma Center Patients Receiving Mandated Alcohol SBI 
In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of College policy targeting integrated substance abuse treatment at trauma centers.
doi:10.1016/j.jsat.2012.08.009
PMCID: PMC3528356  PMID: 22999379
3.  Alcohol Abuse and Illegal Drug Use among Los Angeles County Trauma Patients: Prevalence and Evaluation of Single Item Screener 
The Journal of trauma  2009;66(5):1461-1467.
Background
The misuse of alcohol and illicit drugs is implicated with injury and repeat injury. Admission to a trauma center provides an opportunity to identify patients with substance use problems and initiate intervention and prevention strategies. To facilitate the identification of trauma patients with substance use problems, we studied alcohol abuse and illegal substance use patterns in a large cohort of urban trauma patients, identified correlates of alcohol abuse, and assessed the utility of a single item binge-drinking screener for identifying patients with past 12-month substance use problems.
Methods
Between February 2004 and August 2006, 677 patients from four large trauma centers in Los Angeles (LA) County were interviewed. The sample was broadly representative of the entire LA County trauma center patient population.
Results
24% of patients met criteria for alcohol abuse and 15% reported using an illegal drug other than marijuana in the past 12-months. Male gender, assaultive injury, peritrauma substance use, and history of binge drinking were prominent risk factors. A single-item binge drinking screen correctly identified alcohol abuse status in 76% of all patients; the screen also performed moderately well in discriminating between those who had or had not used illegal drugs in the past 12-months, with sensitivity estimates reaching 0.79 and specificity estimates reaching 0.74.
Conclusions
A large proportion of urban trauma patients abuse alcohol and use illegal drugs. Distinct sociodemographic and substance use history may indicate underlying risky behaviors. Interventions and injury prevention programs need to address these causal behaviors to reduce injury morbidity and recidivism. In the busy trauma care setting, a one-item screener could be helpful in identifying patients who would benefit from more thorough assessment and possible brief intervention.
doi:10.1097/TA.0b013e318184821d
PMCID: PMC2909486  PMID: 19430255
4.  Web-based screening and brief intervention for poly-drug use among teenagers: study protocol of a multicentre two-arm randomized controlled trial 
BMC Public Health  2012;12:826.
Background
Mid to late adolescence is characterised by a vulnerability to problematic substance use since the consumption of alcohol and illicit drugs is frequently initiated and increased in this life period. While the detrimental long- and short-term effects of problematic consumption patterns in adolescence pose a major public health concern, current prevention programs targeting alcohol- and other substance-using adolescents are scarce. The study described in this protocol will test the effectiveness of a web-based brief intervention aimed at reducing problematic alcohol use and promoting abstinence from illegal drugs in adolescents with risky substance use aged 16 to 18 years old in four EU-countries.
Methods/design
To determine the effectiveness of our web-BI, we apply a two-arm randomized controlled trial (RCT) study design, with baseline assessment at study entry and a three month follow-up assessment. Adolescents aged 16 to 18 years from Belgium, the Czech Republic, Germany, and Sweden will be randomly assigned to either the fully electronically delivered brief intervention group (N = 400) or an assessment only control group (N = 400) depending on their screening for risky substance use (using the CRAFFT). Recruitment, informed consent, randomization, intervention and follow-up will be implemented online. Primary outcomes are reductions in frequency and quantity of use of alcohol and drugs other than alcohol over a 30 day period, as well as consumption per typical occasion. Secondary outcomes concern changes in substance use related cognitions including the constructs of the Theory of Planned Behaviour, implementation intentions, and stages of change. Moreover the study addresses a number of moderator variables, including age of first use, general psychopathology and quality of parent–child relationship.
Discussion
The trial is expected to contribute to the growing literature on theory- and web-based brief interventions for adolescents. We will explore the potential of using web-based technologies as means of delivering preventive interventions. In doing so we are among the first to target the relevant group of young poly-drug users in Europe.
Trial registration
Current Controlled Trials ISRCTN95538913
doi:10.1186/1471-2458-12-826
PMCID: PMC3524050  PMID: 23013141
5.  Temporal and spatial variation in bird and human use of beaches in southern California 
SpringerPlus  2013;2:38.
Southern California’s beaches can support a remarkable diversity of birds along the Pacific Flyway. We asked whether seasonal, annual, and spatial factors affect bird richness and abundance on public beaches. To do so, we conducted three years of monthly bird surveys on 12 sandy beaches in Ventura California. Across all surveys, we counted 22 shorebird species, 8 gull species, 24 other water bird species, and 24 landbird species. Sanderling, western gull, Heerman’s gull, willet, marbled godwit, and whimbrel were the most abundant members of the bird community. Beach wrack was uncommon, particularly where beaches were groomed, and did not have a large effect on bird abundance, though it was positively associated with overall bird richness. Beaches near estuaries tended to be wide, and such beaches had a higher richness and abundance of birds. Beaches with shallow slopes tended to have more gulls and shorebirds. People and (illegal) unleashed dogs were common, particularly at beaches fronted by houses. The abundance and richness of shorebirds and the richness of other waterbirds was lower where human activity was high. Bird richness and abundance was strongly affected by season, with the highest density of birds being seen during the fall shorebird migration. Gull abundance peaked earlier (August-September) than shorebird abundance (October through December). A brief pulse of shorebirds also occurred in May due to spring migration. Comparing these data with surveys in the 1990’s found no evidence for a decline in shorebirds over time, though black-bellied plover appear to still be recovering from the strong 1997-1998 ENSO. Opportunities to conserve birds on these beaches are limited, but could include enforcing leash laws and setting up human exclosures near estuary mouths.
doi:10.1186/2193-1801-2-38
PMCID: PMC3579413  PMID: 23450765
Shorebirds; Beaches; Disturbance; Wrack
6.  Long term marijuana users seeking medical cannabis in California (2001–2007): demographics, social characteristics, patterns of cannabis and other drug use of 4117 applicants 
Background
Cannabis (marijuana) had been used for medicinal purposes for millennia. Cannabinoid agonists are now attracting growing interest and there is also evidence that botanical cannabis is being used as self-medication for stress and anxiety as well as adjunctive therapy by the seriously ill and by patients with terminal illnesses. California became the first state to authorize medicinal use of cannabis in 1996, and it was recently estimated that between 250,000 and 350,000 Californians may now possess the physician's recommendation required to use it medically. More limited medical use has also been approved in 12 additional states and new initiatives are being considered in others. Despite that evidence of increasing public acceptance of "medical" use, a definitional problem remains and all use for any purpose is still prohibited by federal law.
