Polydrug use among 15- to 16-year olds: Similarities and differences in Europe

Aims: We describe types of polydrug use among school students across Europe and explore differences between high, medium and low drug prevalence countries.

Method: Analysis is based on survey data from over 70,000 15- to 16-year-old school students in 22 European countries. Polydrug use (defined as the use of two or more listed substances during the last 30 days) is compared across three country clusters based on drug prevalences by hierarchical cluster analysis. Affinity between substances is measured by pairwise associations and regression analysis was used to assess the differences in rate ratio across the country clusters.

Results: A third of all school students had consumed two or more substances. The most common combinations were: alcohol and cigarettes, followed by alcohol or cigarettes combined with cannabis, followed by alcohol or cigarettes, cannabis and at least one other illegal drug. Pairwise associations show that cannabis and cocaine users are more likely to use illegal drugs than the general student populations but least likely to do so in countries with high prevalence levels (p < 0.0005).

Conclusion: Consideration of country differences and objective measures for the concept of normalization could help to inform more holistic prevention initiatives that respond to country-specific contexts.     

Cocaine and crack use and dependence in Europe – experts view on an increasing public health problem

Background: The spread of cocaine and crack use in Europe poses a challenge to the European health-care systems. The assessment of the extent of the problem as well as the support needs of the users require involving all relevant parties in research and future planning.

Method: Within the framework of a European multi-center and multi-modal research project, experts of nine European cities were interviewed according to a standardised structural interview protocol.

Results: Cocaine use is considered to be on the increase in Europe. The prevalence rates vary substantially between countries and the problem emerges in different target groups in distinct patterns of use. Although cocaine and crack specific risks can be diagnosed, health risks follow basically the general risks of illicit drug use. Proposals for future planning include the broadening of the existing services and the implementation of evidence-based approaches to the problem.

Conclusion: In dealing with the cocaine problem in Europe, a comprehensive public health approach is appropriate. An overall strategy should include preventive, harm reductive as well as rehabilitative measures. Consequently, cross-national guidelines should be established and their implementation as well as evaluation should be monitored.     

An exploration of alcohol use severity and route of drug administration among persons that use heroin and cocaine

ABSTRACT

Background: Alcohol use is prevalent among populations of persons that use illicit drugs. Problematic alcohol use among persons that use heroin and cocaine has been associated with poor treatment adherence, abstinence maintenance, and mental health concerns. Fully exploring how alcohol use severity interacts with route of administration (ROA) may be of notable importance in development of treatment protocols for persons that use heroin and cocaine. Methods: Data from a neurological and sociobehavioral assessment of risk factors among injection and noninjection drug users known as the NEURO-HIV Epidemiologic Study was used in the analyses. Participants (N = 551) included those who reported their level of past-30-day alcohol use and past-6-month heroin and cocaine use. Results: Multiple logistic regression analyses found that both problematic and moderate alcohol users were significantly less likely than abstainers to report injecting heroin and cocaine. Both problematic and moderate alcohol users were significantly more likely than abstainers to snort substances. Conclusions: Alcohol use may play a role in promoting or impeding the use of substances through certain ROAs. Treatment protocols that transition persons that use injection heroin and cocaine to noninjection use of these substances may be used in conjunction with treatments that reduce alcohol consumption as a means to reduce noninjection drug use.     

Provision of harm reduction and drug treatment services in custodial settings – Findings from the European ACCESS study

Aims: The aim of the study was to survey the availability, coverage and quality of harm reduction and drug treatment services delivered to drug users in prisons across Europe. Methods: A survey was conducted between 2012 and 2013 among the 29 European countries. An electronic semistructured questionnaire was sent to the national institutions responsible for prison services, and 27 countries responded. In addition, good practice interventions for drug offenders have been collated by 15 national experts covering 15 European countries. The interventions were described and assessed as to their quality through using European monitoring centre for drugs and drug addiction (EMCDDA) standard tools for reporting and quality assessment. Findings: Drug treatment including detoxification and opioid substitution treatment (OST) is available in prisons of most European countries. However, OST is unavailable in five countries. Almost all countries provide prison-based harm reduction measures to prevent and treat infectious diseases among prisoners. Especially, testing and treatment for HIV and tuberculosis are provided, while other measures, such as the distribution of condoms or bleach, and especially needle and syringe programmes are still rare. Conclusions: Access to and coverage of OST in prisons is higher in countries with a long history of OST provision, while in countries that introduced OST more recently the scale of OST is usually lower. Access to hepatitis C treatment is often limited in prisons due to the lack of drug abstinence or a health insurance.     

