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1.  Coverage of overdose prevention programs for opiate users and injectors: a cross-sectional study 
Harm Reduction Journal  2014;11(1):33.
The use of opiates, particularly heroin, remains an important cause of morbidity and mortality. Half of the deaths among heroin consumers are attributed to overdose. In response to this problem, overdose prevention programs (OPPs) were designed. The objective of our study was to assess coverage of OPPs among the target population in a specific Spanish region (Catalonia) and to identify characteristics related to attendance.
A cross-sectional survey recruited individuals from outpatient treatment centers (OTCs), therapeutic communities (ThCs), and harm reduction facilities (HRFs) in Catalonia. From 513 participants, 306 opiate users and/or injectors were selected for this study. Coverage was calculated as the proportion of subjects who declared having participated in an OPP. A Poisson regression with robust variance was used to assess factors (socio-demographic aspects and psychoactive substance use patterns) associated to OPP participation, taking into account recruitment strategy.
Average age of the 306 subjects was 39.7 years (s.d.: 7.7); 79% were male; 79.2% lived in urban areas and 56.3% were unemployed or had never worked. Overall OPP coverage was 43.5% (95% CI: 37%–49%). Training was received mostly in HRF (60%), followed by OTC (24.4%), prison (19%), and ThC (16%). OPP sessions were attended by 41% of Spanish-born study participants and by 63.3% of foreigners; 92.2% of the participants lived in urban areas. The Poisson regression analysis adjusted by age, sex, and type of recruitment center showed that OPP participation rates were higher for individuals with foreign nationality (PR = 1.3; 95% CI: 1.04–1.72), for those living in municipalities with more than 100,000 inhabitants (PR = 2.0; 95% CI: 1.37–2.81) or the Barcelona conurbation (PR = 2.5; 95% CI: 1.68–3.77), and for those having ever been in prison (PR = 1.6; 95% CI: 1.41–1.81) and had first consumption when they were less than 12 years old (PR = 1.2; 95% CI: 1.06–1.45).
Coverage as a whole can be considered high. However, in Catalonia, new strategies ought to be developed in order to attract opiate users and injectors not currently participating, by expanding OPP offer to services and regions where coverage is poor.
PMCID: PMC4247710  PMID: 25416534
Coverage; Drug injectors; Harm reduction program; Heroin overdose; Opiates users; Drug and overdose prevention program
2.  Let it grow—the open market solution to marijuana control 
Harm Reduction Journal  2014;11(1):32.
This commentary evaluates regulatory frameworks for the legalized production, sale, and use of marijuana. Specifically, we argue that the primary goal of legalization should be the elimination of the illicit trade in marijuana and that maximizing market participation through open markets and personal cultivation is the best approach to achieving this goal. This argument is based on the assertion that regulatory models based on a tightly controlled government market will fail because they replicate the fatal flaws of the prohibition model. This commentary argues that an examination of the reasons for prohibition’s failure—to wit, the inability of government to control the production of marijuana—completely undercuts the basic premise of a tightly controlled market, which depends on the ability of the government to control production. The public interest would be better served by an effective regulatory framework which recognizes and takes advantage of competitive market forces. This analysis argues that reducing teenage access to marijuana requires the elimination of an overcapitalized illicit market. Further, it asserts that this goal and maximization of tax revenue from a legal marijuana market are mutually exclusive objectives.
PMCID: PMC4247667  PMID: 25403234
Cannabis; Decriminalization; Drug traffic; Government policy; Drug legalization (United States); Drug control (economic aspects); Drug policy; Legalization markets; Marijuana; Regulation
3.  Mexico’s “ley de narcomenudeo” drug policy reform and the international drug control regime 
Harm Reduction Journal  2014;11(1):31.
It has been over half a century since the landmark Single Convention on Narcotic Drugs was adopted, for the first time unifying international drug policy under a single treaty aimed at limiting use, manufacture, trade, possession, and trafficking of opiates, cannabis, and other narcotics. Since then, other international drug policy measures have been adopted, largely emphasizing enforcement-based approaches to reducing drug supply and use. Recently, in response to concerns that the historic focus on criminalization and enforcement has had limited effectiveness, international drug policies have begun to undergo a paradigm shift as countries seek to enact their own reforms to partially depenalize or deregulate personal drug use and possession. This includes Mexico, which in 2009 enacted national drug policy reform partially decriminalizing possession of small quantities of narcotics for personal consumption while also requiring drug treatment for repeat offenders. As countries move forward with their own reform models, critical assessment of their legal compatibility and effectiveness is necessary. In this commentary we conduct a critical assessment of the compatibility of Mexico’s reform policy to the international drug policy regime and describe its role in the current evolving drug policy environment. We argue that Mexico’s reform is consistent with flexibilities allowed under international drug treaty instruments and related commentaries. We also advocate that drug policy reforms and future governance efforts should be based on empirical evidence, emphasize harm reduction practices, and integrate evidence-based evaluation and implementation of drug reform measures.
PMCID: PMC4234880  PMID: 25395346
International drug policy; Single convention; Harm reduction; Mexico drug policy; Drug policy reform; UN office of drugs and crime; Global health
4.  A cost-benefit/cost-effectiveness analysis of an unsanctioned supervised smoking facility in the Downtown Eastside of Vancouver, Canada 
Harm Reduction Journal  2014;11(1):30.
Smoking crack involves the risk of transmitting diseases such as HIV and hepatitis C (HCV). The current study determines whether the formerly unsanctioned supervised smoking facility (SSF)—operated by the grassroot organization, Vancouver Area Network of Drug Users (VANDU) for the last few years—costs less than the costs incurred for health-care services as a direct consequence of not having such a program in Vancouver, Canada.
