Chemical hazards related to clandestine drug laboratories

The number of clandestine drug laboratories in the United States and Europe has increased as a result of the rising popularity of methamphetamine, Ecstasy, and gamma-hydroxybutyrate among young people and drug abusers, and a shift from complex production procedures for these drugs to simpler "cold cook" methods involving household chemicals. Fires, explosions, corrosive chemicals, and toxic substances at clandestine drug laboratories have caused injuries and deaths among police officers, firefighters, and the public. Impurities in clandestine synthetic drugs have also caused injuries among people consuming the drugs. Information about these hazards should be communicated to public safety professionals and young people to reduce the number of injuries and deaths.     

Alcohol, drugs and Australian young people

Experimentation with alcohol and other drugs is often seen as a normal part of adolescent development. The harm associated with substance misuse in young people include injury, violent behaviour, sexual risk taking, drink-driving, overdose, toxicity and death (1-4). Australian young people are drinking alcohol and using illicit substances at an earlier age than previous cohorts (5). hey are more likely to binge drink, have poly-substance use and are at risk of co-morbid mental health problems (1-3). The reasons young people use drugs are complex and varied. An effective response to illicit drug use by young people has to be holistic, as complex and varied as the needs it addresses. It must seek to prevent minimize and manage harm caused by drug use and must be provided to and involve young people in the context of their family, peer group, school and community. Reaching out to young people with drug and alcohol problems is everyone's responsibility. Australia has developed specific prevention and early intervention programs for young people at risk of substance abuse however, further research and development is still needed for effective prevention, early intervention and treatment programs.     

Harm reduction: Australia as a case study.

This paper explicates the term, "harm reduction"; demonstrates that harm reduction has a long tradition; and uses one country, Australia, as a case study. Harm reduction can be understood as "policies and programs which are designed to reduce the adverse consequences of mood altering substances without necessarily reducing their consumption"; it is consistent with the best traditions of both medicine and public health. Although it is difficult to interpret trends in mortality from alcohol, tobacco, and illicit drugs to determine whether harm reduction in Australia "worked", the effectiveness of harm-reduction policies and programs in controlling HIV among injecting drug users (IDUs) seems extremely strong and suggests that benefits of harm-reduction programs for other drugs will become apparent in time.     

Responsible use to responsible harm: illicit drug use and peer harm reduction in a darknet cryptomarket

Sale of illicit drugs through online ‘cryptomarkets’ is a notable innovation in the illicit drug market. Cryptomarkets present new ways of configuring risk and harm in relation to drug use. I examine the kinds of knowledge and discourses users employed to do this. I argue that the lay/expert divide that creates a hierarchy of knowledge around drug use and harms is increasingly undermined by the creation of knowledge communities by drug users who make drug use work effectively for them. I draw on the discussion forum of a now defunct English language focused cryptomarket, anonymised as ‘Merkat’, collected between 2015 and 2016. Typically, vendors in the major cryptomarkets are based in the USA, UK, China, the Netherlands and Australia. Buyers were mainly located in the USA, UK, Australia and Western Europe. I scraped the market forum threads and coded on emergent themes. I found that risk worked along four axes, cultural normalisation/pathologisation, chemical potency, legal/policy and market, each of which required a set of practices and orientations to manage successfully. Users indicated that they had adapted many harm reduction practices, while also promoting a ‘responsible harm’ orientation where they sought to own and take charge of harm. The support infrastructure drew on knowledge from drug users, vendors and interested professionals. I conclude that cryptomarkets can provide a community infrastructure that supports the exchange of drugs and configures them as risky but manageable objects.     

Social controls,harm minimisation and interactive outreach: the public health implications of an ethnography of drug use

Abstract: This is a report on ethnographic research with the members of a social network of young, recreational, illicit drug users in Perth, Western Australia, with whom I maintained close social interaction for over twelve months. Following the work of Zinberg, the article outlines some of the main social controls employed by these young drug users to reduce drug-related harm. These social controls are of two types: sanctions (the rules prescribing certain behaviours and proscribing others) and rituals (the stylised behaviour surrounding the use of drugs). There exists an ideology of harm minimisation amongst drug users which may provide the basis for innovative programs. The implications of these findings are discussed with reference to one particular public health strategy, outreach, and the possibility of a more active, reciprocal and beneficial engagement between drug users and researchers, health educators and policy makers is suggested.     

