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Kahn B, Kazatchkine M. Europe must continue to lead on harm reduction. Harm Reduct J 2024; 21:172. [PMID: 39300436 DOI: 10.1186/s12954-024-01067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 07/27/2024] [Indexed: 09/22/2024] Open
Abstract
Europe has been at the forefront of harm reduction since its inception. These important early steps were in large part a response to the dramatically expanding HIV epidemic, and investing in these innovative interventions early and robustly had a transformative effect. This brought about not just pioneering services but also pioneering policy changes. However, while Western Europe and Member States in the European Union often have been at the vanguard of harm reduction innovation and vocal advocates for public health and human rights-based drug policy reform, the situation has been much different in the "wider" WHO European region, which also includes Eastern and Southeastern Europe as well as Central Asia. This is a result not just of limited budgets for health, but also of punitive laws and policies and persistent stigma and discrimination. Even as harm reduction has demonstrated huge successes in Europe, there is a need to move forward a wider array of services to respond to an evolving and increasingly complex drug situation in Europe. Instead, it is a lack of political will and of political courage that is holding back the establishment, expansion, and deepening of these essential, lifesaving interventions. Responding proactively and effectively to this changing drug situation will require redoubled investment in public health and harm reduction approaches.
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Affiliation(s)
- Brendan Kahn
- Department of Political Science, University of Vienna, Vienna, Austria.
- Global Commission on Drug Policy, Geneva, Switzerland.
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Bailey A, DaCunha A, Napoleon SC, Kang AW, Kemo M, Martin RA. Provision of medications to treat opioid use disorder via a mobile health unit: A scoping review. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 164:209431. [PMID: 38852822 PMCID: PMC11300152 DOI: 10.1016/j.josat.2024.209431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/10/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Mobile health units (MHUs) provide a variety of low-barrier services to populations that face systemic barriers to healthcare access. However, MHUs are not a common delivery method for medications to treat opioid use disorder (MOUD), and, of these, there is no consensus regarding MHU targeted objectives and outcomes. This scoping review seeks to summarize the state of the literature examining the delivery of MOUD by MHUs in the United States. METHODS A search of PubMed, PsycInfo, and CINAHL on February 21, 2023, found 223 articles. Two authors completed title and abstract and full text reviews and extracted data relevant to intervention and study design, program objectives, and study outcomes. Ten articles fit the study's inclusion criteria (nine total interventions). RESULTS Of the 10 studies, six were cohort designs, three were cross-sectional (one with qualitative interviews), and one study conducted qualitative interviews only. Most studies were located in the Northeastern United States. MHU interventions primarily aimed to provide MOUD and to retain populations in treatment. Two interventions aimed to engage patients and then transfer them to fixed-site MOUD providers. Across four interventions that provided buprenorphine, 1- and 3-month retention rates varied from 31.6 % to 72.3 % and 26.2 % to 58.5 %, respectively. Qualitative interviews found that MOUD delivery from the MHU was characterized by less stigma/judgment and greater privacy compared to fixed-site, and it was flexible and low-barrier. MHUs were reportedly underutilized by the target populations, suggesting a lack of awareness from community members with opioid use disorder. CONCLUSIONS MHUs that deliver MOUD are both under-provided and -utilized. Future research should continue to assess MOUD provision from MHUs with an emphasis on robust study design, application to other formulations of MOUD, and evaluation of outcomes such as participant satisfaction and key informant perceived challenges. REGISTRATION Submitted to Open Science Framework (OSF) Repository on February 6, 2023.
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Affiliation(s)
- Amelia Bailey
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.
| | - Alyssa DaCunha
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Siena C Napoleon
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Augustine W Kang
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA; Stanford University School of Medicine, Stanford, CA, USA
| | - Madeleine Kemo
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Rosemarie A Martin
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
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Markoulidakis A, Hickman M, McAuley A, Barnsdale LR, Welton NJ, Glancy M, Shivaji T, Collins C, Lang J, de Wit F, Hunt G, Wilkinson L, Fraser R, Yeung A, Horsburgh K, Priyadarshi S, Hutchinson SJ, Jones HE. Prevalence of opioid dependence in Scotland 2015-2020: A multi-parameter estimation of prevalence (MPEP) study. Addiction 2024; 119:1410-1420. [PMID: 38631671 DOI: 10.1111/add.16500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Drug-related deaths in Scotland more than doubled between 2011 and 2020. To inform policymakers and understand drivers of this increase, we estimated the number of people with opioid dependence aged 15-64 from 2014/15 to 2019/20. DESIGN We fitted a Bayesian multi-parameter estimation of prevalence (MPEP) model, using adverse event rates to estimate prevalence of opioid dependence jointly from Opioid Agonist Therapy (OAT), opioid-related mortality and hospital admissions data. Estimates are stratified by age group, sex and year. SETTING Scotland, 2014/15 to 2019/20. PARTICIPANTS People with opioid dependence and potential to benefit from OAT, whether ever treated or not. Using data from the Scottish Public Health Drug Linkage Programme, we identified a baseline cohort of individuals who had received OAT within the last 5 years, and all opioid-related deaths and hospital admissions (whether among or outside of this cohort). MEASUREMENTS Rates of each adverse event type and (unobserved) prevalence were jointly modelled. FINDINGS The estimated number and prevalence of people with opioid dependence in Scotland in 2019/20 was 47 100 (95% Credible Interval [CrI] 45 700 to 48 600) and 1.32% (95% CrI 1.28% to 1.37%). Of these, 61% received OAT during 2019/20. Prevalence in Greater Glasgow and Clyde was estimated as 1.77% (95% CrI 1.69% to 1.85%). There was weak evidence that overall prevalence fell slightly from 2014/15 (change -0.07%, 95% CrI -0.14% to 0.00%). The population of people with opioid dependence is ageing, with the estimated number of people aged 15-34 reducing by 5100 (95% CrI 3800 to 6400) and number aged 50-64 increasing by 2800 (95% CrI 2100 to 3500) between 2014/15 and 2019/20. CONCLUSIONS The prevalence of opioid dependence in Scotland remained high but was relatively stable, with only weak evidence of a small reduction, between 2014/15 and 2019/20. Increased numbers of opioid-related deaths can be attributed to increased risk among people with opioid dependence, rather than increasing prevalence.