Results
California's 1996 initiative allowed cannabis to be recommended, not only for serious illnesses, but also "for any other illness for which marijuana provides relief," thus maximally broadening the range of allowable indications. In effect, the range of conditions now being treated with federally illegal cannabis, the modes in which it is being used, and the demographics of the population using it became potentially discoverable through the required screening of applicants. This report examines the demographic profiles and other selected characteristics of 4117 California marijuana users (62% from the Greater Bay Area) who applied for medical recommendations between late 2001 and mid 2007.
Conclusion
This study yielded a somewhat unexpected profile of a hitherto hidden population of users of America's most popular illegal drug. It also raises questions about some of the basic assumptions held by both proponents and opponents of current policy.
doi:10.1186/1477-7517-4-16
PMCID: PMC2175501  PMID: 17980043
7.  Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the life shift/shift gears study 
Background
Although screening, brief intervention, and referral to treatment (SBIRT) has shown promise for alcohol use, relatively little is known about its effectiveness for adult illicit drug use. This randomized controlled trial assessed the effectiveness of the SBIRT approach for outcomes related to drug use among patients visiting trauma and emergency departments (EDs) at two large, urban hospitals.
Methods
A total of 700 ED patients who admitted using illegal drugs in the past 30 days were recruited, consented, provided baseline measures of substance use and related problems measured with the Addiction Severity Index-Lite (ASI-Lite), and then randomized to the Life Shift SBIRT intervention or to an attention-placebo control group focusing on driving and traffic safety (Shift Gears). Both groups received a level of motivational intervention matched to their condition and risk level by trained paraprofessional health educators. Separate measurement technicians conducted face-to-face follow-ups at 6 months post-intervention and collected hair samples to confirm reports of abstinence from drug use. The primary outcome measure of the study was past 30-day drug abstinence at 6 months post-intervention, as self-reported on the ASI-Lite.
Results
Of 700 participants, 292 (42%) completed follow-up. There were no significant differences in self-reported abstinence (12.5% vs. 12.0% , p = 0.88) for Life Shift and Shift Gears groups, respectively. When results of hair analyses were applied, the abstinence rate was 7 percent for Life Shift and 2 percent for Shift Gears (p = .074). In an analysis in which results were imputed (n = 694), there was no significant difference in the ASI-Lite drug use composite scores (Life Shift +0.005 vs. Shift Gears +0.017, p = 0.12).
Conclusions
In this randomized controlled trial, there was no evidence of effectiveness of SBIRT on the primary drug use outcome.
Trial registration
ClinicalTrials.gov NCT01683227.
doi:10.1186/1940-0640-9-8
PMCID: PMC4046000  PMID: 24886786
Screening and brief intervention; Drug use; Emergency department patients
8.  Seroprevalence of and risk factors for HIV‐1 infection among female commercial sex workers in South America 
Sexually Transmitted Infections  2006;82(4):311-316.
Objective
Assessment of HIV prevalence and associated risk behaviours among female commercial sex workers (FCSW) across major cities in South America.
Methods
Seroepidemiological, cross sectional studies of 13 600 FCSW were conducted in nine countries of South America during the years 1999–2002. Participants were recruited in brothels, massage parlours, hotels, and streets where anonymous questionnaires and blood samples were collected. HIV infection was determined by enzyme linked immunosorbent assay (ELISA) screening and western blot confirmatory tests.
Results
The overall HIV seroprevalence was 1.2% (range 0.0%–4.5%). The highest HIV seroprevalences were reported in Argentina (4.5%) and Paraguay (2.6%); no HIV infected FCSW were detected in Venezuela and Chile. Consistent predictors of HIV seropositivity were: (1) a previous history of sexually transmitted infections (STI, AORs = 3.8–8.3), and (2) 10 years or more in commercial sex work (AORs = 2.2–24.8). In addition, multiple (⩾3) sexual contacts (AOR = 5.0), sex with foreigners (AOR = 6.9), use of illegal drugs (AOR = 3.2), and marijuana use (AOR = 8.2) were associated with HIV seropositivity in Southern Cone countries.
Conclusions
Consistently low HIV seroprevalences were detected among FCSW in South America, particularly in the Andean region. Predictors of HIV infection across the continent were STI and length of commercial sex work; however, use of illegal drugs, especially marijuana, and sexual contacts with foreigners were also found to be associated risk factors in the Southern Cone region. Interventions for the control of HIV and other STI need to be region and country specific; drug use appears to have an ever increasing role in the spread of HIV among heterosexually active populations.
doi:10.1136/sti.2005.018234
PMCID: PMC2564717  PMID: 16877581
HIV; prevalence; risk factors; South America; female; sex workers
9.  The Consumption of Khat and Other Drugs in Somali Combatants: A Cross-Sectional Study 
PLoS Medicine  2007;4(12):e341.
Background
For more than a decade, most parts of Somalia have not been under the control of any type of government. This “failure of state” is complete in the central and southern regions and most apparent in Mogadishu, which had been for a long period in the hands of warlords deploying their private militias in a battle for resources. In contrast, the northern part of Somalia has had relatively stable control under regional administrations, which are, however, not internationally recognized. The present study provides information about drug abuse among active security personnel and militia with an emphasis on regional differences in relation to the lack of central governmental control—to our knowledge the first account on this topic.
Methods and Findings
Trained local interviewers conducted a total of 8,723 interviews of armed personnel in seven convenience samples in different regions of Somalia; 587 (6.3%) respondents discontinued the interview and 12 (0.001%) were excluded for other reasons. We assessed basic sociodemographic information, self-reported khat use, and how respondents perceived the use of khat, cannabis (which includes both hashish and marijuana), psychoactive tablets (e.g., benzodiazepines), alcohol, solvents, and hemp seeds in their units. The cautious interpretation of our data suggest that sociodemographic characteristics and drug use among military personnel differ substantially between northern and southern/central Somalia. In total, 36.4% (99% confidence interval [CI] 19.3%–57.7%) of respondents reported khat use in the week before the interview, whereas in some regions of southern/central Somalia khat use, especially excessive use, was reported more frequently. Self-reported khat use differed substantially from the perceived use in units. According to the perception of respondents, the most frequent form of drug use is khat chewing (on average, 70.1% in previous week, 99% CI 63.6%–76.5%), followed by smoking cannabis (10.7%, 99% CI 0%–30.4%), ingesting psychoactive tablets (8.5%, 99% CI 0%–24.4%), drinking alcohol (5.3%, 99% CI 0%–13.8%), inhaling solvents (1.8%, 99% CI 0%–5.1%), and eating hemp seeds (0.6%, 99% CI 0%–2.0%). Perceived use of khat differs little between northern and southern Somalia, but perceived use of other drugs reaches alarmingly high levels in some regions of the south, especially related to smoking cannabis and using psychoactive tablets.
