Effect of fear of AIDS on sharing of injection equipment among drug abusers

Prevalence and correlates of intravenous methadone syrup administration in Adelaide, Australia

AIMS

The aims of this study were to determine the prevalence of methadone syrup injecting in Adelaide, South Australia and to characterize methadone injectors, including their heroin use and risk behaviours associated with heroin overdose.

DESIGN

Cross-sectional design.

SETTING

Community setting, principally metropolitan Adelaide.

PARTICIPANTS

Current heroin users (used heroin in the last 6 months), recruited through snowballing.

MEASUREMENTS

Structured questionnaire.

FINDINGS

Of 365 participants, 18.4% reported having ever injected methadone syrup and 11.0% had injected methadone in the last 6 months. Those that had injected methadone were more likely to be male, and were more likely to be receiving methadone maintenance. They were also maintained on higher doses of methadone than subjects not injecting methadone. A history of methadone injection was associated with more heroin overdose experiences and greater dependence on heroin. Methadone injectors were also more likely to engage in risky behaviours associated with heroin overdose, including using heroin when no other people were present, not trial-tasting new batches of heroin and polydrug use.

CONCLUSIONS

Methadone syrup injectors appear to be at greater risk of a series of harms than subjects not injecting methadone. The prevalence of methadone syrup injecting in Adelaide, South Australia was 11%, which was lower than prevalence in Sydney, New South Wales, but higher than in Melbourne, Victoria. Jurisdictional differences concerning the prevalence of methadone syrup injecting may reflect differing policies by each state to methadone dispensing.

Opiates: are there under-utilized and unexplored areas of prevention?

This paper explores the varied and potentially conflicting goals of preventive measures as applied to opiate use. These goals relate both to the overall extent of opiate use and the amount of harm arising from this drug use. Prevention involves the control both of the supply side and the demand for opiates. Particular targets may include sharing equipment, injecting, progression to more harmful routes of administration, prevention of development of dependence, harmful sequelae of opiate use and co-morbidity. There may be a place for manipulating the black market for opiates to channel users in directions that achieve particular prevention goals, and being more selective about targeting particular groups of users at particular times. It is the role of scientists to quantify the dimensions of harm and the likely impact on these dimensions of particular interventions. It is then up to elected representatives to determine the priorities.

Opiate treatments

One of the greatest of challenges facing medicine is to devise effective and appropriate treatments for opiate problems. Such treatments are based on principles derived from the disciplines of pharmacology and psychology, but are also shaped by social issues and even by the views of practitioners. There are many misconceptions about opiate problems. In this review it is suggested that there are good reasons for stating that opiate users do change over time, treatment can also lead to change and psychological interventions are of great importance. However, current methods of opiate detoxification are of low efficacy and methadone maintenance, although of benefit for some, is not a panacea for opiate problems.

Severity of heroin dependence and HIV risk. II. Sharing injecting equipment

One of the most conspicuous risks of HIV transmission among drug injectors involves sharing injecting equipment which has been contaminated by infected blood. The present study investigates the relationship between severity of dependence upon heroin and the sharing of previously used injecting equipment (passive sharing). Four-hundred-and-eight heroin users were contacted and interviewed. Two-hundred-and-eighty-one (69% of the total heroin sample) had injected drugs on at least one occasion, and 204 of the 281 injectors (73%) had shared injecting equipment on at least one occasion after it had been used by someone else. The more severely dependent heroin injectors were more likely to have shared injecting equipment. As users become more dependent upon heroin, the types of factors which predispose them towards sharing may change. Less dependent users were more likely to use in public and 'social' settings, and they may be more likely to share injecting equipment with people they do not know well. The more dependent users appear to use heroin in private settings and to be at greater risk of sharing with dealers, perhaps because of the urgency of their need for drugs at times when they are in withdrawal. One of the most frequently cited reasons for sharing was that sterile injecting equipment was difficult to obtain. It is a matter for some concern that many of the sharers in our sample (24%) reported having shared used injecting equipment while in custody. There was good overall awareness of the risks of health problems associated with injecting among our subjects. However, awareness of risk was not associated with avoidance of sharing behaviour.

The Fifth Thomas James Okey Memorial Lecture: research and practice: the necessary symbiosis

What relationship should exist between research and practice in the field of addictive behaviour? Are the perspectives essentially independent, or is there a necessary interaction? The extent of productive interaction is considered in three examples; (i) detoxification, (ii) stable abstinence, and (iii) goals other than abstinence. Changes are occurring in the drugs being used, the extents and types of associated co-morbidity, the levels of public and professional concern, and the explanatory paradigms which are dominant; and so it will be increasingly important for both practitioners and researchers to be sensitive and reactive to these changing circumstances. The most productive state for both research and practice will exist when they both feed off, and feed into each other--when there is indeed a necessary symbiosis.