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Affiliation(s)
- Andreas Markoulidakis
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Public Health Scotland, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew McAuley
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Megan Glancy
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | | | | | | | | | | | - Rosalyn Fraser
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Alan Yeung
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Saket Priyadarshi
- Alcohol and Drug Recovery Services, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Sharon J Hutchinson
- Public Health Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Pirnia B. Opioid agonist treatment in Iran after an opium poppy ban in Afghanistan. Lancet Psychiatry 2024; 11:411-412. [PMID: 38760108 DOI: 10.1016/s2215-0366(24)00112-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 03/31/2024] [Indexed: 05/19/2024]
Affiliation(s)
- Bijan Pirnia
- Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Bijan Center for Substance Abuse Treatment, Tehran 1574843919, Iran.
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Ahmad A, Bromberg DJ, Shrestha R, Salleh NM, Bazazi AR, Kamarulzaman A, Shenoi S, Altice FL. Higher methadone dose at time of release from prison predicts linkage to maintenance treatment for people with HIV and opioid use disorder transitioning to the community in Malaysia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104369. [PMID: 38484531 PMCID: PMC11056294 DOI: 10.1016/j.drugpo.2024.104369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Incarcerated people with HIV and opioid-dependence often experience poor post-release outcomes in the absence of methadone maintenance treatment (MMT). In a prospective trial, we assessed the impact of methadone dose achieved within prison on linkage to MMT after release. METHODS From 2010 to 2014, men with HIV (N = 212) and opioid dependence before incarceration were enrolled in MMT within 6 months of release from Malaysia's largest prison and followed for 12-months post-release. As a prospective trial, allocation to MMT was at random and later by preference design (predictive nonetheless). MMT dosing was individually targeted to minimally achieve 80 mg/day. Time-to-event analyses were conducted to model linkage to MMT after release. FINDINGS Of the 212 participants allocated to MMT, 98 (46 %) were prescribed higher dosages (≥80 mg/day) before release. Linkage to MMT after release occurred in 77 (36 %) participants and significantly higher for those prescribed higher dosages (46% vs 28 %; p = 0.011). Factors associated with higher MMT dosages were being married, on antiretroviral therapy, longer incarceration periods, having higher levels of depression, and methadone preference compared to randomization. After controlling for other variables, being prescribed higher methadone dosage (aHR: 2.53, 95 %CI: 1.42-4.49) was the only independent predictor of linkage to methadone after release. INTERPRETATION Higher doses of methadone prescribed before release increased the likelihood of linkage to MMT after release. Methadone dosing should be introduced into international guidelines for treatment of opioid use disorder in prisons and further post-release benefits should be explored. FUNDING National Institute of Drug Abuse (NIDA).
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Affiliation(s)
- Ahsan Ahmad
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Daniel J Bromberg
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Department of Social and Behavioral Sciences, New Haven, CT, USA
| | - Roman Shrestha
- University of Connecticut, Department of Allied Health Sciences, Storrs, CT, USA
| | - Na Mohd Salleh
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; University of Malaya, Faculty of Medicine, Department of Social and Preventive Medicine, Kuala Lumpur, Malaysia
| | - Alexander R Bazazi
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Adeeba Kamarulzaman
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; University of Malaya, Faculty of Medicine, Department of Social and Preventive Medicine, Kuala Lumpur, Malaysia
| | - Sheela Shenoi
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Yale University School of Public Health, Department Epidemiology of Microbial Diseases, New Haven, CT, USA.
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Handanagic S, Broz D, Finlayson T, Kanny D, Wejnert C. Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities. Drug Alcohol Depend 2024; 257:111251. [PMID: 38457965 PMCID: PMC11031279 DOI: 10.1016/j.drugalcdep.2024.111251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities. METHODS PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals. RESULTS Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23). CONCLUSIONS The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.
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Affiliation(s)
- Senad Handanagic
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, USA.
| | - Dita Broz
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, USA
| | - Teresa Finlayson
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, USA
| | - Dafna Kanny
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, USA
| | - Cyprian Wejnert
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, USA
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Young AM, Havens JR, Cooper HLF, Fallin-Bennett A, Fanucchi L, Freeman PR, Knudsen H, Livingston MD, McCollister KE, Stone J, Vickerman P, Freeman E, Jahangir T, Larimore E, White CR, Cheatom C, Community Staff K, Design Team K. Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia. BMJ Open 2024; 14:e083983. [PMID: 38431295 PMCID: PMC10910671 DOI: 10.1136/bmjopen-2024-083983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia. METHODS AND ANALYSIS KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness. ETHICS AND DISSEMINATION The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings. TRIAL REGISTRATION NUMBER NCT05657106.
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Affiliation(s)
- April M Young
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah L F Cooper
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Laura Fanucchi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia R Freeman
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah Knudsen
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Melvin D Livingston
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kathryn E McCollister
- Division of Health Services Research and Policy, University of Miami, Coral Gables, Florida, USA
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Edward Freeman
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | - Tasfia Jahangir
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Elizabeth Larimore
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Carol R White
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | | | - KyOSK Community Staff
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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Ponticiello M, Azbel L, Tate MM, Bromberg DJ, Pykalo I, Kiriazova T, Saichuk N, Altice FL. Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia's full-scale invasion, and contested methadone objects. Front Psychiatry 2023; 14:1227216. [PMID: 38098632 PMCID: PMC10720714 DOI: 10.3389/fpsyt.2023.1227216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 12/17/2023] Open
Abstract
Background After pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal informal governance by a social hierarchy that operates in parallel to formal prison authorities. This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia's full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions. Methods In-depth qualitative interviews (N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion. Findings Criminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of "methadone" varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture's rules and lacked the social ties necessary to procure drugs illegally. Conclusion It appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course.
