Self-perceived health among Canadian opiate users: a comparison to the general population and to other chronic disease populations

BACKGROUND: There are an estimated 40,000 to 90,000 injection opiate users in Canada. The social, economic and health consequences of opiate addiction have been well documented. However, there are no data on the self-perceived health status of opiate users in Canada. Therefore, the goal of this research is to gain an understanding of the self-perceived health status of opiate users by comparing the health-related quality of life of opiate users to chronic disease populations and to the general population. METHODS: The SF-36 was administered to a nonrandom sample of 143 opiate users entering low-threshold methadone treatment. Two sample t-tests were performed to assess statistical differences, at a 5% level of significance, between population scores across SF-36 dimensions. RESULTS: Opiate users perceived both their mental and physical health as worse than the general population and individuals with minor and serious medical problems, but comparable to those with diagnosed psychiatric illnesses. CONCLUSIONS: Methadone treatment services should incorporate both primary care and psychiatric care into their programs, or at the very least secure appropriate referral mechanisms to ancillary services to ensure that the health concerns of opiate users are dealt with in the context of their treatment program.     

Estimating the number of HIV-infected injection drug users in Bangkok: a capture--recapture method.

OBJECTIVES. The purpose of the study was to estimate the number of injection drug users infected with the human immunodeficiency virus (HIV) in Bangkok to allow planning for health services for this population. METHODS. A two-sample capture-recapture method was used. The first capture listed all persons on methadone treatment for opiate addiction from April 17 through May 17, 1991, at 18 facilities in Bangkok. The second capture involved urine testing of persons held at 72 Bangkok police stations from June 3 through September 30, 1991. Persons whose urine tests were positive for opiate metabolites or methadone were included on the second list. RESULTS. The first capture comprised 4064 persons and the recapture 1540 persons. There were 171 persons included on both lists, yielding an estimate of 36,600 opiate users in Bangkok. Existing data indicate that 89% of opiate users in Bangkok inject drugs and that about one third are infected with HIV, yielding an estimate of approximately 12,000 HIV-infected injection drug users in Bangkok in 1991. CONCLUSIONS. During the 1990s the number of cases of acquired immunodeficiency syndrome (AIDS) and other HIV-related diseases, including tuberculosis, in the population of HIV-infected injection drug users in Bangkok will increase dramatically, placing new demands on existing health care facilities. The capture-recapture method may be useful in estimating difficult-to-count populations, including injection drug users.     

Roaming through methodology. XXXI. Estimating partially hidden populations: heroin addicts in Amsterdan

To estimate the size of a partly hidden population the capture-recapture method can be used. The estimation is based on analysis of the overlap between several samples of the population of interest. The quality of this capture-recapture estimation highly depends on whether the assumptions of the method are or are not met: samples should be independent, the population should be closed, the overlap should be recognised, and samples should contain only individuals originating from the population of interest. Violation of these assumptions may lead to a serious underestimation or (more often) overestimation. The number of problematic heroin addicted people in Amsterdam was estimated on the basis of registered numbers in the easily accessible methadone programme of the municipal health organisation, in the police station methadone treatment programme, and in the hospital registration in the first quarter of 1997: 4130 (95% confidence interval: 3750-4570).     

Hidden need for drug treatment services: measuring levels of problematic drug use in the North West of England

BACKGROUND: In the North West of England, data on drug users are routinely collected from a variety of agencies including specialist treatment centres, police and probation services. However, the covert nature of drug use means that alone, these conventional monitoring systems cannot provide the epidemiology required to target and develop drug treatment and prevention initiatives. METHODS: Utilizing surveillance data and capture-recapture techniques we estimate the rates of problematic drug users by age and sex in five North West health authorities and one local authority. RESULTS: Analyses show concentrations of problematic drug use in large metropolitan areas (Liverpool and Manchester) with levels as high as 34.5 and 36.5 per 1000 population (ages 15-44), respectively, and, for males, levels exceed 50 per 1000 in three authorities. Patterns of prevalence for those aged 25 and over differed from those in the younger age groups, with disproportionate levels of young users outside metropolitan areas. The proportion of young users already in treatment (21.3 per cent) was lower (older users, 35.3 per cent), with overall proportions in treatment varying between health authorities (range 26.2-46.5 per cent). CONCLUSION: With a multi-agency approach, established monitoring systems can be used to measure hidden populations of drug users. Estimates of the current populations of such users in the North West of England suggest that planned increases of people in treatment by 100 per cent would fail to accommodate even current level of problematic users. A holistic approach to new initiatives must ensure that the high level of relapse once drug users are discharged are reduced and that the needs of young users are addressed before prolonged treatment is required.     

