Taming demons: the reduction of harm resulting from use of illicit drugs

Restricting availability is the major response to illicit drugs in most Western countries including Australia. Prohibition may reduce harm when the drug in question is in low demand, controls are difficult to subvert, and when similar drugs are less toxi; or unavailable. However, the health, social and economic costs of supply reduction are substantial and increasing for both injecting drug users and the general community. Population adjusted mortality of heroin users has doubled in Australia in the last decade. The possible impact of supply reduction policy on the spread of HIV infection among IDUs is an important but largely neglected consideration. The effectiveness of supply restriction policy in decreasing the availability of drugs or in reducing drug-related harm is unlikely to be increased significantly by more vigorous implementation of supply reduction or adoption of new technology. Conversely, on the basis of existing data, greater availability of HIV prevention measures attractive to the target population (including especially drug treatment such as methadone maintenance) is likely to be effective and cost-effective. The costs and benefits of innovative methods of providing currently illicit drugs to those who are determined to use them requires careful evaluation and comparison with existing policies. Policy on illicit drugs in most countries including Australia is still dominated by concern about drug use rather rhan focused on the need to reduce drug-related problems which is the agreed aim of national drug policy. (Aust NZ 3 Med 1992; 22: 204–208.)     

The first week after drug treatment: the influence of treatment on drug use among women offenders.

Over the last decade, there has been a dramatic rise in the number of women arrested for drug offenses, and many have serious drug abuse problems. Increasingly, these women have been mandated to drug treatment, often in community-based settings. This article examines the impact of the treatment programs on the short-term posttreatment drug use of women offenders (N = 165) leaving two community-based treatment programs in Portland, Oregon. Our analyses indicate that women who abstained from drug use during the first week after treatment were more likely than those who used drugs during this time to have remained in treatment longer, received a plan to make a successful transition out of treatment, avoided associations with other drug users after leaving treatment, and obtained encouragement from individuals and groups in support of abstinence.     

THE FIRST WEEK AFTER DRUG TREATMENT: THE INFLUENCE OF TREATMENT ON DRUG USE AMONG WOMEN OFFENDERS

Over the last decade, there has been a dramatic rise in the number of women arrested for drug offenses, and many have serious drug abuse problems. Increasingly, these women have been mandated to drug treatment, often in community-based settings. This article examines the impact of the treatment programs on the short-term posttreatment drug use of women offenders (N = 165) leaving two community-based treatment programs in Portland, Oregon. Our analyses indicate that women who abstained from drug use during the first week after treatment were more likely than those who used drugs during this time to have remained in treatment longer, received a plan to make a successful transition out of treatment, avoided associations with other drug users after leaving treatment, and obtained encouragement from individuals and groups in support of abstinence.     

What Are We Learning from the FDA-Mandated Cardiovascular Outcome Studies for New Pharmacological Antidiabetic Agents?

Cardiovascular disease (CVD) is common in patients with diabetes. For these patients, clinicians should seek diabetes treatment that is beneficial rather than harmful in relation to CVD. Until recently, there have been many treatments for hyperglycemia, whose impact on CVD has been controversial. The aims of this review are to evaluate the effectiveness of antihyperglycemic medications on risk factors for CVD and to examine the impact of these drugs on CVD in cardiovascular (CV) outcome trials. In this article, we summarize current knowledge about the impacts of these drugs on various risk factors as well as CV outcomes. We identify the recent emergence of trials with antihyperglycemic agents showing newly discovered CV benefits as well as past trials with antihyperglycemic agents not showing much benefit on CV events. Rather than focusing on treatment strategies, we review the effects of individual drug classes on CV outcomes. We also briefly review goal-driven glycemia reduction and its impact on CVD. We conclude that antihyperglycemic agents are associated with improvement in CV risk factors in patients with diabetes and insulin resistance; in fact, a few drugs reduced CV events in randomized CV outcome trials. Therefore, the use of these drugs is appropriate for reducing glucose and decreasing CV event risk in a select subpopulation.     