Conclusions
Our data suggest that drug use has quantitatively and qualitatively changed over the course of conflicts in southern Somalia, as current patterns are in contrast to traditional use. Although future studies using random sampling methods need to confirm our results, we hypothesize that drug-related problems of armed staff and other vulnerable groups in southern Somalia has reached proportions formerly unknown to the country, especially as we believe that any biases in our data would lead to an underestimation of actual drug use. We recommend that future disarmament, demobilization, and reintegration (DDR) programs need to be prepared to deal with significant drug-related problems in Somalia.
Having interviewed military personnel in Somali, Michael Odenwald and colleagues conclude that drug-related problems, mainly relating to the use of khat, have reached proportions formerly unknown to the country.
Editors' Summary
Background.
Somalia—a country in eastern Africa—has been torn apart by civil war over the past few decades. Fighting among clans and warlords has caused the near-complete breakdown of state control in the central and southern regions of the country (including the capital, Mogadishu) although independent administrations provide some governmental control in the northern regions of Somaliland and Puntland. Efforts to establish a transitional federal government have largely failed and, to date, it has been impossible to initiate a nationwide disarmament, demobilization, and reintegration (DDR) program in Somalia for ex-combatants, a key step in the transition from war to peace. As in other war-torn countries, the social and economic reintegration of ex-combatants into civil society in Somalia is likely to be difficult. However, without effective reintegration, ex-combatants may take up arms again because they have no means of economic support or become disaffected and seek to destabilize the peace.
Why Was This Study Done?
One risk factor for poor adjustment to civilian life among ex-combatants is substance abuse. Many ex-combatants use drugs to help them deal with traumatic war-related memories, but unrecognized drug abuse can hinder reintegration, increase criminality, and threaten the peace-building process. Most studies on substance abuse and treatment of drug-related problems of former combatants have been done in Western countries. Very little is known about how many ex-combatants abuse drugs and the types of drugs they abuse in postconflict regions in Africa. This information is needed if DDR programs are to be effective. In this study, therefore, the researchers have investigated drug use among “convenience” samples of combatants in seven regions of Somalia. Convenience samples are groups of people chosen to participate in a study because they were available rather than groups chosen randomly from the whole population.
What Did the Researchers Do and Find?
Trained interviewers asked more than 8,000 military personnel about their own recent use of khat (chewing khat leaves releases an amphetamine-like stimulant), a legally traded drug in Somalia, where its use has long been commonplace. The interviewers also asked the respondents how much they thought others in their military personnel unit used khat and other drugs such as cannabis, psychoactive drugs (tranquilizers and other drugs that change mood, behavior, and thinking), solvents, alcohol, and hemp seeds. (Note that the researchers relied on perceived drug use; alcohol is illegal in Somalia, which is a Muslim country, and the use of drugs other than khat is not generally acknowledged.) Over the whole of Somalia, one-third of respondents said they had used khat recently. The highest levels of self-reported use were in southern/central Somalia, where up to two-thirds of combatants used it. More respondents in southern/central Somalia reported using an excessive amount of khat (more than two “bundles” of khat per day for one week) and having sleepless nights (a side-effect of khat) than in northern Somalia. The overall perceived use of khat (two-thirds of combatants) was higher than the self-reported use but similar in northern and southern/central regions. Finally, the perceived use of other drugs was highest in the southern/central regions.
What Do These Findings Mean?
The use of convenience samples (which may not be representative of the whole population) and other aspects of this study mean that the numerical values of these findings may be inaccurate. For example, the levels of self-reported khat use may be underestimates because drug-using combatants may have been undersampled or not all combatants may have responded honestly. Nevertheless, these findings confirm that khat is the most commonly consumed drug among combatants and reveal a large increase in the number of people using it in southern/central Somalia since the conflict began (only one in five adult males used khat in these regions in 1980). They also reveal that more khat is being consumed by some individuals than previously, particularly in the southern/central regions, and uncover a worrying increase in the perceived use of other drugs, again mainly in the southern/central regions. These changes in the traditional patterns of drug use in Somalia, if confirmed in studies that use random sampling methods, suggest that future DDR programs in Somalia will need to be prepared to deal with major drug-related problems and that drug use among the general population might have reached dimensions formerly unknown to the country.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040341.
Information about Somalia is available from the US Department of State, the United Nations, and Swiss Peace, a peace research institute
The US Council on Foreign Relations, the Beyond Intractability Knowledge Base Project (based at the University of Colorado), and the UN DDR Resource Centre provide general information on DDR programs
The Multi-Country Demobilization and Reintegration program provides additional information about ongoing DDR programs in other parts of Africa (in English and French)
DrugScope (a UK charity) provides information about khat
The US National Drug Intelligence Center provides information about khat in the US
The UK Advisory Council on the Misuse of Drugs provides an assessment of the risk of khat to individuals and communities in the UK
The Vivo Foundation supports programs that relieve the trauma of stress, including PTSD
doi:10.1371/journal.pmed.0040341
PMCID: PMC2121109  PMID: 18076280
10.  Experiences with Policing among People Who Inject Drugs in Bangkok, Thailand: A Qualitative Study 
PLoS Medicine  2013;10(12):e1001570.
Using thematic analysis, Kerr and colleagues document the experiences of policing among people who inject drugs in Bangkok and examine how interactions with police can affect drug-using behaviors and health care access.
Please see later in the article for the Editors' Summary
Background
Despite Thailand's commitment to treating people who use drugs as “patients” not “criminals,” Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.
Methods and Findings
Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.
Conclusions
This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In many countries, the dominant strategy used to control illegal drugs such as heroin and methamphetamine is criminal law enforcement, a strategy that sometimes results in human rights abuses such as ill-treatment by police, extrajudicial killings, and arbitrary detention. Moreover, growing evidence suggests that aggressive policing of illicit drug use can have adverse public-health consequences. For example, the fear engendered by intensive policing may cause people who inject drugs (PWID) to avoid services such as needle exchanges, thereby contributing to the HIV/AIDS epidemic. One country with major epidemics of illicit drug use and of HIV/AIDS among PWID is Thailand. Although Thailand reclassified drug users as “patients” instead of “criminals” in 2002, possession and consumption of illicit drugs remain criminal offenses. The 2002 legislation also created a system of compulsory drug detention centers, most of which lack evidence-based addiction treatment services. In 2003, the Thai government launched a campaign to suppress drug trafficking and to enrol 300,000 people who use drugs into treatment. This campaign received international criticism because it involved extensive human rights violations, including more than 2,800 extrajudicial killings of suspected drug users and dealers.
