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.     

The effect of injecting drug use history on disease progression and death among HIV-positive individuals initiating combination antiretroviral therapy: collaborative cohort analysis

Background

We examined whether determinants of disease progression and causes of death differ between injecting drug users (IDUs) and non‐IDUs who initiate combination antiretroviral therapy (cART).

Methods

The ART Cohort Collaboration combines data from participating cohort studies on cART‐naïve adults from cART initiation. We used Cox models to estimate hazard ratios for death and AIDS among IDUs and non‐IDUs. The cumulative incidence of specific causes of death was calculated and compared using methods that allow for competing risks.

Results

Data on 6269 IDUs and 37 774 non‐IDUs were analysed. Compared with non‐IDUs, a lower proportion of IDUs initiated cART with a CD4 cell count <200 cells/μL or had a prior diagnosis of AIDS. Mortality rates were higher in IDUs than in non‐IDUs (2.08 vs. 1.04 per 100 person‐years, respectively; P<0.001). Lower baseline CD4 cell count, higher baseline HIV viral load, clinical AIDS at baseline, and later year of cART initiation were associated with disease progression in both groups. However, the inverse association of baseline CD4 cell count with AIDS and death appeared stronger in non‐IDUs than in IDUs. The risk of death from each specific cause was higher in IDUs than non‐IDUs, with particularly marked increases in risk for liver‐related deaths, and those from violence and non‐AIDS infection.

Conclusion

While liver‐related deaths and deaths from direct effects of substance abuse appear to explain much of the excess mortality in IDUs, they are at increased risk for many other causes of death, which may relate to suboptimal management of HIV disease in these individuals.     

"Injection first": a unique group of injection drug users in Tijuana, Mexico

Using baseline data from a study of injection drug users (IDUs) in Tijuana, Mexico (N = 1,052), we identified social and behavioral factors associated with injecting at the same age or earlier than other administration routes of illicit drug use (eg, “injection first”) and examined whether this IDU subgroup had riskier drug using and sexual behaviors than other IDUs. Twelve‐percent “injected first.” Characteristics independently associated with a higher odds of “injection first” included being younger at first injection, injecting heroin as their first drug, being alone at the first injection episode, and having a sexual debut at the same age or earlier as when they initiated drug use; family members’ illicit drug use was associated with lower odds of injecting first. When adjusting for age at first injection and number of years injecting, “injection first” IDUs had lower odds of ever overdosing, and ever trading sex. On the other hand, they were less likely to have ever been enrolled in drug treatment, and more commonly obtained their syringes from potentially unsafe sources. In conclusion, a sizable proportion of IDUs in Tijuana injected as their first drug using experience, although evidence that this was a riskier subgroup of IDUs was inconclusive. (Am J Addict 2011;21: 23–30)     

Factors associated with injection cessation, relapse and initiation in a community-based cohort of injection drug users in Chennai, India

Aims To characterize factors associated with injection cessation, relapse and initiation. Design The Madras Injection Drug User and AIDS Cohort Study (MIDACS) is a prospective cohort of injection drug users (IDUs) recruited in 2005–06 with semi‐annual follow‐up to 2009. Discrete‐time survival models were used to characterize predictors of time to first injection cessation and relapse. Setting Chennai, India. Participants A total of 855 IDUs who reported injecting in the 6 months prior to baseline and had >1 follow‐up visit. Measurements Cessation was defined as the first visit where no injection drug use was reported (prior 6 months) and relapse as the first visit where drug injection (prior 6 months) was reported after first cessation. Findings All participants were male; median age was 35 years. Over 3 years, 92.7% reported cessation [incidence rate (IR): 117 per 100 person‐years]. Factors associated positively with cessation included daily injection and incarceration and factors associated negatively with cessation included marriage, alcohol and homelessness. Of those who reported cessation, 23.6% relapsed (IR: 19.7 per 100 person‐years). Factors associated positively with relapse included any education, injection in the month prior to baseline, sex with a casual partner, non‐injection drug use, incarceration and homelessness. Alcohol was associated negatively with relapse. The primary reasons for cessation were medical conditions (37%) and family pressure (22%). The majority initiated with non‐injection drugs, transitioning to injection after a median 4 years. Conclusions Injection drug users in southern India demonstrate a high rate of injection cessation over 3 years, but relapse is not uncommon. Compensatory increases in alcohol use indicate that cessation of injection does not mean cessation of all substance use. Family pressure, concerns about general health, fear of human immunodeficiency virus infection and a history of non‐injection drug use are important correlates of cessation.     

