The impact of treatment on 3 years' outcome for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

AIM: To examine the impact of treatment for heroin dependence on drug use, injection-related risk-taking, health problems, criminality and general physical and mental health over 3 years among heroin-dependent Australians. DESIGN: Longitudinal prospective cohort study. PARTICIPANTS: A total of 615 heroin users enrolled in the Australian Treatment Outcome Study; 94.5% of the sample completed at least one follow-up interview over 36-month follow-up. FINDINGS: The proportion who reported using heroin in the preceding month continued to decrease significantly from baseline to 24-month follow-up (99% versus 35%), with this rate remaining stable to 36-month follow-up. The reduction in heroin use was accompanied by reductions in other drug use. There were also substantial reductions in risk-taking, crime, injection-related health problems and improvements in general physical and mental health. Positive outcomes were associated with more time in maintenance therapies and residential rehabilitation and fewer treatment episodes. Time spent in detoxification was not associated with positive outcomes. Major depression was also associated consistently with poorer outcome. CONCLUSIONS: At 3 years, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure.     

Suicide among heroin users: rates,risk factors and methods

ABSTRACT The current paper examines critically the literature on suicide rates, suicide risk factors and methods employed for suicide among heroin users, and compares these to those of the general population. Heroin users have a death rate 13 times that of their peers, and deaths among heroin users attributed to suicide range from 3–35%. Overall, heroin users are 14 times more likely than peers to die from suicide. The prevalence of attempted suicide is also many orders of magnitude greater than that of community samples. The major general population risk factors for suicide also apply to heroin users (gender, psychopathology, family dysfunction and social isolation). Heroin users, however, have extremely wide exposure to these factors. They also carry additional risks specifically associated with heroin and other drug use. Drugs as a method of suicide play a larger role in suicide among heroin users than in the general population. Heroin, however, appears to play a relatively small role in suicide among this group. Overall, suicide is a major clinical issue among heroin users. It is concluded that suicide is a major problem that treatment agencies face, and which requires targeted intervention if the rates of suicide among this group are to decline.     

The transition from injection to non-injection drug use: long-term outcomes among heroin and cocaine users in New York City

AIMS: To characterize heroin and cocaine users in New York City who have changed from injection to non-injection drug administration and to identify factors associated with long-term non-injection use. DESIGN: Two cross-sectional studies of heroin and cocaine users in New York City. SETTINGS AND PARTICIPANTS: New admissions were recruited at drug abuse treatment programs (2000-04) and respondent-driven sampling was used to recruit drug users from the community (2004). Both injecting and non-injecting drug users participated in each study. 'Former injectors' were defined operationally as people who had used heroin and/or cocaine in the 6 months prior to the interview and who had injected illicit drugs in the past, but whose most recent injection was more than 6 months before the study interview. 'Current' injectors were defined as people who had injected heroin and/or cocaine in the 6 months prior to the interview. MEASUREMENTS: A structured interview on drug use history was administered, and a serum sample was collected and tested for the human immunodeficiency virus (HIV). FINDINGS: A total of 104 former injectors was recruited for the drug abuse treatment program study, and 229 current injectors were recruited for the community recruitment study; 160 former injectors and 1731 current injectors were recruited from the drug abuse treatment study. Compared with the current injectors, former injectors were older and more likely to be African American. The former injectors reported long intervals since their most recent injection, a mean of 8 years in the drug abuse treatment program study and a mean of 12 years in the community recruitment study. The most common reasons for stopping injection drug use included concerns about health, social stigmatization and self-image, and preference for intranasal use as a route of drug administration. The results were highly consistent across the two studies. CONCLUSIONS: The transition from injection to non-injection use appears to be relatively stable behavior change for many former injectors, who report a decade or more without injecting. Developing a greater understanding of the transition from injection to stable non-injection drug use may provide insights into the natural histories of drug use and addiction.     

