The Spread of Intravenous Drug Use and AIDS in a Neighborhood in Spain

Can a Neighborhood Fall Sick? Opioid Addiction, Collective Violence and Currents of Death in Contemporary India

Opioid abuse is an increasingly global phenomenon. Rather than assuming it to be a uniformly global or neoliberal pathology, how might we better understand comparative and locally specific dimensions of opioid addiction? Working with neighborhoods as a unit of analysis, this article analyzes the striking differences between patterns of addiction and violence in two proximate and seemingly similar urban poor neighborhoods in Delhi, India. Rather than global or national etiologies, I suggest that an attention to sharp ecological variation within epidemics challenges social scientists to offer more fine-grained diagnostics. Using a combination of quantitative and ethnographic methods, I show how heroin addiction and collective violence might be understood as expressions of what Durkheim called "suicido-genetic currents." I suggest the idea of varying currents as an alternative to the sociology of neighborhood "effects" in understanding significant differences in patterns of self-harm and injury across demographically similar localities.

Cannabis cultivation in Spain: A profile of plantations, growers and production systems

BACKGROUND

The European market for cannabis derivatives is being transformed. The cultivation of cannabis within the EU and the shift of demand from hashish to domestic marihuana are key aspects of this transformation. Spain, formerly central to the trade of Moroccan hashish, is becoming a marihuana-producing country. The emergence of "import-substitution" has been researched in other EU countries, but thus far the Spanish case remains undocumented.

METHODS

This paper is based on analysis of data of 748 cannabis plantations seized by Spanish police in 2013. The sample comprises reports of seizures identified through a survey of online news and police reports. "Event-analysis" methods were applied to these sources.

RESULTS

The analysis offers a typology of plantations, a profile of participants and the different production systems, and a model of regional distribution. Half of the plantations were small (less than 42 plants) and half contained between 100 and 1000 plants, with an average size of 261 plants. About three-quarters of plants were cultivated indoors using stolen electricity. 86% of all plants seized were from large-scale plantations (more than 220 plants). Most plantations were located along the Mediterranean coast, where population and tourism are concentrated. Over three-quarters of those indicted by police were Spanish (85%). Among the foreign owners of big plantations, Dutch nationals predominated. The number of seized plants by province was directly associated with the number of grow shops (β=0.962, p<0.001).

CONCLUSION

The rise of large-scale cannabis plantations in the Spanish Mediterranean coast is increasingly replacing import of Moroccan hashish. Indoor cultivation supported by grow shops, that provide the technology and know-how, seem to be the dominant form of organization in this emerging industry. Large-scale plantations may have met most of the demand for marihuana in 2013.

A Brief History of Cannabis Policies in Spain (1968–2003)

Spain was one of the first countries in Europe to decriminalize drug use and one of the last to embrace harm reduction. As such, Spain's drug policies often appear to be rather contradictory. In this paper we will review the current status of drug laws and the major drug policies that have been implemented in Spain over the last 25 years concerning cannabis; their demographic, political, and economic contexts; and their apparent consequences. We will follow a chronological approach that outlines every major change that occurred during that period while trying to provide some sociopolitical background. We have divided the period under study into four major phases. Each phase addresses a major political change or shift in the social response to drug-related problems. In this account, we will apply to cannabis policies the conceptual distinctions introduced by MacCoun and Reuter in their recent revision of alternative drug policies (2001), especially their tripartite division between punitive, depenalizing, and legalizing regimes and the associated processes of promotion and commercialization. One essential question that concerns the Spanish case is the relationship between legal changes, their implementation, and long-term oscillations in consumption rates.

Estimating the size of the population of persons who inject drugs in the island of Montréal, Canada, using a six-source capture-recapture model

BACKGROUND

To plan and implement services to persons who inject drugs (PWID), knowing their number is essential. For the island of Montréal, Canada, the only estimate, of 11,700 PWID, was obtained in 1996 through a capture-recapture method. Thirteen years later, this study was undertaken to produce a new estimate.

