Baseline assessment of community knowledge and attitudes toward drug use and harm reduction in Kabul, Afghanistan

Introduction and Aims. Problem drug use has been identified as a significant public health problem in Afghanistan. The study aim was to assess community knowledge and attitude toward drug use and harm reduction in Kabul, Afghanistan. Design and Methods. A cross‐sectional convenience sample of community representatives of 10 possible professions were recruited, distributed between the 17 Kabul city districts in 2007. A questionnaire measured sociodemographic characteristics and awareness, knowledge, and attitudes toward drug use and harm reduction. Logistic regression and cluster analysis were performed to test for associations with participant attitude. Results. Of 210 participants, mean age was 36.7 years. Most (98.6%) were Afghan and employed (87.6%). Most (88.6%) were aware of problem drug use in Afghanistan, primarily attributed to unemployment. The majority of participants agreed that addiction is a disease (88.6%) and believed more and better treatment and vocational training facilities were needed (90.5%). Use of only punitive measures in response to drug use was favoured by few (7.1%) participants. Only 33.3% of participants could correctly identify legal consequences of drug use. Discussion and Conclusions. Community acknowledgement of problem drug use and support for addiction treatment are present in Kabul, Afghanistan. However, knowledge gaps concerning drug laws and harm reduction should be addressed in efforts to introduce culturally appropriate harm reduction programming.[Stanekzai MR, Todd CS, Orr MG, Bayan S, Rasuli MZ, Wardak S‐R, Strathdee SA. Baseline assessment of community knowledge and attitudes toward drug use and harm reduction in Kabul, Afghanistan. Drug Alcohol Rev 2012;31:451–460]     

Sociodemographic Disparities in Access to Addiction Treatment Among a Cohort of Vancouver Injection Drug Users

Vancouver's explosive HIV epidemic among injection drug users (IDUs) has received international attention due to the presence of a large needle exchange program. The role of addiction treatment has not been evaluated in this setting. We evaluated factors associated with use of addiction treatment among a prospective cohort of Vancouver IDUs. Addiction treatment was negatively associated with Aboriginal ethnicity and unstable housing, both of which have been associated with HIV infection in previous studies. These findings demonstrate low levels of addiction treatment among Vancouver IDUs and suggest that programs may need to be targeted towards specific populations with poor access.     

Perceived Addiction Treatment Needs Among Alcohol Using Injection Drug Users

ABSTRACT

Hazardous drinking is common among active injection drug users (IDUs). This report examines: (1) the perceived alcohol and drug treatment needs of a cohort of IDUs, and (2) whether perceived needs predict treatment entry. One hundred and eighty-seven AUDIT-positive ($ 8), active IDUs were recruited between 2/98–10/99 for the Brief Alcohol Intervention for Needle Exchangers (BRAINE) trial. At entry, about 18% of participants perceived no need for substance abuse treatment, 52% for drug treatment alone, 26% for drug and alcohol treatment, and only 3% a need for alcohol treatment only. Very high levels of drinking and adverse drinking consequences were observed among those perceiving no need for treatment of alcohol problems. Perceived need for alcohol treatment was positively associated with measures of adverse drinking consequences and DSM-IV diagnosis for alcohol dependence. Persons who at baseline perceived the need for alcohol treatment were more likely to enter alcohol treatment at 6-month follow-up than those withouta perceived need (20% vs. 5%;p = .006).We conclude that IDUs with co-occurring alcohol-use disorders perceive alcohol treatment needs as less immediate than drug treatment. Because perceived need predicts treatment entry, changing alcohol treatment perceptions in IDUs promises the potential of significant long-term public health benefits.     

The Risk of Emergency Room Treatment Due to Overdose in Injection Drug Users

ABSTRACT

This cohort study was conducted to identify risk factors for lifetime emergency room treatment due to overdose in injection drug users. Data of 1049 patients on admission for opioid detoxification were analyzed. More than every third injection drug user (34.7%) experienced emergency room treatment due to an overdose. Using multiple logistic regression not living with a significant other drug user (odds ratio [OR] = 1.78, P = .002), history of suicide attempt (OR = 3.0, P = .000), daily use of barbiturates (OR = 2.17, P = .006) and cannabis (OR = 1.89, P = .001) were independently associated with emergency room treatment, whereas shorter duration of opioid use (OR = 0.23, P = .001) was independently associated with lack of emergency room treatment. Suicidal thoughts and multiple use of central nervous system depressants should be considered in injection drug users entering the emergency room due to an overdose. Emergency rooms should be seen as important places for offering further assistance (e.g., counselling) or referral to an addiction unit to drug users.     