The data pertaining to the attendance at the SSF was gathered in 2012–2013 by VANDU. By relying on this data, a mathematical model was employed to estimate the number of HCV infections prevented by the former facility in Vancouver’s Downtown Eastside (DTES).
The DTES SSF’s benefit-cost ratio was conservatively estimated at 12.1:1 due to its low operating cost. The study used 70% and 90% initial pipe-sharing rates for sensitivity analysis. At 80% sharing rate, the marginal HCV cases prevented were determined to be 55 cases. Moreover, at 80% sharing rate, the marginal cost-effectiveness ratio ranges from $1,705 to $97,203. The results from both the baseline and sensitivity analysis demonstrated that the establishment of the SSF by VANDU on average had annually saved CAD$1.8 million dollars in taxpayer’s money.
Funding SSFs in Vancouver is an efficient and effective use of financial resources in the public health domain; therefore, Vancouver Coastal Health should actively participate in their establishment in order to reduce HCV and other blood-borne infections such as HIV within the non-injecting drug users.
PMCID: PMC4251950  PMID: 25395278
Supervised smoking facility; Crack; VANDU; Hepatitis C; Downtown Eastside
5.  Self-reported changes in drug use behaviors and syringe disposal methods following the opening of a supervised injecting facility in Copenhagen, Denmark 
Harm Reduction Journal  2014;11(1):29.
In Denmark, the first standalone supervised injecting facility (SIF) opened in Copenhagen’s Vesterbro neighborhood on October 1, 2012. The purpose of this study was to assess whether use of services provided by the recently opened SIF was associated with changes in injecting behavior and syringe disposal practices among people who inject drugs (PWID). We hypothesized that risk behaviors (e.g., syringe sharing), and unsafe syringe disposal (e.g., dropping used equipment on the ground) had decreased among PWID utilizing the SIF.
Between February and August of 2013, we conducted interviews using a survey (in English and Danish) with forty-one people who reported injecting drugs at the SIF. We used descriptive statistics and McNemar’s test to examine sociodemographic characteristics of the sample, current drugs used, sites of syringe disposal before and after opening of the SIF, and perceived behavior change since using the SIF.
Of the interviewed participants, 90.2% were male and the majority were younger than 40 years old (60.9%). Three-quarters (75.6%) of participants reported reductions in injection risk behaviors since the opening of the SIF, such as injecting in a less rushed manner (63.4%), fewer outdoor injections (56.1%), no longer syringe sharing (53.7%), and cleaning injecting site(s) more often (43.9%). Approximately two-thirds (65.9%) of participants did not feel that their frequency of injecting had changed; five participants (12.2%) reported a decrease in injecting frequency, and only two participants (4.9%) reported an increase in injecting frequency. Twenty-four (58.5%) individuals reported changing their syringe disposal practices since the opening of the SIF; of those, twenty-three (95.8%) reported changing from not always disposing safely to always disposing safely (McNemar’s test p-value < 0.001).
Our findings suggest that use of the Copenhagen SIF is associated with adoption of safer behaviors that reduce harm and promote health among PWID, as well as practices that benefit the Vesterbro neighborhood (i.e., safer syringe disposal). As a public health intervention, Copenhagen’s SIF has successfully reached PWID engaging in risk behavior. To fully characterize the impacts of this and other Danish SIFs, further research should replicate this study with a larger sample size and prospective follow-up.
PMCID: PMC4226898  PMID: 25352296
Supervised injecting facility; Drug consumption room; People who inject drugs; Injection drug users; Harm reduction; Risk behaviors; Syringe disposal; Denmark
6.  Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study 
Harm Reduction Journal  2014;11(1):28.
We surveyed a population of injection drug users (IDUs) frequenting the mobile Baltimore City Needle Exchange Program (BNEP) to investigate self-care factors associated with chronic wounds, a significant cause of morbidity especially among older IDUs.
Participants ≥18 years old completed a survey regarding chronic wounds (duration ≥8 weeks), injection and hygiene practices. Study staff visually verified the presence of wounds. Participants were categorized into four groups by age and wound status. Factors associated with the presence of chronic wounds in participants ≥45 years were analyzed using logistic regression.
Of the 152 participants, 19.7% had a chronic wound. Of those with chronic wounds, 18 were ≥45 years old (60.0%). Individuals ≥45 years old with chronic wounds were more likely to be enrolled in a drug treatment program (Odds ratio (OR) 3.4, 95% Confidence interval (CI) 1.0–10.8) and less likely to use cigarette filters when drawing up prepared drug (OR 0.2, 95% CI 0.03–0.7) compared to the same age group without chronic wounds. Compared to individuals <45 years old without chronic wounds, individuals ≥45 with a chronic wound were more likely to report cleaning reused needles with bleach (OR 10.7, 95% CI 1.2–93.9) and to use the clinic, rather than an emergency room, as a primary source of medical care (OR 3.4, 95% CI 1.1–10.4).
Older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene behaviors than their peers and younger IDUs without wounds in Baltimore City. Because of these differences, older IDUs with wounds may be more receptive to community-based healthcare and substance abuse treatment messages.
PMCID: PMC4213493  PMID: 25326686
Chronic wounds; Injection drug use; Aging; Harm reduction
7.  Establishing a community-based participatory research partnership among people who use drugs in Ottawa: the PROUD cohort study 
Harm Reduction Journal  2014;11(1):26.