Comparing Injection and Non-Injection Routes of Administration for Heroin,Methamphetamine, and Cocaine Users in the United States

ABSTRACT

Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration—injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.     

Patterns of alcohol use among men receiving treatment for heroin and/or cocaine use in England,Brazil and Spain. A cross-country analysis

Abstract

Introduction: Although alcohol is widely used concurrently with illicit drugs, the role of alcohol in recovery from and relapse to drug use is under-researched. This study investigates drinking patterns and factors associated with harmful drinking among men receiving community treatment for heroin and/or cocaine use.

Methods: Secondary analysis of 3 cross-sectional studies in England (n?=?153), Brazil (n?=?149) and Spain (n?=?131) was conducted. Sociodemographic, alcohol consumption (AUDIT), substance use, treatment characteristics, and physical health were assessed. Logistic regression determined factors associated with harmful drinking.

Results: 41% of men receiving heroin and/or cocaine treatment met criteria for harmful drinking. Of this, 28% were not receiving treatment for alcohol. Factors identified with harmful drinking among those who were not receiving treatment for alcohol use were as follows: homeless, unemployment/receiving benefits, poly drug use, history of injecting drug(s), hepatitis C seropositive, and receiving treatment for heroin use with/without treatment for cocaine use. Participants from England who met criteria for harmful drinking were more likely to report not receiving treatment for alcohol use than those from Brazil and Spain.

Discussion: Findings show that harmful drinking is common among men in treatment for drug use and remains neglected by the services.     

Epidemiological indicators and ethnographic realities of female cocaine use

This study is an ethnographic examination of differences in the male-to-female ratio among cocaine users in epidemiological indicators from emergency room departments, local drug-user treatment programs, and the pretrial detention center. In-depth interviews were conducted with female cocaine users. The lower female ratio in drug treatment and emergency department sources seems related to barriers to drug-user treatment for women and the image of emergency departments as an extension of the criminal justice system. The women's involvement in visible illegal activities and their perception as easy arrestees may explain the arrestee data ratio. The findings indicate that epidemiological indicators may misrepresent the gender distribution among drug users.     

Factors associated with sex-trade involvement among female injection drug users in a Canadian setting

Background: We undertook this study to evaluate the factors associated with sex-trade involvement among a cohort of female injection drug users (IDUs).

Methods: We performed a prospective analysis of factors associated with sex-trade involvement among female participants enrolled in a prospective cohort study of Vancouver injection drug users. We examined HIV-status during follow-up and measured time updated social, sex- and drug-related variables relating to activities engaged in during the previous six months. Variables potentially associated with sex-trade involvement were evaluated using generalized estimating equations (GEE) with logit link for binary outcomes.

Results: Between May 1, 1996 and November 30, 2003, 565 participants were recruited into the cohort of whom 336 (59%) reported being involved in the sex-trade at baseline. Factors associated with reporting sex-trade involvement among women in the adjusted model included incarceration, daily injected cocaine use, daily crack use, borrowing syringes, lending syringes, and having sought but been unable to access addiction treatment during the previous six months.

Conclusions: Our study demonstrates significant risky sexual and injection behaviours as well as difficulties with access to addiction treatment among female IDUs involved in the sex-trade in Vancouver.     

