Heavy Injection Drug Use Is Associated with Lower Percent Body Fat in a Multi-Ethnic Cohort of HIV-Positive and HIV-Negative Drug Users from Three U.S. Cities

Background: The clinical implications of lower body weight in drug using populations are uncertain given that lower mean weights may still fall within the healthy range. Objectives: To determine the effect of type, mode and frequency of drug use on underlying body composition after accounting for differences in body shape and size. Methods: We conducted a cross-sectional analysis of 511 participants from the Tufts Nutrition Collaborative (TNC) Study. Data included measures of body composition, a 24-hour dietary recall, and a detailed health history and lifestyle questionnaire. Multivariate regression analysis was used to determine the independent effect of drug use on percent body fat (BF) after adjusting for BMI and waist circumference. Results: Heavy injection drug users (IDUs) had a 2.6% lower percent BF than non-users after adjusting for BMI, waist circumference, and other confounders. (p = 0.0006). Differences in percent BF were predominantly due to higher lean mass, rather than lower fat mass. Cocaine and heroin had similar effects on body composition. Conclusions: In the U.S., where the general population is prone to over-nutrition, the average percent BF for heavy injectors does not fall into a range low enough to suggest harmful effects. However, in populations with substantial levels of under-nutrition, small differences in percent BF among drug users will have a greater impact on health status. Scientific Significance: Differences in BMI, weight and body composition are not always straightforward. Accounting for underlying nutritional status and relative differences in fat and FFM is critical when interpreting results. diagnosed patients and prevent them from returning to prison.     

Service Use and Barriers to Care among Heroin Users: Results from a National Survey

Background: Heroin use is associated with many serious consequences.While effective treatments exist, barriers to services persist. Understanding service use and barriers to treatment can structure treatment practice and target interventions for those who are most at risk. Objectives: To describe patterns and correlates of substance abuse service utilization and treatment barriers among a nationally representative sample of heroin users. Methods: Data for this study were derived from the National Epidemiologic Survey on Alcohol and Related Conditions. This study focused on lifetime heroin users (N = 150). Results: Fifty-nine percent of heroin users reported receiving at least one treatment service. The most common services used were 12-step programs, detoxification, and rehabilitation. Approximately 44% reported at least one barrier to treatment. The most common were lack of motivation and beliefs that it could be managed alone. In a multivariate logistic regression, having a heroin use disorder was associated with a greater likelihood of receiving services (OR = 6.09) and experiencing a barrier (OR = 11.11) compared to those without a disorder. Conclusions and Scientific Significance: High rates of service use and barriers were observed for all levels of heroin involvement. These findings underscore the importance of improving access to services for this group, even when full criteria for a drug disorder is not met. Integration of motivational approaches is also needed within the most common services used. To our knowledge, this is the first study to describe patterns and correlates of service use using a nationally representative community sample of heroin users.     

Drug Network Characteristics as a Predictor of Cessation of Drug Use Among Adult Injection Drug Users: A Prospective Study

Few studies have examined recovery from opiate and cocaine dependence without treatment, referred to as “natural recovery,” “spontaneous recovery,” and “spontaneous remission.” The present study examined the relationship between network characteristics and cessation of heroin, cocaine, and crack use in a sample of underclass inner-city injection drug users in Baltimore, Maryland. Participants were enrolled in an experimental human immunodeficiency virus (HIV) preventive intervention. Between the baseline and follow-up interviews, which averaged 5.2 months, 24 (7%) of 335 participants reported ceasing to use heroin, cocaine, and crack. Individuals who had reported cessation of drug use at follow-up had reported at baseline a smaller proportion of their network members with whom they used drugs (p <. 02). Using multiple logistic regression analyses and adjusting for baseline drug use, enrollment in drug treatment, and demographic and background variables, cessation of drug use was associated with a lower proportion of personal network members in one's drug network (odds ratio [OR] = 25.4, p. 05). The data from this study suggest that network members have potential for social influence on the cessation of drug use.     