The impact of illicit drug supply reduction on health and social outcomes: the heroin shortage in the Australian Capital Territory

Aims We seek to establish whether a substantial decline in the supply of heroin, as measured by indicators such as drug purity, is related to changes in drug‐related health indicators such as ambulance callouts to heroin overdoses and numbers participating in methadone treatment programmes, and to changes in levels of property crime. The guiding hypothesis is that reduced supply will result in positive health and social outcomes. Design Standard time‐series methods are employed to analyse official data from local law‐enforcement and heroin supply indicators and several health and social outcome indicators within the Australian Capital Territory (ACT), spanning the late 1990s to early 2002. Autoregressive moving average (ARMA) models are estimated to remove autocorrelation from these series. Cross‐correlation and autoregression models are then employed to identify the best predictive models. Findings When autocorrelation has been removed, a reduction in heroin purity predicts a large decline in heroin‐related ambulance callouts and an increase in methadone treatment programme enrolments. There is little evidence of an increase in negative outcomes due to heroin users switching to other drugs. A reduction in purity also predicts declines in robbery and burglary but not in theft. Conclusion The overall evidence indicates modest links between the declines in heroin supply and increases in positive health outcomes and decreases in crime, as predicted by a simple economic model. Due to the shortness of some of the series and consequent limitations in statistical power, these conclusions should be regarded as tentative.     

Supply control and harm reduction: lessons from the Australian heroin 'drought'

Aims To examine the effects of supply‐side drug law enforcement on the dynamics of the Australian heroin market and the harms associated with heroin. Setting Around Christmas 2000, heroin users in Sydney and other large capital cities in Australia began reporting sudden and significant reductions in the availability of heroin. The changes, which appear to have been caused at least in part by drug law enforcement, provided a rare opportunity to examine the potential impact of such enforcement on the harm associated with heroin. Design Data were drawn from a survey of 165 heroin users in South‐Western Sydney, Australia; from the Drug Use Monitoring in Australia (DUMA) project; from NSW Health records of heroin overdoses; and from the Computerized Operational Policing System (COPS) database. Findings Heroin price increased, while purity, consumption and expenditure on the drug decreased as a result of the shortage. The fall in overall heroin use was accompanied by a significant reduction in the rate of overdose in NSW. However, the health benefits associated with the fall in overdose may have been offset by an increase in the use of other drugs (mainly cocaine) since the onset of the heroin shortage. There does not appear to have been any enduring impact on crime rates as a result of the heroin ‘drought’. Conclusion Supply control has an important part to play in harm reduction; however, proponents of supply‐side drug law enforcement need to be mindful of the unintended adverse consequences that might flow from successfully disrupting the market for a particular illegal drug.     

Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies

Aims To review the literature on mortality among dependent or regular users of opioids across regions, according to specific causes, and related to a number of demographic and clinical variables. Methods Multiple search strategies included searches of Medline, EMBASE and PsycINFO, consistent with the methodology recommended by the Meta‐analysis of Observational Studies in Epidemiology (MOOSE) group; grey literature searches; and contact of experts for any additional unpublished data from studies meeting inclusion criteria. Random‐effects meta‐analyses were conducted for crude mortality rates (CMRs) and standardized mortality ratios (SMRs), with stratified analyses where possible. Meta‐regressions examined potentially important sources of heterogeneity across studies. Results Fifty‐eight prospective studies reported mortality rates from opioid‐dependent samples. Very high heterogeneity across studies was observed; pooled all‐cause CMR was 2.09 per 100 person‐years (PY; 95% CI; 1.93, 2.26), and the pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out‐of‐treatment periods had higher mortality risk than in‐treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). Causes of death varied across studies, but overdose was the most common cause. Multivariable regressions found the following predictors of mortality rates: country of origin; the proportion of sample injecting; the extent to which populations were recruited from an entire country (versus subnational); and year of publication. Conclusions Mortality among opioid‐dependent users varies across countries and populations. Treatment is clearly protective against mortality even in non‐randomized observational studies. Study characteristics predict mortality levels; these should be taken into account in future studies.     