METHODS

PWID were defined as individuals aged 14-65 years, having injected recently and living on the island of Montréal. The study period was 07/01/2009 to 06/30/2010. An estimate was produced using a six-source capture-recapture log-linear regression method. The data sources were two epidemiological studies and four drug dependence treatment centres. Model selection was conducted in two steps, the first focusing on interactions between sources and the second, on age group and gender as covariates and as modulators of interactions.

RESULTS

A total of 1480 PWID were identified in the six capture sources. They corresponded to 1132 different individuals. Based on the best-fitting model, which included age group and sex as covariates and six two-source interactions (some modulated by age), the estimated population was 3910 PWID (95% confidence intervals (CI): 3180-4900) which represents a prevalence of 2.8 (95% CI: 2.3-3.5) PWID per 1000 persons aged 14-65 years.

CONCLUSIONS

The 2009-2010 estimate represents a two-third reduction compared to the one for 1996. The multisource capture-recapture method is useful to produce estimates of the size of the PWID population. It is of particular interest when conducted at regular intervals thus allowing for close monitoring of the injection phenomenon.

Anthropology and addiction: an historical review

AIMS

This paper reviews the world anthropology of drugs and alcohol use literature, identifying key issues addressed by anthropologists, methods and theoretical models in use, trends in focus over time and future directions.

METHODS

Papers and books that comprise the literature were identified through computer search using the keywords: ethnography of drug use (and variants, e.g. drug ethnography, qualitative approaches in drug research), ethnography of drinking, anthropology and drug use, and anthropology and drinking. Search engines included Google Scholar, EBSCOHost, AnthroSource and PubMed. Identified sources were read and integrated into the review.

RESULTS AND CONCLUSIONS

The literature search identified a rich and growing literature on the anthropology of drinking and drug use. The research and published literature on the anthropology of drug use has grown and diversified since the 1970s, found acceptance in the wider multi-disciplinary domain of alcohol and drug studies and developed beyond the socio-cultural model to include life-style, critical medical anthropology and experiential explanatory models. Anthropological research has helped to shape the field of addiction science, e.g. ethnographic studies show that the lived worlds and self-identities of drug users have cultural order and socially constructed purpose and meaning, and experiential research shows that some addictions or aspects of addictions can be affirmative, creative and sustainable, at least at the individual level. The human immunodeficiency virus/acquired immune deficiency syndrome pandemic has significantly increased anthropological research on drug-related issues world-wide.

Initiation to drug injection among street youth: a gender-based analysis

OBJECTIVE(S)

To estimate the incidence rate of initiation into drug injection and to identify predictors of initiation into drug injection separately among street girls and boys.

DESIGN

Data from two consecutive prospective street youth cohort studies (1995-2001 and 2001-2005) were used to conduct these analyses, stratified by gender.

METHODS

Data were collected using semi-annual interviewer-administered questionnaires. Variables from the following domains were considered in Cox regression models: socio-demographic characteristics, early and current substance abuse, marginalization, childhood traumatic sexual events and injection exposure.

RESULTS

Of the 946 youth who had never injected drugs at study entry, 86.4% completed at least two questionnaires representing 243 girls and 574 boys. Incidence rates of injection of 7.0 and 5.9 per 100 person-years were observed among these girls and boys respectively. Among girls, cocaine or crack use (adjusted hazard ratio (AHR)=1.97), heroin use (AHR=2.86), homelessness (AHR=2.49) and hanging out regularly with people who inject (AHR=4.46) all independently increased risk of first injection. Among boys, age decreased risk of initiating injection (AHR=0.90/year), while cocaine or crack use (AHR=2.14), heroin use (AHR=3.56), homelessness before age 16 (AHR=1.68), incest or rape before age 14 (AHR=1.98) and hanging out regularly with people who inject (AHR=1.66) all independently increased this risk.

CONCLUSIONS

Our findings suggest similar rates of initiation among girls and boys; however, factors associated with initiation vary by gender. This might lead to the design of more effective programs to prevent initiation into drug injection.

Problematic heroin use incidence trends in Spain

AIMS

To estimate the annual incidence of heroin use in Spain.

