Estimating the effect of differing assumptions on the population health impact of introducing a Reduced Risk Tobacco Product in the USA

We use Population Health Impact Modelling to assess effects on tobacco prevalence and mortality of introducing a Reduced Risk Tobacco Product (RRP). Simulated samples start in 1990 with a US-representative smoking prevalence. Individual tobacco histories are updated annually until 2010 using estimated probabilities of switching between never/current/former smoking where the RRP is not introduced, with current users subdivided into cigarette/RRP/dual users where it is. RRP-related mortality reductions from lung cancer, IHD, stroke and COPD are derived from the histories and the assumed relative risks of the RRP.A basic analysis assumes a hypothetical RRP reduces effective dose 80% in users and 40% in dual users, with an uptake rate generating ∼10% RRP and ∼6% dual users among current users after 10 years. Sensitivity study changes in tobacco prevalence and mortality from varying effective doses, current smoking risks, quitting half-lives and rates of initiation, switching, re-initiation and cessation. They also study extreme situations (e.g. everyone using RRP), and investigate assumptions which might eliminate the RRP-related mortality reduction. The mortality reduction is proportional to the dose reduction, increasing rapidly with time of follow-up. Plausible increases in re-initiation or dual users’ consumption, or decreased quitting by smokers would not eliminate the drop.     

Syringe Exchange in Germany

Syringe exchange in Germany is clearly linked to a recent shift of local responses to drug-use(r) associated problem. Since the end of the 1980s metropolitan communities in Northern and Central Germany-concerned by the emergence of “Open Drug Scenes,” increasing HIV and mortality rates among drug users, and drug-use-related property crime-began to favor measures of survival-oriented drug-user help. While die Federal Government still favors repression and law enforcement efforts, they nevertheless made syringe exchange explicitly legal in 1992-some 5 years after the creation of local Syringe Exchange Programs. In general, the new approach of local authorities includes a variety of services, such as housing facilities, crisis intervention centers, primary medical care, maintenance with substitute drugs, and syringe exchange programs. The creation of pilot heroin maintenance programs is planned for Frankfurt and Hamburg. While the established programs are successfully functioning in large cities such as Hamburg, Bremen, and Frankfurt, the demand for sterile needles and syringes remains unmet in smaller cities and in the conservative governed Bundesländer (states), where pharmacies remain the primary and often single legal supply source for syringes. Another major problem continues to be the drug-use situation in prisons. Although injection drug use is common in prisons, injection equipment is not legally available for the 10,000 injecting drug users imprisoned at any given time. Two of Germany's 220 prisons started an experimental syringe exchange in 1996.     

Concerns that an opioid antidote could “make things worse”: Profiles of risk compensation beliefs using the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale

Abstract

Background and aims: As opioid overdose death rates reach epidemic proportions in the United States, the widespread distribution of naloxone is imperative to save lives. However, concerns that people who use drugs will engage in riskier drug behaviors if they have access to naloxone remain prevalent, and the measurement scales to assess these risk compensation concerns remain under researched. This study aims to examine the validity of the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale and to understand the effect of overdose education and naloxone distribution (OEND) training on risk compensation beliefs across demographic and professional populations. Methods: A total of 1424 participants, 803 police officers, 137 emergency medical services (EMS)/fire personnel, and 484 clinical treatment and social service providers were administered surveys before and after attending an OEND training. Survey items measured the endorsement of opioid overdose knowledge and attitudes, as well as risk compensation beliefs. Results: Police and EMS/fire personnel expressed greater endorsement of risk compensation beliefs than clinical treatment and social service providers at both pre- and post-OEND training. Although endorsement of risk compensation beliefs was significantly reduced in each of the 3 groups after the training, reductions were greatest among EMS/fire personnel, followed by providers, then police. Moreover, younger, male, and black participants endorsed greater beliefs in risk compensatory behaviors as compared with their older, female, and white counterparts. Conclusion: This study validated a novel measure of naloxone-related risk compensation beliefs and suggests participating in OEND trainings decreases beliefs in naloxone-related risk compensation behaviors. OEND trainings should consider addressing concerns about naloxone “enabling” drug use, particularly in law enforcement settings, to continue to reduce stigma surrounding naloxone availability.     

Getting to know Mark,a homeless alcohol-dependent artist,as he finds his way out of the river

Managed Alcohol Programs (MAPs) are a relatively recent addition to the repertoire of harm reduction approaches for persons experiencing severe alcohol dependence. In these settings, clients, who are typically homeless, are provided with a maintenance amount of alcohol while residing in a shelter setting. This case study examines the living experience of a homeless alcohol-dependent client of a MAP in an effort to articulate the process factors related to engagement with this form of treatment. The participant, a 48-year-old white male, participated in a series of qualitative interviews that took place prior to admission, immediately following admission, following re-admission, and after completion of the program over the course of 18 months. A grounded theory approach to data analysis was undertaken. The findings suggest that the primary utility of the MAP was in stabilizing a range of problems such that he was provided with the time, energy, and resources necessary to engage in the critically important task of constructing valued identity, place, and meaning and purpose in life.     