Public health consequences among first responders to emergency events associated with illicit methamphetamine laboratories--selected states, 1996-1999

Methamphetamine, a central nervous system stimulant, is manufactured in illicit laboratories using over-the-counter ingredients. Many of these ingredients are hazardous substances that when released from active or abandoned methamphetamine laboratories can place first responders at risk for serious injuries and death. In 16 states, the Agency for Toxic Substances and Disease Registry maintains the Hazardous Substances Emergency Events Surveillance (HSEES) system to collect and analyze data about the morbidity and mortality associated with hazardous substance-release events. Based on events reported to HSEES during 1996-1999, this report describes examples of events associated with illicit methamphetamine laboratories that resulted in injuries to first responders in three states, summarizes methamphetamine-laboratory events involving injured first responders, and suggests injury prevention methods to protect first responders.     

Illicit i.v. drugs. A public health approach

This article explores, from a public health perspective, the harm done by Canadian drug laws, to both individuals and society. It challenges the perceived dichotomy of legalization and criminalization of intravenous drugs. The article then expands the discussion by exploring eight legal options for illicit drugs and examines how these options interact with the marginalization of users, the illicit drug black market, and levels of drug consumption. While the main focus of this article is intravenous drugs, it draws some lessons from cannabis research.     

Factors related to the potential risk of trying an illicit drug among high school students in Paris

To identify risk factors of trying an illicit drug among adolescents exposed to an environment strongly using licit drugs, attitude toward illicit drugs, and use of tobacco, alcohol and tranquilizers were explored in a high school in Paris, April 1990. After a semi-directive interview and a pilot test, 233 students of one class chosen at random out of three at each high school level, completed an anonymous questionnaire. Logistic regression was used to detect risk factors of trying an illicit drug. Three kinds of risk factors were identified: (a) licit drugs: alcoholic drunkenness and abstaining from tranquilizers if personal discomfort is present, (b) peer modeling: presence of a fellow using marijuana, and (c) risk notion: weak risk notion on hashish use and belief that hard and soft drug use are not related. One student in 3 appeared at potential risk of trying an illicit drug. The risk factors suggested by this study may be used to set a policy of illicit drug primary prevention among adolescent specified populations. The importance of environmental factors is underlined.     

The Chinese government's response to drug use and HIV/AIDS: A review of policies and programs

Illicit drug use has become popular in China. Acknowledging the challenge of illicit drug use, China has adopted several new policies on the management of illicit drug use in recent years. This study reviews the current policies on drug use and assesses the harm reduction interventions among drug users in China. The review documents that the new policies on drug use provide a variety of choices of detoxification treatment for drug users. The methadone maintenance treatment and needle exchange programs have been adopted as harm reduction models in China. Most of the reviewed harm reduction programs have been successfully implemented and yielded positive effects in reducing drug related risk behaviors among drug users. Although there remain barriers to the effective implementation of policies on drug use and harm reduction programs, Chinese government has shown their commitment to support the expansion of harm reduction interventions for drug users throughout the country.     

Temporal correlation between opiate seizures in East/Southeast Asia and B.C. heroin deaths: a transoceanic model of heroin death risk

BACKGROUND: Because heroin supply changes cannot be measured directly, their impact on populations is poorly understood. British Columbia has experienced an injection drug use epidemic since the 1980s that resulted in 2,590 illicit drug deaths from 1990-1999. Since previous work indicates heroin seizures can correlate with supply and B.C. receives heroin only from Southeast Asia, this study examined B.C. heroin deaths against opiate seizures in East/Southeast Asia. METHODS: Opiate seizures in East/Southeast Asia and data from two B.C. mortality datasets containing heroin deaths were examined. The Pearson correlation coefficient for seizures against each mortality dataset was determined. RESULTS: Opiate seizures, all illicit drug deaths and all opiate deaths concurrently increased twice and decreased twice from 1989-1999, and all reached new peak values in 1993. Three B.C. sub-regions exhibited illicit drug deaths rate trends concurrent with the three principal datasets studied. The Pearson correlation coefficient for opiate-induced deaths against opiate seizures from 1980-1999 was R=0.915 (p<0.0001), and for illicit drug deaths against opiate seizures from 1987-1999 was R=0.896 (p<0.0001). CONCLUSIONS: From 1980-1999, opiate seizures in East/Southeast Asia were very strongly correlated with B.C. opiate and illicit drug deaths. The number of B.C. heroin-related deaths may be strongly linked to heroin supply. Enforcement services are not effective in preventing harm caused by heroin in B.C.; therefore, Canada should examine other methods to prevent harm. The case for harm reduction is strengthened by the ineffectiveness of enforcement and the unlikelihood of imminent eradication of heroin production in Southeast Asia.     

