The use of alprazolam by people who inject drugs in Melbourne, Australia

Introduction and Aims. In Australia, people who inject drugs (PWID) commonly report the use of benzodiazepines (BZDs). This paper explores the emerging use of alprazolam among PWID in Melbourne, Australia. Design and Methods. This study reports on 3 years of data collected through the Victorian Illicit Drug Reporting System (2008–2010). Structured interviews were conducted with 451 PWID and analysed using odds ratios and χ²‐tests for trends over time. Results. While the proportion of PWID reporting recent BZD use remained stable over time, the proportion reporting alprazolam to be their most commonly used BZD fluctuated, peaking in 2009. Alprazolam users were significantly more likely to report using illicit BZDs and to report recent BZD injection compared with users of other BZDs. Alprazolam use was associated with the sale of drugs for cash, but not with other criminal activities. Discussion and Conclusion. The fluctuations in alprazolam use over time may be reflective of medical practitioners ceasing to prescribe alprazolam in response to reports of associated harms; however, this may in turn be driving the illicit alprazolam market. While the data do not indicate a clear association between alprazolam use and harms, considering the potential severity of associated harms and the association between alprazolam use and anterograde amnesia, patterns of alprazolam use among PWID should be closely monitored. Potential changes to prescribing practice should consider unintended consequences, such as replacement with other BZD types, or illicitly obtained BZDs.[Horyniak D, Reddel S, Quinn B, Dietze P. The use of alprazolam by people who inject drugs in Melbourne, Australia. Drug Alcohol Rev 2012;31:585–590]     

High risk injecting behaviour among people who inject pharmaceutical opioids in Australia

BackgroundUse of opioid analgesic medicines has doubled globally over the past decade, with a concomitant increase in prevalence of injection of pharmaceutical opioids (PO), including in Australia. This study investigates types of PO injected, methods used to prepare PO for injection and correlates of recent (last 6 months) PO injection among a large national sample of people who inject drugs (PWID).MethodsThe Australian NSP Survey (ANSPS), conducted annually at ∼50 NSP services across Australia, consists of a brief self-administered questionnaire and provision of a capillary dried blood spot for HIV and hepatitis C antibody testing. Data from 2014 were used to conduct univariable and multivariable logistic regression analysis to determine factors independently associated with recent injection of PO.ResultsAmong 1488 ANSPS respondents who were identified as opioid injectors, 57% (n = 848) reported injection of PO in the previous six months. The majority of PO injectors (85%) reported filtering PO prior to injection, although use of efficacious wheel filters was relatively rare (11%). Correlates of POs injection included daily injection (AOR = 1.65, 95% CI 1.31–2.08), receptive sharing of syringes (AOR = 2.00, 95% CI 1.43–2.78), receptive sharing of drug preparation equipment (AOR = 1.55, 95% CI 1.19–2.01), drug overdose in the previous year (AOR = 1.81, 95% CI 1.36–2.42) and residence in inner regional (AOR = 3.27, 95% CI 2.21–5.23) or outer regional/remote (AOR = 5.50, 95% CI 3.42–8.84) areas of Australia.ConclusionPO injection is geographically widespread among Australian PWID and takes place in the context of poly-drug use. People who inject POs are at high risk of overdose, injection related injury and disease and blood borne viral infections. Harm reduction services that target this group, including in non-urban areas, should deliver health education regarding PO-specific overdose risks, the requirement to adequately filter PO before injection and to ensure that both naloxone and specialist pill filters are readily accessible.     

Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney,Australia

Introduction and Aims. Cleaning needles/syringes is an important second‐line harm reduction strategy, yet there is limited information on practices employed by people who inject drugs in Australia. This study attempts to identify and assess cleaning practices in terms of the techniques involved and the social contexts in which cleaning takes place. Design and Methods. As part of an exploratory qualitative study in south‐west Sydney, in‐depth interviews and simulated cleaning exercises were conducted with 12 people who inject drugs. Interviews were digitally recorded and transcribed verbatim. Open coding was used to inductively classify data into themes, and data were examined for patterns and variations in the relationships within and between themes. Results. Data indicate that cleaning and reuse of needles/syringes was common in this small sample. The most frequently utilised reagent was cool water. While all participants reported cleaning and reusing only their own equipment, none of the techniques demonstrated would have been sufficient to deactivate human immunodeficiency virus or hepatitis C virus. Discussion and Conclusions. Results suggest that even where cleaning of needles and syringes is widespread, people who inject drugs may not engage in efficacious cleaning. The combination of the complexity of current cleaning messages and a lack of accurate information about efficacious techniques are likely to contribute to poor cleaning practice. Australia could benefit from the development of a nationally consistent cleaning message; however, the evidence would suggest that this would need to be accompanied by strategies designed to simplify and disseminate this information in order to increase the uptake of efficacious cleaning methods by people who inject drugs [Nathani J, Iversen J, Shying K, Byrne J, Maher L. Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney, Australia. Drug Alcohol Rev 2010]     