PARTICIPANTS AND DESIGN

Data on individuals' year of first heroin use (from 1971 to 2005), year of first heroin treatment between 1991 and 2005 and most frequent route of heroin administration when presenting to treatment were obtained from the Spanish Drug Observatory Register and used to calculate the delay between onset and treatment. By using a log-linear model approach it was possible to correct for missing observations (heroin users who presented for treatment before 1991 and those who had still not presented by the end of 2005) and to estimate heroin incidence over time.

FINDINGS

The estimated incidence of problematic heroin use in the population aged 15-44 peaked at 190 per 100,000 in 1980--after rising rapidly from less than 40 per 100,000 in 1971--and fell subsequently to about 8 per 100,000 in 2005. On average, incidence was five times higher in men. Injecting heroin incidence peaked and declined rapidly from 1980; as heroin smoking did not decline as rapidly, from 1985 onwards its estimated incidence has remained above that of heroin injecting. The delay between starting heroin use and entering treatment had a median of 3 years.

CONCLUSIONS

We demonstrate the utility of a method to estimate heroin incidence from analysis of observed trends in presentations at specialist drug treatment facilities. The estimates suggest that incidence of heroin use, especially injecting, has fallen since 1980 and is now lower than in the early 1970s.

New injectors and the social context of injection initiation

BACKGROUND

Preventing the onset of injecting drug use is an important public health objective yet there is little understanding of the process that leads to injection initiation. This paper draws extensively on narrative data to describe how injection initiation is influenced by social environment. We examine how watching other people inject can habitualise non-injectors to administering drugs with a needle and consider the process by which the stigma of injecting is replaced with curiosity.

METHOD

In-depth interviews (n=54) were conducted as part of a 2-year longitudinal study examining the behaviours of new injecting drug users.

RESULTS

Among our sample, injection initiation was the result of a dynamic process during which administering drugs with a needle became acceptable or even appealing. Most often, this occurred as a result of spending time with current injectors in a social context and the majority of this study's participants were given their first shot by a friend or sexual partner. Initiates could be tenacious in their efforts to acquire an injection trainer and findings suggest that once injecting had been introduced to a drug-using network, it was likely to spread throughout the group.

CONCLUSION

Injection initiation should be viewed as a communicable process. New injectors are unlikely to have experienced the negative effects of injecting and may facilitate the initiation of their drug-using friends. Prevention messages should therefore aim to find innovative ways of targeting beginning injectors and present a realistic appraisal of the long-term consequences of injecting. Interventionists should also work with current injectors to develop strategies to refuse requests from non-injectors for their help to initiate.

Transition to injection drug use among street youth--a qualitative analysis

OBJECTIVES

To examine social contexts and processes influencing transition to drug injection among street youth.

METHODS

42 street youth participated in in-depth interviews. A typology of experiences was built founded on youth's street life and drug use trajectories. The transition to drug injection was examined through these experiences.

RESULTS

We identified five types of mutually exclusive experiences. The "downtowner's" experience is characterised by early street life and drug consumption trajectories, and a strong identification with the downtown milieu. These youth progress from one drug to another and, in a milieu where drug injection is omnipresent, this escalation culminates in transition to injection. The "tripper" street life and substance use trajectories begin later and are less intense. Most "tripper" youth are already chronic hallucinogens users when they arrive in downtown Montréal. Although they judge "junkies" severely, they show some ambivalence towards injection. The "on the go" experience is characterised by trajectories of drug use and street life that are intermingled, leading to a loss of control. These youth, who often have serious delinquent behaviours, come to downtown Montréal to party and consume drugs, mostly stimulants. Their drug use pattern and network make them at high risk of starting cocaine injection. The "hard-luck's" experience is characterised by a lack of identification with the downtown milieu. These youth who use drugs recreationally, end up in the streets accidentally, often because of unemployment. The "alcoholic' experience is related to alcohol misuse. These youth usually end up in the streets due to this dependence. Their street involvement is mostly an experience of solitude. The risk of transitioning to injection for both these types is low.