A social network perspective on heroin and cocaine use among adults: evidence of bidirectional influences

Aims   While several studies have documented a relationship between initiation of drug use and social network drug use in youth, the direction of this association is not well understood, particularly among adults or for stages of drug involvement beyond initiation. The present study sought to examine two competing theories (social selection and social influence) in the longitudinal relationship between drug use (heroin and/or cocaine) and social network drug use among drug-experienced adults.
Design   Three waves of data came from a cohort of 1108 adults reporting a life-time history of heroin and/or cocaine use.
Setting   Low-income neighborhoods with high rates of drug use in Baltimore, Maryland.
Participants   Participants had weekly contact with drug users and were 18 years of age or older.
Measurements   Drug use data were self-report. Network drug use was assessed through a social network inventory. Close friends were individuals whom the participant reported seeing daily or rated as having the highest level of trust.
Findings   Structural equation modeling indicated significant bidirectional influences. The majority of change in network drug use over time was due to change in the composition of the network rather than change in friends' behavior. Drug use by close peers did not influence participant drug use beyond the total network.
Conclusions   There is evidence of both social selection and social influence processes in the association between drug use and network drug use among drug-experienced adults.     

Arthritis health service utilization among the elderly: The role of urban-rural residence and other utilization factors

Objective. To compare the impact of urban-rural residence and other factors on the utilization of any type of arthritis-related physician care and on rheumatologist utilization. Methods. A population-based random sample of adults 65 years of age or older with self-reported arthritis from 10 urban and 12 rural Iowa counties were surveyed by telephone interview. We estimated the arthritis prevalence and health service utilization in this sample and evaluated the effects of predisposing, enabling, and need factors on utilization and satisfaction. Health care utilization was defined as ever having visited specific types of providers for arthritis-related care. Results. A total of 488 individuals participated: 227 from urban counties and 261 rural respondents. Urban respondents more commonly reported having received a diagnosis of osteoarthritis from their physicians but were less likely to report rheumatoid arthritis. A greater proportion of urban versus rural respondents had utilized any physician for arthritis care (50.7% versus 41.0%, P = 0.032) and had more often seen an orthopedist (18.1% versus 9.6%, P = 0.006) or general internist (18.5% versus 8.8%, P = 0.002). A diagnosis of rheumatoid arthritis, younger age, living with another person, higher income, and further distance from an arthritis provider were significantly associated with prior rheumatologist utilization. The strongest adjusted predictor of any physician visit for arthritis care was whether older adults drove themselves to their provider. For rheumatologist utilization, a diagnosis of rheumatoid arthritis and age were independently associated. Conclusions. The most striking finding was the consistent association of need factors (such as the desire for medical advice), joint swelling, and the presence of a diagnosis of rheumatoid arthritis with physician utilization. We identified significant urban-rural variations in factors both enabling and predisposing to arthritis care, although urban-rural status did not appear to independently influence arthritis physician utilization. In a rural state with a relatively small number of rheumatologists, deleterious enabling factors such as greater distance from the doctor and lack of supplemental insurance did not provide significant obstacles to either rheumatologist or generalist utilization.     

Asthma associated with the use of cocaine,heroin, and marijuana: A review of the evidence

Objective: A review of the evidence was conducted regarding asthma associated with the use of cocaine, heroin, and marijuana. Data Sources: A search of the English literature was performed via PubMed/Medline and EMBASE using the search terms asthma AND cocaine, heroin, and marijuana. When pertinent articles were found, salient references in those articles were assessed. Study Selection: Due to the relatively small number of studies, we included all studies and cases. Results: For several decades, case reports, retrospective studies, and laboratory investigations have demonstrated that inhalation of cocaine or heroin is associated with increased asthma symptoms and reduced pulmonary function. Smoking crack cocaine, nasal insufflation of cocaine or heroin, and smoking heroin increases the risk of emergency department visits and hospitalizations for asthma. Although frequent smoking of marijuana may cause symptoms of cough, sputum production, and wheezing in the general population, more studies are needed specifically in patients with asthma. Smoking marijuana with concomitant tobacco use is common and further worsens the respiratory symptoms. Conclusions: Use of cocaine and heroin in patients with asthma should be avoided. Pending further studies, it would be prudent for patients with asthma to avoid smoking marijuana. Clinicians need to be vigilant regarding use of these drugs in their patients with hyperreactive airway disease.     