The effect of stimulant and sedative use on treatment outcome of patients admitted to methadone maintenance treatment

While methadone maintenance treatment (MMT) has been demonstrated to be an effective treatment for opiate dependence, its impact on the treatment outcome of other illicit drug abuse is not as clear. Using the initial urine drug screen (UDS) and follow-up UDS at 1, 6, 12, and 24 months, 167 patients consecutively admitted to MMT were evaluated for opiate, sedative (predominantly benzodiazepine), and stimulant (predominantly cocaine) use. Retention for the opiate only group was 97.32 days longer on average than for patients using opiates along with stimulants, sedatives, or both stimulants and sedatives. Patients abusing opiates only had the greatest decrease in drug use; however, MMT was also associated with decreases in cocaine and sedative use over the 24 month follow-up period. There was no evidence that patients "switched" their drugs of abuse with time in treatment. The negative impact of non-opiate drug use on outcome in MMT and its implications for treatment planning are discussed.     

Changing Trends in Drug Use: an initial follow-up of a local heroin using community

A cohort of 101 heroin users and suppliers involved in a local community network were monitored over an 18 month period by staff at two community drug treatment agencies. The relative impact of police action and therapeutic intervention on this network is detailed and discussed. Few (7%) were still known to be using exclusively heroin after this time with many moving their dependency to other drugs, including alcohol, alone or in combination. Analysis of events suggests that the disruption of the social centre which had come to be associated with the use and supply of drugs has had a major effect on the dissolution of the heroin network equal in importance to the apprehension of larger dealers or the expansion of treatment services.     

Impact of use of multiple antimicrobials on changes in susceptibility of gram-negative aerobes.

Evaluation of antimicrobial usage vs. susceptibility relationships typically involves single agents. However, susceptibility profiles may be affected by multiple drugs. From 1992 through 1996, we studied relationships between drug usage and the susceptibility (only susceptibility rates of > or = 70%) of Acinetobacter anitratus (baumannii), Enterobacter aerogenes, Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis, and Serratia marcescens to 22 agents. Linear regression was used to assess usage of each agent vs. susceptibility to it and to all agents. Only relationships with a coefficient of determination of > or = 0.5 and a negative slope were evaluated and classified as increasing drug use and decreasing susceptibility (increasing D, decreasing %S) or decreasing drug use and increasing susceptibility (decreasing D, increasing %S). The mean numbers (range) of drugs associated with a change in susceptibility were 1.7 (0-14) and 0.6 (0-7), respectively, for increasing D, decreasing %S and decreasing D, increasing %S relationships. Multiple antimicrobials are associated with susceptibility to other drugs; thus, surveillance of these relationships should not be limited to single drugs.     

Type and pattern of illicit drug use and access to health care services for HIV-infected people

Approximately 28% of HIV-infected people in treatment in the United States report using illicit drugs. Illicit drug users have poorer course of HIV disease than non-drug users, which is thought to be due to their irregular use of HIV medical services. We examined associations between type (cocaine versus opioids) and pattern of drug use (drug use at baseline, 6-month follow-up, both periods, and nonuse) and health care utilization for a large sample of HIV-infected individuals drawn from a multisite project that evaluated the impact of medical outreach interventions for populations at risk of poor retention in HIV care. Across all types and patterns of drug use, drug users were more likely to have suboptimal ambulatory care, miss scheduled appointments, use the emergency department, have unmet support services needs, and were less likely to take antiretroviral medications. Additionally, while people who started using drugs during the follow-up period and consistently used drugs across both periods differed from nonusers on missed appointments (odds ratio [OR] = 2.20 for starters versus nonusers, OR = 2.92 for consistent users versus nonusers), emergency department use (OR = 4.93 for starters versus nonusers, OR = 2.24 for consistent users versus nonusers), and antiretroviral medication use at follow-up (OR = 0.23 starters versus nonusers, OR = 0.19 for consistent users versus nonusers), those who stopped using drugs after the baseline period did not differ from nonusers. We conclude that health care utilization is poorer for people who use illicit drugs than those who do not, and stopping drug use may facilitate improvements in health care utilization and HIV outcomes for this population.     