Grounded in a community-based participatory research (CBPR) framework, the PROUD (Participatory Research in Ottawa: Understanding Drugs) Study aims to better understand HIV risk and prevalence among people who use drugs in Ottawa, Ontario. The purpose of this paper is to describe the establishment of the PROUD research partnership.
PROUD relies on peers’ expertise stemming from their lived experience with drug use to guide all aspects of this CBPR project. A Community Advisory Committee (CAC), comprised of eight people with lived experience, three allies and three ex-officio members, has been meeting since May 2012 to oversee all aspects of the project. Eleven medical students from the University of Ottawa were recruited to work alongside the committee. Training was provided on CBPR; HIV and harm reduction; and administering HIV point-of-care (POC) tests so that the CAC can play a key role in research design, data collection, analysis, and knowledge translation activities.
From March-December 2013, the study enrolled 858 participants who use drugs (defined as anyone who has injected or smoked drugs other than marijuana in the last 12 months) into a prospective cohort study. Participants completed a one-time questionnaire administered by a trained peer or medical student, who then administered an HIV POC test. Recruitment, interviews and testing occurred in both the fixed research site and various community settings across Ottawa. With consent, prospective follow-up will occur through linkages to health care records available through the Institute for Clinical and Evaluation Sciences.
The PROUD Study meaningfully engaged the communities of people who use drugs in Ottawa through the formation of the CAC, the training of peers as community-based researchers, and integrated KTE throughout the research project. This project successfully supported skill development across the team and empowered people with drug use experience to take on leadership roles, ensuring that this research process will promote change at the local level. The CBPR methods developed in this study provide important insights for future research projects with people who use drugs in other settings.
PMCID: PMC4203893  PMID: 25307356
CBPR; Drug use; Harm reduction; HIV; Ottawa
8.  Injecting drug use in Manipur and Nagaland, Northeast India: injecting and sexual risk behaviours across age groups 
Harm Reduction Journal  2014;11(1):27.
There is an HIV epidemic among people who inject drugs (PWID) in Manipur and Nagaland, Northeast India. Approximately one-third of PWID across these two states are aged below 25 years, yet until now there has been no systematic investigation of the differences between the younger and older PWID. We sought to profile differences in drug use and sexual practices across age groups and to examine whether age is associated with injecting and sexual risk behaviours.
We used combined cross-sectional survey data collected in 2009 from two surveys involving a total of 3,362 (male) PWID in eight districts of Manipur and Nagaland. All data were collected using interviewer-administered questionnaires.
Compared to PWID aged 35 years or older, PWID aged 18 to 24 years were more likely share needles/syringes in both Manipur (OR =1.8) and Nagaland (OR =1.6). Compared to PWID aged 35 years or older, PWID aged 18 to 24 years were almost two times as likely to draw up drug solution from a common container at their last injection in Manipur (OR =1.8). In Nagaland, PWID aged 18 to 24 years were more likely to use condoms consistently with both casual (OR =3.1) and paid (OR =17.7) female sexual partners compared to PWID aged 35 years or older.
Risky injecting practices were more common among younger PWID in both Manipur and Nagaland, while unprotected sex was more common among older PWID in Nagaland. There is a clear need to focus public health messages across different age groups.
PMCID: PMC4210540  PMID: 25312004
Injecting drug use; HIV; Youth
9.  Harm reduction and knowledge exchange—a qualitative analysis of drug-related Internet discussion forums 
Novel psychoactive substances (NPS) are continuously and increasingly appearing on the international drug market. Global Internet forums are a publicly available reality where users anonymously discuss and share information about NPS. The aim of this study was to explore and characterize the discussions about NPS on international Internet forums.
The most post-frequent NPS discussions were collected from three “leading edge” international Internet forums. A total of 13,082 posts from 60 threads of discussion were systematically examined and interpreted to reveal recurring topics and patterns. Each thread was coded with emerging topics and supporting quotations from the data set. Eventually, codes with coherent meaning were arranged into 51 broader categories of abstraction, which were combined into four overarching themes.
Four themes emerged during the analysis: (1) uncovering the substance facts, (2) dosage and administration, (3) subjectively experienced effects, and (4) support and safety. The first theme dealt primarily with substance identification, pharmacology, and assessed not only purity but also legal status and acquisition. The second theme focused on administration techniques, dose recommendations, technical talk about equipment, and preferred settings for drug use. The third theme involved a multitude of self-reported experiences, in which many different aspects of intoxication were depicted in great detail. The users emphasized both positive and negative experiences. The last theme incorporated the efforts of the communities to prevent and minimize harm by sharing information about potential risks of the harmful effects or contraindications of a substance. Also, online support and guidance were given to intoxicated persons who experienced bad or fearful reactions.
The findings showed that the discussions were characterized by a social process in which users supported each other and exchanged an extensive and cumulative amount of knowledge about NPS and how to use them safely. Although this publicly available knowledge could entail an increase in drug use, the main characteristics of the discussions in general were a concern for safety and harm reduction, not for recruiting new users. Drug-related Internet forums could be used as a location for drug prevention, as well as a source of information for further research about NPS.
PMCID: PMC4160913  PMID: 25200686
Novel psychoactive substances; Legal highs; Research chemicals; Internet drugs; Harm reduction; Internet forum; Drug use
10.  The role of substance use and morality in violent crime - a qualitative study among imprisoned individuals in opioid maintenance treatment 
Opioid maintenance treatment (OMT) is regarded as a crime control measure. Yet, some individuals are charged with violent criminal offenses while enrolled in OMT. This article aims to generate nuanced knowledge about violent crime among a group of imprisoned, OMT-enrolled individuals by exploring their understandings of the role of substances in violent crime prior to and during OMT, moral values related to violent crime, and post-crime processing of their moral transgressions.