CONCLUSIONS

Some combinations of street life and drug use trajectories seem to contribute to injection among street youth. Some important factors interact and increase the risk of street youth transitioning to injection: poor personal assets; early rupture with primary social institutions; social integration into subcultures where both street life and "drug trips" are fashionable, drug preferences and the local drug market.

The Influence of Family and Peer Risk Networks on Drug Use Practices and Other Risks among Mexican American Noninjecting Heroin Users

Noninjecting heroin use (NIU) is spreading among social networks of young Mexican American polydrug users. This article examines the influence of family and peer networks on NIU behavior and other drug practices and risks. This study delineates the extent to which a culturally relevant modification of the "network facilitation" theoretical approach can increase both a theoretical and practical understanding of drug use and related risk behaviors. Using the methods of analytic ethnography, it identifies, describes, and explains variations in the social networks among this marginalized population and how specific aspects of Mexican American culture (familismo, and collectivismo) affects risk behaviors.

Transitions to injecting drug use among noninjecting heroin users: social network influence and individual susceptibility

OBJECTIVES

To determine the incidence/predictors of transitions to injecting among noninjecting heroin users (NIUs).

METHODS

Street-recruited NIUs in New York City, March/1996-March/2003, were interviewed for a prospective cohort study about social network influence (communication promoting injecting; exposure to injectors) and individual susceptibility. A transition to injecting was the first drug injection following baseline. Hazards ratios (HRs) (P < 0.05) were estimated by Cox proportional hazards regression, stratified by baseline injecting history.

RESULTS

Of 369 (64% of 579) followed, former-injectors were more likely to transition to injecting (33% or 53/160 vs. 12% or 25/209; 16.0/100 person-years-at-risk [pyar] vs. 4.6/100 pyar; HR = 3.25). Independent predictors among never-injectors included using > or =2 bags of heroin daily (HR = 7.0); social network influence (communication) and homelessness (HR = 6.3); shorter-term heroin use (HR = 5.3); social network influence (exposure) and physically abused (HR = 4.7); friends approve/condone drug injecting (HR = 3.5); lower perceived social distance from injectors (HR = 2.9); and younger age at first heroin use (HR = 1.2). Independent predictors among former-injectors were social network influence (communication) and lower perceived social distance from injectors (HR = 3.4); white race/ethnicity (HR = 2.0); not very afraid of needles (HR = 1.8); and younger age (HR = 1.1).

CONCLUSIONS

The risk of initiating injecting was lower than the risk of resuming injecting. Social network influence facilitates transitioning to injecting among those susceptible. Interventions to prevent injecting should address both social network influence and individual susceptibility.

Trends in Human Immunodeficiency Virus Infection among Drug Users in a Detoxification Unit

In a cross-sectional study of 1111 injection drug users (IDUs) admitted to a hospital detoxification unit between 1987 and 2001, characteristics of substance abuse and blood samples were obtained at study entry. The median age at admission was 27 years, the median age at first injection of drugs was 19 years, and the median duration of injection drug use was 84 months. Overall prevalence of human immunodeficiency virus (HIV) infection was 60% (58% in men, 66% in women; P=.026). Age at start of and duration of injection drug use were associated with HIV infection (P<.001). The rate of HIV infection in persons with short duration of drug use (<24 months) was higher among women (45%) than among men (21%) (P=.002). The prevalence of HIV infection among IDUs <21 years old at first use of injection drugs and among patients reporting <48 months of injection drug use was significantly lower in those who started injection drug use after 1992 (19% vs. 53% of IDUs; odds ratio, 4.42; 95% confidence interval, 1.80-10.85). Awareness of acquired immunodeficiency syndrome, preventive measures, and substance abuse treatment have contributed to the stabilization of the HIV epidemic. The higher prevalence of HIV infection among women IDUs and among young IDUs who recently began injecting drugs emphasizes the need to target HIV-transmission risk reduction interventions early.