Profiles of Club Drug Users in Treatment

There is little in the literature about treatment of persons with problems with “club” or “party” drugs. This paper looks at the characteristics of individuals admitted to treatment for primary, secondary, or tertiary problems with club drugs such as ecstasy, gamma-hydroxybutyrate (GHB), ketamine, flunitrazepam (Rohypnol), methamphetamine, and hallucinogens (e.g., LSD) in programs funded by the Texas Commission on Alcohol and Drug Abuse. Some 38,350 unduplicated records from 1988 through 2003 of persons admitted with problems with club drugs were compared against users of alcohol or other drugs. Club drug users were more impaired on five of six Addiction Severity Index (ASI) indices at admission and they were more likely to use multiple substances more often. They were more likely than users of alcohol or other drugs to complete treatment, but this varied by drug. At follow-up 90 days after discharge, club drug users continued to report more ASI problems. Profiles of these clients show that ecstasy use has spread beyond the club culture, as indicated by the changes in client demographics over time. GHB clients presented a mixed picture of severe problems at admission and good response to treatment. Hallucinogen clients were young and less likely to complete treatment, while Rohypnol users were on the Texas-Mexico border. The methamphetamine epidemic has resulted in increased admissions, and the proportion of “Ice” smokers has increased. However, methamphetamine clients were less likely to complete treatment and their higher level of problems at admission and follow-up are of concern. Of special note are the indications of co-occurring problems and the need for both mental health and substance dependence treatment for some clients.     

Medical Illness and Comorbidities in Drug Users: Implications for Addiction Pharmacotherapy Treatment

Providing effective medical care to those with substance use disorders can be a challenge to clinicians. In this article, we briefly summarize issues that occur frequently in the medical treatment of substance users. The focus of this article is twofold. The first is to briefly summarize common co-occurring medical illnesses in those manifesting substance use disorders with an emphasis on issues related to providing effective treatment for these diseases in this population. Using specific examples of frequently occurring comorbid medical illness in substance users, including infectious diseases (hepatitis C and HIV disease), sexually transmitted diseases, and pregnancy as examples, the complexities of medical care for this population is demonstrated. Second, this article addresses some of the difficulties encountered in pharmacotherapy aimed specifically at treatment of substance use disorders. For example, difficulties in managing concomitant opiate therapy in those requiring medications for medical illness that may have strong and adverse interactions with opiates are addressed. Adverse events reported for some substance use disorder pharmacotherapies are also highlighted. We conclude with a brief review of models of care that have been effective in addressing the needs of this challenging population that can provide additional means for enhancing the clinical care of substance users.     

Characteristics of Aboriginal Injecting Drug Users in Sydney,Australia: Prison History,Hepatitis C Status and Drug Treatment Experiences

Abstract

Australian Aboriginals are overrepresented in prisons and tend to be overrepresented in studies of injecting drug users (IDU). The aim of this study was to examine differences between Aboriginal and non-Aboriginal IDUs in terms of gender, prison history and hepatitis C status and testing. Secondary analyses were conducted on data from three cross-sectional studies of IDUs. These studies employed similar methodologies, with recruitment being through needle and syringe programs, methadone clinics, snowballing and street intercepts. All studies were coordinated through the National Drug and Alcohol Research Centre. Aboriginal people were overrepresented in all studies, were more likely to have been incarcerated and to report heroin as their drug of choice than non-Aboriginal IDUs. Females tended to be overrepresented among Aboriginal IDUs, were more likely to have been incarcerated and had a longer period of time since their last hepatitis C test than non-Aboriginal female IDUs. Aboriginal people are overrepresented among IDUs in Sydney. Given their greater risk of incarceration, particularly among females, Aboriginal IDUs were at greater risk of hepatitis C exposure than non-Aboriginal IDUs. The prison setting provides an opportunity to promote drug treatment and hepatitis C testing, though more needs to be done to reduce drug use and incarceration.     

Hepatitis C Among Injecting Drug Users Is Two Times Higher in Stockholm,Sweden than in Rotterdam,the Netherlands

This study assessed risk behavior and preventive measures for hepatitis C among injecting drug users in Rotterdam, the Netherlands (452 participants, 2002–2003) and Stockholm, Sweden (310 participants, 2004–2006), two cities with contrasting drug policies. Uni- and multivariate logistic regression models were used. We found that the prevalence of hepatitis C was almost two times higher in participants from Stockholm than in participants from Rotterdam, even after adjustment for sex sharing paraphernalia (adjusted relative risk: 1.92, 95% confidence interval: 1.60–2.29). Follow-up comparative studies are needed to determine if policies with structured health programs can decrease transmission of hepatitis C.     