Social Capital and Risk Level of Posttreatment Drug Use: Implications for Harm Reduction among Male Treated Addicts in Hong Kong

Since relapse is common among treated addicts, harm reduction efforts should be made to minimize their levels of risk in their reuse of drugs. This paper applies the social capital framework to analyze how a treated addict's social network affects the risk level of posttreatment drug use. Embeddedness in a pro-social network reestablished by a treated addict can facilitate positive social capital in the forms of tutelage of a normal life, informal social control from nondrug-using people, and lessening of perceived public discrimination. On the contrary, reentering a network of active addicts can produce negative social capital in the forms of tutelage of the addict lifestyle, lack of informal social control from nondrug-using people, and reinforcement of perceived public discrimination. The possession of positive social capital greatly enhances the treated addict's likelihood to reduce the risk level of posttreatment drug use, whereas the possession of negative social capital reduces such likelihood. Data used in this paper were extracted from a study of 200 male former clients of a voluntary residential treatment agency in Hong Kong. Implications of the findings for helping male treated addicts to generate positive social capital as a posttreatment harm reduction measure are discussed.     

HCV prevalence and risk behaviours among injectors of new psychoactive substances in a risk environment in Hungary—An expanding public health burden

BackgroundIn Hungary a large increase in injecting new psychoactive substances (NPS) coincided with decreasing harm reduction efforts and rising HCV infection. We describe these, and assess changes in HCV prevalence and risk behaviours, 2011–2014, among NPS injectors, using 2011–2015 syringe exchange programme (SEP) data as a key contextual (‘risk environment’) variable.MethodsWe conducted repeated national sero-behavioural surveys in people who inject drugs (PWID) injecting in the last month and attending SEPs or drug treatment centres (n = 399, 2011; 384, 2014), using face-to-face interviews and dried blood-spot samples. Prevalence of injected drugs and SEP coverage (2011–2015) were assessed through our national SEP monitoring system and using population size estimates.ResultsNPS injecting tripled among PWID attending SEPs in Hungary (2011: 26%; 2015: 80%). Among NPS injectors, HCV prevalence, sharing syringes and sharing any injecting equipment (last month), doubled (2011–2014: 37%–74%, 20%–48%, 42%–71%, respectively), significantly exceeding prevalence in other PWID groups. Among young NPS injectors (aged < 25), HCV prevalence increased 7-fold (12%–76%), among new injectors (injecting < 2 years) 4-fold (13%–42%), coupled with high levels of equipment sharing (79% and 72% respectively). Not using a condom at last intercourse (79%), ever-imprisonment (65%) and last-year homelessness (57%) were highly prevalent among NPS injectors (2014). The number of syringes distributed per estimated PWID nationally fell from 114 to 81 (2011–2014) and dropped to 28 in 2015.ConclusionNPS injectors in Hungary are at severe risk of blood-borne infections due to high levels of injecting and sexual risk behaviours within a high-risk environment, including continuously low SEP provision, imprisonment and homelessness. An HIV outbreak cannot be excluded. Stronger investment in evidence-based prevention measures, with special focus on young and new injectors, and expansion of hepatitis C treatment are urgently needed.     

Predictors for Dropping-Out From Methadone Maintenance Therapy Programs Among Heroin Users in Southern Taiwan

This study examined the methadone maintenance therapy (MMT) retention rates of heroin users in Taiwan and the predictors for dropout in the 18-month period after starting MMT. We consecutively recruited 368 intravenous heroin users receiving MMT in 2007–2008 and applied Cox proportional hazards regression analysis to determine the predictive effect of pre- and in-treatment variables on early discontinuation of MMT. The retention rate at 18 months was 32.3%. High heroin expenses, more severe harm caused by heroin use, perceived lower family support, and lower methadone dosage at 3 months after starting MMT increased the risk of dropout in the follow-up period.     

Is There a Moral Duty to Die?

In recent years, there has been a great deal of philosophical discussion about the alleged moral right to die. If there is such a moral right, then it would seem to imply a moral duty on others to not interfere with the exercise of the right. And this might have important implications for public policy insofar as public policy ought to track what is morally right. But is there a moral duty to die? If so, under what conditions, if any, ought one to have such a duty, and why? In this paper, I distinguish between different moral grounds for the putative moral duty to die: deontological, intuitionist, and contractarian. Subsequently, I argue in support of Paul Menzel's theory of health care distribution. More precisely, I concur with his claim that there is a moral duty to die inexpensively in health care contexts. Then I provide and defend a philosophical analysis of the conditions in which such a duty could exist.