Lessons from the History of the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Epidemic among Spanish Drug Injectors

In Spain, approximately 10 years passed between the time when human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) harm-reduction programs should have been developed with sufficient coverage to have an optimum impact on public health (before the HIV/AIDS epidemic's explosion in 1984) and the date of their actual implementation. This delay yielded an enormous cost for the country. The introduction of the virus in drug injector networks during a period of widespread diffusion of heroin injection and the lack of political awareness of the growing problem were 2 important factors that contributed to the important diffusion of the HIV infection among Spanish injection drug users. Lessons can be learned that may be of great interest in countries or territories facing similar challenges now and in the future.

Reasons for selecting an initial route of heroin administration and for subsequent transitions during a severe HIV epidemic

AIM

To identify the most important reasons for selecting a particular route of heroin administration and for subsequent transitions during a period of epidemic HIV transmission. To study temporal trends in these reasons.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Nine hundred heroin users in three Spanish cities: 305 in Seville, 297 in Madrid and 298 in Barcelona.

MEASUREMENTS

A separate analysis was made of the reasons for five types of behaviour: (a) selecting injection as the initial usual route of heroin administration (URHA); (b) changing the URHA to injection; (c) never having injected drugs; (d) selecting the smoked or sniffed route as the initial URHA; and (e) changing the URHA to a non-injected route. Subjects were invited to evaluate the importance of each reason included in a closed list. Spontaneously self-perceived reasons were also explored in an open-ended question for each of the five types of behaviour studied.

FINDINGS

The primary reason selected for each type of behaviour was: (a) pressure of the social environment; (b) belief that injection is a more efficient route than smoking or sniffing heroin; (c) concern about health consequences (especially fears of HIV and overdose), and fear of blood or of sticking a needle into one's veins; (d), pressure of the social environment and (e) concern about health consequences and vein problems. For women, having a sexual partner who injected heroin played a decisive role in initiating or changing to injection. Few people spontaneously mentioned market conditions for purchasing heroin as an important reason for any behaviour, nor did many mention risk of overdose as reasons for (c) or (d).

CONCLUSIONS

These findings should be considered when designing interventions aimed at preventing initiation of injecting or facilitating the transition to non-injected routes.

Toward a bio-cultural and political economic integration of alcohol, tobacco and drug studies in the coming century

The 18th and early 20th centuries witnessed the disintegration of a unified approach to understanding the human condition. Political economy, the broad study of human society, fragmented into an array of university-based disciplines, each reductionistically focused on its narrow arena of specialized research. Medicine, which had been concerned with health in social and historic contexts, narrowed its focus to the microscopic level and to encapsulated understandings of the immediate effects of pathogens and of the structures of disintegrated organ systems. Similarly, anthropology, which continued to wave a banner of holism, retreated for much of the 20th century into fine-grained cultural studies of seemingly isolated human communities on the one hand, and highly specialized biological and biobehavioral analyses of only tangential concern to cultural concerns on the other. Consequently, it has appeared at times as if anthropology would fragment into two or more disciplines and the opportunity for an integrated understanding of the human condition would be lost in the process. As we approach ever closer to the 21st century, however, the felt need for interdisciplinary and intradisciplinary reintegration has grown stronger. This trend is manifest increasingly in the field of alcohol, tobacco, and drug studies, and suggests one of the places anthropology may be going in the future. In this light, this paper examines the use of a critical biocultural model employed in the anthropological assessment of the Hartford Syringe Exchange Program. This model integrates the political economy of risk behavior, the ethnographic examination of insider understandings, meaning systems and behaviors, and the biological analysis of health-related issues. Methodologically, the assessment combined methods and concepts from all of the major subfields of anthropology.

Psychosocial considerations for the prevention of HIV infection in injecting drug users

In this article, the authors discuss a study that investigated the meaning that injecting drug users attribute to risk behaviors linked to HIV transmission, especially through the use of nonsterile syringes or the failure to use condoms. To do this, social discourses with respect to the prevention of HIV infection are evaluated. The discussion focuses on how these discourses affect the daily practices of heroin users, practices that in turn influence discourses. Ethnography was used to observe 78 heroin users and 35 people following a methadone treatment program. Observation was carried out in a central district of Barcelona, Spain, with a low socioeconomic level. The results are a useful starting point for generating strategies aimed at preventing HIV transmission among this population on personal, community, and sociostructural levels.