Efficacy of mobile telephone contact for follow-up in injecting heroin users

Background: Prospective follow-up of heroin users is known to be difficult due to their unstable lifestyle, and high follow-up rates have usually demanded major tracking efforts. In Sweden, mobile telephones are commonly used by heavy drug users for drug trading. Objectives: This methodology study aims to examine the efficacy of mobile telephone contact for prospective follow-up interviews with injecting heroin users recruited at the syringe exchange program of Malmö, Sweden. Methods: Seventy-eight heroin users with mobile telephone numbers were included. Subjects reported using heroin for 28 days of the previous 30 days, and only 8% reported they had recently been engaged in work or studies. Clients were contacted between 15 and 21 times over 2 years, with each contact attempt generally involving two telephone calls on consecutive days. Results: During follow-up, 68% of subjects had been successfully contacted for at least one follow-up interview (on average 6.9 interviews), and 25% of follow-up attempts were successful. In 23% of the sample (n = 18), at least 50% of follow-up attempts were successful, and these subjects tended to be older (p = .05) and more likely to be female (p = .07), whereas follow-up rates were unrelated to baseline heroin use. Conclusions and Scientific Significance: Despite limited effort, and despite the severe situation of intravenous heroin users, mobile telephone contact can be used with heavy drug users in the present setting.     

Flashblood: blood sharing among female injecting drug users in Tanzania

Aims This study examined the association between the blood‐sharing practice of ‘flashblood’ use and demographic factors, human immunodeficiency virus (HIV) status and variables associated with risky sex and drug behaviors among female injecting drug users. Flashblood is a syringe‐full of blood passed from someone who has just injected heroin to someone else who injects it in lieu of heroin. Design A cross‐sectional study. Setting Dar es Salaam, Tanzania. Participants One hundred and sixty‐nine female injecting drug users (IDUs) were recruited using purposive sampling for hard‐to‐reach populations. Measurements The association between flashblood use, demographic and personal characteristics and risky sex and drug use variables was analyzed by t‐test and χ² test. The association between flashblood use and residential neighborhood was mapped. Findings Flashblood users were more likely to: be married (P = 0.05), have lived in the current housing situation for a shorter time (P < 0.000), have been forced as a child to have sex by a family member (P = 0.007), inject heroin more in the last 30 days (P = 0.005), smoke marijuana at an earlier age (P = 0.04), use contaminated rinse‐water (P < 0.03), pool money for drugs (P < 0.03) and share drugs (P = 0.000). Non‐flashblood users were more likely to live with their parents (P = 0.003). Neighborhood flashblood use was highest near downtown and in the next two adjoining suburbs and lowest in the most distant suburbs. Conclusions These data indicate that more vulnerable women who are heavy users and living in shorter‐term housing are injecting flashblood. The practice of flashblood appears to be spreading from the inner city to the suburbs.     

Drug use in rural China: a preliminary investigation in Hunan Province

Aims To compare characteristics and illicit drug abuse patterns among drug abusers in rural and urban areas of Hunan Province, China. Measurements and design Data collected by public security bureau on newly registered drug abusers between 2005 and 2008 in five urban and five rural areas (n = 1639) were extracted anonymously and analyzed. Setting and participants All newly registered drug users in urban (n = 812) and rural (n = 827) areas of Hunan Province were included. Findings Drug users from the rural areas were younger [31 (6.6) versus 34 (8.0) years, P < 0.001], with a higher proportion of males (86% versus 82%, P < 0.05) or married (34% versus 27%, P < 0.01). Rural drug users reported an earlier onset of drug use [27 (5.9) versus 30 (7.9) years old, P < 0.001], were more likely to report heroin as their primary drug of abuse (53% versus 47%, P < 0.001) and had a lower prevalence of criminal activities (19% versus 31%, P < 0.001). Rural drug users were less likely to report needle sharing (1.8% versus 4.3%, P < 0.01), less likely to report being human immunodeficiency virus positive (0.8% versus 2.6%, P < 0.01) and less likely to report prior drug treatment participation (2.8% versus 6.8%, P < 0.001). Conclusions Drug abuse is a substantial problem in both urban and rural areas in China. The very low proportion of newly registered drug users reporting any prior drug abuse treatment points to the importance of expanding substance abuse treatments, especially in rural areas where treatment penetration is even lower than in urban areas.     