The prevalence and correlates of gamma-hydroxybutyrate (GHB) overdose among Australian users

Aim The aim of this study was to examine the correlates, context and risk perceptions regarding gamma‐hydroxybutyrate (GHB) overdose among a sample of recreational GHB users in Australia. Design A cross‐sectional survey of 76 GHB users who were administered a structured interview on GHB use. They were asked a series of questions regarding whether they had ever experienced a GHB overdose, the context of their most recent GHB overdose, and about their perceptions of the risks of GHB overdose. Findings This sample of GHB users had not had a long or extensive experience with GHB use; despite this, half (53%) had experienced a GHB overdose. This sample of GHB users appeared to be well‐educated, employed and a history of either drug treatment or incarceration was uncommon. There were no differences between those who had or had not overdosed in terms of socio‐demographic characteristics, extent of other drug use or typical patterns of other drug use when using GHB. However, those who had overdosed on GHB had used it more times during their life‐time, and had been using it for a longer period of time. Conclusions GHB‐related overdoses were common among a sample of GHB users who had only recently begun using the drug. The only apparent distinguishing factor between those who had and had not overdosed on GHB was the amount of experience with GHB use.     

Reductions in costly healthcare service utilization: findings from the Care Advocate Program

OBJECTIVES: To determine whether a telephone care-management intervention for high-risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization. DESIGN: Randomized, controlled trial measuring healthcare services utilization over three 12-month periods (pre-, during, and postintervention). SETTING: Two social service organizations partnered with a Medicare HMO and four contracted medical groups in southern California. PARTICIPANTS: Eight hundred twenty-three patients aged 65 and older; eligibility was determined using an algorithm to target older adults with high use of insured healthcare services. INTERVENTION: After assessment, members in the intervention group were offered mutually agreed upon referrals to home- and community-based services (HCBS), medical groups, or Medicare HMO health plan and followed monthly for 1 year. MEASUREMENTS: Insured medical service utilization was measured across three 12-month periods. Acceptance and utilization of Care Advocate (CA) referrals were measured during the 12-month intervention period. RESULTS: CA intervention members were significantly more likely than controls to use primary care physician services (odds ratio (OR)=2.05, P<.001), and number of hospital admissions (OR=0.43, P<.01) and hospital days (OR=0.39, P<.05) were significantly more stable for CA group members than for controls. CONCLUSION: Results suggest that a modest intervention linking older adults to HCBS may have important cost-saving implications for HMOs serving community-dwelling older adults with high healthcare service utilization. Future studies, using a national sample, should verify the role of telephone care management in reducing the use of costly medical services.     

Cannabis use and dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing

Aims. To examine: (i) the prevalence of cannabis use and DSM-IV cannabis dependence among Australian adults, and (ii) correlates of level of cannabis involvement. Design. Cross-sectional survey assessing substance use and DSM-IV substance use disorders (abuse and dependence). Setting and participants. A household survey of a nationally representative sample of 10 641 Australians aged 18 years and older. Measurements. Trained interviewers administered a structured, modified version of the Composite International Diagnostic Interview (CIDI). Findings. In the past 12 months, 2.2% (95%CI:1.8, 2.6) of adults were diagnosed with DSM-IV cannabis use disorder, comprising cannabis dependence (1.5%; 95%CI: 1.2, 1.8) and cannabis abuse (0.7%, 95%CI: 0.6, 0.8). Almost one-third of cannabis users (31.7%; 95%CI: 27.7, 35.7) met criteria for cannabis dependence (21%; 95%CI: 16.7, 25.3) and abuse (10.7%; 95%CI: 8.0, 13.4). Multinomial logistic regression revealed that compared to non-dependent cannabis users, non-users were more likely to be female, aged 25 + years, out of the labour force and married/ de facto , and displayed lower levels of co-morbidity. In contrast, dependent cannabis users were more likely to be 18-24 years old, unemployed, and displayed higher levels of co-morbidity than non-dependent users. Conclusions. Cannabis use disorders affect approximately 300 000 Australian adults. A better understanding of the factors associated with cannabis dependence may help identify groups who have difficulties controlling use and aid the development of strategies for reducing cannabis-related harm.