Incidence and prevalence of hepatitis C among clients of a Brisbane methadone clinic: factors influencing hepatitis C serostatus

Abstract: The objective of this study was to describe the incidence and prevalence of hepatitis C infection among clients of a methadone program in Queensland. The clinical notes of clients receiving methadone for treatment of opiate dependence who first registered at the clinic after 1989 were perused for information about their serological status for hepatitis C and hepatitis B infections during a six–week period in 1994. We followed hepatitis C negative clients until August–September 1995. At study entry, 69 per cent of the clients were recorded as being hepatitis C positive. Of those who were negative, the seroconversion rate was 11 per 100 person–years. The high incidence and prevalence of hepatitis C among methadone clients emphasises the need for effective early intervention strategies to prevent the transmission of hepatitis C among injecting drug users.     

Heroin-assisted treatment as a response to the public health problem of opiate dependence

Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.     

Carriage of Staphylococcus aureus among injection drug users: lower prevalence in an injection heroin maintenance program than in an oral methadone program.

OBJECTIVES: To compare the prevalence of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) carriage among injection drug users (IDUs) treated in an injection heroin maintenance program with that among IDUs treated in an oral methadone program, and to determine predictors of S. aureus carriage. DESIGN: Survey. SETTING: Two opiate maintenance programs at a psychiatric university clinic. PARTICIPANTS: A volunteer sample consisting of 94 (74%) of 127 IDUs treated in an injection opiate maintenance program with at least twice daily injections of heroin, and 70 (56%) of 125 IDUs treated in an oral methadone program. RESULTS: Addicts treated in the intravenous heroin substitution program had a significantly lower overall rate of S. aureus carriage (37 of 94 [39.4%] vs 42 of 70 [60%]; P = .009) and a significantly lower rate of nasal carriage (21 of 94 [22.3%] vs 30 of 70 [42.9%]; P = .005) than did addicts treated in the oral methadone program. Being treated in the oral methadone program was the only independent predictor of S. aureus carriage (odds ratio, 2.27; 95% confidence interval, 1.19-4.31; P = .012). All S. aureus isolates were susceptible to oxacillin. CONCLUSIONS: The regular use of needles under aseptic conditions did not increase the rate of S. aureus carriage among IDUs. Further studies are necessary to investigate whether the lower rate of S. aureus carriage among IDUs treated with intravenous heroin leads to a lower incidence of S. aureus infections in these patients.     

Jail management of arrestees/inmates enrolled in community methadone maintenance programs

Anecdotal evidence suggests that many jails fail to adequately detoxify arrestees/inmates who are enrolled in methadone programs, but there are few empirical data. The objective of this study was to assess how jails manage arrestees/inmates enrolled in methadone programs. A national survey of 500 jails in the United States was conducted. Surveys were mailed to the 200 largest jails in the country in addition to a random sample of 300 of the remaining jails (10% sample). Jails were specifically asked about management of opiate dependency among arrestees/inmates enrolled in methadone programs. Weighted logistic regression analyses were conducted to assess predictors of continuing methadone during incarceration and use of recommended detoxification protocols. Among the 245 (49%) jails that responded, only 1 in 4 (27%) reported they contacted the methadone programs regarding dose, and only 1 in 8 (12%) continued methadone during the incarceration. Very few (2%) jails used methadone or other opiates for detoxification. Most used clonidine. However, half (48%) of jails failed to use clonidine, methadone, or other opiates to detoxify inmates from methadone. Weighted logistic regression models showed that moderately large jails and those located in the South and Midwest were significantly more likely to continue methadone. Very large jails, those with an estimated prevalence of opiate dependence of 6%–10% among arrestees/inmates, and those located in the Northeast were significantly more likely to use recommended detoxification protocols. Very few jails provided continuous treatment to arrested persons on methadone, and half failed to detoxify arrestees/ inmates using recommended protocols. These practices jeopardize the health and wellbeing of persons enrolled in methadone programs and underscore the need for uniform national policies within jails.     

Norplant as a Contraceptive Device in Enugu, Eastern Nigeria

This paper is an evaluation of acceptability and use-experience with the contraceptive device Norplant at the University of Nigeria Teaching Hospital, Enugu, Eastern Nigeria. Over a period of 36 months, 173 women (8% of the clinic population) accepted the implant. Use of Norplant was concentrated among high-parity women, and the proportion of Norplant users was highest among women aged 30–34 years. Comparing Norplant and IUD users, we found Norplant users to be significantly less highly educated with <1% of Norplant users having tertiary education compared to 25% of new IUD users. The continuation rate with Norplant was 89% at three years, suggesting this method has the potential for improving the low contraceptive prevalence in this region.     