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Affiliation(s)
- Matthew Ponticiello
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Lyu Azbel
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Mary M. Tate
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Iryna Pykalo
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
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Downing BC, Hickman M, Jones NR, Larney S, Sweeting MJ, Xu Y, Farrell M, Degenhardt L, Jones HE. Prevalence of opioid dependence in New South Wales, Australia, 2014-16: Indirect estimation from multiple data sources using a Bayesian approach. Addiction 2023; 118:1994-2006. [PMID: 37292044 DOI: 10.1111/add.16268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 05/09/2023] [Indexed: 06/10/2023]
Abstract
AIMS To estimate the prevalence of, and number of unobserved people with opioid dependence by sex and age group in New South Wales (NSW), Australia. DESIGN We applied a Bayesian statistical modelling approach to opioid agonist treatment records linked to adverse event rate data. We estimated prevalence from three types of adverse event separately: opioid mortality, opioid-poisoning hospitalizations and opioid-related charges. We extended the model and produced prevalence estimates from a 'multi-source' model based on all three types of adverse event data. SETTING, PARTICIPANTS AND MEASUREMENTS This study was conducted in NSW, Australia, 2014-16 using data from the Opioid Agonist Treatment and Safety (OATS) study, which included all people who had received treatment for opioid dependence in NSW. Aggregate data were obtained on numbers of adverse events in NSW. Rates of each adverse event type within the OATS cohort were modelled. Population data were provided by State and Commonwealth agencies. FINDINGS Prevalence of opioid dependence among those aged 15-64 years in 2016 was estimated to be 0.96% (95% credible interval [CrI] = 0.82%, 1.12%) from the mortality model, 0.75% (95% CrI = 0.70%, 0.83%) from hospitalizations, 0.95% (95% CrI = 0.90%, 0.99%) from charges and 0.92% (95% CrI = 0.88%, 0.96%) from the multi-source model. Of the estimated 46 460 (95% CrI = 44 680, 48 410) people with opioid dependence in 2016 from the multi-source model, approximately one-third (16 750, 95% CrI = 14 960, 18 690) had no record of opioid agonist treatment within the last 4 years. From the multi-source model, prevalence in 2016 was estimated to be 1.24% (95% CrI = 1.18%, 1.31%) in men aged 15-44, 1.22% (95% CrI = 1.14%, 1.31%) in men 45-64, 0.63% (95% CrI = 0.59%, 0.68%) in women aged 15-44 and 0.56% (95% CrI = 0.50%, 0.63%) in women aged 45-64. CONCLUSIONS A Bayesian statistical approach to estimate prevalence from multiple adverse event types simultaneously calculates that the estimated prevalence of opioid dependence in NSW, Australia in 2016 was 0.92%, higher than previous estimates.
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Affiliation(s)
- Beatrice C Downing
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Montreal, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Yixin Xu
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Colledge-Frisby S, Ottaviano S, Webb P, Grebely J, Wheeler A, Cunningham EB, Hajarizadeh B, Leung J, Peacock A, Vickerman P, Farrell M, Dore GJ, Hickman M, Degenhardt L. Global coverage of interventions to prevent and manage drug-related harms among people who inject drugs: a systematic review. Lancet Glob Health 2023; 11:e673-e683. [PMID: 36996860 DOI: 10.1016/s2214-109x(23)00058-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/18/2023] [Accepted: 01/27/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Harm reduction and treatment programmes are essential for reducing harms for people who inject drugs (PWID). We aimed to update estimates from a 2017 review of global coverage of needle and syringe exchange programmes (NSPs), opioid agonist treatment (OAT), and other harm reduction services that target PWID (eg, take-home naloxone [THN] programmes, supervised consumption facilities, and drug checking services). METHODS We did a systematic review of available evidence from peer-reviewed and grey literature databases for studies published between Jan 1, 2017, and May 31, 2022. Programmatic data were collected on the availability of services, the number of sites, people accessing services, and equipment distributed in countries where there is evidence of injecting drug use. National estimates of coverage of OAT (ie, number of people accessing OAT per 100 PWID) and NSPs (ie, number of needles and syringes distributed per PWID per year) were generated where available using the most recent data. Regional and global estimates were derived and compared with WHO indicators. The study was registered with PROSPERO (CRD42020173974). FINDINGS We included 195 studies and found there were 90 countries implementing OAT (75% of the PWID population) and 94 countries implementing NSPs (88% of the global PWID population). Only five countries (2% of the global PWID population) are providing high coverage of both services. Far fewer countries were implementing THN programmes (n=43), supervised consumption facilities (n=17), and drug checking services (n=26), with nine countries implementing all five services. Globally, we estimated there were 18 (95% uncertainty interval [UI] 12-27) people accessing OAT per 100 PWID, and 35 (95% UI 24-52) needles and syringes being distributed per person who injects drugs per year. More countries reported high (OAT 24; NSPs 10), moderate (OAT 8; NSPs 15), and low (OAT 38; NSPs 47) coverage of services compared with the previous review. INTERPRETATION Global coverage of OAT and NSPs has increased modestly in the past 5 years but remains low for most countries. Programmatic data on other key harm reduction interventions are scarce. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Samantha Colledge-Frisby
- National Drug Research Institute Melbourne, Curtin University, Melbourne, VIC, Australia; National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
| | - Sophie Ottaviano
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Paige Webb
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Jason Grebely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Alice Wheeler
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Evan B Cunningham
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Behzad Hajarizadeh
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Janni Leung
- National Centre for Youth Substance Use Research, University of Queensland, Brisbane, QLD, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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11
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Rostam-Abadi Y, Gholami J, Jobehdar MM, Ardeshir M, Aghaei AM, Olamazadeh S, Taj M, Saeed K, Mojtabai R, Rahimi-Movaghar A. Drug use, drug use disorders, and treatment services in the Eastern Mediterranean region: a systematic review. Lancet Psychiatry 2023; 10:282-295. [PMID: 36848914 DOI: 10.1016/s2215-0366(22)00435-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 02/26/2023]
Abstract
Drug use is an increasing global public health concern. We reviewed the prevalence and patterns of drug use, drug use disorders, and the extent of treatment services in 21 countries and one territory in the Eastern Mediterranean region from 2010 to 2022. Online databases were systematically searched on April 17, 2022, along with other sources for grey literature. The extracted data were analysed and used for synthesis at the country, subregional, and regional levels. The prevalence of drug use is higher in the Eastern Mediterranean region than global estimates, with cannabis, opium, khat, and tramadol among the main drugs used in the region. Data on the prevalence of drug use disorders were scarce and heterogeneous. Treatment facilities for drug use disorders are available in most countries, but opioid agonist treatment exists in only seven countries. There is a need to expand evidence-based and cost-effective care. Limited data exist, especially regarding drug use disorders, treatment coverage, and drug use among women and young people.
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Affiliation(s)
- Yasna Rostam-Abadi
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jaleh Gholami
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maral Mardaneh Jobehdar
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ardeshir
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardavan Mohammad Aghaei
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sogol Olamazadeh
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahshid Taj
- Mental Health and Substance Abuse Unit, Department of Non-Communicable Diseases and Mental Health, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Khalid Saeed
- Mental Health and Substance Abuse Unit, Department of Non-Communicable Diseases and Mental Health, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health and Department of Psychiatry, Johns Hopkins University, Baltimore, MD, USA
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS) WHO Collaborating Center, Tehran University of Medical Sciences, Tehran, Iran.