RESEARCH REPORT A meta-analysis of predictors of continued drug use during and after treatment for opiate addiction

Abstract Aims. Many people treated for opiate addiction continue to use drugs during and after treatment. It may be possible to improve outcomes by addressing patient characteristics that predict continued drug use. This review uses meta-analytic techniques to identify risk factors for continued drug use in patients treated for opiate abuse. Design and Measurements. A thorough search of the published literature yielded 69 studies that reported information on the bivariate association between one or more independent variables and continued use of illicit drugs during and after treatment for opiate addiction. Findings. Most of the patient variables summarized have weak longitudinal relationships with continued drug use, although several variables display moderate longitudinal associations. Ten variables show statistically significant and longitudinally predictive relationships (average r 0.1) with continued use, including: high level of pretreatment opiate/drug use, prior treatment for opiate addiction, no prior abstinence from opiates, abstinence from/light use of alcohol, depression, high stress, unemployment/employment problems, association with substance abusing peers, short length of treatment, and leaving treatment prior to completion. Several other variables may be potentially longitudinally predictive. Conclusions. To prevent relapse, treatment interventions should address multiple variables because no single variable strongly predicts continued drug use.     

Treatment of tuberculosis infection

Tuberculosis is a chronic bacterial infection caused by Mycobacterium tuberculosis. It continues as an important cause of morbidity and mortality worldwide, especially in impoverished countries and where human immunodeficiency virus infection is endemic. The modern treatment of tuberculosis is based on the administration of effective drugs. Regimens do not differ for pulmonary and extra-pulmonary tuberculosis. In order to prevent the emergence of drug-resistant organisms, which is present initially in very small numbers, at least two effective drugs are always required. Short-course therapy has been developed to mitigate the consequences of patient default. It is best considered as consisting of two phases. An initial 2-month intensive phase of daily therapy should include isoniazid, rifampin, ethambutol and pyrazinamide. A consolidation phase of daily therapy with isoniazid and rifampin should be continued for an additional 4 months, preferably more for special clinical circumstances. This standardized drug strategy is successful only if the resources conserved by shortening treatment are used to maintain patient compliance. Completely supervised regimens have been also developed with success. Defaults lead not only to treatment failure but also the emergence and transmission of drug-resistant organisms. Treatment of confirmed or suspected drug-resistant tuberculosis is difficult and should only be made on experts consultation. More difficult to use and/or less effective than first line drugs, second line drugs could be chosen and associated. However drug toxicities should be monitored, with greatest concern to hepatitis. Follow-up of patients must be organised until 2 years after the completion of therapy to detect relapses. Treatment includes prophylactic measures which are a major modality for decreasing the spread of infection.     

Pharmacokinetics of calcium-entry blockers

Effective use of drugs in therapy depends not only on clinical acumen but also on the availability of relevant pharmacokinetic and pharmacodynamic data. Such information assists in development of safe dosing regimens, prediction of abnormal handling of drugs in states of disease and disorder and anticipation of drug interactions. For the calcium-entry blocking agents now available in the United States (verapamil, nifedipine and diltiazem), these data appeared well after clinical patterns of use evolved. Nonetheless, their relevance continues to be demonstrated by the dependence of each agent on intact liver blood flow and function for normal rates of elimination; by the nonlinear kinetic characteristics for verapamil and diltiazem (and probably for nifedipine, as well) and the derivative implications for decreased dosing frequency requirements; and by observations now appearing on the relation between plasma drug levels and drug effects, both therapeutic and toxic. Such data are discussed herein, with emphasis on those aspects that impact on the clinical use of the calcium-entry antagonists.     