The Role of Medicaid HMO Enrollment in the Longitudinal Utilization of Medical Care Services in a Cohort of Injecting Drug Users in Baltimore, Maryland

Although injecting drug users (IDUs) are highly dependent on Medicaid, the literature has not explored the effect of Medicaid HMO enrollment on medical care utilization. This longitudinal analysis compares 6-month utilization levels of IDUs in Medicaid HMOs with those of other Medicaid-enrolled IDUs and IDUs in other insurance arrangements. The analysis includes 1064 participants from the AIDS Link to Intravenous Experience (ALIVE) study, a natural history study of HIV infection in a community-based sample of IDUs in Baltimore, Maryland. A generalized linear modeling approach was used to examine self-reported inpatient admissions, ER visits, and ambulatory care visits from January 1995 through June 1997. Non-HMO Medicaid beneficiaries had more inpatient admissions and ambulatory care visits than Medicaid HMO enrollees. These findings suggest that HMO enrollment has been effective in lowering utilization among IDUs in Medicaid, but it is unclear whether utilization differences are the result of inappropriate utilization or access issues.     

A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program

Introduction and Aims. Systematic reviews and meta‐analyses show that needle exchange programs reduce HIV and HCV transmission for injection drug users (IDUs) but far less is known about the injection practices of IDUs enrolled in these programs. This study adopts a mixed methods approach to quantify high‐risk injection practice patterns among IDUs enrolled in a needle exchange program in Victoria, British Columbia, Canada and gather qualitative data to understand underlying injection behaviour rationales and patterns. Design and Methods. Survey data collected in 2008 from 105 IDUs registered as clientele of the AIDS Vancouver Island‐Street Outreach Services (AVI‐SOS) Needle Exchange were analysed via univariate and multivariate statistical methods. Presentation of this analysis to an AVI‐SOS needle exchange clientele group generated qualitative data offering an explanation for quantitative results. Results. Univariate analysis showed all respondents reporting at least one high‐risk practice within the past month. Multivariate logistic regression analysis using input from AVI‐SOS clientele confirmed the importance of housing status as a determinant of injection practices. Discussion and Conclusions. The importance of housing status points to the need to combine harm reduction services, for example needle exchange and appropriate housing and highlights the benefits of including IDUs in data interpretation.[Gibson EK, Exner H, Stone R, Lindquist J, Cowen L, Roth EA. A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program. Drug Alcohol Rev 2011;30:360–365]     

静脉吸毒人群前瞻性队列研究1年随访死因分析

目的:了解四川省某地区静脉吸毒人群的死亡情况.方法:于2002年¨月筛选和招募静脉吸毒人群队列376人,队列随访1年.筛选时调查静脉吸毒人群的社会人口学和吸毒行为特征,对死亡人员进行死因分析.结果:队列随访1年中死亡28人,死亡率为77.32/1000人年,标准化死亡比(SMR)为47.46,95%可信区间为[31.52～68.47].死因中因吸毒过量死亡占64.3%(18人),与吸毒有关的意外伤害死亡占14.3%(4人),其他21.4%(6人).队列随访中未见艾滋病病例.结论:需进一步加强吸毒人群的死亡研究,以便开展针对性的干预措施来降低静脉吸毒人群的死亡率.     

A Cross-Sectional Study on Prevalence of Non-Fatal Drug Overdose and Associated Risk Characteristics Among Out-of-Treatment Injecting Drug Users in North Vietnam

In a community-based cross-sectional survey among out-of-treatment male opiate injecting drug users (IDU) aged 18–45, data on non-fatal overdose were collected using a semi-structured questionnaire. From August to September 2003, 299 IDU were recruited in two districts of Bac Ninh, a semi-urban province in North Vietnam. Prevalence of lifetime and recent non-fatal overdose were 43.5 and 83.1%, respectively. Logistic regression analyses showed associations between non-fatal overdose and younger age, unemployment, residence in the provincial township, frequency of injecting, injecting heroin mixed with valium, and history of drug treatment. While recognizing the limitations of this study, it is the first in Southeast Asia to report on prevalence of drug use–related overdose. Future research is recommended on occurrence of fatal overdose in this population.     

Predictors and Outcome of Aftercare Participation of Alcohol and Drug Users Completing Residential Treatment

This study attempts to identify factors associated with greater aftercare participation for 367 adults who completed abstinence-based residential addiction treatment between and at Bellwood Health Services in Toronto, Canada. Pre-treatment substance use, number of days spent in residential treatment, motivation, treatment satisfaction, and demographics were used to determine which characteristics predicted greater aftercare participation. The duration of residential treatment and treatment satisfaction emerged as significant predictors of aftercare attendance. Regular aftercare attendance was associated with lower levels of substance use at 6-month follow-up. Results suggest that a longer duration of residential treatment can influence continuing care engagement and highlight the importance of initial treatment retention for long-term recovery.     