Barriers to practicing risk reduction strategies among people who inject drugs

Introduction and aims: People who inject drugs (PWID) engage in practices that put them at risk for various infections and overdose. The primary aim of this study was to examine common barriers to engaging in two risk reduction practices – cleaning one’s skin at the injection site and always using new needles to inject – among heroin injectors in Denver, CO. Method: In 2010, 48 PWIDs were recruited through street outreach and completed a structured interview that included questions on the frequency of specific risk reduction practices (skin cleaning and using new needles) and barriers associated with these practices. Results: Though many of the reported barriers were similar across the two practices, the most common barriers associated with skin cleaning included being in withdrawal and not being prepared with materials prior to injection. Fear of being arrested and being in withdrawal were most frequently reported for using new needles. Multivariate and t-test analyses demonstrated that individuals who skin cleaned and used new needles more frequently reported less barriers to these practices. Conclusions: Participants reported a number of barriers to risk reduction, including those that are within the personal control of the injector, barriers that are consequences of addiction or psychological problems and those that are structural or a function of the risk environment. Statistical analysis found that PWIDs who were more likely to skin clean and use new needles reported less barriers. Addressing barriers when intervening with PWID appears important to increase the success of risk reduction interventions.     

Extra-legal policing strategies and HIV risk environment: accounts of people who inject drugs in Nigeria

Abstract

This article reports on an exploratory qualitative study investigating extra-legal policing practices and HIV vulnerability among injecting drug users. It draws upon thematic analysis of interview accounts of 29 street-involved PWID, recruited through snowball sampling in Uyo, Nigeria. The data emphasized that policing is a structural mechanism perpetuating drug-related harms and social suffering in the lives of PWID. Policing strategies, including searches, violence and confiscation of sterile needles and syringes, reproduce an environment of fear that undermines risk reduction and contributes to HIV risk via injecting in risky settings and receptive syringe sharing. Accounts highlighted humiliations, labeling and other expressions of contempt as forms of ‘moral policing’, which reinforce stigma and sanction human rights violations. Extra-legal policing practices, including violence, extortion and sexual harassments, adversely affect health and well-being. This raises questions about the effectiveness and legitimacy of policing and highlights a social justice perspective that may contribute to the reduction of health inequalities for PWID. It also provides a social justice and human rights rationale for advocacy for policy reforms, safe injection sites, needle and syringe distribution, oral drug substitution programs and rights-based, public health-oriented policing that enable access to harm reduction services for PWID.     

Patterns of drug preference and use among people who inject drugs in Melbourne,Australia

Background: Understanding of substitution patterns in drug using careers is limited. Between 2009 and mid-2013, the purity-adjusted price of methamphetamine declined sharply in Melbourne in absolute terms and relative to the purity-adjusted price of heroin. We determine whether there were associated increases among people who inject drugs (PWID) in (1) use of methamphetamine and (2) citing methamphetamine as the drug of choice. Method: Responses to “drug of choice” and “most used drug” were obtained from baseline and follow-up interviews of the 688 PWID enrolled in the Melbourne Injecting Drug User Cohort Study between April 2008 and August 2013, categorised as heroin, methamphetamine, cannabis or other. Previous month heroin and methamphetamine use was reported at baseline by 82% and 41% of participants, respectively, and 51% had completed four or more interviews in this period. A Markov model that included marginal effects for methamphetamine purity-adjusted price was used to calculate (1) transitions between drug of choice and (2) conditional probabilities for most used drug. Parameters were determined by fitting multinomial logistic models to appropriate data subsets. Results: At baseline, the majority of participants reported heroin as both their preferred drug and the drug they used most. There were no significant increases in reports of methamphetamine as drug of choice, or as the most used drug. Conclusion: In a cohort of PWID who reported a range of drug behaviours, there was little evidence of drug substitution into methamphetamine, despite substantial declines in its purity-adjusted price.     

Association between binge drug use and suicide attempt among people who inject drugs

Background: People who inject drugs (PWID) have an elevated risk of suicide attempt. Although different substances are associated with suicide attempt, the overall risk posed by binge behavior, a high-risk pattern of drug use, remains unclear. The objective of this study is to assess the association between binge drug use and suicide attempt in a prospective cohort of PWID in Montreal, Canada. Methods: Participants answered a biannual interviewer-administered questionnaire compiling information on sociodemographics, pattern of substance use (cocaine, amphetamine, opioids, sedative-hypnotics, alcohol, and cannabis), and psychosocial stressors and related markers. The relationship between suicide attempt and binge behavior was modeled using generalized estimating equations (GEEs), controlling for type and pattern of substance use, sociodemographic characteristics, and significant mental health markers. Results: Among 1240 participants (mean age ± SD: 38.2 ± 9.8) at baseline, 222 (17.9%) reported binge during the past 6–months. PWID reporting binge were significantly younger (P < .001), less educated (P = .012), less likely male (P = .047), and had shorter history of injection (P < .001). In addition, they were younger at first injection (P = .014), reported higher rates of prostitution and psychological disorders (P = .003), and were more likely to use other drugs except cannabis and alcohol. Binge was independently associated with attempted suicide in the GEE multivariate model (adjusted odds ratio [aOR 95% CI] = 1.91 [1.38–2.65], P < .001). Conclusions: Among PWID at high risk of suicide attempt, those who binge represent a particularly vulnerable subgroup. Although the exact mechanisms underlying this finding remain unresolved, several hypothesis pertaining to the neurobiological and psychosocial consequences of binge, as well as common personality traits, warrant further investigations.     