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12
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Holland A, Stevens A, Harris M, Lewer D, Sumnall H, Stewart D, Gilvarry E, Wiseman A, Howkins J, McManus J, Shorter GW, Nicholls J, Scott J, Thomas K, Reid L, Day E, Horsley J, Measham F, Rae M, Fenton K, Hickman M. Analysis of the UK Government's 10-Year Drugs Strategy-a resource for practitioners and policymakers. J Public Health (Oxf) 2022:6779883. [PMID: 36309802 DOI: 10.1093/pubmed/fdac114] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/10/2022] [Indexed: 11/12/2022] Open
Abstract
In 2021, during a drug-related death crisis in the UK, the Government published its ten-year drugs strategy. This article, written in collaboration with the Faculty of Public Health and the Association of Directors of Public Health, assesses whether this Strategy is evidence-based and consistent with international calls to promote public health approaches to drugs, which put 'people, health and human rights at the centre'. Elements of the Strategy are welcome, including the promise of significant funding for drug treatment services, the effects of which will depend on how it is utilized by services and local commissioners and whether it is sustained. However, unevidenced and harmful measures to deter drug use by means of punishment continue to be promoted, which will have deleterious impacts on people who use drugs. An effective public health approach to drugs should tackle population-level risk factors, which may predispose to harmful patterns of drug use, including adverse childhood experiences and socioeconomic deprivation, and institute evidence-based measures to mitigate drug-related harm. This would likely be more effective, and just, than the continuation of policies rooted in enforcement. A more dramatic re-orientation of UK drug policy than that offered by the Strategy is overdue.
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Affiliation(s)
- Adam Holland
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - Alex Stevens
- School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, CT2 7NZ
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Dan Lewer
- Public Health Specialty Registrar, Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Harry Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, L3 5UX, UK
| | - Daniel Stewart
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - Eilish Gilvarry
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, NE1 7RU, UK
| | - Alice Wiseman
- Association of Directors of Public Health, London, EC4Y 0HA, UK
| | - Joshua Howkins
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | - Jim McManus
- Association of Directors of Public Health, London, EC4Y 0HA, UK
| | | | - James Nicholls
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, FK9 4LA, UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, Bath, BA2 7AY
| | - Kyla Thomas
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | | | - Edward Day
- Institute of Mental Health, University of Birmingham, Birmingham, B15 2TT
| | - Jason Horsley
- National Institute for Health Research Evaluation Trials and Studies Coordinating Centre, University of Southampton, Southampton, SO17 1BJ, UK
| | - Fiona Measham
- Department of Sociology, Social Policy and Criminology, University of Liverpool, Liverpool, L69 3BX
| | - Maggie Rae
- Epidemiological and Public Health Section, Royal Society of Medicine, London, W1G 0AE, UK
| | | | - Matthew Hickman
- Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
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Ivasiy R, Madden LM, Farnum SO, Shumskaya N, de Leon SJG, Bromberg DJ, Kurmanalieva A, Duishenaliev A, Tokubaev R, Altice FL. Implementation opportunities for scaling up methadone maintenance treatment in Kyrgyzstan: Methadone dosage and retention on treatment over two years. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100075. [PMID: 36267100 PMCID: PMC9581459 DOI: 10.1016/j.dadr.2022.100075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 12/01/2022]
Abstract
Background Methadone maintenance treatment (MMT) is the most effective and cost-effective strategy to control HIV in Central Asian countries, where the epidemic is concentrated among people who inject drugs (PWID) who use opioids. Methods Using data from a prospective observational database of all people initiated on MMT in Kyrgyzstan since 2008, we analyzed a more contemporary subset of data for all persons receiving MMT from January 2017 through June 2021 after the national treatment guidelines were changed. Retention on MMT was assessed at 1, 6, 12, and 24 months and predictive variables included were dosage levels, HIV status, and type of clinical setting using survival analysis. Predictors of treatment dropout were estimated using Cox multivariate regression models. Results Among the 940 MMT patients, the proportion receiving low (<40mg), medium (40-85mg), and high (>85mg) dosage levels was 37.9%, 42.2%, and 19.9%, respectively. Increasing MMT dosage level was significantly (p<0.0001) correlated with retention at 1 (90%, 98%, 100%), 6 (42%, 63%, 95%), 12 (33%, 55%, 89%), and 24 (16%, 45%, 80%) months, respectively, with no differences between community and correctional settings. Significant predictors of dropout at 12 months included low (aHR=8.0; 95%CL=5.8-11.0) and medium (aHR=3.5; 95%CL=2.5-4.9) methadone dosage level relative to high dose, receiving MMT in three administrative regions relative to the capital Bishkek, and lower in the tuberculosis-specialized clinic in Bishkek. Clients with HIV receive higher average MMT doses (79.5mg vs 63.1mg; p<0.0001), but MMT retention did not differ after controlling for dosage in this group. Conclusions The proportion of patients receiving optimal dosage was low (19.9%). An implementation strategy that focused on getting a larger proportion of MMT on the optimal dosage to promote retention could potentially improve the quality of existing treatment and promote further scale-up of MMT in Kyrgyzstan.
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Affiliation(s)
- Roman Ivasiy
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
- Center for Interdisciplinary Research on AIDS at Yale University, New Haven, USA
| | - Lynn M. Madden
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- APT Foundation, New Haven, USA
| | - Scott O. Farnum
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- APT Foundation, New Haven, USA
| | - Natalia Shumskaya
- Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, Bishkek, Kyrgyzstan
| | - Samy J. Galvez de Leon
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
| | - Daniel J. Bromberg
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
- Center for Interdisciplinary Research on AIDS at Yale University, New Haven, USA
| | - Ainura Kurmanalieva
- Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, Bishkek, Kyrgyzstan
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
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14
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Pijl EM, Alraja A, Duff E, Cooke C, Dash S, Nayak N, Lamoureux J, Poulin G, Knight E, Fry B. Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review. Subst Abuse Treat Prev Policy 2022; 17:62. [PMID: 36028837 PMCID: PMC9412807 DOI: 10.1186/s13011-022-00463-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/28/2022] Open
Abstract
Background People living in rural and remote communities in Canada are often disproportionately impacted by opioid use disorder. When compared to urban centres, rural and remote populations face additional barriers to treatment, including geographical distance as well as chronic shortages of health care professionals. This integrative review of the literature was conducted to explore the facilitators and barriers of OAT in rural and remote Canadian communities. Methods A search of the literature identified relevant studies published between 2001 and 2021. Results The search strategy yielded 26 scholarly peer-reviewed publications, which explored specific barriers and facilitators to rural and remote OAT in Canada, along with two reports and one fact sheet from the grey literature. Most of the scholarly articles were descriptive studies (n = 14) or commentaries (n = 9); there were only three intervention studies. Facilitators and barriers to OAT programs were organized into six themes: intrapersonal/patient factors, social/non-medical program factors, family/social context factors (including community factors), infrastructure/environmental factors, health care provider factors, and system/policy factors. Conclusions Although themes in the literature resembled the social-ecological framework, most of the studies focused on the patient-provider dyad. Two of the most compelling studies focused on community factors that positively impacted OAT success and highlighted a holistic approach to care, nested in a community-based holistic model. Further research is required to foster OAT programs in rural and remote communities.