Why Was This Study Done?
Drug-related arrests and compulsory detention of drug users are increasing in Thailand but what is the impact of current policing practices on drug users and on public health? In this qualitative study (a study that aims for an in-depth understanding of human behavior), the researchers use thematic analysis informed by the Rhodes' Risk Environment Framework to document the social and structural factors that led to encounters with the police among PWID in Bangkok between 2008 and 2012, the policing tactics employed during these encounters, and the associated health consequences of these encounters. The Risk Environment Framework posits that a range of social, political, economic, and physical environmental factors interact with each other and shape the production of drug-related harm.
What Did the Researchers Do and Find?
Between July 2011 and June 2012, the researchers conducted in-depth interviews with a convenience sample (a non-random sample from a nearby population) of 42 participants in the Mitsampan Community Research Project, an investigation of drug-using behavior, health care access, and drug-related harms among PWID in Bangkok. Respondents reported that policing activities had intensified since rapid urine toxicology screening became widely available and since the initiation of a crackdown on drug users in 2011. They described various forms of violence and misconduct that they had experienced during confrontations with police, including false accusations, degrading stop and search procedures, and excessive use of force. Urine drug testing was identified as a key tool used by the police, with some respondents describing how police caused unnecessary humiliation by requesting urine samples in public places. It was also reported that the police used positive test results as a means of extortion. Finally, some respondents reported feeling powerless in relation to the police and cited fear of retaliation as an important barrier to obtaining redress for police corruption. Others reported that they had adopted strategies to avoid the police such as staying indoors, a strategy likely to impede access to health care, or changing their drug-using behavior by, for example, injecting midazolam rather than methamphetamine, a practice associated with an increased risk of injection-related complications.
What Do These Findings Mean?
These findings suggest that the policing of PWID in Bangkok between 2008 and 2012 involved injustices, human rights abuses, and corruption and highlight the potential for widespread misuse of urine drug testing. Moreover, they suggest that policing practices in this setting may have increased the vulnerability of PWID to poor health by impeding their access to health care and by increasing the occurrence of risky drug-using behaviors. Because this study involved a small convenience sample of PWID, these findings may not be generalizable to other areas of Bangkok or Thailand and do not indicate whether police misconduct and corruption is highly prevalent across the all police departments in Bangkok. Nevertheless, these findings suggest that multilevel structural changes and interventions are needed to mitigate the harm associated with policing of illicit drug use in Bangkok. These changes will need to ensure full accountability for police misconduct and access to legal services for victims of this misconduct. They will also need to include ethical guidelines for urine drug testing and the reform of policies that promote repressive policing and compulsory detention.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001570.
This study is further discussed in a PLOS Medicine Perspective by Burris and Koester
Human Rights Watch, a global organization dedicated to defending and protecting human rights, has information about drug policy and human rights, which includes information on Thailand
The Global Commission on Drug Policy published a report in June 2012 entitled “The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic” (available in several languages)
The Global Commission on HIV and the Law published a report in July 2012 entitled “HIV and the Law: Risk, Rights and Health” (available in several languages), the Open Society Foundations have prepared a briefing on this report
More information about the Mitsampan Community Research Project is available
doi:10.1371/journal.pmed.1001570
PMCID: PMC3858231  PMID: 24339753
11.  Bundling occupational safety with harm reduction information as a feasible method for improving police receptiveness to syringe access programs: evidence from three U.S. cities 
Introduction
In light of overwhelming evidence that access to sterile injection equipment reduces incidence of injection-attributable bloodborne disease without encouraging drug use, many localities have authorized sterile syringe access programs (SAPs), including syringe exchange and pharmacy-based initiatives. Even where such interventions are clearly legal, many law enforcement officers are unaware of the public health benefits and legal status of these programs and may continue to treat the possession of injection equipment as illegal and program participation as a marker of illegal behavior. Law enforcement practice can impede SAP utilization and may increase the risk of needlestick injury (NSI) among law enforcement personnel. Many SAPs conduct little or no outreach to law enforcement, in part because they perceive law enforcement actors as unreceptive to health-promotion programs targeting drug users.
Case description
We report on a brief training intervention for law enforcement personnel designed to increase officer knowledge of and positive attitudes towards SAPs by bundling content that addresses officer concerns about infectious disease and occupational safety with information about the legality and public health benefits of these programs. Pilot trainings using this bundled curriculum were conducted with approximately 600 officers in three US cities.
Discussion and evaluation
Law enforcement officers were generally receptive to receiving information about SAPs through the bundled curriculum. The trainings led to better communication and collaboration between SAP and law enforcement personnel, providing a valuable platform for better harmonization of law enforcement and public health activities targeting injection drug users.
Conclusion
The experience in these three cities suggests that a harm reduction training curriculum that bundles strategies for increasing officer occupational safety with information about the legality and public health benefits of SAPs can be well received by law enforcement personnel and can lead to better communication and collaboration between law enforcement and harm reduction actors. Further study is indicated to assess whether such a bundled curriculum is effective in changing officer attitudes and beliefs and reducing health risks to officers and injection drug users, as well as broader benefits to the community at large.
doi:10.1186/1477-7517-6-16
PMCID: PMC2716314  PMID: 19602236
12.  How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA  
Background
Direct-to-consumer advertising (DTCA) of prescription drugs has increased rapidly in the United States during the last decade, yet little is known about its effects on prescribing decisions in primary care. We compared prescribing decisions in a US setting with legal DTCA and a Canadian setting where DTCA of prescription drugs is illegal, but some cross-border exposure occurs.
Methods
We recruited primary care physicians working in Sacramento, California, and Vancouver, British Columbia, and their group practice partners to participate in the study. On pre- selected days, patients aged 18 years or more completed a questionnaire before seeing their physician. We asked these patients' physicians to complete a brief questionnaire immediately following the selected patient visit. By pairing individual patient and physician responses, we determined how many patients had been exposed to some form of DTCA, the frequency of patients' requests for prescriptions for advertised medicines and the frequency of prescriptions that were stimulated by the patients' requests. We measured physicians' confidence in treatment choice for each new prescription by asking them whether they would prescribe this drug to a patient with the same condition.