Twenty-eight semi-structured interviews were undertaken among 12 OMT-enrolled prisoners. The interviews were audio recorded and transcribed verbatim. An exploratory, thematic analysis was carried out with a reflexive and interactive approach.
Prior to OMT, substances and, in particular, high-dose benzodiazepines were deliberately used to induce ‘antisocial selves’ capable of transgressing individual moral codes and performing non-violent and violent criminal acts, mainly to support costly heroin use. During OMT, impulsive and uncontrolled substance use just prior to the violent acts that the participants were imprisoned for was reported. Yet, to conduct a (violent) criminal act does not necessarily imply that one is without moral principles. The study participants maintain moral standards, engage in complex moral negotiations, and struggle to reconcile their moral transgressions. Benzodiazepines were also used to reduce memories of and alleviate the guilt associated with having committed violent crimes.
Substances are used to transgress moral codes prior to committing and to neutralize the shame and guilt experienced after having committed violent crimes. Being simultaneously enrolled in OMT and imprisoned for a (violent) crime might evoke feelings of ‘double’ shame and guilt for both the criminal behavior prior to treatment and the actual case(s) one is imprisoned for while in OMT. Treatment providers should identify individuals with histories of violent behavior and, together with them, explore concrete episodes of violence and their emotional reactions. Particular attention should be given to potential relationships between substance use and violence and treatment approaches tailored accordingly. What appears as severe antisocial personality disorder may be partly explained by substance use.
PMCID: PMC4142255  PMID: 25142321
Violence; Benzodiazepines; Opioid maintenance treatment; Morality; Prison; Crime; Qualitative methods; Antisocial personality disorder
11.  Ethnic- and gender-specific differences in the prevalence of HIV among patients in opioid maintenance treatment—a case register analysis 
We have sought to identify ethnic- and gender-specific differences in HIV prevalence among heroin users receiving opioid maintenance treatment in the canton of Zurich, Switzerland.
We used a generalized linear model (GEE) to analyze data from the anonymized case register for all opioid maintenance treatments in the canton of Zurich. Patients who received either methadone or buprenorphine between 1991 and 2012 (n = 11,422) were evaluated for gender (male vs. female), ethnic background (Swiss vs. non-Swiss), and lifetime method of drug use (ever injector vs. non-injector). We addressed missing data by multiple imputation.
The overall prevalence of HIV among patients declined substantially from 33.7% in 1991 to 10.6% in 2012 in the complete dataset. In the imputed datasets, the respective prevalence dropped from 32.8% in 1991 to 9.7% in 2012. Non-injectors had a four to five times lower risk ratio (RR) compared to the reference group, ‘Swiss males who ever injected’. In addition, we found a significantly higher risk ratio of HIV prevalence among females who had ever injected; this was true both for the complete dataset and the imputed dataset (Swiss RR 1.18 CI 95% 1.04–1.34, non-Swiss RR 1.58 CI 95% 1.18–2.12).
In this population, gender, ethnic background, and lifetime method of drug use influenced the risk of being HIV positive. Different access to treatment and different characteristics of risk exposure among certain subgroups might explain these findings. In particular, the higher risk for women who inject drugs—especially for those with an immigrant background—warrants additional research. Further exploration should identify what factors deter women from using available HIV-prevention measures and whether and how these measures can be better adapted to high-risk groups.
PMCID: PMC4178317  PMID: 25130184
12.  Prevalence of skin problems and leg ulceration in a sample of young injecting drug users 
Drug users suffer harm from the injecting process, and clinical services are reporting increasing numbers presenting with skin-related problems such as abscesses and leg ulcers. Skin breakdown can lead to long-term health problems and increased service costs and is often the first indication of serious systemic ill health. The extent of skin problems in injecting drug users has not previously been quantified empirically, and there is a dearth of robust topical literature. Where skin problems have been reported, this is often without clear definition and generic terms such as ‘soft tissue infection’ are used which lack specificity. The aim of this study was to identify the range and extent of skin problems including leg ulceration in a sample of injecting drug users. Definitions of skin problems were developed and applied to descriptions from drug users to improve rigour.
Data were collected in needle exchanges and methadone clinics across Glasgow, Scotland, from both current and former drug injectors using face-to-face interviews.
Two hundred participants were recruited, of which 74% (n = 148) were males and 26% (n = 52) were females. The age range was 21–44 years (mean 35 years). Just under two thirds (64%, n = 127) were currently injecting or had injected within the last 6 months, and 36% (n = 73) had previously injected and had not injected for more than 6 months.
Sixty per cent (n = 120) of the sample had experienced a skin problem, and the majority reported more than one problem. Most common were abscesses, lumps, track marks and leg ulcers. Fifteen per cent (n = 30) of all participants reported having had a leg ulcer.
This is an original empirical study which demonstrated unique findings of a high prevalence of skin disease (60%) and surprisingly high rates of leg ulceration (15%). Skin disease in injecting drug users is clearly widespread. Leg ulceration in particular is a chronic recurring condition that is costly to treat and has long-term implications for drug users and services caring for current or former injectors long after illicit drug use has ceased.