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15
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Brothers TD, Lewer D, Jones N, Colledge-Frisby S, Farrell M, Hickman M, Webster D, Hayward A, Degenhardt L. Opioid agonist treatment and risk of death or rehospitalization following injection drug use-associated bacterial and fungal infections: A cohort study in New South Wales, Australia. PLoS Med 2022; 19:e1004049. [PMID: 35853024 PMCID: PMC9295981 DOI: 10.1371/journal.pmed.1004049] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Injecting-related bacterial and fungal infections are associated with significant morbidity and mortality among people who inject drugs (PWID), and they are increasing in incidence. Following hospitalization with an injecting-related infection, use of opioid agonist treatment (OAT; methadone or buprenorphine) may be associated with reduced risk of death or rehospitalization with an injecting-related infection. METHODS AND FINDINGS Data came from the Opioid Agonist Treatment Safety (OATS) study, an administrative linkage cohort including all people in New South Wales, Australia, who accessed OAT between July 1, 2001 and June 28, 2018. Included participants survived a hospitalization with injecting-related infections (i.e., skin and soft-tissue infection, sepsis/bacteremia, endocarditis, osteomyelitis, septic arthritis, or epidural/brain abscess). Outcomes were all-cause death and rehospitalization for injecting-related infections. OAT exposure was classified as time varying by days on or off treatment, following hospital discharge. We used separate Cox proportional hazards models to assess associations between each outcome and OAT exposure. The study included 8,943 participants (mean age 39 years, standard deviation [SD] 11 years; 34% women). The most common infections during participants' index hospitalizations were skin and soft tissue (7,021; 79%), sepsis/bacteremia (1,207; 14%), and endocarditis (431; 5%). During median 6.56 years follow-up, 1,481 (17%) participants died; use of OAT was associated with lower hazard of death (adjusted hazard ratio [aHR] 0.63, 95% confidence interval [CI] 0.57 to 0.70). During median 3.41 years follow-up, 3,653 (41%) were rehospitalized for injecting-related infections; use of OAT was associated with lower hazard of these rehospitalizations (aHR 0.89, 95% CI 0.84 to 0.96). Study limitations include the use of routinely collected administrative data, which lacks information on other risk factors for injecting-related infections including injecting practices, injection stimulant use, housing status, and access to harm reduction services (e.g., needle exchange and supervised injecting sites); we also lacked information on OAT medication dosages. CONCLUSIONS Following hospitalizations with injection drug use-associated bacterial and fungal infections, use of OAT is associated with lower risks of death and recurrent injecting-related infections among people with opioid use disorder.
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Affiliation(s)
- Thomas D. Brothers
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Dan Lewer
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Nicola Jones
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | | | - Michael Farrell
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
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16
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Augarde E, Gunnell D, Mars B, Hickman M. An ecological study of temporal trends in 'deaths of despair' in England and Wales. Soc Psychiatry Psychiatr Epidemiol 2022; 57:1135-1144. [PMID: 35247059 PMCID: PMC9090864 DOI: 10.1007/s00127-022-02251-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 02/18/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE There is growing interest in the concept of 'deaths of despair' (DoD)-defined as deaths from three causes: suicide, drug poisoning, and alcohol-related conditions-as a more comprehensive indicator of the impact of psychological distress on mortality. The purpose of this study is to investigate the degree of commonality in trends and geographic patterning of deaths from these causes in England and Wales. METHODS WHO mortality data were used to calculate age-standardised, sex-specific temporal trends in DoD mortality and in mortality from suicide, drug poisonings, and alcohol-related conditions in England and Wales, 2001-2016. Three-year average crude rates were calculated for English local authorities for 2016-2018 and associations between rates were assessed using Spearman's rank correlation. RESULTS Between 2001 and 2016, the DoD mortality rate increased by 21·6% (males) and 16·9% (females). The increase was largely due to a rise in drug poisoning deaths, with limited tracking between trends in mortality by each cause. DoD mortality risk was highest in middle-aged people; there were rises in all age groups except 15-24 year old males and 65 + females. There were strong positive correlations (r = 0.66(males) and 0.60(females)) between local authority-area drug poisoning and alcohol-specific mortality rates in 2016-2018. Correlations of these outcomes with suicide were weaker (r = 0.29-0.54). CONCLUSIONS DoD mortality is increasing in England and Wales but there is limited evidence of commonality in the epidemiology of cause-specific mortality from the component causes of DoD (suicide, drug poisoning and alcohol-related conditions), indicating the need for tailored prevention for each outcome.
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Affiliation(s)
- Elizabeth Augarde
- Population Health Sciences, University of Bristol, Bristol, UK. .,Department of Health and Social Care, London, UK.
| | - David Gunnell
- Population Health Sciences, University of Bristol, Bristol, UK.,NIHR Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Becky Mars
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK.,NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK.,NIHR School of Public Health Research, University of Bristol, Bristol, UK
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Dorgay CE, Bromberg DJ, Doltu S, Litz T, Galvez S, Polonsky M, Dvoryak S, Altice FL. A pilot implementation study to scale-up methadone in incarcerated persons with opioid use disorder and retain them on treatment after release in Moldova. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103683. [PMID: 35417790 PMCID: PMC9827420 DOI: 10.1016/j.drugpo.2022.103683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Eastern Europe and Central Asia have intertwined HIV and incarceration epidemics, concentrated in people who inject drugs. Moldova is one of the few countries in this region that offers methadone within prisons, but uptake and post-release retention remains suboptimal. Screening, brief intervention, and referral to treatment (SBIRT) procedures are a potential implementation strategy to address this problem. METHODS From June 1, 2017 to March 3, 2018, we conducted a 2-stage SBIRT strategy in nine prisons and four pre-trial detention facilities in Moldova among incarcerated persons with opioid use disorder (OUD; N = 121) and within 90 days of release. Survey results were analyzed to evaluate the effect of the SBIRT strategy on the uptake of and post-release retention on methadone maintenance treatment (MMT). RESULTS Among the 121 screened with OUD, 27 were on MMT at baseline within the prison and this number increased to 41 after the two-step SBIRT intervention, reflecting a 51.9% increase over baseline. Eleven (78.6%) of the 14 participants that newly started MMT did so only after completing both SBIRT sessions. The brief intervention did not significantly improve knowledge about methadone but did improve attitudes towards it. Among the 41 participants who received methadone during this trial, 40 (97.6%) were retained 6 months after release; the one participant not retained was on methadone at the time of the intervention and had planned to taper off. CONCLUSION The SBIRT strategy significantly improved participant attitudes, but treatment initiation mostly occurred after completing both sessions, including soon after release, but remained low overall. Work within the Moldovan prison subculture to dispel negative myths and misinformation is needed to further scale-up OAT in Moldova.