Results
Seventy-eight physicians (Sacramento n = 38, Vancouver n = 40) and 1431 adult patients (Sacramento n = 683, Vancouver n = 748), or 61% of patients who consulted participating physicians on pre-set days, participated in the survey. Exposure to DTCA was higher in Sacramento, although 87.4% of Vancouver patients had seen prescription drug advertisements. Of the Sacramento patients, 7.2% requested advertised drugs as opposed to 3.3% in Vancouver (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.2–4.1). Patients with higher self- reported exposure to advertising, conditions that were potentially treatable by advertised drugs, and/or greater reliance on advertising requested more advertised medicines. Physicians fulfilled most requests for DTCA drugs (for 72% of patients in Vancouver and 78% in Sacramento); this difference was not statistically significant. Patients who requested DTCA drugs were much more likely to receive 1 or more new prescriptions (for requested drugs or alternatives) than those who did not request DTCA drugs (OR 16.9, 95% CI 7.5–38.2). Physicians judged 50.0% of new prescriptions for requested DTCA drugs to be only “possible” or “unlikely” choices for other similar patients, as compared with 12.4% of new prescriptions not requested by patients (p < 0.001).
Interpretation
Our results suggest that more advertising leads to more requests for advertised medicines, and more prescriptions. If DTCA opens a conversation between patients and physicians, that conversation is highly likely to end with a prescription, often despite physician ambivalence about treatment choice.
PMCID: PMC183290  PMID: 12952801
13.  Effects of a One Hour Intervention on Condom Implementation Intentions among Drug Users in Southern California 
AIDS care  2013;25(12):1586-1591.
Approximately 36% of HIV cases are related to substance abuse. Substance abusers, including non-injection drug users, are high-risk for contracting HIV due to risky behaviors, including unprotected sex. Due to these behavioral and infection risks, feasible interventions that focus on condom use within this population are imperative. The current study involved the development of brief intervention designed to increase implementation intentions (situation-linked action plans) to use condoms in convicted non-violent drug offenders participating in drug diversion programs in Southern California. Participants (n = 143) were randomized at the individual level to either waitlist-control or experimental conditions. The randomized wait-list control group received the HIV survey for the pre-test before the intervention, while the experimental group received a neutral, non-HIV related, survey at pre-test. The experimental group received the HIV survey as the post-test after the intervention (wait-list control group received the neutral, non-HIV related, survey). One-tailed Mann Whitney U tests were used to compare the wait-list control and experimental groups. The experimental group was more likely to report stronger implementation intentions to use condoms (p < .001). These results indicate in the short term that a brief, easily disseminated HIV intervention can be effective for increasing implementation intentions to use condoms in an extremely high HIV-risk population.
doi:10.1080/09540121.2013.793271
PMCID: PMC4113195  PMID: 23656365
HIV/AIDS; condoms; Drug Users; implementation intentions; intervention
14.  Forest Elephant Crisis in the Congo Basin  
PLoS Biology  2007;5(4):e111.
Debate over repealing the ivory trade ban dominates conferences of the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES). Resolving this controversy requires accurate estimates of elephant population trends and rates of illegal killing. Most African savannah elephant populations are well known; however, the status of forest elephants, perhaps a distinct species, in the vast Congo Basin is unclear. We assessed population status and incidence of poaching from line-transect and reconnaissance surveys conducted on foot in sites throughout the Congo Basin. Results indicate that the abundance and range of forest elephants are threatened from poaching that is most intense close to roads. The probability of elephant presence increased with distance to roads, whereas that of human signs declined. At all distances from roads, the probability of elephant occurrence was always higher inside, compared to outside, protected areas, whereas that of humans was always lower. Inside protected areas, forest elephant density was correlated with the size of remote forest core, but not with size of protected area. Forest elephants must be prioritised in elephant management planning at the continental scale.
Author Summary
Forest elephants, perhaps a distinct species of African elephant, occur in the forests of West and Central Africa. Compared to the more familiar savannah elephant of Eastern and Southern Africa, forest elephant biology and their conservation status are poorly known. To provide robust scientific data on the status and distribution of forest elephants to inform and guide conservation efforts, we conducted surveys on foot of forest elephant abundance and of illegal killing of elephants in important conservation sites throughout Central Africa. We covered a combined distance of over 8,000 km on reconnaissance walks, and we systematically surveyed a total area of some 60,000 km2 under the auspices of the Monitoring of the Illegal Killing of Elephants (MIKE) programme. Our results indicate that forest elephant numbers and range are severely threatened by hunting for ivory. Elephant abundance increased with increasing distance from the nearest road, and poaching pressure was most concentrated near roads. We found that protected areas have a positive impact on elephant abundance, probably because management interventions reduced poaching rates inside protected areas compared to non-protected forest. Law enforcement to bring the illegal ivory trade under control, and effective management and protection of large and remote national parks will be critical if forest elephants are to be successfully conserved.
A systematic survey of 68,000 km2 throughout Central Africa reveals that the forest elephant--distinct from the savannah elephant--is severely threatened by poaching, despite a near universal ban of trade in ivory.
doi:10.1371/journal.pbio.0050111
PMCID: PMC1845159  PMID: 17407383
15.  Predictors of Drug Use Among South African Adolescents 
Purpose:
To determine the association of frequency of illegal drug use with five groups of factors: environmental stressors; parental drug use; parental child rearing; peer drug use; and adolescent personal attributes.
Methods:
1468 male (45%) and female (55%) adolescents, aged 12 to 17 years (mean=14.76, S.D.=1.51), were interviewed at home in Durban and Capetown, South Africa. Independent measures assessed environmental stressors, parental child rearing, parental drug use, peer drug use, and adolescent personal attributes. The dependent variable was the adolescents’ frequency of illegal drug use.
Results:
Regression analyses showed that personal attributes and peer substance use explained the largest percentage of the variance in the adolescents’ frequency of illegal drug use. In addition, both parental factors and environmental stressors contributed to the explained variance in adolescent drug use above and beyond the two more proximal domains at a statistically significant level.
Conclusions:
Knowing the contribution of more proximal versus more distal risk factors for illegal drug use is useful for prioritizing targets for interventions. Targeting changes in the more proximal predictors (e.g., adolescent personal attributes) may be more effective as well as more feasible than trying to produce change in the more distal factors such as environmental stressors.
doi:10.1016/j.jadohealth.2004.08.004
PMCID: PMC1592364  PMID: 16387245
Adolescence; South Africa; Drug Use
16.  Drug use and nightlife: more than just dance music 
Background
Research over the last decade has focused almost exclusively on the association between electronic music and MDMA (3,4-Methylenedioxymethamphetamine or "ecstasy") or other stimulant drug use in clubs. Less attention has been given to other nightlife venues and music preferences, such as rock music or southern/funky music. This study aims to examine a broader spectrum of nightlife, beyond dance music. It looks at whether certain factors influence the frequency of illegal drug and alcohol use: the frequency of going to certain nightlife venues in the previous month (such as, pubs, clubs or goa parties); listening to rock music, dance music or southern and funky music; or sampling venues (such as, clubs, dance events or rock festivals). The question of how these nightlife variables influence the use of popular drugs like alcohol, MDMA, cannabis, cocaine and amphetamines is addressed.
