Illicit drug-related harm during the Sydney 2000 Olympic Games: implications for public health surveillance and action

Aims To describe presentations to emergency departments during the Sydney 2000 Olympic Games for conditions related to the use of illicit drugs; to discuss the implications of such presentations for surveillance and public health action at similar events in the future. Design Identification of target presentations in sentinel emergency departments; entry of data into a purpose‐built database; and daily electronic transfer of data for central collation and analysis. Setting Fifteen sentinel emergency departments in the greater Sydney metropolitan area for a 38‐day period spanning the Sydney 2000 Olympic Games. Participants Four hundred and twenty‐four presentations to sentinel emergency departments with conditions related to illicit drug use. Measurements Patient's age, sex, country and region of residence, location of emergency department, types of illicit drugs involved and departure status. Findings The mean daily number of presentations for adverse events due to illicit drug use was significantly higher (13.3 versus 8.8 presentations, t = 2.2, P = 0.04) in the 2‐week Olympic Games period than in the lead‐up to the Games, culminating in a large peak following the closing ceremony. There was also a significant increase (5.1 versus 1.7 presentations, t = 2.8, P = 0.007) in the mean daily number of presentations related to use of ecstasy or amphetamines, whereas no change was noted in presentations related to heroin use. Over half (52%) of presentations occurred at two emergency departments in areas known as being ‘hot‐spots’ for illicit drug use. Conclusions Enhanced surveillance of adverse events following illicit drug use, possibly targeting known ‘hot‐spots’, should be considered for future mass events. Advance preparation of preventive strategies, such as ‘party‐safe’ messages, will enable rapid response to unusual patterns of illicit drug‐related harm during future mass events.     

Illicit drugs, infectious disease and public health: A historical perspective.

The present report outlines a presentation by Professor Virginia Berridge at the Second Stanier Lecture held in Halifax, Nova Scotia, on November 5, 2002. The relationship among public health concepts, illicit drug use prevention and policy, and infection control strategies in England and other locations is paralleled over the course of two centuries. This historical journey analyzes changes in public health and demonstrates how history and public health have intersected at various times to result in the public health approaches used today.     

On the legacy of normalization

In 1998 Howard Parker, Judith Aldridge & Fiona Measham published Illegal Leisure, a ground‐breaking study of profound changes in British youth cultures in the 1990s, and the place of drugs and drug use in these upheavals. This work introduced the ‘normalization thesis’ to the social sciences, offering a novel vocabulary for re‐imagining the normative character of young people's attitudes towards and experiences of illicit drug use. Arriving at the dawn of the new century, the book offered a thoroughgoing re‐thinking of the character of youth cultures at a time of great social, cultural, economic and technological disruption. In so doing, the book deftly anticipated many of the most interesting currents of critical drug studies that followed.     

Prevalence of illicit drug use in young Australian women, patterns of use and associated risk factors

Objectives To estimate the prevalence of illicit drug use in young Australian women, determine their patterns of drug use and identify associated risk factors. Methods Data were collected in 2000 as part of the second survey of the youngest cohort in the Australian Longitudinal Study on Women's Health (n = 9512). Results Among women aged 22–27 years, 58% reported having used an illicit drug at some time with most (57%) having used cannabis. Amphetamines (16%), ecstasy/designer drugs (15%) and LSD (14%) were the next three most commonly used drugs. Four different patterns of drug use were identified: past users of cannabis only (39%); current users of cannabis only (17%); past multiple drug users (13%) and current multiple drug users (31%). Living in a de‐facto relationship or never being married, living with non‐family members, a history of physical abuse, sexual intercourse, smoking and binge drinking were associated significantly with exclusive use of cannabis and with use of multiple drugs compared to never using illicit drugs. Living with a partner, experience of sexual or emotional abuse, pregnancy, diagnosis of depression and taking sleeping medication were associated significantly with being a multiple drug user, but not for exclusive cannabis use. Multiple drug users had, on average, used cannabis 2–3 years before using any other drug. Conclusions Given the strong association found between smoking, heavy drinking and drug use of varied patterns, public health initiatives targeted at preventing young women from smoking and drinking should additionally target illicit drug use.     