PMCID: PMC4136408  PMID: 25119472
Leg ulceration; Skin; Prevalence; Drug injecting
13.  Substance use and associated factors among preparatory school students in Bale Zone, Oromia Regional State, Southeast Ethiopia 
The use of cigarettes, alcohol, khat, and other substances is a worldwide threat which especially affects young people and which is also common among the youth of Ethiopia. However, its prevalence and associated factors have not been addressed well yet. Thus, this study aimed to assess the prevalence and associated factors of substance use among preparatory school students in Bale Zone, Oromia Regional State, Southeast Ethiopia.
An institutional-based cross-sectional study was conducted among 603 randomly selected students from five of eight preparatory schools of Bale Zone, Oromia Regional State, Southeast Ethiopia, in March 2013. The sample size was calculated by a single population proportion formula and allocated proportionally for the schools based on the number of students. A pretested structured questionnaire was used to collect the data. The data were analyzed using SPSS version 16.0. Descriptive, bivariate, and multivariate logistic regressions were employed to identify the predictors of substance use.
The overall current prevalence of substance use among the respondents was 34.8% (210). Specifically, 23.6% (102) and 4.6% (28) of the respondents chewed khat and smoked cigarette, respectively. Sex, age, and substance use status of the respondents’ father, mother, siblings, and best friend had an association with substance use. Male respondents were about ten times more at risk of practicing substance use compared to female respondents [adjusted odds ratio (AOR) 11.37, 95% confidence interval (CI) 4.42–29.23]. Respondents whose sibling(s) smokes cigarette were four times more likely to use substance (AOR 4.44, 95% CI 1.11–17.79). Respondents whose best friend chews khat were 11 times more likely to use substance when compared with those whose best friend does not practice the given factor (AOR 11.15, 95% CI 4.43–28.07).
Respondents whose family uses one or more substances were more likely use substance(s). Respondents whose best friend uses substance(s) were more prone to practice substance use. Fifteen years of age of the respondents was the critical age when they began to practice substance use. Sex and family of the respondents were the predicting factors for them to practice substance use or not. Hence, health extension workers and district health workers should tackle substance use of the respondents through focusing the identified factors.
PMCID: PMC4131802  PMID: 25108629
Substance use (khat, alcohol, cigarette, and shisha); Associated factors
14.  Are empty methadone bottles empty? An analytic study 
Methadone maintenance treatment is the most widely prescribed treatment for opiate dependence with proven benefits for patients. In naïve users or in case of recreational misuse, methadone can be a source of potentially lethal intoxications, resulting in fatal overdoses. A few cases of infantile intoxications have been described in the literature, some of which resulted in death. Nowadays, more than 50,000 bottles are used every day in France, most of which are thrown away in the bin. Relatives at home, especially children, can have access to these empty bottles. This study aims to determine whether the residual quantity of methadone in the bottles is associated with a risk of intoxication for someone who has a low tolerance to opiates, such as a child.
The methadone dosage left in a sample of 175 bottles recapped after use by the patients taking their maintenance treatment in an addiction treatment program centre was analysed during a 2-week period in March 2013.
The mean residual quantity of methadone left in each bottle after use is 1.9 ± 1.8 mg and 3.3 ± 2.4 mg in the sample of 60 mg bottles.
There is a potential danger of accidental overdose with empty bottles of methadone syrup, especially for children. To take into account this hazard, several harm reduction strategies can be proposed, such as favouring the taking of the treatment within the delivery centres rather than the ‘take home’ doses, asking methadone users to bring back their used bottles, and raising patients’ awareness of the intoxication risks and the necessary everyday precautions. For stable patients with take home methadone, the use of capsules could be considered.
PMCID: PMC4094677  PMID: 24990630
Methadone; Empty bottles; High-performance liquid chromatography
15.  Variability and dilemmas in harm reduction for anabolic steroid users in the UK: a multi-area interview study 
The UK continues to experience a rise in the number of anabolic steroid-using clients attending harm reduction services such as needle and syringe programmes.
The present study uses interviews conducted with harm reduction service providers as well as illicit users of anabolic steroids from different areas of England and Wales to explore harm reduction for this group of drug users, focussing on needle distribution policies and harm reduction interventions developed specifically for this population of drug users.
The article addresses the complexity of harm reduction service delivery, highlighting different models of needle distribution, such as peer-led distribution networks, as well as interventions available in steroid clinics, including liver function testing of anabolic steroid users. Aside from providing insights into the function of interventions available to steroid users, along with principles adopted by service providers, the study found significant tensions and dilemmas in policy implementation due to differing perspectives between service providers and service users relating to practices, risks and effective interventions.
The overarching finding of the study was the tremendous variability across harm reduction delivery sites in terms of available measures and mode of operation. Further research into the effectiveness of different policies directed towards people who use anabolic steroids is critical to the development of harm reduction.
PMCID: PMC4098923  PMID: 24986546
Harm reduction; Needle and syringe programmes; Anabolic steroids
16.  SMOKE IT! Promoting a change of opiate consumption pattern - from injecting to inhaling 
Intravenous drug use has been predominantly practised since illegal heroin use became known in Germany in the early 1970s. The available data suggest that the risk of accidental overdose when smoking heroin is substantially reduced compared to injecting a substance of unknown purity and quality. Moreover, the risk of transmitting HIV, Hepatitis B or C via blood contact is considerably reduced when smoking heroin rather than when injecting it intravenously. In spite of the significant strain on the lungs and the respiratory tract caused by smoking, it can be concluded that inhalative use - measured by the indicators ‘overdose’ and ‘viral infections’ is considerably less dangerous than intravenous use. Despite these harm-reducing effects of inhalative use, there is only very limited scientific survey on this subject. The project ‘SMOKE IT!’ studied to what extent a change of the consumption method can be supported by making new equipment for drug use available.