Methods
The study sample consisted of 775 visitors of dance events, clubs and rock festivals in Belgium. Study participants answered a survey on patterns of going out, music preferences and drug use. Odds ratios were used to determine whether the odds of being an illegal substance user are higher for certain nightlife-related variables. Furthermore, five separate ordinal regression analyses were used to investigate drug use in relation to music preference, venues visited during the last month and sampling venue.
Results
Respondents who used illegal drugs were 2.5 times more likely to report that they prefer dance music. Goa party visitors were nearly 5 times more likely to use illegal drugs. For those who reported visiting clubs, the odds of using illegal drugs were nearly 2 times higher. Having gone to a pub in the last month was associated with both more frequent alcohol use and more frequent illegal substance use. People who reported liking rock music and attendees of rock festivals used drugs less frequently.
Conclusions
It was concluded that a more extended recreational environment, beyond dance clubs, is associated with frequent drug use. This stresses the importance of targeted prevention in various recreational venues tailored to the specific needs of the setting and its visitors.
doi:10.1186/1747-597X-6-18
PMCID: PMC3160361  PMID: 21794101
17.  Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study 
PLoS Medicine  2012;9(1):e1001164.
In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.
Background
Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.
Methods and Results
We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention “system-related” errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%–78.3%]; 57.5% [33.8%–81.2%]; and 60.5% [48.5%–72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23–7.28) to 2.12 (95% CI 1.71–2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30–3.93) to 1.46 (95% CI 1.20–1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively −12.8% [95% CI −41.1% to 15.5%]; −11.3% [−40.1% to 17.5%]; −20.1% [−52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30–0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.
Conclusions
Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Medication errors—for example, prescribing the wrong drug or giving a drug by the wrong route—frequently occur in health care settings and are responsible for thousands of deaths every year. Until recently, medicines were prescribed and dispensed using systems based on hand-written scripts. In hospitals, for example, physicians wrote orders for medications directly onto a medication chart, which was then used by the nursing staff to give drugs to their patients. However, drugs are now increasingly being prescribed using electronic prescribing (e-prescribing) systems. With these systems, prescribers use a computer and order medications for their patients with the help of a drug information database and menu items, free text boxes, and prewritten orders for specific conditions (so-called passive decision support). The system reviews the patient's medication and known allergy list and alerts the physician to any potential problems, including drug interactions (active decision support). Then after the physician has responded to these alerts, the order is transmitted electronically to the pharmacy and/or the nursing staff who administer the prescription.
Why Was This Study Done?
By avoiding the need for physicians to write out prescriptions and by providing active and passive decision support, e-prescribing has the potential to reduce medication errors. But, even though many countries are investing in expensive commercial e-prescribing systems, few studies have evaluated the effects of these systems on prescribing error rates. Moreover, little is known about the interactions between system design and errors despite fears that e-prescribing might introduce new errors. In this study, the researchers analyze prescribing error rates in hospital in-patients before and after the implementation of two commercial e-prescribing systems.
What Did the Researchers Do and Find?
The researchers examined medication charts for procedural errors (unclear, incomplete, or illegal orders) and for clinical errors (for example, wrong drug or dose) at two Australian hospitals before and after the introduction of commercial e-prescribing systems. At Hospital A, the Cerner Millennium e-prescribing system was introduced on one ward; three other wards acted as controls. At Hospital B, the researchers compared the error rates on two wards before and after the introduction of the iSoft MedChart e-prescribing system. The introduction of an e-prescribing system was associated with a substantial reduction in error rates in the three intervention wards; error rates on the control wards did not change significantly during the study. At Hospital A, medication errors declined from 6.25 to 2.12 per admission after the introduction of e-prescribing whereas at Hospital B, they declined from 3.62 to 1.46 per admission. This reduction in error rates was mainly driven by a reduction in procedural error rates and there was only a limited change in overall clinical error rates. Notably, however, the rate of serious errors decreased across the intervention wards from 0.25 to 0.14 per admission (a 44% reduction), whereas the serious error rate only decreased by 17% in the control wards during the study. Finally, system-related errors (for example, selection of an inappropriate drug located on a drop-down menu next to a likely drug selection) accounted for 35% of errors in the intervention wards after the implementation of e-prescribing.
What Do These Findings Mean?
These findings show that the implementation of these two e-prescribing systems markedly reduced hospital in-patient prescribing error rates, mainly by reducing the number of incomplete, illegal, or unclear medication orders. The limited decision support built into both the e-prescribing systems used here may explain the limited reduction in clinical error rates but, importantly, both e-prescribing systems reduced serious medication errors. Finally, the high rate of system-related errors recorded in this study is worrying but is potentially remediable by system redesign and user training. Because this was a “real-world” study, it was not possible to choose the intervention wards randomly. Moreover, there was no control ward at Hospital B, and the wards included in the study had very different specialties. These and other aspects of the study design may limit the generalizability of these findings, which need to be confirmed and extended in additional studies. Even so, these findings provide persuasive evidence of the current and potential ability of commercial e-prescribing systems to reduce prescribing errors in hospital in-patients provided these systems are continually monitored and refined to improve their performance.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001164.
ClinfoWiki has pages on medication errors and on electronic prescribing (note: the Clinical Informatics Wiki is a free online resource that anyone can add to or edit)
Electronic prescribing in hospitals challenges and lessons learned describes the implementation of e-prescribing in UK hospitals; more information about e-prescribing in the UK is available on the NHS Connecting for Health Website
The Clinicians Guide to e-Prescribing provides up-to-date information about e-prescribing in the USA
Information about e-prescribing in Australia is also available
Information about electronic health records in Australia
doi:10.1371/journal.pmed.1001164
PMCID: PMC3269428  PMID: 22303286
18.  An empirical evaluation of proposed changes for gambling diagnosis in the DSM-5 
Addiction (Abingdon, England)  2012;108(3):575-581.
Aims
Recommendations related to pathological gambling for the fifth edition of the Diagnostic and Statistic Manual for Mental Disorders (DSM) are to eliminate the criterion related to committing illegal acts and reduce the threshold for diagnosis from five to four criteria. This study evaluated the impact of these changes on prevalence rates and classification accuracy.
Design
Data were analyzed from five samples, varying in severity of gambling problems.