The Criminal Justice Experience of African American Cocaine Users in Arkansas

Background: African Americans are incarcerated at rates much higher than other racial and ethnic groups in the United States. Objectives: We sought to qualitatively explore the relationships between ongoing involvement in the criminal justice system and continued drug use in a population of urban and rural African American cocaine users in a southern state. Methods: Semi-structured qualitative interviews were conducted among African American cocaine users in Arkansas between 2010 and 2012. Participants resided in both rural (two counties located in the eastern Arkansas Mississippi delta region) and urban (the county including the capital city of Little Rock) areas. Results: Numerous important themes emerged from participants’ narratives, including chronic involvement with the criminal justice system (being a “career criminal”), continued access to drugs while incarcerated, relapse, and reincarceration and lack of access to effective drug treatment. Conclusion/Importance: The themes which emerged from our data speak to the collective experience that many substance using populations in the United States face in dealing with the criminal justice system. Our findings highlight the need to better, more holistic ways of engaging African American substance users in community based substance use treatment and supportive services.     

Self-esteem and self-efficacy: Associations with alcohol consumption in a sample of adolescents in Northern Ireland

Background: Little is known about the factors that influence injecting drug users’ (IDUs) choice of outlet, and in particular why some IDUs might prefer to use pharmacies. Greater understanding of the influences on this choice will contribute to more sophisticated policy and programme responses for blood-borne virus prevention and for health and wellbeing programmes for people who inject drugs.

Method: In-depth interviews were conducted with 15 IDUs about their experiences of accessing injecting equipment from pharmacies that participated in the government-sponsored pharmacy needle and syringe scheme.

Results: A range of factors influenced participants’ decisions about equipment access. The advantages of the pharmacy scheme access included convenience, relative anonymity, increased positive feelings of self-worth when accessing equipment from pharmacies where they had a good relationship with staff, less police surveillance and access to a greater range of equipment than available in publicly funded Needle and Syringe Programmes. The disadvantages of pharmacy access included the cost of equipment and complications related to methadone dosing and equipment access.

Conclusion: Pharmacy access to injecting equipment is highly valued by IDUs. The results of this study direct attention to several elements of programme and policy in the area that would increase access to equipment from pharmacies relating to cost, need for exchange, police surveillance practices, out-of-hours access and anonymity.     

AIDS among drug users in Europe.

This study was carried out by the Regional Office for Europe of the World Health Organization. It contains information obtained by 31 December 1990 from 31 countries under the headings: illegal use of drugs; AIDS among intravenous drug users; HIV seropositivity among drug users; measures to prevent HIV infection among drug users; training programmes for drug workers.     

Polydrug use and its association with drug treatment outcomes among primary heroin,methamphetamine, and cocaine users

BackgroundPolydrug use may challenge effective treatment for substance use disorders. We evaluate whether secondary substance use modifies the association between treatment and primary drug use among primary heroin, cocaine and methamphetamine (MA) users.MethodsData were obtained from prospective cohort studies on people who use illicit drugs (PWUD) in California, USA. Using repeated monthly data on self-reported secondary substance use (heroin, cocaine, MA, alcohol or marijuana; ≥1 day in a month), primary drug use (≥1 day in a month), and treatment participation, collected via timeline follow-back, we fitted generalized linear mixed multiple regression models controlling for potential confounders to examine the interactions between treatment and secondary substance use on the odds of primary heroin, cocaine and MA use, respectively.ResultsIncluded in our study were 587 primary heroin, 444 primary MA, and 501 primary cocaine users, with a median of 32.4, 13.3 and 18.9 years of follow-up, respectively. In the absence of secondary substance use, treatment was strongly associated with decreased odds of primary drug use (adjusted odds ratios (aORs): 0.25, 95% CI: 0.24, 0.27, 0.07 (0.06, 0.08), and 0.07 (0.07, 0.09)) for primary heroin, MA, and cocaine users, respectively. Secondary substance use of any kind moderated these associations (0.82 (0.78, 0.87), 0.25 (0.21, 0.30) and 0.53 (0.45, 0.61), respectively), and these findings were consistent for each type of secondary substance considered. Moreover, we observed different associations in terms of direction and magnitude between secondary substance use and primary drug use during off-treatment periods across substance types.ConclusionThis study demonstrates secondary substance use moderates the temporal associations between treatment and primary drug use among primary heroin, MA and cocaine users. Disparate patterns of polydrug use require careful measurement and analysis to inform targeted treatment for polydrug users.     