‘SMOKE IT!’ was carried out as a multi-centre survey in drug consumption rooms (DCRs) in five German cities. Participants received ‘SMOKE-IT!’ packs that contained new heroin smoking foils, as well as information about inhalative drug use. The quantitative data collection was aided by a written questionnaire filled out at three different stages in 2012.
The vast majority of the 165 respondents favoured using the foils from the ‘SMOKE-IT!’ packs (82.5%). The survey shows that two-thirds of the sample used the SMOKE-IT foils for inhaling instead of injecting. Almost six out of ten said that smoking was healthier than injecting. Thirty-five percent of the participants named the reduced risk of a hepatitis or HIV infection as a particularly important factor. A third of the respondents used the smoking foils to avoid the danger of an overdose.
Targeted media and personal intervention in association with the dispensation of attractive drug use equipment can motivate opiate users to change their method of drug use. The main reason for inhalative use is that it is significantly less dangerous, measured by the indicators ‘overdose’ and ‘viral infections’. All drop-in centres should expand their syringe-exchange services to include the dispensation of smoking foils.
PMCID: PMC4094754  PMID: 24973031
Drug use; Foil; SMOKE IT; Inhalative; Injection; Harm reduction; Morbidity; Mortality; Route transition interventions
17.  ‘South Asian cocktail’ - the concurrent use of opioids, benzodiazepines and antihistamines among injecting drug users in Nepal and associations with HIV risk behaviour 
Data of the Central Bureau of Statistic of Nepal from 2008 show a total of more than 46,000 illegal drug users, out of which 61% are injecting drug users (IDU). An injecting mix of medicines like opioids, benzodiazepines and antihistamines (the so-called South Asian cocktail) was prevalent. Furthermore, it is estimated that about 70,000 people are living with human immunodeficiency virus (HIV). The government of Nepal has started realizing and recognizing drug use and HIV as significant health and social issues. Harm reduction programs such as needle syringe exchange and opioid substitution treatment are being implemented.
The aim of this study is to obtain specific knowledge on the drug use behaviour and the health status of drug users with a focus on HIV in drug users with concurrent injection of opioids, benzodiazepines and antihistamines. After an initial mapping of Kathmandu Valley, 300 drug users in contact with different treatment and counselling centres were randomly chosen for the interviews. The research questionnaire was designed according to the European Addiction Severity Index (EuropASI) and Maudsley Addiction Profile standards.
Ninety-one percent of the respondents are male and 9% female. Mean age is 28.7 years. Ninety-five percent are injecting drug users with a mean of 8.7 years of drug use history. Eighty-six percent are injecting different ‘cocktails’, usually made of buprenorphine, diazepam, promethazine and/or other substances (30-day prevalence). Similarly, 48% use heroin, whereas only 2% take cocaine/crack. Among those tested for HIV (N = 223), 33% are positive (25% of the sample population). Compared to the other drug users (mainly heroin), the cocktail users show a higher HIV infection rate and more co-infections. Furthermore, risk behaviour, as e.g. needle sharing, is much more common among the cocktail users.
Currently, the mixture of medicines, opioids, benzodiazepines and antihistamines, is the predominant drug in Nepal; the pharmaceutical drugs needed to prepare the cocktail are less expensive than heroin and relatively easy to acquire. The cocktail users show a higher risk behaviour regarding the transmission of HIV than heroin drug users. It needs to be considered which HIV prevention measures are necessary to target the specific needs of drug users who inject a mixture of opioids, benzodiazepines and antihistamines, since the available services (such as needle syringe exchange) do not seem to cover their specific needs (high percentage of needle sharing).
PMCID: PMC4035730  PMID: 24886095
Opiates; Benzodiazepines; Antihistamines; South Asian cocktail; Opioid substitution treatment; HIV; Buprenorphine (injectable)
18.  Long-term survey of a syringe-dispensing machine needle exchange program: answering public concerns 
Syringe-dispensing machines (SDM) provide syringes at any time even to hard-to-reach injecting drug users (IDUs). They represent an important harm reduction strategy in large populated urban areas such as Paris. We analyzed the performance of one of the world's largest SDM schemes based in Paris over 12 years to understand its efficiency and its limitations, to answer public and stakeholder concerns and optimize its outputs.
Parisian syringe dispensing and exchange machines were monitored as well as their sharp disposals and associated bins over a 12-year period. Moreover, mechanical counting devices were installed on specific syringe-dispensing/exchange machines to record the characteristics of the exchange process.
Distribution and needle exchange have risen steadily by 202% for the distribution and 2,000% for syringe recovery even without a coin counterpart. However, 2 machines out of 34 generate 50% of the total activity of the scheme. It takes 14 s for an IDU to collect a syringe, while the average user takes 3.76 syringes per session 20 min apart. Interestingly, collection time stops early in the evening (19 h) for the entire night.
SDMs had an increasing distribution role during daytime as part of the harm reduction strategy in Paris with efficient recycling capacities of used syringes and a limited number of kits collected by IDU. Using counting devices to monitor Syringe Exchange Programs (SEPs) is a very helpful tool to optimize use and answer public and stakeholder concerns.
PMCID: PMC4037274  PMID: 24885902
19.  Do community-based strategies reduce HIV risk among people who inject drugs in China? A quasi-experimental study in Yunnan and Guangxi provinces 
HIV transmission among people who inject drugs (PWID) is high in Yunnan and Guangxi provinces in southwest China. To address this epidemic, Population Services International (PSI) and four cooperating agencies implemented a comprehensive harm reduction model delivered through community-based drop-incenters (DiC) and peer-led outreach to reduce HIV risk among PWID.
