Intérêt d’un programme d’échange de seringues en pharmacie d’officine pour les usagers de drogues par voie intraveineuse

Reprint of: The effect of the Music Day event on community drug use

Illicit drugs consumption can be back-calculated based on the analysis of drug residues in wastewater using the wastewater-based epidemiology method. The Music Day, held on June 21 in France since 1982, has grown to global proportions and is now celebrated as World Music Day. This large outdoor event takes place in many cities with people allowed to play music in the streets. As psychotropic drugs are often associated with music events, the goal of this study is to investigate the use of illicit drugs on this day in Bordeaux, the fifth largest urban area in France. Daily sampling campaigns of composite wastewater were carried out for seven days in two wastewater treatment plants in Bordeaux in 2017 (Music Day) and 2018. World Music Day in Bordeaux has no observable effect on illicit drug consumption even if this event has massive public participation: this is the first report of the absence of an illicit drug consumption increase in a festival of such magnitude, corroborating the effect of others' views and opinions, because this event takes place publicly in the street and not among peers. Different hypothesizes are put forward to explain this fact: inappropriate type of event for drug consumption, effect of other festivals, and influence of the event's timing on a weekday.

Effectiveness of pharmacy-based needle/syringe exchange programme for people who inject drugs: a systematic review and meta-analysis

AIMS

To appraise the evidence critically for effectiveness of pharmacy-based needle/syringe exchange programmes (pharmacy-based NSPs) on risk behaviours (RBs), HIV/HCV prevalence and economic outcomes among people who inject drugs (PWID).

DESIGN

Systematic review and meta-analysis.

SETTING

Primary care setting.

PARTICIPANTS

Of 1568 studies screened, 14 studies with 7035 PWID were included.

MEASURES

PubMed, Embase, Web of Sciences, CENTRAL and Cochrane review databases were searched without language restriction from their inception to 27 January 2016. All published study designs with control groups that reported the effectiveness of pharmacy-based NSP on outcomes of interest were included. Outcomes of interest are risk behaviour (RB), HIV/hepatitis C virus (HCV) prevalence and economic outcomes. The estimates of pooled effects of these outcomes were calculated as pooled odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. Heterogeneity was assessed by I² and χ² tests.

FINDINGS

Most studies (nine of 14, 64.3%) were rated as having a serious risk of bias, while 28.6 and 7.1% were rated as having a moderate risk and low risk of bias, respectively. For sharing-syringe behaviour, pharmacy-based NSPs were significantly better than no NSPs for both main (OR = 0.50, 95% CI = 0.34-0.73; I²  = 59.6%) and sensitivity analyses, excluding studies with a serious risk of bias (OR = 0.52, 95% CI = 0.32-0.84; I²  = 41.4%). For safe syringe disposal and HIV/HCV prevalence, the evidence for pharmacy-based NSPs compared with other NSP or no NSP was unclear, as few of the studies reported this and most of them had a serious risk of bias. Compared with the total life-time cost of US$55 640 for treating a person with HIV infection, the HIV prevalence among PWID has to be at least 0.8% (for pharmacy-based NSPs) or 2.1% (for other NSPs) to result in cost-savings.

CONCLUSIONS

Pharmacy-based needle/syringe exchange programmes appear to be effective for reducing risk behaviours among people who inject drugs, although their effect on HIV/HCV prevalence and economic outcomes is unclear.

Methadone induction in primary care (ANRS-Methaville): a phase III randomized intervention trial

Background

In France, the rapid scale-up of buprenorphine, an opioid maintenance treatment (OMT), in primary care for drug users has led to an impressive reduction in HIV prevalence among injecting drug users (IDU) but has had no major effect on Hepatitis C incidence. To date, patients willing to start methadone can only do so in a methadone clinic (a medical centre for drug and alcohol dependence (CSAPA) or a hospital setting) and are referred to primary care physicians after dose stabilization. This study aims to assess the effectiveness of methadone in patients who initiated treatment in primary care compared with those who initiated it in a CSAPA, by measuring abstinence from street opioid use after one year of treatment.

Methods/Design

The ANRS-Methaville study is a randomized multicenter non-inferiority control trial comparing methadone induction (lasting approximately 2 weeks) in primary care and in CSAPA. The model of care chosen for methadone induction in primary care was based on study-specific pre-training of all physicians, exclusion criteria and daily supervision of methadone during the initiation phase. Between January 2009 and January 2011, 10 sites each having one CSAPA and several primary care physicians, were identified to recruit patients to be randomized into two groups, one starting methadone in primary care (n = 147), the other in CSAPA (n = 48). The primary outcome of the study is the proportion of participants abstinent from street opioids after 1 year of treatment i.e. non-inferiority of primary care model in terms of the proportion of patients not using street opioids compared with the proportion observed in those starting methadone in a CSAPA.

Discussion

The ANRS-Methaville study is the first in France to use an interventional trial to improve access to OMT for drug users. Once the non-inferiority results become available, the Ministry of Health and agency for the safety of health products may change the the New Drug Application (NDA) of methadone and make methadone induction by trained primary care physicians possible.

The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials.

Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.