Health Care Need and Utilization: A Preliminary Comparison of Injection Drug Users,Other Illicit Drug Users,and Nonusers

This paper investigates the relationship between chronic drug use and the health care system. Data from 536 African-American, Hispanic, and non-Hispanic White men and women were analyzed to determine independent risk factors for three outcome variables: 1) Need for health care treatment, 2) Utilization of health care treatment, and 3) Failure to receive needed treatment. Nine independent demographic, health, and drug-use history variables were assessed in logistic regression models. Chronic drug users were more likely in the past year to need health care treatment, were as likely to receive some health care treatment, and were more likely not to receive needed treatment than were nonusers. [Translations are provided in the International Abstracts Section of this issue.]     

Sex Differences in Self-Report of Physical Health by Injection Drug Users

Through heterosexual contact, injection drug users (IDUs) put others at risk of contracting Human Immunodeficiency Virus (HIV) disease. Self-report of health was compared among IDUs in Laredo, Texas, San Diego, California, and San Juan, Puerto Rico, and in a subsample which contained HIV positive subjects from these cities. These data were compared with similar National Opinion Research Center data and indicated that IDUs do not report their health to be different from that of the general public. Previous research has reported sex differences in morbidity and mortality in the non-IDU population. This study found sex differences in perception of health by IDUs in Laredo and San Diego.     

Factors Associated with Recent-Onset Injection Drug Use among Drug Users in Pakistan

Seventy-two recent-onset injection drug users and 241 non-injection drug users were recruited in Quetta and Lahore, Pakistan, in 2003. Trained interviewers administered questionnaires regarding drug use behaviors and perceived changes in drug cost/supply. Logistic regression identified independent correlates of recent-onset injection. In Lahore, a perceived increase in drug cost was associated with higher odds of recent-onset injection, with no association in Quetta. Recent-onset injection was also associated with family history of drug use, group drug use, and sharing snorting/chasing tools. Changes in perception of the drug supply may be associated with recent-onset injection drug use. Familial/social influences were also associated with recent-onset injection, suggesting peer-led interventions could discourage transition to injection drug use.     

Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales

The aim of this study was to compare demographic and drug use profiles of non-needle and syringe programmes (NSP) attendees with NSP attendees from the same geographic area. Two data sources were used. One was from an annual national survey of injecting drug users (IDU) at NSP and analysis was restricted to survey sites in Kings Cross and Kogarah in 2003 (NSP survey). The other was from a survey of IDU who do not use NSP as their primary source of injecting equipment within the same broad geographical region (Access survey). Of the total 264 survey participants, 102 had never attended a NSP (non-NSP attendees) and 162 had previous experience of NSP (NSP attendees). Compared with NSP attendees, non-NSP attendees were less likely to report severe drug problems and more likely to report lower prevalence of HIV, hepatitis B and hepatitis C infection. Nevertheless, about 20% of non-NSP attendees reported re-use of needles and syringes after someone else in the previous month. Compared to NSP attendees, a lower rate of usage of health services was reported by non-NSP attendees. Strategies to promote access to NSP and harm reduction services, including testing for blood-borne viruses, information provision and consideration of referral to treatment among non-NSP attendees are recommended. [Cao W, Treloar C. Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales. Drug Alcohol Rev 2006;25:439 - 444]     

Moving toward Trauma-Informed Practice in Addiction Treatment: A Collaborative Model of Agency Assessment

Abstract

Clients in substance abuse treatment need, in addition to evidence-based and sensitive treatment services in general, a system of care that takes into account the impact of trauma and violence in so many of their lives. In addition, services need to be delivered in a way that avoids triggering trauma memories or causing unintentional re-traumatization. To that end, this article describes an agency self-assessment process that combines a trauma-informed assessment, a NIATx process of “walking-through” and use of the Institute of Healthcare Improvement's Plan-Do-Study-Act (PDSA) cycles, and a user-friendly format. The trauma-informed assessment is designed to address issues of safety of clients and staff members, reduction of re-traumatization, consistency in practice, and client empowerment. It brings a non-judgmental, collaborative approach to process and practice improvement. The article describes how the assessment process can be—and has been—used to develop an Action Plan, including trainings and the identification of “trauma champions”; i.e., staff who will continue to spread trauma-informed changes and new evidence-based practices throughout the agency. As we enter a period of healthcare reform, addressing trauma as an integral part of addiction treatment also allows us to better deal with the totality of our clients’ health problems.     

Assessing Covariates of Drug Use Trajectories Among Adolescents Admitted to a Drug Addiction Center: Mental Health Problems,Therapeutic Alliance,and Treatment Persistence

This study aimed to assess covariates of drug use trajectories among 102 adolescents admitted to a drug user treatment program between November 2005 and November 2006 in Québec, Canada. The influences of mental health, therapeutic alliance, and treatment persistence were examined. The Addiction Severity Index was used to measure drug use severity and mental health problems; the California Psychotherapy Alliance Scales was used for therapeutic alliance. latent growth curve analysis showed associations between (1) mental health and initial drug use severity; (2) therapeutic alliance and initial drug use severity; and (3) number of post-treatment sessions attended and drug use severity over time.