Impact of in-patient research participation on subsequent heroin use patterns: implications for ethics and public health

Aims Research on drug dependence often involves the administration of drugs of abuse to experienced drug users under controlled laboratory conditions. The primary objective of this study was to assess whether participation in such research alters the frequency of heroin use by non‐treatment‐seeking opioid‐dependent volunteers after study completion. Design Data were examined from four in‐patient studies involving controlled opioid administration. Setting Substance Use Research Center at Columbia University, New York State Psychiatric Institute. Participants Sixty‐nine heroin‐dependent volunteers. Measurements Participants' self‐reported heroin use prior to and 1 month after study participation was compared using a Wilcoxon test. Because a number of participants reported that they had stopped using heroin, a logistic regression was used to identify correlates of heroin cessation 1 month after study completion. Findings One hundred and one participants entered laboratory studies and 69 completed them. Self‐reported heroin use significantly decreased 1 month after study participation [1.7 (±2.0) bags per day] compared to baseline [6.8 (±4.2) bags per day], P < 0.001 among the 69 completers. In addition, 42% of the completers were heroin‐abstinent 1 month after study completion. Being African American, having a history of opioid dependence treatment, reporting heavier heroin use at baseline and a longer history of heroin use were correlated with cessation of heroin use. Conclusions Participation in opioid administration studies does not increase subsequent heroin use and for some individuals leads to accessing opioid dependence treatment and cessation of heroin use in the short term.     

Primary care-based ambulatory opioid detoxification

OBJECTIVE: To determine the feasibility of primary care-based ambulatory opioid detoxification (AOD) using two protocols: clonidine and clonidine plus naltrexone. SETTING: The Central Medical Unit (CMU)—a freestanding primary care medical clinic staffed by physicians and nurse practitioners. PATIENTS: Injection drug users (IDUs) seeking substance abuse treatment between the ages of 18 and 50 years who were addicted to opioids (e.g., heroin) and not currently in drug treatment. INTERVENTIONS: In the clonidine protocol, clonidine was administered every 4 hours “as needed” for up to 12 days. In the clonidine plus naltrexone protocol, clonidine was administered and naltrexone was administered in increasing doses over five days. Both protocols included “adjuvant” medications for muscle cramps, insomnia, and vomiting. Successfully detoxified patients were referred to ongoing drug treatment. DESIGN: A prospective nonrandomized clinical trial. MEASUREMENTS AND MAIN RESULTS: One hundred forty opioid-addicted IDUs were referred to the medical clinic for AOD. Among the 125 patients who enrolled in the study, 57 selected clonidine and 68 selected clonidine/naltrexone. The treatment groups (clonidine vs clonidine/naltrexone) were similar at baseline with respect to: age at first heroin use (21 years vs 23 years), mean admission opioid craving score (45/100 vs 49/100), and withdrawal symptom score (19/72 vs 18/72). Overall, 70% (88/125) of the AODs were successful, including 42% (24/57) for clonidine and 94% (64/68) for clonidine/naltrexone (p<0.001). CONCLUSIONS: This study suggests that primary care-based AOD can be safely and effectively carried out by primary care providers and that clonidine/naltrexone may be more effective in this setting than is clonidine alone. Ambulatory opioid detoxification can give internists a larger role in initiating drug treatment for IDUs who are addicted to opioids.     

Interpersonal Discrimination and the Health of Illicit Drug Users

Although discrimination has been shown to adversely affect the health of marginalized populations, there is a paucity of research on the health impacts of discrimination experienced by illicit drug users. The purpose of this study was to examine the association between interpersonal discrimination and the mental and physical health of illicit drug users taking into account several potential confounding factors. A sample of 1,008 active illicit substance users (defined as having used cocaine, crack, or heroin in the previous 2 months) were recruited in three New York City neighborhoods between August 2000 and January 2001 using street-outreach techniques. Discrimination due to illicit drug use was the most common form of interpersonal discrimination experienced and more than one-half the study participants reported experiencing discrimination due to more than one attribute. Discrimination was significantly associated with poor mental health (measured by the SF-36 mental health score), depression (measured by the CES-D), and the number of self-reported chronic physical health conditions. The presence of multiple stigmatizing characteristics was associated with poorer mental and physical health. Discrimination may contribute to poor mental and physical health in this marginalized population, potentially complicating the provision of substance abuse treatment.     