Effects of a sustained heroin shortage in three Australian States

BACKGROUND: In early 2001 in Australia there was a sudden and dramatic decrease in heroin availability that occurred throughout the country that was evidenced by marked increases in heroin price and decreases in its purity. AIM: This study examines the impact of this change in heroin supply on the following indicators of heroin use: fatal and non-fatal drug overdoses; treatment seeking for heroin dependence; injecting drug use; drug-specific offences; and general property offences. The study was conducted using data from three Australian States [New South Wales (NSW), Victoria (VIC) and South Australia (SA)]. METHODS: Data were obtained on fatal and non-fatal overdoses from hospital emergency departments (EDs), ambulance services and coronial systems; treatment entries for heroin dependence compiled by State health departments; numbers of needles and syringes distributed to drug users; and data on arrests for heroin-related incidents and property-related crime incidents compiled by State Police Services. Time-series analyses were conducted where possible to examine changes before and after the onset of the heroin shortage. These were supplemented with information drawn from studies involving interviews with injecting drug users. RESULTS: After the reduction in heroin supply, fatal and non-fatal heroin overdoses decreased by between 40% and 85%. Despite some evidence of increased cocaine, methamphetamine and benzodiazepine use and reports of increases in harms related to their use, there were no increases recorded in the number of either non-fatal overdoses or deaths related to these drugs. There was a sustained decline in injecting drug use in NSW and VIC, as indicated by a substantial drop in the number of needles and syringes distributed (to 1999 levels in Victoria). There was a short-lived increase in property crime in NSW followed by a sustained reduction in such offences. SA and VIC did not show any marked change in the categories of property crime examined in the study. CONCLUSIONS: Substantial reductions in heroin availability have not occurred often, but in this Australian case a reduction had an aggregate positive impact in that it was associated with: reduced fatal and non-fatal heroin overdoses; reduced the apparent extent of injecting drug use in VIC and NSW; and may have contributed to reduced crime in NSW. All these changes provide substantial benefits to the community and some to heroin users. Documented shifts to other forms of drug use did not appear sufficient to produce increases in deaths, non-fatal overdoses or treatment seeking related to those drugs.     

Multiple Substance Use by Alcoholics

Use of drugs by 1,340 alcoholic clients of 17 New York alcoholism rehabilitation units was assessed for pre-treatment and three and eight month post-treatment periods. Drug use was reported by 44% of the clients before treatment and about 30% after treatment. Clients who were drinking greater amounts of ethanol before treatment tended to be drug users after treatment. Only a slight substitution of drug use for alcohol use was found from before to after treatment. Alcoholic substance users were more likely to be behaviourally and physiologically impaired than were alcohol users. Greater impairment for alcoholic and substance users was found both before and after treatment. Special categories of pre-treatment drug use showed differential predictive relationship with alcohol use after treatment. Drug use by alcoholics was shown to be related to a number of dysfunctional behaviours indicating a need for improved assessment and treatment of substance users in alcoholism rehabilitation programmes.     

Changes in women's use of illicit drugs following imprisonment

Aim   To provide data on changes in illegal drug use in women following imprisonment.
Design   Prospective cohort study.
Setting   Recruitment took place in two prisons in the Midlands and South-East England and follow-up in 13 prisons across England.
Participants   A total of 505 women prisoners participated, a response rate of 82%.
Measurements   Questions about drug use were contained within a questionnaire which examined broad aspects of health. On entry into prison, women answered questions about daily drug use and injecting drug use prior to imprisonment. One month later the questionnaires examined drug use during this period of imprisonment.
Findings   Prior to imprisonment, 53% [95% confidence interval (CI): 49–58%] of women took at least one illegal drug daily and 38% (CI: 34–42%) said they had ever injected drugs. Following imprisonment, some women continued to use drugs; 14% (CI: 10–20%) of women reported using at least one illegal drug daily and 2% (CI: 0.7–5%) of women had injected drugs. There were important changes in the types of drugs used; there was a change in use from crack and heroin to benzodiazepines and opiate substitutes. Prior to imprisonment, women most commonly used crack and heroin, but in prison the two most commonly used illegal drugs were benzodiazepines and opiate substitutes.
Conclusions   The study provides quantitative evidence of the impact of imprisonment on drug use among women. It highlights the need for enhanced drug treatment services and stronger measures to reduce the availability of illegal drugs to women in prison.     

Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial†

Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.     

Current stage in inflammatory bowel disease: What is next?

In recent years,the incidence of inflammatory bowel disease(IBD) has been on the rise,extending to countries where it was infrequent in the past. As a result,the gap between high and low incidence countries is decreasing. The disease,therefore,has an important economic impact on the healthcare system. Advances in recent years in pharmacogenetics and clinical pharmacology have allowed for the development of treatment strategies adjusted to the patient profile. Concurrently,new drugs aimed at inflammatory targets have been developed that may expand future treatment options. This review examines advances in the optimization of existing drug treatments and the development of novel treatment options for IBD.     

Economics of youth drug use, addiction and gateway effects

The use of illicit drugs by American youth rose dramatically during the 1990s. Reducing these trends is an important policy objective. However, for policies to be effective it is important to understand the key causal links that lead to substance use and abuse. Policy makers must understand whether attempts to reduce the demand for one drug have impacts on the current and future use of other drugs. This paper overviews an economic approach to modeling drug use, addiction and gateway effects, emphasizing the potential of this method for identifying causal links in consumption. The paper demonstrates how this multi-substance theory of drug use leads to empirical specifications that can identify the impact of consumption of one drug on the contemporaneous and future consumption of other drugs. This is followed by a discussion of what types of data would be needed to estimate these effects.     

Pharmacologic treatment of cardiac arrhythmias: 25 years of progress

This review of practical and theoretical advances in antiarrhythmic drug therapy consists of four parts. Part 1, on clinical applications, compares the approaches to treatment 25 years ago with those of today, examines the current status of antiarrhythmic drugs used 25 years ago, reports on drugs approved for clinical use during the past 25 years, reviews new experimental drugs and suggests an approach to classification of antiarrhythmic drugs. Part 2 summarizes the contributions of cellular electrophysiology to the understanding of drug action, with emphasis on the drug-induced block of the voltage- and time-dependent properties of the rapid sodium channel. The subsequent section contains a brief discussion of the impact made by the new knowledge and the new diagnostic technology on the contemporary practices. The main conclusions are 1) that the more rational approach to treatment has benefited proportionately more patients with supraventricular than with ventricular arrhythmias, and 2) that new advances have made it possible to design successful treatments for certain patients with problems that could not be resolved in the past.     

Pharmacogenomics in gastroenterologic diseases

Pharmacogenomics is the study of genetic variations that produce a modification of the response to drugs. These variations are expressed as a different capacity for the metabolism or the transport of drugs, or a variable activity of drug receptors. Drug use in gastroenterology offers different examples of the use of pharmacogenomic analysis in the identification of the appropriate drug and drug dose for each individual patient. The use of proton pump inhibitors in the treatment of gastroesophagic reflux disease and Helicobacter pylori eradication may be optimized by the analysis of polymorphisms of the CYP2C19 gene. Additionally, the study of variants of IL28 helps in the identification of patients with more chances of response to the treatment of hepatitis C with interferon and ribavirin. The analysis of polymorphisms of the gene coding for the enzyme thiopurine methyl transferase (TPMT) helps in the reduction of the risks associated with the use of azathioprine in the treatment of inflammatory bowel disease. In this way, pharmacogenomics constitute not only a therapeutic tool that already shows an impact in the individualization of drug use in gastroenterology but also a tool with a great projection in the future.