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Affiliation(s)
- Coriann E Dorgay
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States
| | - Daniel J Bromberg
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States; Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Svetlana Doltu
- Act For Involvement, 7A Varșovia street, Chișinău, 2060, Republic of Moldova
| | - Taylor Litz
- Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Samy Galvez
- Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Maxim Polonsky
- Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, 5 Biloruska Str. Office 20, 27, Kyiv, 04050 Ukraine
| | - Frederick L Altice
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States; Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; University of Malaya, 50603 Kuala Lumpur, Malaysia.
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18
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O'Hara GL, Liberman AR, Polonsky M, Azbel L, Marcus R, Doltu S, Cugut S, Altice FL. Multi-level implementation factors that influence scale-up of methadone maintenance treatment in Moldovan prisons: A qualitative study. J Subst Abuse Treat 2022; 136:108660. [PMID: 34801282 PMCID: PMC10879837 DOI: 10.1016/j.jsat.2021.108660] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/22/2021] [Accepted: 11/10/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION People who inject drugs (PWID) are overrepresented in prison populations, especially in the Eastern European and Central Asian region (EECA), where HIV incidence and mortality continue to rise. Modeling data suggest that methadone maintenance treatment (MMT) scale-up in prison with continuation after release could substantially reduce new HIV infections. Moldova, one of four countries in the EECA to have introduced MMT in prisons, has faced challenges with its scale-up. METHOD To improve implementation of MMT in Moldovan prisoners, we analyzed the qualitative interviews of 44 recently released Moldovan prisoners with opioid use disorder who either accepted or rejected MMT while incarcerated; these 44 were among a subset of 56 participants in a quantitative survey who had complete interview data. After translating and back-translating interviews, we used content analysis to identify key barriers and facilitators to MMT uptake. RESULTS Our qualitative analyses revealed that positive attitudes toward methadone facilitated treatment uptake, yet the study identified three thematic barriers as to why PWID do not accept MMT while in prison, including: 1) negative personal attitudes toward MMT; 2) stigmatization of MMT by informal hierarchies within prison; and 3) distrust of the formal prison hierarchy (i.e., administration), which provides MMT. CONCLUSION Overall, the social forces of the two prisoner hierarchies and distrust between them appeared to outweigh the perceived benefits of MMT and impacted MMT uptake. Here we provide strategies to promote MMT more effectively in prison settings.
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Affiliation(s)
- George L O'Hara
- Yale University School of Medicine, Section of Infectious Diseases, 333 Cedar St, New Haven, CT 06510, USA
| | - Amanda R Liberman
- Yale University School of Medicine, Section of Infectious Diseases, 333 Cedar St, New Haven, CT 06510, USA.
| | - Maxim Polonsky
- Yale University School of Medicine, Section of Infectious Diseases, 333 Cedar St, New Haven, CT 06510, USA
| | - Lyuba Azbel
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, 333 Cedar St, New Haven, CT 06510, USA.
| | - Svetlana Doltu
- Act for Involvement (AFI) Nongovernmental organization, Varșovia St 2060, Chișinău 2060, Republic of Moldova
| | - Sergiu Cugut
- Act for Involvement (AFI) Nongovernmental organization, Varșovia St 2060, Chișinău 2060, Republic of Moldova.
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, 333 Cedar St, New Haven, CT 06510, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, 60 College St, New Haven, CT 06510, USA.
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19
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Chaillon A, Bharat C, Stone J, Jones N, Degenhardt L, Larney S, Farrell M, Vickerman P, Hickman M, Martin NK, Bórquez A. Modeling the population-level impact of opioid agonist treatment on mortality among people accessing treatment between 2001 and 2020 in New South Wales, Australia. Addiction 2022; 117:1338-1352. [PMID: 34729841 PMCID: PMC9299987 DOI: 10.1111/add.15736] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS The individual-level effectiveness of opioid agonist treatment (OAT) in reducing mortality is well established, but there is less evidence on population-level benefits. We use modeling informed with linked data from the OAT program in New South Wales (NSW), Australia, to estimate the impact of OAT provision in the community and prisons on mortality and the impact of eliminating excess mortality during OAT initiation/discontinuation. DESIGN Dynamic modeling. SETTING AND PARTICIPANTS A cohort of 49 359 individuals who ever received OAT in NSW from 2001 to 2018. MEASUREMENTS Receipt of OAT was represented through five stages: (i) first month on OAT, (ii) short (1-9 months) and (iii) longer (9+ months) duration on OAT, (iv) first month following OAT discontinuation and (v) rest of time following OAT discontinuation. Incarceration was represented as four strata: (i) never or not incarcerated in the past year, (ii) currently incarcerated, (iii) released from prison within the past month and (iv) released from prison 1-12 months ago. The model incorporated elevated mortality post-release from prison and OAT impact on reducing mortality and incarceration. FINDINGS Among the cohort, mortality was 0.9 per 100 person-years, OAT coverage and retention remained high (> 50%, 1.74 years/episode). During 2001-20, we estimate that OAT provision reduced overdose and other cause mortality among the cohort by 52.8% [95% credible interval (CrI) = 49.4-56.9%] and 26.6% (95% CrI =22.1-30.5%), respectively. We estimate 1.2 deaths averted and 9.7 life-years gained per 100 person-years on OAT. Prison OAT with post-release OAT-linkage accounted for 12.4% (95% CrI = 11.5-13.5%) of all deaths averted by the OAT program, primarily through preventing deaths in the first month post-release. Preventing elevated mortality during OAT initiation and discontinuation could have averted up to 1.4% (95% CrI = 0.8-2.0%) and 3.0% (95% CrI = 2.1-5.3%) of deaths, respectively. CONCLUSION The community and prison opioid agonist treatment program in New South Wales, Australia appears to have substantially reduced population-level overdose and all-cause mortality in the past 20 years, partially due to high retention.