Gender differences in the initiation of injection drug use among young adults

To characterize the circumstances surrounding initiation of injecting drug use, data were collected from 229 young, recently initiated injection drug users enrolled through community-based recruitment in Baltimore, Maryland. Gender differences in the pattern of initiation, the number of persons present at initiation, risky injection, and sexual behaviors at initiation, as well as behaviors after initiation, were examined. Overall, men and women were similar statistically with respect to age at initiation (19.5 years) and risk behaviors at initiation. While men were initiated by men (77%), women were more often initiated by women (65%), most of whom were friends (75%) or relatives (23%). The percentage of women infected with human immunodeficiency virus (HIV) was slightly greater than that of men, 17% versus 11% (P < .2), whether initiated by a man or a woman. Persons who self-initiated had a lower HIV prevalence and fewer HIV-related risk behaviors. Analysis of variance assessed differences in the HIV risk profiles of female and male IDUs who were initiated by someone of the same sex, of the opposite sex, or who self-initiated. These results indicated that (1) young women and men had similar patterns of injection initiation; (2) most women were initiated by female friends, running counter to earlier literature claims that women were initiated to injection drug use by male sex partners; and (3) women initiated by men had a marginally greater mean score on the HIV risk profile.

Adoption of injection practices in heroin users in Guangxi Province, China

This preliminary study collected data from 326 heroin users in Guangxi Province, China, in 1997. Logistic regression analysis was performed to identify the risk factors for injection. Survival analysis identified factors independently associated with time from initiation of heroin use to adoption of injection. Four factors were independently associated with injection: number of friends who used heroin in the last year, duration of heroin use, dose of heroin consumed, and total number of times detoxified in drug treatment and rehabilitation centers. Only gender and duration of heroin use were independently associated with time to first injection. Median time to first injection was 11 months for males and 22 months for females. Median time to first injection varied by age. Median time to injection for those who used heroin for more than one year was 8.1 months; it was 19.1 months for on to five years of use, and 40.5 months for more than five years of use. This study's preliminary findings suggest that younger, more recent heroin users, and males are at increased risk of becoming injectors, a major risk behavior for HIV acquisition.

Tecatas: an ethnotheoretical look at Mexican American female injecting drug users

Ethnotheory is suggested as a way to study the roles Mexican American female injecting drug users play. It is suggested that ethnotheory extends present theoretical models used to explain and modify female IDUs' behavior; provide insights on female IDUs' roles useful for the development of effective intervention strategies; and suggests a type of ethnographic data collection that uncovers the subject's view of reality. Three detailed ethnographic excerpts from Mexican American female IDUs illustrate how female IDUs manage the array of roles they play and how information gained through ethnotheory is useful in the design of culturally relevant interventions.

Use of needles and syringes in Miami and Valencia: observations of high and low availability

Two studies engaged in gathering data on injecting drug users (IDUs) employed supplementary resources to enhance their ethnographic components and compare patterns of use of needles/syringes (n/s) in two geographically similar but culturally distinct cities. Despite its policy of making n/s highly available at fair prices, Valencia, Spain, has markedly higher rates of HIV seroprevalence among its IDUs than does Miami, Florida, where possession of n/s is illegal. Ethnographically based models that track IDUs through choices of injection venues help to explain this difference. Inability of IDUs in Valencia to use their own domiciles as venues for injection contrasts sharply with problems of Miami IDUs, who have access to houses but have difficulty finding n/s. This research suggests that intervention in Valencia needs to focus on how people select places where they inject, and intervention in Miami needs to focus on improving availability of n/s.

[The persistence of risky conduct for HIV transmission among intravenous drug users in Madrid, Seville, and Valencia. The Working Group of the Médicos del Mundo for the Monitoring of HIV Infection and the Risk Practices of Intravenous Drug Users]

OBJECTIVE

To determine the prevalence of HIV infection and risk-taking behavior for infection among intravenous drug users in Madrid, Seville, and Valencia (Spain). To study the main factors associated with such behavior.