中国九城市1301名社区美沙酮维持治疗门诊患者偷吸海洛因及影响因素分析

目的 了解社区美沙酮维持治疗患者治疗期间偷吸海洛因的情况及其影响因素.方法 在江苏、安徽、云南3省9个城市社区美沙酮维持治疗门诊中抽取1301名符合条件的患者进行问卷调查与随机尿吗啡定性检测.收集一般人口学、艾滋病/毒品滥用相关高危行为、参加美沙酮维持治疗情况、抑郁与焦虑及偷吸海洛因等信息.结果 1301名调查对象中男性居多(76.2%),年龄(34.6±6.5)岁,受教育程度以初中及以下为主(71.7%).平均维持治疗剂量(48.1±29.4)mg/d,目前治疗剂量自我满意度平均得分为8.6,尿吗啡检测阳性率为27.7%.有抑郁和焦虑症状者比例分别为38.3%和18.4%,抑郁合并焦虑症状的比例为14.2%.婚姻状况、治疗时间的长短、目前治疗剂量自我满意度及是否曾退出治疗对偷吸海洛因影响的差异有统计学意义,而性别、教育程度及治疗剂量对偷吸海洛因的影响差异无统计学意义.不同省份间影响偷吸海洛因的因素有所不同,但对当前剂量自我满意度是共同的影响因素.结论 提高门诊服务质量及服药依从性、延长参加治疗的时间、提高患者对治疗剂量的满意度及避免脱失对减少治疗期间偷吸海洛因有重要意义.     

Achieving a high coverage – the challenge of controlling HIV spread in heroin users

In China, the national plan to open 1000 methadone clinics over a five-year period provides a unique opportunity to assess the impacts of harm reduction in a country with concentrated HIV epidemic amongst heroin users. To track the progress of this public health response, data were collected from the first methadone clinic in Liuzhou, Guangxi, a province with a high HIV prevalence. In the first 15 months of its operation, a cumulative total of 488 heroin users, 86% of which male, had joined the programme. The first dose of methadone was given efficiently at a median of 2 days after registration. Of the 240 heroin users attending the clinic in August 2006, 61% took methadone for four days or more each week. The number of active methadone users, however, leveled off at around 170 after the first two months, despite the availability of capacity to deliver more services. The reasons for this observation are: firstly, the provision of one single service that may not be convenient to all heroin users; and secondly, concerns of heroin users who may feel insecure to come forward. As broad coverage is essential in ultimately reducing HIV risk, a low threshold approach is crucial, which should be supported by the removal of social obstacles and a refinement of the administrative procedures.     

Missed Opportunities for Hepatitis C Testing in Opioid Treatment Programs

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.HCV recently surpassed HIV as a cause of death in the United States.1,2 Approximately 3.2 million people nationwide are living with chronic hepatitis, but most are unaware of their status because of limited opportunities for testing.3–6 Persons who inject drugs are particularly at risk for HCV infection as a result of sharing and reusing of needles.4,7 The estimated prevalence of antibodies to HCV (anti-HCV) among injection drug users ranges from 35% to 65%.8 The Centers for Disease Control and Prevention (CDC) thus recommends routine HCV testing for all current or former injection drug users.1,9 Offering HCV testing services in drug abuse treatment programs could help increase HCV case finding and reduce transmission.10,11 It could also help foster the adoption of preventive behaviors: knowledge of one’s anti-HCV status may indeed lead to safer injection practices (or other protective behaviors).12,13I examined the availability of on-site HCV testing services in opioid treatment programs (i.e., physical facilities with resources dedicated specifically to treating opiate dependence with methadone, buprenorphine, or both).14,15 Opioid treatment programs treat both persons who inject drugs and people who have opiate addiction but do not inject drugs. The current recommended HCV testing protocol requires the collection of venous blood, performed by qualified staff (i.e., phlebotomists).16 However, the availability of (1) human resources required to offer HCV testing services and (2) on-site HCV testing services at opioid treatment programs nationwide is not known. I examined relations among the availability of on-site HCV testing services, human resources for HCV testing, and the proportion of injection drug users among opioid treatment program clients.     

Prevalence of problematic cocaine consumption in a city of Southern Europe,using capture-recapture with a single list

This study aims to determine the magnitude and characteristics of problematic cocaine consumption in the city of Barcelona, Spain. Capture-recapture with a single source was used to estimate prevalence. Log-linear regression models with interaction terms were fitted to the total sample and to subgroups according to other drugs consumed. Emergency room indicator data were obtained from the Barcelona Drug Information System. Drug-related emergencies of Barcelona residents for 1999 were analyzed. During 1999, a total of 4,035 drug-related emergencies were seen in Barcelona hospitals. Of these, 1,656 (41%) involved cocaine consumption; 41% of these patients had consumed cocaine with an opiate; 29% used cocaine with other substances; and 30% used cocaine alone. It was estimated that there was a total of 25,988 problematic cocaine users (95% confidence interval 11,782–58,064), yielding a rate of 31.27 per 1,000 inhabitants aged 15 to 54 years (95% confidence interval 14.2–69.9). The number of cocaine-related emergencies was high enough to allow capture-recapture to be applied, thus obtaining an estimate of the prevalence of problematic cocaine consumption, and high enough to characterize users according to different profiles. The use of capture-recapture with a single source can be interesting for problems related to the urban context.     