The Investigation of HIV and HCV Infection and Risk Factors among Opiate Drug Users in Beijing,China

Objective: To explore the prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) and the risk factors among opiate drug users in Beijing. Methods: The opiate drug users enrolled in methadone maintenance treatment clinics of Beijing from 30 November 2004 to 31 March 2008 were investigated. The blood samples were collected and tested for HIV and HCV infection and questionnaires were used for all subjects admitted. Results: Among 1211 eligible subjects, 12 HIV and 713 HCV-positive subjects were observed; the HIV and HCV prevalences were .99% and 58.88%, respectively. Young age, unemployment, injection drug use, and more frequent and longer drug use were the independent risk factors for HCV infection using the multiple logistic regression analysis. The younger drug users are more likely to be infected than the older ones, and the adjusted odds ratios (OR) of 18–30 and 30–40 versus 40–54 years were 1.81 (95% confidence interval (95% CI): 1.13–1.92) and 1.51 (95% CI: 1.08–2.10). The drug users who were unemployed (OR = 1.70, 95% CI: 1.23–2.37), with injection drug use (OR = 10.99, 95% CI: 7.26–16.65), with more frequent drug use (OR = 2.42, 95% CI: 1.31–2.46), and with longer heroin abuse history (OR = 8.06, 95% CI: 1.19–57.54) were more likely to be infected with HCV. Conclusions: The HCV infection was popular among opiate drug users in Beijing. The findings indicated the need for educating the users taking into account their low literacy levels and the necessity for job training and decreasing the injection drug use and the frequency of drug use administrated as the prevention and intervention methods for controlling the HIV/HCV infection in this population.     

Drug use patterns and infection with sexually transmissible agents among young adults in a high-risk neighbourhood in New York City

Aims To determine relationships between drug use ‘hardness’ (defined in increasing order of hardness as no drug use, marijuana use, non‐injected heroin or cocaine use, crack smoking and injection drug use) and prevalences of several sexually transmissible infections among young adults in a high‐risk neighbourhood. Drug users, particularly injection drug users and crack smokers, may be a core group for some sexually transmitted infections. Design Cross‐sectional survey and assays of young adults from (a) a household probability sample and (b) a targeted sample of youth who have used injected drugs, crack, other cocaine or heroin. Setting Bushwick, an impoverished New York City minority neighbourhood with major drug markets. Participants A total of 363 18–24‐year‐olds from a household probability sample; 165 Bushwick 18–24‐year‐olds who have used injected drugs, crack, other cocaine or heroin. Measurements Drug use by self‐report; serum‐ and urine‐based assays for HIV, hepatitis B and C, syphilis, gonorrhoea, chlamydia and herpes simplex (type 2). Findings Household‐sample prevalences: HIV, hepatitis C and syphilis, 1%; gonorrhoea 3%; chlamydia 5%; past or present hepatitis B infection 8%; herpes simplex (type 2) 18%. In combined household and targeted samples, hepatitis C and HIV were concentrated among drug injectors. Herpes simplex (type 2), syphilis and hepatitis B increased among women with ‘hardest drug ever used’. Conclusions Using ‘harder’ drugs is associated with some but not all of these infections. Prevention efforts should help youth avoid unsafe sex and higher‐risk drugs.     