We used 2012 behavioral survey data to evaluate the effectiveness of this model for achieving changes in HIV risk, including never sharing needles or syringes, always keeping a clean needle on hand, HIV testing and counseling (HTC), and consistent condom use. We used respondent-driven sampling to recruit respondents. We then used coarsened exact matching (CEM) to match respondents during analysis to improve estimation of the effects of exposure to both DiC and outreach, only DiC, and only outreach, modeled using multivariable logistic regression.
We found a significant relationship between participating in both peer-led DiC-based activities and outreach and having a new needle on hand (odds ratio (OR) 1.53, p < .05) and consistent condom use (OR 3.31, p < .001). We also found a significant relationship between exposure to DiC activities and outreach and HIV testing in Kunming (OR 2.92, p < .01) and exposure to peer-led outreach and HIV testing through referrals in Gejiu, Nanning, and Luzhai (OR 3.63, p < .05).
A comprehensive harm reduction model delivered through peer-led and community-based strategies reduced HIV risk among PWID in China. Both DiC activities and outreach were effective in providing PWID behavior change communications (BCC) and HTC. HTC is best offered in settings like DiCs, where there is privacy for testing and receiving results. Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grassroot organizations. Outreach appears to be most effective for referring PWID into HTC, especially when DiC-based HTC is not available and increasing awareness of DiCs where PWID can receive more intensive BCC interventions.
PMCID: PMC4022425  PMID: 24885778
Social marketing; Drop-in center; Community-based outreach; Behavior change communication (BCC); People who inject drugs (PWID); Respondent-driven sampling (RDS); Needle-syringe exchange program (NSP); Condom use; HIV testing and counseling (HTC); Coarsened exact matching (CEM)
20.  A Scopus-based examination of tobacco use publications in Middle Eastern Arab countries during the period 2003–2012 
Tobacco smoking is the main health-care problem in the world. Evaluation of scientific output in the field of tobacco use has been poorly explored in Middle Eastern Arab (MEA) countries to date, and there are few internationally published reports on research activity in tobacco use. The main objectives of this study were to analyse the research output originating from 13 MEA countries on tobacco fields and to examine the authorship pattern and the citations retrieved from the Scopus database.
Data from 1 January 2003 through 31 December 2012 were searched for documents with specific words regarding the tobacco field as 'keywords’ in the title in any 1 of the 13 MEA countries. Research productivity was evaluated based on a methodology developed and used in other bibliometric studies.
Five hundred documents were retrieved from 320 peer-reviewed journals. The greatest amount of research activity was from Egypt (25.4%), followed by the Kingdom of Saudi Arabia (KSA) (23.2%), Lebanon (16.3%), and Jordan (14.8%). The total number of citations for the 560 documents, at the time of data analysis (27 August 2013), was 5,585, with a mean ± SD of 9.95 ± 22.64 and a median (interquartile range) of 3(1–10). The h-index of the retrieved documents was 34. This study identified 232 (41.4%) documents from 53 countries in MEA-foreign country collaborations. By region, MEA collaborated most often with countries in the Americas (29.6%), followed by countries in the same MEA region (13.4%), especially KSA and Egypt.
The present data reveal a promising rise and a good start for research productivity in the tobacco field in the Arab world. Research output is low in some countries, which can be improved by investing in more international and national collaborative research projects in the field of tobacco.
PMCID: PMC4012166  PMID: 24885706
Bibliometric; Tobacco smoking; Middle Eastern Arab; Scopus
21.  A drug use survey among clients of harm reduction sites across British Columbia, Canada, 2012 
In British Columbia (BC), understanding of high-risk drug use trends is largely based on survey and cohort study data from two major cities, which may not be representative of persons who use drugs in other regions. Harm reduction stakeholders, representing each of the five geographic health regions in BC, identified a need for data on drug use to inform local and regional harm reduction activities across the province. The aims of this project were to (1) develop a drug use survey that could be feasibly administered at harm reduction (HR) sites across all health regions and (2) assess the data for differences in reported drug use frequencies by region.
A pilot survey focusing on current drug use was developed with stakeholders and administered among clients at 28 HR supply distribution sites across the province by existing staff and peers. Data were collated and analysed using univariate and bivariate descriptive statistics to assess differences in reported drug use frequencies by geography. A post-survey evaluation was conducted to assess acceptability and feasibility of the survey process for participating sites.
Crack cocaine, heroin, and morphine were the most frequently reported drugs with notable regional differences. Polysubstance use was common among respondents (70%) with one region having 81% polysubstance use. Respondents surveyed in or near their region's major centre were more likely to report having used crack cocaine (p < 0.0001) and heroin (p < 0.0001) in the past week as compared to those residing >50 km from the major centre. Participants accessing services >50 km from the regional centre were more likely to have used morphine (p < 0.0001). There was no difference in powder cocaine use by client/site proximity to the regional centre. Participating sites found the survey process acceptable, feasible to administer annually, and useful for responding to client needs.
The survey was a feasible way for harm reduction sites across BC to obtain drug use data from clients who actively use drugs. Drug use frequencies differed substantially by region and community proximity to the regional centre, underlining the need for locally collected data to inform service planning.