HIV transmission and the cost-effectiveness of methadone maintenance

OBJECTIVES: This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic. METHODS: We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%. RESULTS: Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots. CONCLUSIONS: Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.     

Attitudes and practices regarding the use of methadone in US State and federal prisons

In the United States, vigorous enforcement of drug laws and stricter sentencing guidelines over the past 20 years have contributed to an expanded incarcerted population with a high rate of drug use. One in five state prisoners reports a history of injection drug use, and many are opiate dependent. For over 35 years, methadone maintenance therapy has been an effective treatment for opiate dependence; however, its use among opiate-dependent inmates in the United States is limited. In June 2003, we conducted a survey of the medical directors of all 50 US states and the federal prison system to describe their attitudes and practices regarding methadone. Of the 40 respondents, having jurisdiction over 88% (n=1,266,759) of US prisoners, 48% use methadone, predominately for pregnant inmates or for short-term detoxification. Only 8% of respondents refer opiate-dependent inmates to methadone programs upon release. The results highlight the need to destigmatize the use of methadone in the incarcerated setting, expand access to methadone during incarceration, and to improve linkage to methadone treatment for opiate-dependent offenders who return to the community.     

Approaches to methadone treatment: harm reduction in theory and practice

The paper analyses methadone treatment in Copenhagen -- as it is described by methadone users and staff at different outpatient centres. The starting point is a theoretical model distinguishing between two different approaches to methadone treatment: 'palliative' and 'curative'. Included in the model are three dimensions (1) treatment goals at the methadone centres (abstinence vs. stabilisation) (2) treatment focus (focus on addiction vs. focus on the consequences of addiction) and (3) conceptualisation of methadone (methadone as similar to or different from heroin). The paper shows that there is a discrepancy between the attitudes of the staff and those of the users. While the staff favour an almost clear-cut palliative approach to methadone treatment, defining curative goals as both unrealistic and as belonging to the past, the users prefer an approach that does not exclude the goal of abstinence and does not focus on the consequences of drug use alone but also on their problematic relationship to drugs (legal as well as illegal). Furthermore, the users' attitudes towards methadone are far more ambivalent than the staff's. For the users, methadone is not just medicine; it is also a dependence-producing and 'dangerous' drug.     

Anergy compromises screening for tuberculosis in high-risk populations.

Anergy may occur in groups at high risk for tuberculosis, compromising tuberculin skin testing. Within New York City's correctional system, anergy prevalence was 25% among opiate users referred to detoxification programs and 3% in the general population. Correlates of anergy were recent weight loss and needle sharing. The high prevalence of anergy among opiate users compromises the utility of tuberculosis screening and suggests the need for routine chest x-rays to detect pulmonary tuberculosis in some high-risk-populations.     

Drug-related mortality and its impact on adult mortality in eight European countries

OBJECTIVE: To estimate the mortality rates from drug-related deaths and other causes among problem drug users and population attributable risk of death due to opiate use in eight study sites in Europe. METHODS: Opiate users were recruited from drug treatment centres during the period 1990-1998 and deaths followed up through national or local mortality registries. Gender-specific overall mortality rate, proportion of deaths by cause (drug-related, HIV, other), standardized mortality ratios (SMRs), and the attributable risk fraction (ARF) were estimated. RESULTS: Crude mortality rates varied from 1 per 100 person-years in the Dublin and London cohorts to 3.8 per 100 person-years in Barcelona. The highest drug-related mortality rate was 10 per 1,000 person-years in Barcelona; the rates were approximately 7 per 1,000 person-years in Denmark, London, Rome, and Vienna, and <3.5 per 1,000 person-years for the others cohorts. The mortality rate for AIDS was <2 per 1,000 person-years in all the cohorts except Lisbon, Rome, and Barcelona, for which it was approximately 6 per 1,000 person-years. The highest SMR among males was 21.1 in Barcelona, and among females the highest SMRs were 53.7 and 37.7 in Barcelona and Rome, respectively. In Denmark the ARF was 5%, whereas it was >10% in all other study sites and 24% in Barcelona. CONCLUSION: Cohort mortality studies, especially in combination with estimates of prevalence, provide useful insights into the impact of opiate use on mortality across European countries and emphasize how preventing overall and drug-related deaths among opiate users can significantly improve the health of the population.