Settings and participants
Surveys of randomly-selected household residents in the US (n=2417), gambling patrons (n=450), individuals in brief intervention studies (n=375), patients in community-based gambling treatment programs (n=149), and participants in randomized intervention studies (n=319).
Measurements
The National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS) was administered to all participants. Internal consistency and factor structure were evaluated using both ten and nine criteria. Base rates, hit rates, sensitivity, specificity, and overall agreement were compared across classification systems, using DSM-IV classification as the standard.
Findings
Eliminating the illegal acts criterion did not impact internal consistency and modestly improved variance accounted for in the factor structure. In comparing a classification system using four of ten criteria versus one using four of nine, the four of nine system yielded equal or slightly better classification accuracy in all comparisons and across all samples.
Conclusions
These data suggest that inclusion of the illegal acts criterion does not appear necessary for diagnosis of pathological gambling, and, if it is eliminated, reducing the cutpoint to four results in more consistent diagnoses relative to the current classification system.
doi:10.1111/j.1360-0443.2012.04087.x
PMCID: PMC3807122  PMID: 22994319
pathological gambling; gambling; diagnoses; DSM-5
19.  COMPARING THE EFFECTIVENESS OF TWO FORMS OF TIME-SPACE SAMPLING TO IDENTIFY CLUB DRUG-USING YOUNG ADULTS 
Journal of drug issues  2008;38(4):1061-1081.
Time-space sampling has been used to generate representative samples of both hard-to-reach and location-based populations. Because of its emphasis on multi-tiered randomization (i.e., time, space, and individual), some have questioned the feasibility of time-space sampling as a cost-effective strategy. In an effort to better understand issues related to drug use among club-going young adults (ages 18 to 29) in the New York City nightlife scene, two variations of time-space sampling methods were utilized and compared (Version 1: randomized venue, day, and individuals within venues: Version 2: randomized venue and day). A list of nightlife venues were randomized and survey teams approached potential participants as they entered or exited venues to conduct brief anonymous surveys. Over the course of 24 months, 18,169 approaches were conducted and 10,678 consented to complete the brief questionnaire (V1 response rate = 46.0%, V2 response rate = 62.5%). Drug use was fairly common, with nearly two-thirds of the sample reporting having ever tried an illegal drug and more than half of drug users specifically tried either MDMA/ecstasy and/or cocaine. There were few differences between young adults surveyed during Version 1 and Version 2. Time-space sampling is an effective strategy to quickly detect and screen club drug users. Although caution is urged, elimination of the third tier of randomization (i.e., individual level counting) from time-space sampling may significantly improve response rates while only minimally impacting sample characteristics.
PMCID: PMC2914223  PMID: 20686625
20.  The temporal relationship between drug supply indicators: an audit of international government surveillance systems 
BMJ Open  2013;3(9):e003077.
Objectives
Illegal drug use continues to be a major threat to community health and safety. We used international drug surveillance databases to assess the relationship between multiple long-term estimates of illegal drug price and purity.
Design
We systematically searched for longitudinal measures of illegal drug supply indicators to assess the long-term impact of enforcement-based supply reduction interventions.
Setting
Data from identified illegal drug surveillance systems were analysed using an a priori defined protocol in which we sought to present annual estimates beginning in 1990. Data were then subjected to trend analyses.
Main outcome measures
Data were obtained from government surveillance systems assessing price, purity and/or seizure quantities of illegal drugs; systems with at least 10 years of longitudinal data assessing price, purity/potency or seizures were included.
Results
We identified seven regional/international metasurveillance systems with longitudinal measures of price or purity/potency that met eligibility criteria. In the USA, the average inflation-adjusted and purity-adjusted prices of heroin, cocaine and cannabis decreased by 81%, 80% and 86%, respectively, between 1990 and 2007, whereas average purity increased by 60%, 11% and 161%, respectively. Similar trends were observed in Europe, where during the same period the average inflation-adjusted price of opiates and cocaine decreased by 74% and 51%, respectively. In Australia, the average inflation-adjusted price of cocaine decreased 14%, while the inflation-adjusted price of heroin and cannabis both decreased 49% between 2000 and 2010. During this time, seizures of these drugs in major production regions and major domestic markets generally increased.
Conclusions
With few exceptions and despite increasing investments in enforcement-based supply reduction efforts aimed at disrupting global drug supply, illegal drug prices have generally decreased while drug purity has generally increased since 1990. These findings suggest that expanding efforts at controlling the global illegal drug market through law enforcement are failing.
doi:10.1136/bmjopen-2013-003077
PMCID: PMC3787412  PMID: 24080093
AUDIT; PUBLIC HEALTH
21.  The Impact of Legalizing Syringe Exchange Programs on Arrests Among Injection Drug Users in California 
Journal of Urban Health   2007;84(3):423-435.
Legislation passed in 2000 allowed syringe exchange programs (SEPs) in California to operate legally if local jurisdictions declare a local HIV public health emergency. Nonetheless, even in locales where SEPs are legal, the possession of drug paraphernalia, including syringes, remained illegal. The objective of this paper is to examine the association between the legal status of SEPs and individual arrest or citation for drug paraphernalia among injection drug users (IDUs) in California from 2001 to 2003. Using data from three annual cross-sections (2001-03) of IDUs attending 24 SEPs in 16 California counties (N = 1,578), we found that overall, 14% of IDUs in our sample reported arrest or citation for paraphernalia in the 6 months before the interview. Further analysis found that 17% of IDUs attending a legal SEP (defined at the county level) reported arrest or citation for drug paraphernalia compared to 10% of IDUs attending an illegal SEP (p = 0.001). In multivariate analysis, the adjusted odds ratio of arrest or citation for drug paraphernalia was 1.6 [95% confidence interval (CI) = 1.2, 2.3] for IDUs attending legal SEPs compared to IDUs attending illegal SEPs, after controlling for race/ethnicity, age, homelessness, illegal income, injection of amphetamines, years of injection drug use, frequency of SEP use, and number of needles received at last visit. IDUs attending SEPs with legal status may be more visible to police, and hence, more subject to arrest or citation for paraphernalia. These findings suggest that legislative efforts to decriminalize the operation of SEPs without concurrent decriminalization of syringe possession may result in higher odds of arrest among SEP clients, with potentially deleterious implications for the health and well-being of IDUs. More comprehensive approaches to removing barriers to accessing sterile syringes are needed if our public health goals for reducing new HIV/HCV infections are to be obtained.
doi:10.1007/s11524-006-9139-1
PMCID: PMC2231826  PMID: 17265133
Law enforcement; HIV; Arrests; Injection drug use; Syringe exchange programs; Policy
22.  Alcohol misuse 
Clinical Evidence  2011;2011:1017.