Emerging drugs and alternative possibilities in the treatment of tuberculosis

Introduction: Tuberculosis (TB) remains a global health problem. Drug resistance, treatment duration, complexity, and adverse drug reactions associated with anti-TB regimens are associated with treatment failure, prolonged infectiousness and relapse. With the current set of anti-TB drugs the goal to end TB has not been met. New drugs and new treatment regimens are needed to eradicate TB.

Areas covered: Literature was explored to select publications on drugs currently in phase II and phase III trials. These include new chemical entities, immunotherapy, established drugs in new treatment regimens and vaccines for the prophylaxis of TB.

Expert opinion: Well designed trials, with detailed pharmacokinetic/pharmacodynamic analysis, in which information on drug exposure and drug susceptibility of the entire anti-TB regimen is included, in combination with long-term follow-up will provide relevant data to optimize TB treatment.

The new multi arm multistage trial design could be used to test new combinations of compounds, immunotherapy and therapeutic vaccines. This new approach will both reduce the number of patients exposed to inferior treatment and the financial burden. Moreover, it will speed up drug evaluation.

Considering the investments involved in development of new drugs it is worthwhile to thoroughly investigate existing, non-TB drugs in new regimens.     

Polydrug Use and HIV Risk Among People Who Inject Heroin in Tijuana,Mexico: A Latent Class Analysis

Background: Although most people who inject drugs (PWID) in Tijuana, Mexico, primarily inject heroin, injection and non-injection use of methamphetamine and cocaine is common. We examined patterns of polydrug use among heroin injectors to inform prevention and treatment of drug use and its health and social consequences. Methods: Participants were PWID residing in Tijuana, aged ≥18 years who reported heroin injection in the past six months and were recruited through respondent-driven sampling (n = 1,025). Latent class analysis was conducted to assign individuals to classes on a probabilistic basis, using four indicators of past six-month polydrug and polyroute use: cocaine injecting, cocaine smoking or snorting, methamphetamine injecting, and methamphetamine smoking or snorting. Latent class membership was regressed onto covariates in a multinomial logistic regression. Results: Latent class analyses testing 1, 2, 3, and 4 classes were fit, with the 3-class solution fitting best. Class 1 was defined by predominantly heroin use (50.2%, n = 515); class 2 by methamphetamine and heroin use (43.7%, n = 448), and class 3 by methamphetamine, cocaine, and heroin use (6.0%, n = 62). Bivariate and multivariate analyses indicated a group of methamphetamine and cocaine users that exhibited higher-risk sexual practices and lower heroin injecting frequency, and a group of methamphetamine users who were younger and more likely to be female. Conclusions: Discrete subtypes of heroin PWID were identified based on methamphetamine and cocaine use patterns. These findings have identified subtypes of heroin injectors who require more tailored interventions to reduce the health and social harms of injecting drug use.     

Pharmacoeconomic and clinical implications of sequential therapy for metastatic renal cell carcinoma patients in Central and Eastern Europe

Introduction: The incidence and mortality rates of kidney cancer in the Central and Eastern European (CEE) region are among the highest in the world. Access to second and subsequent lines of metastatic renal cell carcinoma (mRCC) therapies is highly varied in the region. Despite the increasing body of evidence supporting the clinical benefit of multiple lines of treatment, access to treatment beyond first line is restricted in many of these countries.

Areas covered: The adoption of targeted therapies for the first-line treatment of mRCC in the region was slow and faced many obstacles. In order to evaluate the current status of treatment beyond the first-line setting in the CEE region, this review examines the availability and reimbursement of mRCC drugs and clinical practice in institutions that treat patients with mRCC.

Expert opinion: This review highlights the need to raise awareness among physicians, payers and regulators on clinical trial and cost-effectiveness data regarding the treatment of mRCC beyond the first line. The obstacles to mRCC drug access highlighted in this review need to be overcome to ensure that patients are receiving the best treatment available.     