MATERIAL AND METHODS

Personal interviews were carried out with 821 intravenous drug users recruited in 1994 and 1995 among recent participants in three needle-exchange programs. Subjects were asked about their risk-taking behavior in the 30 days preceding the interview. Bivariate statistical methods and logistical regression techniques were used.

RESULTS

In the month before the interview, 13.8% of the subjects in Valencia, 18.1% in Madrid, and 26.9% in Seville used needles that had been used by other people, usually (73-88%) without disinfecting them effectively. Condom use during the reference period was 50% in Seville, 42.5% in Madrid, and 34.2% in Valencia. The prevalence of HIV infection ranged from 30.1% in Seville to 43. 2% in Madrid. Multivariate analysis showed that the factors most closely associated with accepting used needles were: needle sharing (OR = 12.2), residence in Seville (OR = 6.6), and HIV positivity (OR = 4.6). The factors most closely associated with not using condoms systematically were: ignorance of personal HIV serological state (OR = 4.1), needle sharing (OR = 3.7), and HIV negativity (OR = 3.3).

CONCLUSIONS

The risk of HIV transmission among intra-venous drug users in Spain is high (infection and risk-taking behavior have a high prevalence), so programs designed to reduce this risk should be increased quickly.

Needle exchange and reduction of harm: an anthropological view

Overwhelming evidence from all over the world confirms that needle exchange programs (NEPs) in widely varied forms have value in prevention of HIV infection among injecting drug users (IDUs). Unfortunately, the United States has relatively few active NEPs because of political opposition to adoption of any policy that would give the appearance of condoning use of illegal drugs. Some additional opposition comes from the affected communities themselves. NEPs that assiduously construct links with affected communities have highest probabilities of effectiveness. Studies of NEPs, with some notable exceptions, still lack anthropological evaluations of their impact, and this deficiency needs more attention in future efforts to frame, implement, and evaluate NEPs.

The heroin epidemic in New York City: current status and prognoses

Since 1989, heroin production worldwide has risen; in New York City, as its purity rose and prices fell, street-level markets were restructured and offered heroin in addition to cocaine and crack (which had been popular during the 1980s). While officials estimate that there are between 500,000 and one million hard-core, chronic heroin users nationwide, evidence of supplemental users heralding another heroin era includes: more overdoses and overdose deaths, greater demand for treatment, larger seizures of heroin at all levels of distribution and related arrests, and broader media coverage. In this article, the authors describe the characteristics of populations in which there may have been a percentage increase of new users, such as young middle- or upper-class European-Americans, young Puerto Ricans and recent Haitian and Russian immigrants. The abstinence of young African-Americans is also noted. The article ends with a preliminary needs assessment of the new users in the areas of health (including AIDS), housing, employment, treatment, arrest and imprisonment.

Non-fatal injuries and the use of psychoactive drugs among young adults in Spain

We compared the prevalence of injuries requiring medical treatment in the general population, in cocaine users and in heroin users, and we studied the factors associated with the occurrence of injuries in these groups, using data from two interview surveys carried out in 1993 in Spain: the National Health Interview Survey, a national representative sample of the non-institutionalized general population, and a survey of a non-probability sample of heroin or cocaine users selected from the community. The subjects included in the study were persons 16-40 years of age in urban areas: 4261 persons from the general population, 369 cocaine users and 215 heroin users. The annual prevalence of injuries requiring medical treatment was 7.9 percent in the general population, 10.8 percent in cocaine users and 35.2 percent in heroin users. There was a statistically significant positive association of injury occurrence (1) among the general population: with male sex, alcohol use, use of tranquillizers/sleeping pills, and the use of antidepressants or stimulants; (2) in cocaine users: with the use of opiates other than heroin; and (3) in heroin users: with alcohol use, the use of tranquillizers/sleeping pills, and the injected route. The only statistically significant negative association was with the amount of cocaine consumed among heroin users. The results suggest that other psychoactive substances besides alcohol are positively associated with injury occurrence, and that cocaine use may contribute to a reduced risk of injuries associated with the use of depressants (alcohol, tranquillizers, heroin).