Introduction
Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the World Health Organization (WHO) as one of the top 5 risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. This review covers interventions in hazardous or harmful, but not dependent, alcohol users.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions in hazardous or harmful drinkers in the primary-care setting? What are the effects of interventions in hazardous or harmful drinkers in the emergency-department setting? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions in primary care and in emergency departments: brief intervention (single or multiple session), universal screening plus brief interventions, and targeted screening plus brief interventions.
Key Points
Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the WHO as one of the top 5 risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption.
This review covers interventions in hazardous or harmful (but not dependent) alcohol users. Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the individual's risk of alcohol-related harm, but is not currently causing alcohol-related harm.Harmful alcohol consumption is a pattern of consumption likely to have already led to alcohol-related harm.
Single- or multiple-session brief intervention reduces alcohol consumption over 1 year in hazardous drinkers treated in the primary-care setting, but we don't know how it affects mortality.
Brief intervention (single or multiple session) is also effective at reducing alcohol consumption in people treated in the emergency department, although the evidence is not as strong.
Adding universal screening to brief intervention enhances its benefits when given in primary care. We found insufficient RCT evidence to assess whether universal screening and brief intervention is any more effective than usual care in emergency departments.We don't know whether targeted screening is effective, as we found no RCT evidence assessing its use in primary or emergency care.
PMCID: PMC3275317  PMID: 21426592
23.  Treatment for illegal drug use disorders: the role of comorbid mood and anxiety disorders 
BMC Psychiatry  2014;14:89.
Background
Our aim was to examine whether comorbid mood and anxiety disorders influence patterns of treatment or the perceived unmet need for treatment among those not receiving treatment for illegal drug use disorders.
Methods
Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, 2001–2002 and 2004–2005, n = 34,653). Lifetime DSM-IV illegal drug use disorder (abuse and dependence), as well as comorbid mood (major depression, dysthymia, manic disorder, hypomanic disorder) and anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety) were ascertained by a standardized psychiatric interview. Treatment for illegal drug use disorders and perceived unmet need for treatment were assessed among individuals with illegal drug use disorder. Odds of treatment and odds of perceived unmet need for treatment were assessed using logistic regression, adjusting for socio-demographic characteristics, treatment for mood and anxiety disorders, and comorbid alcohol use disorder.
Results
Out of 34,653 participants, 1114 (3.2%) had a diagnosis of lifetime illegal drug use disorder: 21.2% had a comorbid mood disorder only, 11.8% a comorbid anxiety disorder only, and 45.9% comorbid mood and anxiety disorders. Comorbid mood and anxiety disorders were not related to treatment for illegal drug use disorders but were associated with an elevated likelihood of unmet need for treatment: compared to participants with no comorbidities, multivariate ORs were 2.21 (95% CI: 1.23- 4.10) for mood disorder only, 2.38 (95% CI: 1.27-4.45) for anxiety disorder only, and 2.90 (95% CI: 1.71-4.94) for both mood and anxiety disorders.
Conclusions
Individuals with an illegal drug use disorder and comorbid mood or anxiety disorders are disproportionately likely to report unmet need for treatment. Integrated mental health and substance use programs could prove effective in addressing their treatment needs.
doi:10.1186/1471-244X-14-89
PMCID: PMC3986906  PMID: 24670230
Illegal drug use disorder; Treatment; Unmet need for treatment; Mood disorders; Anxiety disorders; Epidemiology; General population sample
24.  Prospective Study of the Association Between Neurobehavior Disinhibition and Peer Environment on Illegal Drug Use in Boys and Girls 
Background
Individual and contextual factors jointly participate in the onset and progression of substance abuse; however, the pattern of their relationship in males and females has not been systematically studied.
Objectives
Male and female children and adolescents were compared to determine the relative influence of individual susceptibility (neurobehavior disinhibition or ND) and social environment (deviancy in peers) on use of illegal drugs.
Methods
Boys (N = 380) and girls (N = 127) were prospectively tracked from age 10–12 to age 16 to delineate the role of ND and peer deviancy on use of illegal drugs.
Results
Girls exhibited lower ND scores than boys in childhood and were less inclined to affiliate with deviant peers. These differences were reduced or disappeared by mid-adolescence. In boys only, peer deviancy in childhood mediated the association between ND and illegal drug use at age 16. In both genders, peer deviancy in mid-adolescence mediated ND and substance abuse at age 16.
Conclusions
Individual and contextual risk factors promoting substance abuse are more salient at a younger age in boys compared to girls.
Scientific Significance
These results point to the need for earlier screening and intervention for boys.
doi:10.1080/00952990902825405
PMCID: PMC2716067  PMID: 19462297
Adolescence; gender; illegal drug involvement; neurobehavior disinhibition; peer deviancy
25.  Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the non-medical use of psychoactive substances: a systematic review protocol 
Systematic Reviews  2012;1:22.
Background
There is a significant public health burden associated with substance use in Canada. The early detection and/or treatment of risky substance use has the potential to dramatically improve outcomes for those who experience harms from the non-medical use of psychoactive substances, particularly adolescents whose brains are still undergoing development. The Screening, Brief Intervention, and Referral to Treatment model is a comprehensive, integrated approach for the delivery of early intervention and treatment services for individuals experiencing substance use-related harms, as well as those who are at risk of experiencing such harm.
Methods
This article describes the protocol for a systematic review of the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment model for reducing the non-medical use of psychoactive substances. Studies will be selected in which brief interventions target non-medical psychoactive substance use (excluding alcohol, nicotine, or caffeine) among those 12 years and older who are opportunistically screened and deemed at risk of harms related to psychoactive substance use. We will include one-on-one verbal interventions and exclude non-verbal brief interventions (for example, the provision of information such as a pamphlet or online interventions) and group interventions. Primary, secondary and adverse outcomes of interest are prespecified. Randomized controlled trials will be included; non-randomized controlled trials, controlled before-after studies and interrupted time series designs will be considered in the absence of randomized controlled trials. We will search several bibliographic databases (for example, MEDLINE, EMBASE, CINAHL, PsycINFO, CORK) and search sources for grey literature. We will meta-analyze studies where possible. We will conduct subgroup analyses, if possible, according to drug class and intervention setting.
Discussion
This review will provide evidence on the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment protocol aimed at the non-medical use of psychoactive substances and may provide guidance as to where future research might be most beneficial.
doi:10.1186/2046-4053-1-22
PMCID: PMC3433383  PMID: 22587894
Brief intervention; Drug use; Psychoactive substance; Referral to treatment; SBIRT; Screening; Substance use; Systematic review

Results 1-25 (688435)