Sterile syringe access conditions and variations in HIV risk among drug injectors in three cities

Aim Better sterile syringe access should be associated with a lower likelihood of syringe re‐use and receptive syringe sharing, although few empirical studies have examined gradients in syringe access using both individual and ecological data. In this study, we compare syringe re‐use and receptive syringe sharing among injection drug users (IDUs) with syringe exchange program (SEP) and legal over‐the‐counter pharmacy access with limits on syringes that can be purchased, exchanged or possessed to IDUs with no pharmacy sales but unlimited syringe access through SEPs. We address three questions: ( 1 ) Does residing in an area with no legal syringe possession increase the likelihood of police contact related to possessing drug paraphernalia? ( 2 ) Among direct SEP users, is use of more permissive SEPs associated with less likelihood of syringe re‐use and receptive syringe sharing? ( 3 ) Among non‐SEP users, is residing in an area with pharmacy access associated with lower likelihood of syringe re‐use and receptive syringe sharing? Design Quantitative survey of IDUs recruited from SEPs, subject nomination and outreach methods. Multivariate analyses compared police contact, syringe re‐use and receptive syringe sharing among IDUs recruited in three cities. Findings In multivariate analyses, we found that police contact was associated independently with residing in the area with no legal possession of syringes; among SEP users, those with access to SEPs without limits had lower syringe re‐use but not lower syringe sharing; and that among non‐SEP users, no significant differences in injection risk were observed among IDUs with and without pharmacy access to syringes. Conclusion We found that greater legal access to syringes, if accompanied by limits on the number of syringes that can be exchanged, purchased and possessed, may not have the intended impacts on injection‐related infectious disease risk among IDUs.     

Illicit drug initiation among institutionalized drug users in China

Aims To examine the circumstances and correlates associated with initiation of illicit drug use among institutionalized drug users in China. Design Cross‐sectional, retrospective study. Settings Six compulsory drug cessation programs in Yunnan Province and Gunagxi Zhuang Autonomous Region of China. Participants A gender‐stratified random sample of 833 drug users (88% males and 12% females) enrolled in compulsory drug cessation programs in November 1996. Measurements Circumstances of illicit drug initiation (age, type of drugs, routes of drug administration, social setting, source of drugs, reasons for drug use), the risk behaviors and risk perceptions prior to drug initiation. Findings The majority of participants initiated drug use with heroin (90%). Initial drugs were frequently administered through sniffing/snorting (55%) and smoking cigarettes mixed with a drug (38%). First drug use occurred most commonly at a friend’s home (65%) and in the company of other drug users (83%). Drugs were generally provided free for first‐time use by other drug users (72%). Reasons for first drug use included experimentation (90%), being lured into drugs by other people (44%) and relaxation (42%). Most drug users had a history of regular cigarette smoking (89%), alcohol consumption (49%) and deviant behaviors (51%) prior to their drug initiation. The majority perceived that their friends (90%) and neighbors (88%) used illicit drugs. Conclusions The findings are similar to studies in western countries with respect to the pattern and correlates of illicit drug initiation, and underscore the need for drug prevention efforts in China.     

Reinfection with hepatitis C virus following sustained virological response in injection drug users

Background and Aim: Despite that 60–90% of injection drug users (IDUs) are infected with hepatitis C virus (HCV) infection, IDUs are often denied therapy based on concerns of reinfection following treatment. However, there are little data in this regard. We evaluated HCV re‐infection following sustained virologic response (SVR) among HCV‐infected IDUs having received HCV treatment in a multidisciplinary program. Methods: Following treatment, participants were encouraged to return at follow‐up intervals of 1 year and illicit drug use histories were obtained. In those with SVR, HCV RNA testing by PCR was performed to determine if relapse or reinfection occurred. Results: Among 58 receiving HCV treatment between January 2002 and December 2006, 60% (35 of 58) achieved an SVR. Patients were followed for a median of 2.0 years following SVR (range, 0.4–5.0 years), with ongoing illicit and injection drug use reported in 54% (19 of 35) and 46% (16 of 35). Of the 35 with SVR, 28 remained HCV RNA negative during follow‐up (80%), with four lost to follow‐up and one dying of hepatocellular carcinoma and two cases of reinfection were observed (2 of 35). The rates of reinfection were 3.2 per 100 p‐y (95% CI:0.4, 11.5) overall and 5.3 per 100 p‐y (95% CI:0.6, 19.0) among those reporting injecting following SVR (n = 16). One of two participants with HCV re‐infection spontaneously cleared virus following reinfection. Conclusion: The rate of reinfection following treatment for HCV infection among current and former IDUs engaged in a multidisciplinary program is low.     