Extent of illicit drug use and dependence, and their contribution to the global burden of disease

This paper summarises data for the prevalence, correlates, and probable adverse health consequences of problem use of amphetamines, cannabis, cocaine, and opioids. We discuss findings from systematic reviews of the prevalence of illicit drug use and dependence, remission from dependence, and mortality in illicit drug users, and evidence for acute and chronic effects of illicit drug use. We outline the regional and global distribution of use and estimated health burden from illicit drugs. These distributions are likely to be underestimates because they have not included all adverse outcomes of drug use and exclude those of cannabis--the mostly widely used illicit drug. In high-income countries, illicit drug use contributes less to the burden of disease than does tobacco but a substantial proportion of that due to alcohol. The major adverse health effects of cannabis use are dependence and probably psychotic disorders and other mental disorders. The health-related harms of cannabis use differ from those of amphetamine, cocaine, and opioid use, in that cannabis contributes little to mortality. Intelligent policy responses to drug problems need better data for the prevalence of different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas.     

Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France

Aims To evaluate the associations between methadone and high‐dose buprenorphine maintenance treatment and illicit drug use and injection among drug users in France. Design A cross‐sectional study. Data were gathered using a questionnaire administered containing closed‐ended questions. Setting Drug dependence clinics (DDC) and general practitioners’ (GPs) offices in three French cities. Participants Drug users undergoing maintenance treatment with methadone (n = 197) and buprenorphine (n = 142). Measurements Interviews covered the use of illicit drugs (heroin, cocaine or crack) and injection practices (illicit drugs and/or substitution drugs) during the last month, current treatment modalities, socio‐demographic and health characteristics. Bivariate analysis and multivariate logistic regressions were conducted. Findings Overall, 35.4% of respondents (34.5% in the methadone group, 36.6% in the buprenorphine group, P= 0.69) had used at least one illicit drug, 25.7% reported having injected drugs and 15.3% had injected the substitution drug. Injection was more common among buprenorphine‐maintained individuals (40.1%) than among users on methadone (15.2%) (P < 0.01). Multivariate analyses indicate that the type of substitution drug (buprenorphine versus methadone) was not associated with illicit drug use (OR = 1.1; 95% CI = 0.7–1.8). In the buprenorphine group, injection was related independently to social situation, as measured by housing (unstable versus stable housing, OR = 4.3; 95% CI = 1.6–11.5), but this was not the case in the methadone group. The risk of injection increased with buprenorphine dosage (high/low dosage OR = 6.2; 95% CI = 2.0–19.7), but this association was not observed in the methadone group. Conclusion Further studies comparing the benefits of these two types of treatment should be carried out, taking outcomes such as physical health, mental health and social functioning into consideration.     

Towards a new model of evidence for public health

BackgroundWe are faced with a growing crisis of non-communicable diseases driven by factors such as unhealthy diets, physical inactivity, tobacco use, and alcohol consumption, compounded by major inequalities in health. Over recent decades, biomedical research methods have helped to answer many important questions about treatment and prevention, but the kinds of tools that can tell us which intervention to choose over another are not invariably the most appropriate to address complex challenges such as designing healthier cities, or creating healthier, more sustainable food systems. The aim of this project was to identify the main obstacles to obtaining valid and appropriate evidence to guide public health decision making, and propose a set of solutions to address these problems.MethodsWe conducted a series of case studies to illustrate some of the problems with the current dominance of the biomedical approach to the generation and use of evidence for complex public health problems, including an analysis of the types of projects funded by the National Institute for Health Research (NIHR) Public Health Research (PHR) Programme since 2009. We held a workshop on Sept 12–13, 2016, for several internationally recognised experts on complex systems approaches to public health evidence to produce a consensus statement.FindingsThe NIHR case study showed that funding from the PHR Programme has predominantly gone to the evaluation of downstream, individual-level interventions, with only a small proportion devoted to assessment of upstream policy actions (>75% of the 110 funded proposals examined downstream or midstream interventions). The key conclusions from the meeting are that current approaches to research and policy in major public health problems such as obesity have reached an impasse. Breaking this impasse will require a move beyond linear models of cause and effect to embrace complex systems approaches to both the generation and use of evidence. Achieving a solution will require many changes, ranging from strategic shifts in the way research is funded to new conceptual models for tackling public health problems at system level.InterpretationThere is a pressing need to change the focus of research and action to tackle complex public health problems. Research funding must address the challenges of evaluating not only complex interventions, but also simple interventions within complex systems. The tools required to do this are still in the early stages of development, but we need to rebalance our approach to public health research to encompass complex systems science and methods in addition to more traditional biomedical approaches. The expert group will publish its views in a consensus paper towards the end of 2016.FundingThis work is supported by a grant from The Health Foundation.     

A World Health Organization perspective on alcohol and illicit drug use and health

Alcohol and illicit drug use has a significant impact on global health. Alcohol consumption is increasing worldwide, particularly in developing countries and countries in transition, leading to an increasing number of health and social problems, both acute and chronic. Illicit drug use is also increasing, particularly injection drug use, followed by an epidemic spread of HIV and other blood-borne infections. Alcohol and illicit drug use are related to key determinants of population health and are also an outcome of poor health. Globalized marketing and trade, and rapid social changes and development in the absence of strong policies and investments in public health have led to an increased availability, use and problems related to alcohol and other substance use. Public health policies and substantial investments in effective prevention and treatment approaches are needed in order to reduce the negative impact of alcohol and other drug use at national and global levels.     