Predictors of Drug Use in Prison among Incarcerated Black Men

Background: Black men currently comprise a substantial percentage of prisoners in the United States. Drug dependence is common among prison populations, and US prisons are high-risk environments for drug use. Prison drug use exacerbates health problems disproportionately prevalent among Black men and prisoners. Objectives: The goal of this research was to examine predictors of prison drug use among incarcerated Black men. Methods: This study examined drug use within the prison environment in a random sample of 134 Black men incarcerated in maximum-security correctional institution. The Addiction Severity Index (ASI) was used to measure illicit drug use history and the extent to which drug use occurred within the prison environment. Results: Seventy-five percent of the participants reported a history of illicit drug use. Overall, 20% (n 25) of the participants, or 25% of those with a history of drug use, reported using drugs during a time frame consistent with incarceration. Participants with lengthier histories of drug use (OR: 1.1, 95% CI 1.0–1.2) and those who were incarcerated longer (OR: 1.1, 95% CI 1.0–1.2) were more likely to use drugs in prison. Drug use in prison was associated with history of injection drug use and with probation/parole status when arrested. Conclusions: Prisoners are engaging in illicit drug use while incarcerated, suggesting that they could benefit from harm reduction and drug treatment services offered during incarceration. Scientific significance: Drug treatment programs that address long-standing addictions and coping mechanisms for lengthy prison stays, specifically, would be especially useful for this population.     

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.     

Patterns of substance use and correlates of lifetime and active injection drug use among women in Malaysia

ABSTRACT

Background: While drug use is associated with HIV risk in Southeast Asia, little is known about substance use behaviors among women, including drug injection. Objectives: To describe patterns of substance use among women using alcohol and drugs in Malaysia and identify correlates of lifetime and active drug injection, a risk factor for HIV transmission. Methods: A survey of 103 women who used drugs in the last 12 months assessed drug use history and frequency, including drug injection and drug use during pregnancy, self-reported HIV-status, childhood and adulthood physical and sexual abuse, and access to and utilization of harm reduction services, including needle-syringe exchange programs (NSEP) and opioid agonist maintenance therapy (OAT). Principal component analyses (PCA) were conducted to assess drug use grouping. Results: Amphetamine-type substances (ATS; 82.5%), alcohol (75.7%) and heroin (71.8%) were the most commonly used drugs across the lifetime. Drug injection was reported by 32.0% (n = 33) of participants with 21.4% (n = 22) having injected in the last 30 days. PCA identified two groups of drug users: opioids/benzodiazepines and club drugs. Lifetime drug injection was significantly associated with lower education, homelessness, prior criminal justice involvement, opioid use, polysubstance use, childhood physical and sexual abuse, and being HIV-infected, but not with prior OAT. Conclusion: Women who use drugs in Malaysia report high levels of polysubstance use and injection-related risk behaviors, including sharing of injection equipment and being injected by others. Low OAT utilization suggests the need for improved access to OAT services and other harm reduction measures that prioritize women.     

Hair testing and self-report of cocaine use by heroin users

Aim Failure to disclose cocaine use can have a negative impact on medical care and research validity. This study was performed to identify predictors of cocaine non‐disclosure among individuals who self‐reported heroin use during a medical care encounter. Design A prospective comparison of self‐report of cocaine use among heroin users and hair analysis for cocaine. Setting Four health‐care clinics at an academic, inner‐city hospital. Participants Patients presenting for a health‐care visit who were willing to self‐report use of heroin and were not engaged in any form of drug treatment. Measurements (1) Self‐report using standardized instruments: the Drug Addiction Severity Test (DAST), the Addiction Severity Index (ASI) and quantity/frequency questions for heroin and cocaine use. (2) Biochemical evidence: analysis of hair by radioimmunoassay (RIA) for cocaine and opiate levels. Findings Among 336 heroin users who tested positive for cocaine in hair, 34.2% did not report their recent cocaine use. The mean cocaine level for discordant individuals was significantly lower than for concordant individuals (109.6 ng/10 mg versus 470.57 ng/10 mg; P < 0.0001). Multivariate predictors of disclosure included opiate and cocaine levels in hair and the ASI drug severity subscore. Conclusions Although self‐report has been validated for treatment system patients, almost a third of the out‐of‐treatment heroin users in this medical clinic study failed to disclose concomitant cocaine use. The likelihood of non‐disclosure was greatest for heavy users of heroin and light users of cocaine. Confirmation of self‐report with biochemical analysis in the medical setting may be necessary to improve both clinical care and research validity.