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Affiliation(s)
- Antoine Chaillon
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW, Australia
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Nicola Jones
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW, Australia.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) and Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, Canada
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW, Australia
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Annick Bórquez
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA.,National Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW, Australia
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20
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Bachireddy C, Shrestha R, Bromberg DJ, Azbel L, Kurmanalieva A, Wegman M, Shumskaya N, Rozanova J, Meyer JP, Altice FL. Methadone within prison and linkage to and retention in treatment upon community release for people with opioid use disorder in Kyrgyzstan: Evaluation of a national program. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 101:103558. [PMID: 34915426 PMCID: PMC9998103 DOI: 10.1016/j.drugpo.2021.103558] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 11/07/2021] [Accepted: 11/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND HIV incidence in Eastern Europe and Central Asia (EECA) continues to increase, primarily among people who inject drugs (PWID) and people in prisons. In Kyrgyzstan, an estimated 35% of people in prison are PWID, and 10% have been diagnosed with HIV. In 2008, Kyrgyzstan became the first country in EECA to provide free and voluntary methadone in prisons. We examine the impact of this national program on methadone within prison as well as linkage to and retention in treatment upon release to the community. METHODS Administrative data from a national methadone registry with de-identified information were assessed retrospectively. We examined the delivery of methadone services, including the duration of treatment both within prison and after release, for all prisoners who were prescribed methadone in Kyrgyz prisons from 2008 to 2018. Reasons for discontinuing methadone, HIV status and methadone dose are also analyzed. RESULTS Between 2008 and 2018, nine of Kyrgyzstan's 16 prisons offered methadone, and 982 incarcerated people initiated methadone within prison. Prisoners prescribed methadone were mostly male (96.2%), in their mid-30s (mean=34.9 years), and had been incarcerated for a relatively long time (mean = 44.1 months); their mean treatment duration in prison was 12.5 months, and 31.6% had HIV. A subsample (N = 645; 65.7%) of these were released to the community. Of these 645 people, 356 (55.2%) were not taking methadone at the time of release, 128 (19.8%) were on methadone and continued it after release, and the remainder (N=161, 25.0%) were on methadone at the time of release, but subsequently discontinued it, most within the first 7 days after release. Among those continuing methadone, 14.8% (N=19) remained on treatment ≥ 12 months. Independent correlates of linkage to methadone after release included positive HIV status (adjusted hazard ratio (aHR)=1.55; p = 0.033), receipt of methadone before their incarceration (aHR=2.01; p = 0.039), and receipt of methadone at the time of release (aHR = 20.81; p<0.001). CONCLUSION This is the first evaluation of within-prison methadone treatment in EECA. Uptake of methadone within prison and retention in treatment after release were both low. Continuous maintenance of treatment throughout incarceration is an opportunity to optimize HIV prevention and link patients to methadone post-release.
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Affiliation(s)
- Chethan Bachireddy
- Virginia Commonwealth University School of Medicine, Richmond, VA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PS, United States
| | - Roman Shrestha
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States; Yale University School of Medicine, New Haven, CT, United States
| | - Daniel J Bromberg
- Yale University School of Public Health, New Haven, CT, United States; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States
| | - Lyu Azbel
- Yale University School of Medicine, New Haven, CT, United States
| | | | - Martin Wegman
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Natalya Shumskaya
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States
| | - Julia Rozanova
- Yale University School of Medicine, New Haven, CT, United States
| | - Jaimie P Meyer
- Yale University School of Medicine, New Haven, CT, United States
| | - Frederick L Altice
- Yale University School of Medicine, New Haven, CT, United States; Yale University School of Public Health, New Haven, CT, United States; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States.
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21
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Padmanathan P, Forbes H, Redaniel MT, Gunnell D, Lewer D, Moran P, Watson B, Degenhardt L, Hickman M. Self-harm and suicide during and after opioid agonist treatment among primary care patients in England: a cohort study. Lancet Psychiatry 2022; 9:151-159. [PMID: 34921800 DOI: 10.1016/s2215-0366(21)00392-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The first 4 weeks after initiation and cessation of opioid agonist treatment for opioid dependence are associated with an increased risk of all-cause mortality and overdose. We aimed to investigate whether the rate of self-harm and suicide among people who were prescribed opioid agonist treatment differs during initiation, cessation, and the remainder of time on and off treatment. METHODS We did a retrospective cohort study and used health-care records from UK Clinical Practice Research Datalink, linked to mortality and hospital admission data, for adults (age 18-75 years at cohort entry) who were prescribed opioid agonist treatment at least once in primary care in England between Jan 2, 1998, and Nov 30, 2018. We estimated rates and adjusted risk ratios (aRRs) of hospital admissions for self-harm and death by suicide, comparing time during and after treatment, as well as comparing stable periods of time on treatment with treatment initiation, cessation, and the remaining time off treatment. FINDINGS Between Jan 2, 1998, and Nov 30, 2018, 8070 patients (5594 [69·3%] men and 2476 [30·7%] women) received 17 004 episodes of opioid agonist treatment over 40 599 person-years. Patients were mostly of White ethnicity (7006 [86·8%] patients). 807 episodes of self-harm (1·99 per 100 person-years) and 46 suicides (0·11 per 100 person-years) occurred during the study period. The overall age-standardised and sex-standardised mortality ratio for suicide was 7·5 times (95% CI 5·5-10·0) higher in the study cohort than in the general population. Opioid agonist treatment was associated with a reduced risk of self-harm (aRR in periods off treatment 1·50 [95% CI 1·21-1·88]), but was not significantly associated with suicide risk (aRR in periods off treatment 1·21 [0·64-2·28]). Risk of self-harm (aRR 2·60 [95% CI 1·83-3·70]) and suicide (4·68 [1·63-13·42]) were both elevated in the first 4 weeks after stopping opioid agonist treatment compared with stable periods on treatment. INTERPRETATION Stable periods of opioid agonist treatment are associated with reduced risk of self-harm, emphasising the importance of improving retention of patients in treatment. The first month following cessation of opioid agonist treatment is a period of increased risk of suicide and self-harm, during which additional psychosocial support is required. FUNDING Medical Research Council.