Knowledge and barriers associated with assessment and treatment for hepatitis C virus infection among people who inject drugs

Introduction and Aims. Uptake of treatment for hepatitis C virus (HCV) infection among people who inject drugs is low. Further understanding is required of the relationship between HCV knowledge and treatment willingness, assessment and treatment in this population. Design and Methods. A cross‐sectional self‐administered survey was conducted with clients of four opioid substitution therapy (OST) clinics and the Medically Supervised Injecting Centre in Sydney, Australia. Results. Of 132 participants, 85 (64%) self‐reported having HCV infection. HCV knowledge was mixed (mean 6.5, range 0–12) and was relatively lower on items measuring knowledge of factors impacting HCV‐related disease progression. The likelihood of being in a higher knowledge category was associated with being female [adjusted odds ratio (AOR) = 3.78, 95% confidence interval (CI) (1.79, 7.98)], higher formal education [AOR = 3.28, 95% CI (1.57, 6.88)], being on a current OST program [AOR = 2.61, 95% CI (1.10, 6.19)] and being older [AOR = 1.04, 95% CI (1.01, 1.09)]. Participants receiving OST were more likely to report higher willingness to have HCV treatment [OR = 4.45, 95% CI (2.23, 8.17)]. Having been assessed for HCV treatment was associated with younger age [AOR = 0.93; CI 95% (0.88, 1.00)] and higher formal education [AOR = 7.81; 95% CI (1.62, 37.71)]. Discussion and Conclusions. Overall, knowledge scores were mid‐range. Knowledge of modifiable factors influencing HCV‐related liver disease progression was particularly low indicating the need for ongoing education. Education should also be targeted at older people and those not on OST, and be inclusive of those with lower literacy levels.[Treloar C, Hull P, Dore GJ, Grebely J. Knowledge and barriers associated with assessment and treatment for hepatitis C virus infection among people who inject drugs. Drug Alcohol Rev 2012]     

Utilization of buprenorphine and methadone among opioid users who inject drugs

ABSTRACT

Background: There has been a rise in opioid abuse and related injection drug use in the United States, and treatment for opioid use disorders may be underutilized. The study aim was to describe utilization of opioid agonist therapy (OAT), and assess factors associated with utilization of OAT, among persons who inject drugs (PWID) in the Seattle metropolitan area. Methods: Data were obtained from the 2015 National HIV Behavioral Surveillance (NHBS) system among PWID in the Seattle area. Persons aged ≥18 years who injected drugs in the past year were recruited using respondent-driven sampling. Local supplemental questions assessed whether participants had received methadone or buprenorphine treatment in the past year. The analysis was restricted to participants who reported use of any opioids in the past year. Analyses compared the demographic, health insurance status, duration of injection drug use, prior history of overdose, prior receipt of hepatitis C virus/human immunodeficiency virus (HCV/HIV) testing (self-report), and screening positive for HCV/HIV via study testing between methadone- or buprenorphine-treated and untreated PWID. Multivariate logistic models were performed to assess adjusted associations with receipt of any OAT. Results: The sample included 487 PWID who used opioids in the past year, of whom 27.1% (95% confidence interval [CI]: 23.1–31.1) reported past-year treatment with methadone and 4.7% (95% CI: 2.8–6.6) reported treatment with buprenorphine. There were no significant differences in demographics among participants who did and did not report past-year OAT; however, participants who were treated with methadone were more likely to be insured and have hepatitis C. After adjustment for other covariates, having health insurance was strongly associated with receipt of OAT (adjusted odds ratio [aOR] = 18.6; 95% CI: 2.5–138.7). Conclusions: OAT, in particular buprenorphine, has been underutilized by opioid-using PWID in the Seattle area. Health insurance is a critical factor for enabling PWID to utilize OAT treatment for opioid use disorders.     

The willingness of people who inject drugs in Boston to use a supervised injection facility

ABSTRACT

Background: In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness. Methods: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%). Results: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9–15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8–14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2–21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6–14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9–18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2–14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2–14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2–10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3–8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2–8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2–7.4; P = .02). Conclusions: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.