Social dimensions of adolescent substance use

Objectives. The aim of this study was to explore in detail the relationship between various social aspects of young people's lives and substance use and differences in the degree of influence exerted by the different social factors as a function of age. Design, setting, participants. The study was a survey of pupils aged 11‐16 in a stratified sample of five English schools. Data from 4516 participants were obtained in relation to their cigarette, alcohol and illicit drug use and their contact with the police, perceived academic achievements and future expectations, religious beliefs, family structure, the importance of family versus peer opinions and suspension from school. Measures. Cumulative, age‐specific preferences of substance misuse were compared. Logistic regression was used to rank the various risk factors. Results. Substantial differences were found between substance users and non‐users and the various risk factors being examined. For example, of those who had only been in trouble with the police, 18.8% used illegal drugs compared with 1.6% of those who had not had a police contact and who had no other risk factors. Many of these relationships were age‐sensitive. For instance, the negative relationship between belief in God and illicit drug use became stronger as age increased (non‐believers: y = 8.1886x ‐ 9.16 R² = 0.9484; believers: y = 5.1514x ‐ 8.08 R² = 0.9247). These results suggest that, within this sample of English adolescents, there was a strong relationship between substance use and the social factors examined. Although there were differences depending upon whether cigarette, alcohol or illicit drug use was being modelled, logistic regression indicated that the social factors could be ranked in the following order of importance: concurrent use of the second and third substances, having been in trouble with the police, perceived poor academic performance and low future academic expectations, a lack of religious belief, coming from a non‐intact family, favouring peer over family opinion and having been suspended from school. Many of these relationships were age‐sensitive with substance use peaking at age 15. Conclusion. The models and relationships presented in this paper show that a constellation of behaviours are related to adolescent substance use. Also demonstrated is that behaviours cannot be considered in isolation, but need to be examined from an holistic or biopsychosocial standpoint. These relationships are complex and future research should consider not only causality of adolescent substance use, but also of the aetiology of the satellite behaviours.     

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.     

Poor adherence to HIV monitoring and treatment guidelines for HIV-infected injection drug users

Objectives

There is growing concern about access to HIV/AIDS care among injection drug users (IDUs). We examined rates of CD4 cell count monitoring and correlates among HIV‐infected IDUs.

Methods

This prospective observational cohort study of 460 community‐recruited HIV‐infected IDUs was situated in a Canadian city where all medical care is provided free of charge. Over a median follow‐up period of 76 months, we evaluated factors associated with CD4 cell count monitoring through a linkage with a centralized CD4 registry.

Results

Overall, <5% of IDUs had CD4 monitoring consistent with local therapeutic guidelines. In multivariate analyses, after adjustment for being on antiretroviral therapy [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.84–2.70, P<0.001] female gender (OR 0.71, 95% CI 0.57–0.89, P=0.003), non‐White ethnicity (OR 0.75, 95% CI 0.60–0.94, P=0.014), use of methadone maintenance therapy (OR 1.66, 95% CI 1.42–1.94, P<0.001) and daily heroin use (OR 0.72, 95% CI 0.61–0.85, P<0.001) were independently associated with CD4 monitoring.

Conclusions

Strategies to improve CD4 surveillance among IDUs are critically important, particularly for female and non‐White IDUs. Expanded treatment for heroin dependence appears to have the greatest potential for improved care.     

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.     

Heroin use among youths incarcerated for illicit drug use: psychosocial environment, substance use history, psychiatric comorbidity, and route of administration

This study examines differences in psychosocial characteristics, substance use history, and psychiatric comorbidity in relation to heroin use among youths aged 15 to 22 incarcerated in 2003 for illicit drug use in northern Taiwan. Factors associated with heroin use included experiences of child abuse, having friends with illicit drug use, poor school attendance, polydrug use, and early age of drug initiation. Heroin users were found to have more severe clinical manifestation and experiences of conduct and anxiety disorders than non-heroin users; injection users tended to have a longer heroin history. This information may help guide future prevention programs to reduce heroin problems in youth.     

Substance Use Predictors of Poor Medication Adherence: The Role of Substance Use Coping Among HIV-Infected Patients in Opioid Dependence Treatment

Many HIV-infected injection drug users (IDUs) continue to use illicit substances despite being in substance use treatment. Substance use is associated with non-adherence to HIV medications; however underlying mechanisms regarding this relation are understudied. The current investigation examined the role of substance use coping in terms of the relation between substance use and HIV medication adherence. Participants were 121 HIV-infected IDUs (41 % female, M age = 47, SD = 7.1) in opioid dependence treatment. Participants completed self-report questionnaires, were administered clinical interviews and oral toxicology screens, and used a medication-event-monitoring-system cap to assess 2 week HIV medication adherence. The use of cocaine and multiple substances were significantly related to decreased medication adherence. Substance use coping mediated these associations. Findings highlight the importance of assessing, monitoring, and targeting ongoing substance use, and ways to increase positive coping for HIV-infected IDUs in substance use treatment to aid in HIV medication adherence.     

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.