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Affiliation(s)
- Prianka Padmanathan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Specialist Drug and Alcohol Service, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK.
| | - Harriet Forbes
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Theresa Redaniel
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Applied Research Collaboration West, Bristol, UK
| | - David Gunnell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute of Health Research Biomedical Research Centre at the University Hospitals, Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Dan Lewer
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Paul Moran
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Applied Research Collaboration West, Bristol, UK; National Institute of Health Research Biomedical Research Centre at the University Hospitals, Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Ben Watson
- Bristol Specialist Drug and Alcohol Service, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute of Health Research Biomedical Research Centre at the University Hospitals, Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
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22
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Stone J, Artenie A, Hickman M, Martin NK, Degenhardt L, Fraser H, Vickerman P. The contribution of unstable housing to HIV and hepatitis C virus transmission among people who inject drugs globally, regionally, and at country level: a modelling study. Lancet Public Health 2022; 7:e136-e145. [PMID: 35012711 PMCID: PMC8848679 DOI: 10.1016/s2468-2667(21)00258-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND A considerable proportion of people who inject drugs are unstably housed. Although unstable housing is associated with HIV and HCV infection among people who inject drugs, its contribution to transmission is unknown. We estimated the global and national proportions of incident HIV and HCV infections among people who inject drugs attributed to housing instability from 2020 to 2029. METHODS In this modelling study, we developed country-level models of unstable housing and HIV and HCV transmission among people who inject drugs in 58 countries globally, calibrated to country-specific data on the prevalences of HIV and HCV and unstable housing. Based on a recently published systematic review, unstably housed people who inject drugs were assumed to have a 39% (95% CI 6-84) increased risk of HIV transmission and a 64% (95% CI 43-89%) increased risk of HCV transmission. We used pooled country-level estimates from systematic reviews on HCV and HIV prevalence in people who inject drugs. Our models estimated the transmission population attributable fraction (tPAF) of unstable housing to HIV and HCV transmission among people who inject drugs, defined as the percentage of infections prevented from 2020 to 2029 if the additional risk due to unstable housing was removed. FINDINGS Our models were produced for 58 countries with sufficient data (accounting for >66% of the global people who inject drugs population). Globally, we project unstable housing contributes 7·9% (95% credibility interval [CrI] 2·3-15·7) of new HIV infections and 11·2% (7·7-15·5) of new HCV infections among people who inject drugs from 2020 to 2029. Country-level tPAFs were strongly associated with the prevalence of unstable housing. tPAFs were greater in high-income countries (HIV 17·2% [95% CrI 5·1-30·0]; HCV 19·4% [95% CrI 13·8-26·0]) than in low-income or middle-income countries (HIV 6·6% [95% CrI 1·8-13·1]; HCV 8·3% [95% CrI 5·5-11·7]). tPAFs for HIV and HCV were highest in Afghanistan, Czech Republic, India, USA, England, and Wales where unstable housing contributed more than 20% of new HIV and HCV infections. INTERPRETATION Unstable housing is an important modifiable risk factor for HIV and HCV transmission among people who inject drugs in many countries. The study emphasises the importance of implementing initiatives to mitigate these risks and reduce housing instability. FUNDING National Institute for Health Research and National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse.
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Affiliation(s)
- Jack Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Adelina Artenie
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Division of Global Public Health, University of California San Diego, San Diego, CA, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
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23
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Vo AT, Magana C, Hickman M, Borquez A, Beletsky L, Martin NK, Cepeda JA. Assessing HIV and overdose risks for people who use drugs exposed to compulsory drug abstinence programs (CDAP): A systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103401. [PMID: 34389218 PMCID: PMC9027650 DOI: 10.1016/j.drugpo.2021.103401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/06/2021] [Accepted: 07/21/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Evidence supports integrating drug use treatment, harm reduction, and HIV prevention services to address dual epidemics of drug use disorders and HIV. These dual epidemics have spurred a rise in legally-enforced compulsory drug abstinence programs (CDAP), despite limited evidence on its effectiveness. We conducted a systematic review and meta-analysis evaluating the association between CDAP exposure and HIV and overdose-related risk. METHODS We searched PubMed, EBSCOhost and Sociological Abstracts for studies that contained an individual-level association between CDAP exposure and related HIV or overdose risks, with no date restrictions. Meta-analyses were conducted on data abstracted from eligible studies, using pooled random-effects models and I-squared statistics. We assessed quality of the studies across 14 criteria for observational studies. RESULTS Out of 2,226 abstracts screened, we included 8 studies (5253 individuals/776 events) across China, Mexico, Thailand, Norway, and the United States. All but two were cross-sectional analyses, limiting strength of observed associations. In the two studies that reported association between CDAP and HIV seropositivity or receptive syringe sharing, findings were inconsistent and did not indicate that those with exposure to CDAP had increased odds of HIV or syringe sharing. However, we found the odds of experiencing non-fatal overdose in lifetime and in the last 6-12 months were 2.02 (95% CI 0.22 - 18.86, p = 0.16) to 3.67 times higher (95% CI 0.21 - 62.88, p = 0.39), respectively, among those with CDAP exposure than those without. CONCLUSION Research assessing HIV risk associated with CDAP is scant and inconclusive, while evidence of robust associations between CDAP and overdose risk continues to mount. More rigorous, longitudinal studies are needed to evaluate the causal relationships between CDAP and these health outcomes. Aside from the growing evidence base on collateral harms, ethical considerations dictate that voluntary, evidence-based drug treatment should be prioritized to address the drivers of excess morbidity and mortality among people who use drugs.
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Affiliation(s)
- Anh T Vo
- Division of Infectious Diseases and Global Public Health, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA.
| | - Christopher Magana
- Division of Infectious Diseases and Global Public Health, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA
| | | | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA
| | - Leo Beletsky
- Division of Infectious Diseases and Global Public Health, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA; Northeastern University School of Law and Bouvé College of Health Sciences, Boston, MA, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA; Population Health Sciences, University of Bristol, UK
| | - Javier A Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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24
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Larney S, Jones H, Rhodes T, Hickman M. Mapping drug epidemiology futures. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103378. [PMID: 34321152 DOI: 10.1016/j.drugpo.2021.103378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 01/19/2023]
Abstract
Epidemiology is a core discipline generating evidence to inform and drive drug policy. In this essay, we speculate on what the future of drug epidemiology might become. We highlight for attention two areas shaping the future of drug epidemiology: nesting epidemiology within a 'syndemic' and 'relational' approach; and innovating in relation to causal inference in the face of complexity. We argue that shifts towards a more relational approach emphasise contingency, including in relation to how drugs might constitute benefit or harm. This leads us to speculate on a 'positive epidemiology'; one that is configured not merely in relation to harm but also in relation to the potential benefits of drugs in relation to well-being. In responding to the complex challenges of delineating contingent causalities, we emphasise the potential of carefully conducted observational study designs that go beyond statistical associations to test causal inference. We acknowledge that each of these developments we describe - a shift towards more relational approaches which emphasise contingent causation, and methodological innovations in relation to establishing causal inference - can be at odds with the other in how they imagine drug epidemiology futures.
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Affiliation(s)
- Sarah Larney
- Centre de Recherche du CHUM and Université de Montréal, Canada.
| | - Hannah Jones
- Bristol Medical School, University of Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, UK
| | - Tim Rhodes
- London School of Hygiene and Tropical Medicine, UK; Centre for Social Research in Health, University of New South Wales, Australia
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