PMCID: PMC4016659  PMID: 24766846
Harm reduction; Persons who use drugs; Survey; Surveillance
22.  Increases and decreases in drug use attributed to housing status among street-involved youth in a Canadian setting 
Among a cohort of drug-using street-involved youth, we sought to identify the prevalence of reporting increases and decreases in illicit drug use due to their current housing status and to identify factors associated with reporting these changes.
This longitudinal study was based on data collected between June 2008 and May 2012 from a prospective cohort of street-involved youth aged 14–26 in Vancouver, Canada. At semi-annual study follow-up visits, youth were asked if their drug use was affected by their housing status. Using generalized estimating equations, we identified factors associated with perceived increases and decreases in drug use attributed to housing status. Among our sample of 536 participants at baseline, 164 (31%) youth reported increasing their drug use due to their housing situation and 71 (13%) reported decreasing their drug use. In multivariate analysis, factors that were positively associated with perceived increases in drug use attributed to housing status included the following: being homeless, engaging in sex work and drug dealing. Regular employment was negatively associated with increasing drug use due to housing status. Among those who reported decreasing their drug use, only homelessness was significant in bivariate analysis.
Perceived changes in drug use due to housing status were relatively common in this setting and were associated with being homeless and, among those who increased their drug use, engaging in risky income generation activities. These findings suggest that structural factors, particularly housing and economic opportunities, may be crucial interventions for reducing or limiting drug use among street-involved youth.
PMCID: PMC3999483  PMID: 24721725
Homelessness; Drug use; Street-involved youth; Stable housing; Risk behaviour; Employment
23.  Rapid Assessment Response (RAR) study: drug use, health and systemic risks—Emthonjeni Correctional Centre, Pretoria, South Africa 
Correctional centre populations are one of the populations most at risk of contracting HIV infection for many reasons, such as unprotected sex, violence, rape and tattooing with contaminated equipment. Specific data on drug users in correctional centres is not available for the majority of countries, including South Africa. The study aimed to identify the attitudes and knowledge of key informant (KI) offender and correctional centre staff regarding drug use, health and systemic-related problems so as to facilitate the long-term planning of activities in the field of drug-use prevention and systems strengthening in correctional centres, including suggestions for the development of appropriate intervention and rehabilitation programmes.
A Rapid Assessment Response (RAR) methodology was adopted which included observation, mapping of service providers (SP), KI interviews (staff and offenders) and focus groups (FGs). The study was implemented in Emthonjeni Youth Correctional Centre, Pretoria, South Africa. Fifteen KI staff participants were interviewed and 45 KI offenders.
Drug use is fairly prevalent in the centre, with tobacco most commonly smoked, followed by cannabis and heroin. The banning of tobacco has also led to black-market features such as transactional sex, violence, gangsterism and smuggling in order to obtain mainly prohibited tobacco products, as well as illicit substances.
HIV, health and systemic-related risk reduction within the Correctional Service sector needs to focus on measures such as improvement of staff capacity and security measures, deregulation of tobacco products and the development and implementation of comprehensive health promotion programmes.
PMCID: PMC3976637  PMID: 24708609
Correctional Services; Drug use; Infectious diseases; Health promotion; Harm reduction; South Africa
24.  Injecting on the Island: a qualitative exploration of the service needs of persons who inject drugs in Prince Edward Island, Canada 
Few studies have investigated the service needs of persons who inject drugs (PWID) who live in less populated regions of Canada. With access to fewer treatment and harm reduction services than those in more urban environments, the needs of PWID in smaller centres may be distinct. As such, the present study examined the needs of PWID in Prince Edward Island (PEI), the smallest of Canada's provinces.
Eight PWID were interviewed about the services they have accessed, barriers they faced when attempting to access these services, and what services they need that they are not currently receiving.
Participants encountered considerable barriers when accessing harm reduction and treatment services due to the limited hours of services, lengthy wait times for treatment, and shortage of health care practitioners. They also reported experiencing considerable negativity from health care practitioners. Participants cited incidences of stigmatisation, and they perceived that health care practitioners received insufficient training related to drug use. Recommendations for the improvement of services are outlined.
The findings indicate that initiatives should be developed to improve PWID's access to harm reduction and treatment services in PEI. Additionally, health care practitioners should be offered sensitisation training and improved education on providing services to PWID. The findings highlight the importance of considering innovative alternatives for service provision in regions with limited resources.
PMCID: PMC3975878  PMID: 24593319
Injection drug use; Harm reduction; Service provision; Syringe access; Canada
25.  Estimating the number of injection drug users in greater Victoria, Canada using capture-recapture methods 
Population size estimation is critical for planning public health programmes for injection drug users. Estimation is difficult, as these populations are considered 'hidden’ or 'hard to reach’. The currently accepted population size estimate for greater Victoria, Canada is between 1,500 and 2,000 individuals, which is dated prior to the year 2000, and is likely an underestimate.
We used three mark-recapture methods (the Lincoln-Petersen estimator, Huggins' model, and Pledger's model) to estimate population size using cross-sectional survey data collected in 2003 and 2005. Data come from a closed population with two time-ordered samples from the same source. We compare our estimates with the currently accepted estimate that is based on the registry of a Victoria needle exchange.
All methods provided population size estimates that were higher than the currently accepted estimate. Huggins' method produced wider confidence intervals. Point estimates of population size from the three methods ranged from 3,329 to 3,342.
Our estimates will aid health authorities in planning for harm reduction programmes. Repeating the methods as further phases of I-Track data become available will ensure that the population estimates remain up to date.
PMCID: PMC3946204  PMID: 24589019
Injection drug user; Public health; Capture-recapture; Population size

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