No end to the crisis without an end to the waiver

ABSTRACT. Background: National adolescent drug use surveys are distributed in United States schools. Survey results determine trends in drug use and inform research and prevention efforts; however, students who have dropped out of school or were truant the day of the survey are excluded. Examining drug trends in a high-risk population (adolescents admitted for drug treatment) may better characterize drug users and their use patterns. Methods: The current study examined questionnaires completed by 939 adolescents admitted for substance abuse treatment between 1995 and 2010. Results: Age of first use (ranging from 13.2 years for alcohol to 15.1 years for cocaine) was significantly younger for cigarettes, alcohol, and cannabis than for “harder” drugs such as cocaine and heroin, and adolescents increased their use of almost every substance (except inhalants) with increasing age. This was not true of national data. Additionally, in the national data, less than 1.5% of participants reported using any of the harder drugs more than 5 times, but in the McLean data, even for harder drugs, >10% of adolescents used >50 times. Conclusions: In the high-risk sample examined here, progression to harder drugs is accelerated and increases with age regardless of sex. These data underscore the importance of prevention and immediate treatment when adolescent substance use is identified.     

Illicit drug use among Bangladeshi women living in the United Kingdom: An exploratory qualitative study of a hidden population in East London

This explorative study focused on Bangladeshi women using illicit drugs in the London Borough of Tower Hamlets, which has a large Bangladeshi population. The study was designed to: examine Bengali women's perceptions of their drug use and perception of treatment services; identify the cultural determinants of service utilization; examine the concept of izzat (honour) and its role in contributing to the secrecy surrounding Bengali women's drug use; examine the pressures that have contributed to Bengali women accessing drug treatment services in Tower Hamlets; and examine barriers to the utilization of drug treatment services.

?Eight Bengali female drug users were recruited via two treatment settings and one by snowballing methods and data gathering was through qualitative discourse.

?The findings revealed that Bengali female drug users constitute a hidden population that is engaging in high-risk behaviours, especially unsafe sex. Cultural constructs, such as shame about drug use, antipathy towards injecting and stigmatization of drug use in the community are all present in this group. Gender role expectations are particularly pronounced for this group and they face greater gender discrimination from within their community in respect of substance use and misuse than their male counterparts. They experience profound barriers to treatment, which prevent them from accessing services at an earlier stage in their drug use. Their presentation to drug services frequently involves a coercive element whether from family members or social services.

?Service provision should include targeted hepatitis- and HIV-prevention programmes.     

Mandatory assessment of drug users in Malaysia: Implications on human rights

Aim: The study is founded upon a critical analysis of the extent to which the mandatory drug assessment in funneling drug users under Malaysia's compulsory treatment and rehabilitation programme is consistent with the principles of human rights guaranteed under the Malaysian Constitution.

Method: Empirical qualitative data from a case study encompassing direct observations of natural sites, a focus group comprising former and recovering drug users, secondary data from official documents and case files.

Results: Findings show that the mandatory drug assessment of drug users is subject to arbitrary arrest, unnecessary prolonged detention, lack of medical assistance and non-compliance to due process.

Conclusions: The mandatory drug assessment of drug users in Malaysia entails serious infringements of the principles of human rights.     

Drug-Abusing Homeless Clients in California's Substance Abuse Treatment System

Abstract

As many as one-half to three-fourths of homeless persons have diagnoses of alcohol or other drug dependence. Rates of alcohol and other drug use disorders, and the social costs associated with untreated substance disorder, are higher among homeless than nonhomeless persons. Despite the high level of need for treatment, relatively few substance-abusing homeless individuals receive treatment for their drug problems, suggesting difficulties in accessing treatment. This study addresses access by focusing on the select group of homeless drug users who have overcome barriers to enter the substance abuse treatment system in California and by examining differences between these homeless treatment clients and nonhomeless drug-using clients. Major findings from bivariate and logistic regression analyses performed on 187 homeless and 1,820 nonhomeless treatment clients are that homeless clients were more likely than nonhomeless clients to have a primary drug problem of cocaine/crack and to be injecting methamphetamine and other amphetamines, and that they were no less likely to complete their treatment program. An implication of this study is that homeless persons with primary drug problems appear to have no less commitment to achieving treatment goals than their nonhomeless counterparts.