The study of transitions in the route of drug use: the route from one route to another

Route of administration of various drugs is an area of study to which specific attention must be paid in study of different HIV risks of drug use by various routes. If changes in route are seen in individuals or within populations, then study of these transitions in route may identify new approaches which could be developed in HIV prevention. The consideration in this paper is based around ten questions: (i) What is a transition? (ii) Do routes of administration vary by time and place? (iii) Is choice of route influenced by availability of drug paraphernalia? (iv) How does the context influence initial choice of administration, and possible subsequent transitions? (v) Are lapse and relapse meaningful concepts? (vi) Transitions: how much of it is going on? (vii) How much does change of route (with the same drug) signify a change of drug effect, its significance, or its relationship with other risk behaviour? (viii) Is change of route of use of one drug always accompanied by the same change of route of other drugs? (ix) Injectors/non-injectors and sharers/non-sharers: do these behavioural characteristics exist as categories or are they distributed along a continuum? (x) Are transitions reversible? This paper is accompanied by two research reports which describe explorations into the extent and nature of transitions amongst heroin users.

Risk factors for shooting gallery use and cessation among intravenous drug users

BACKGROUND

Shooting galleries, locations where intravenous drug users (IVDUs) can rent or borrow needles and syringes, are a high-risk environment for HIV-1 transmission. This study investigates risk factors for lifetime attendance at shooting galleries and differentiates characteristics of those who continue to frequent shooting galleries and those who have stopped.

METHODS

We interviewed 2615 active IVDUs in Baltimore in 1988 and 1989 and determined patterns of IV drug use, sociodemographics, and HIV-1 serostatus as related to persistence vs cessation of shooting gallery use.

RESULTS

Over half (52%) of active IVDUs reported ever using a shooting gallery, with 33% reporting use within the prior 3 months. In multivariate analysis, lifetime shooting gallery use was associated with male gender, homosexuality/bisexuality, low socioeconomic status, Black race, and heavier drug involvement. Persistent shooting gallery users were more frequently male, homosexual/bisexual, homeless, less educated, and started IV drug use more recently compared with those who ceased going to shooting galleries.

CONCLUSIONS

Shooting gallery attendance may be pragmatic from a sociological and economic perspective, but it carries with it a heightened risk of acquiring HIV-1 infection.

Sharing spoons: a risk factor for HIV-1 infection in Vienna

Sharing of needles and syringes plays a central role in HIV-1 transmission among intravenous drug users (IVDUs). There have been several suggestions to protect the injecting population from further harm, but focused mainly on the use of sterile needles and syringes as well as information about safer sexual behavior. This study examined a total of 366 IVDUs at the drug dependence out-patient ward of the Psychiatric University Clinic of Vienna. HIV-1 antibodies were found in 29.7% (58) in 1989 and in 26.9% (42) in 1990. The results show that in 1989 14% and in 1990 5% IVDUs who never shared needles or syringes or other drug paraphernalia were found to be HIV-1 positive. In spite of the high information standard among Viennese drug addicts on risk reduction, the underestimated co-factors during drug administration might be responsible for a further HIV-1 transmission. Educational interventions on this subject should address even IVDUs who do not share needles and have adjusted to 'safer sex' practices.

Changing cocaine smoking rituals in the Dutch heroin addict population

Recently the use patterns, circumstances and consequences of cocaine have become of interest to both researchers and policy makers in Europe. Currently only a few studies have been conducted of the social epidemiology of cocaine. In this article, focus is placed upon the use of cocaine in one subpopulation, heroin addicts. Based mainly upon ethnographic research conducted in the city of Rotterdam it can be estimated that the prevalence of cocaine use in this population has reached a very high level. The mode of ingesting cocaine parallels that of heroin; Injecting Drug Users inject cocaine-hydrochloride, heroin smokers smoke cocaine base. This cocaine base is mainly processed by users themselves. An exception to this rule of self-processing can be found in the most marginalized addicts who do not have access to the house addresses where both heroin and cocaine-hydrochloride are sold. In this group the selling of 'cooked cocaine', a crack-like product, has occurred. The circumstances and potential consequences of the emergence of 'cooked cocaine' are discussed.

Fear of AIDS among intravenous drug users in London and New York

Intravenous drug users in drug treatment centers in London (N = 89) and New York City (N = 100) were given a 31-item, closed-ended questionnaire which asked them to rate levels of fear they experienced and to note fear-related behavior during the previous 8 weeks. Users reported an awareness of AIDS and had changed their behavior to reduce their risk of contracting the disease. The higher rates of AIDS within the study population in New York were associated with (1) higher levels of fear of AIDS on the part of the subjects interviewed and (2) higher rates of behavior change to limit the risk of contracting AIDS.