Setting Limits: Gambling,Science and Public Policy—summary of results

The gambling industry has grown into a global business in the 21st century. This has created the need for a new emphasis on problem prevention. This article highlights the core themes of the book Setting Limits: Gambling, Science and Public Policy, taking a broad view of the consequences of gambling for society as a burden on health, well-being and equality. The book covers the extent of gambling and gambling-related problems in different societies and presents a critical review of research on industry practices, policy objectives and preventive approaches, including services to people suffering from gambling and its consequences. It discusses the developments in game characteristics and gambling environments and provides evidence on how regulation can affect those. Effective measures to minimize gambling harm exist and many are well supported by scientific evidence. They include restrictions on general availability as well as selective measures to prevent gamblers from overspending. The revenue generated from gambling for the industry, governments, and providers of public services funded from gambling returns presents an obstacle to developing policies to implement harm-reduction measures. A public interest approach must weigh these interests against the suffering and losses of the victims of gambling.     

Elevated overdose mortality rates among First Nations individuals in a Canadian setting: a population‐based analysis

Aims To determine the total burden of illicit drug overdose mortality over the study period in the province of British Columbia and investigate possible population‐level determinants by estimating rates among subgroups including First Nations individuals. Design Review of coroner case files. Setting The province of British Columbia, Canada. Participants Individuals dying from an illicit drug overdose between 2001 and 2005. Measurements Age‐adjusted mortality rates, standardized mortality ratios (SMR) and years of potential life lost (YPLL), stratified by major population groups. Findings Over the study period, 909 individuals died from illicit drug overdoses, including 104 (11.4%) First Nations individuals. Compared to the general population, First Nations males and females suffered from substantially elevated SMR and YPLL. In a multivariate logistic regression analysis, First Nations deaths were significantly more likely to be among women, related to injection drug use and to have occurred in the Downtown Eastside area of Vancouver, the local epicentre of human immunodeficiency virus infection and open drug use (all P < 0.05). Conclusions This report found highly elevated overdose death rates and levels of premature mortality among First Nations Canadians in British Columbia compared to the general population. While previously unidentified, these findings are consistent with the poorer population health profile of First Nations Canadians. Although further research is needed to identify the causes of the elevated death rates, our findings support increased availability of evidence‐based overdose prevention measures.     

Alcohol: No Ordinary Commodity. A summary of the book

This article summarizes the contents of Alcohol: No Ordinary Commodity—Research and public policy ( Babor et al. 2003 ). The first part of the book describes why alcohol is no ordinary commodity, and presents epidemiological data on the global burden of alcohol‐related problems. The second part of the book reviews the scientific evidence for strategies and interventions designed to prevent or minimize alcohol‐related harm: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drinking‐driving countermeasures, regulating alcohol promotion, education and persuasion strategies and treatment services. The final section considers the policymaking process on the local, national and international levels, and provides a synthesis of evidence‐based strategies and interventions from a policy perspective.     

Factors associated with high-frequency illicit methadone use among rural Appalachian drug users

Abstract

Background: In recent years there has been a sharp increase in the use of illicit methadone as well as methadone-related overdose deaths. Objective: The purpose of this study was to describe factors associated with low- and high-frequency methadone use in a cohort of rural Appalachian drug users. Methods: Interviews assessing sociodemographics, illicit drug use and drug treatment, psychiatric disorders, health and sociometric drug network characteristics were conducted with 503 rural drug users between 2008 and 2010. A two-level mixed effects regression model was utilized to differentiate low- (one use per month or less in the past six months) versus high-frequency (daily or weekly use in the past six months) illicit methadone users. Results: The lifetime prevalence of illicit methadone use in this population was 94.7% (n?=?476) and slightly less than half (46.3%) were high-frequency users. In the mixed effects regression model, initiating illicit methadone use at a younger age was associated with high-frequency illicit methadone use. Taking a prescribed medication for a physical problem, undergoing additional weeks of outpatient drug free treatment, daily OxyContin® use in the past month, and having fewer ties and second-order connections in the drug network reduced the odds of high-frequency illicit methadone use. Conclusions: Rates of illicit methadone use and high-frequency illicit methadone use among this sample of rural drug users were considerably higher than those previously reported in the literature. Health practitioners in rural areas should routinely screen for illicit opioid use, including methadone.