Combined naloxone/methadone preparations for opiate substitution therapy

Every opportunity should be used to reduce the risk of HIV-1 infection and transmission among intravenous drug users (IVDUs). Methadone maintenance is widely accepted to keep the drug user away from risk-laden practices and to stop intravenous drug use. In order to minimize the diversion and intravenous abuse of methadone in maintenance programs, the effects of a combined naloxone/methadone preparation through oral intake and the effects of an intravenous administration were tested. In opiate addicts, the intravenous administration of this mixture caused a severe withdrawal syndrome lasting for 15 to 30 minutes. The oral administration of this combination was indistinguishable from methadone alone. It is argued that this combination therapy prevents the intravenous abuse of methadone in maintenance programs.

Trends of HIV-1 risk reduction among initiates into intravenous drug use 1982-1987

To assess how injection practices may have changed during the course of the AIDS epidemic, active intravenous drug users (IVDUs) recruited from the community were asked to report year of first injection as well as specific details about the first 3 months after initial injection: frequencies of injection, using sterile needles, sharing needles and other equipment. For the analysis, the users were sorted into successive cohorts of initiation (by year of first injection), and tests for trends were completed using Mantel-Haenszel statistics. Among the 421 IVDUs who reported first injection between 1982 and 1987, the use of new sterile needles to self-administer drugs increased (p less than .05) along with its corollary behavior (i.e., using equipment one is sure that no one else had used before). Conversely, there was a decrease in the proportion of those who always used equipment previously used by another IVDU (p less than .05) and a decrease in the number of needle-sharing partners (p less than .01). Over the 6 years, heroin as first drug decreased and cocaine increased (p less than .01). Although these data are from a cross-sectional interview study, they suggest a shift toward lower risk practices among new IVDUs between 1982 and 1987. The shift from heroin to cocaine is compatible with other evidence on the cocaine epidemic.

Monitoring HIV-1 infection prevalence among intravenous drug users in Vienna 1986-1990

A standardised method to monitor HIV-1 infection levels and trends among injecting drug users (IDUs) was periodically administered at the drug addiction outpatient ward of the Psychiatric University Clinic of Vienna. A total of 715 injecting drug users were examined. HIV-1 antibodies were found in 8.5% of the IDUs in 1985/86, 14.5% in 1986/87, 27.7% in 1988, 29.7% in 1989 and 26.9% in 1990. Sharing was extensive in infected IDUs. After introduction of methadone maintenance in Austria more than 50% of the IDUs were receiving methadone and, in 1990, 88% of the infected IDUs were treated with methadone.

Anaesthesia and substance abuse

Current practices in the abuse of illicit drugs in the United Kingdom are described with particular reference to their pathological effects and the implications for anaesthesia. Practical guidelines are given for the anaesthetic and peri- and postoperative management of addicts.

Fear of contagion: the public response to AIDS

The threat of Acquired Immunodeficiency Syndrome (AIDS) has triggered a specific public response: fear of contagion, an anxiety over the perceived threat of catching the disease. Four behaviors characterize this fear: avoidance, attempting extreme precautions, lack of regard for the victims, and expressions of fear of catching the disease. Social and cultural values, which attach a deep symbolic meaning to AIDS, combine with misperceptions about transmission to create this public reaction. This fear results in the isolation and rejection of AIDS and potential AIDS clients. Fear of contagion may be a useful concept in nursing interventions for motivating risk-reduction behavior and creating a more therapeutic environment for persons with AIDS. Agendas for nursing research are suggested.

[AIDS epidemiology and prevention in i.v. drug addicts]

The incidence of AIDS cases in intravenous drug abusers is growing faster than in other risk groups, in Switzerland as well as in Europe in general. By end of May 1988, 27% of all AIDS cases registered nationally were injecting drugs. The prevalence of HIV antibodies is known from selected samples only, on the basis of voluntary testing. In 1986, among all intravenous drug users in residential treatment nation-wide, 90% were tested and thereof 55% seropositive. In a sample of drug abusers in out-patient treatment in Zurich in 1987, seropositivity was documented for 42% of male and 63% of female patients. According to registered AIDS cases, there is no differential risk for both sexes. Duration of intravenous drug abuse is the only relevant risk factor so far. Preventive change in risk taking behaviour is a minimalization of utilizing contaminated syringes/needles and a minimalization of unprotected sex (safer sex by regular use of condoms). An analysis of published data demonstrates that dissemination of information and availability of syringes/condoms are a pre-requisite for behaviour change, but by no means sufficient in order to elicit behaviour change. Drug abusers engaged in out-patient/residential treatment are available in high proportions for voluntary testing and for the intended behavioural changes. It is therefore of primary preventive interest to engage as many intravenous drug abusers as possible in treatment. Apart from drug-free residential treatment, out-patient treatment using Methadone provides positive results, whereas compulsory measures are considered to be of doubtful value.