Patterns of Drug Use and HIV-Related Risk Behaviors among Incarcerated People in a Prison in Iran

Previous research indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions have been introduced into prisons in Iran, such as methadone maintenance treatment (MMT). MMT is now provided to opioid-dependent prisoners in 142 of the 230 prisons and correctional settings in Iran. A baseline behavioral survey was conducted in Karaj Central prison which mainly holds prisoners with drug-related charges. Overall, 203 male prisoners from randomly selected rooms in two prison blocks were interviewed using a structured questionnaire in 2007, just before the introduction of MMT program in this prison. Among participants, 7% reported never having used illicit drugs in their lifetime, but 51% had used non-injecting illicit drugs, and as high as 42% reported having injected an illicit drug. Up to 79% (160/203) of all participants reported using drugs, and about 6% (12/203) reported drug injecting during their current incarceration term. Same-gender sexual practice during current incarceration term was reported by 2.5% (5/203) of all male prisoners. Comparison between injecting and non-injecting drug-using prisoners indicated that drug injectors had higher rates of previous incarcerations, commenced drug use at a younger age, were more likely to have used illicit drugs in the previous week, were more likely to have been treated by a physician for drug addiction, had higher rates of registration for methadone treatment inside prison, and were more likely to have been tested for HIV infection. These study findings provide a behavioral profile of prisoners in regard to drug-related harm and can be considered in any plan to introduce or improve provision of MMT in prisons in Iran or other countries with similar features.     

Comparing 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression

High rates of both illicit drug use and depression are consistently reported among gay men. However, little is known about how beliefs about drug use shape clinical encounters between gay men and health professionals, and that in turn affect clinical communication and care, particularly in relation to depression. We compared 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression. Semi-structured interviews were conducted during August-December 2006 with 16 general medical practitioners working in seven 'gay-friendly' practices in Sydney, Adelaide and a rural-coastal city in New South Wales, and during February-May 2008 with 40 gay men with depression recruited through four Sydney and Adelaide practices. A thematic analysis of these two sets of interviews found that doctors expressed the beliefs that: illicit drug use is related to depression in gay men; illicit drug use impedes effective diagnosis and treatment of depression in gay men; and illicit drug use increases the level of complexity involved in caring for gay men with depression. Gay men expressed the beliefs that: illicit drug use is closely related to depression; illicit drug use can be helpful in dealing with difficult experiences; and illicit drug use is just what you do as a gay man living in a big city. Both groups believed drug use and depression were related, but doctors emphasised the negative outcomes of drug use and interpreted these in relation to health. Gay men believed that drugs could have both negative and positive uses and differentiated between health and social outcomes. While the doctors articulated a pragmatic position on drug use, which is consistent with harm reduction principles, communication with gay male patients could be enhanced if both groups acknowledged their divergent views of illicit drugs and their potential role in mental health.     

Health effects from unintentional occupational exposure to opioids among law enforcement officers: Two case investigations

Recent increases in the rate of drug overdose-related deaths, the emergence of potent opioids such as carfentanil, and media reports of incidents have raised concerns about the potential for work-related exposure to a variety of illicit drugs among law enforcement officers (LEOs), other emergency responders, and other workers in the United States. To characterize the risk associated with unintentional occupational exposure to drugs, we retrospectively investigated two incidents that occurred in 2017 and 2018 where LEOs were exposed to opioid and stimulant drugs and experienced health effects. We interviewed five affected LEOs and others. We reviewed records, including emergency department documentation, incident reports, forensic laboratory results, and when available, body camera footage. Multiple drug types, including opioids and nonopioids, were present at each incident. Potential routes of exposure varied among LEOs and were difficult to characterize with certainty. Health effects were not consistent with severe, life-threatening opioid toxicity, but temporarily precluded affected LEOs from performing their essential job duties. While health risks from occupational exposure to drugs during law enforcement activities cannot currently be fully characterized with certainty, steps to prevent such exposures should be implemented now. The creation and implementation of appropriate controls plus education and training are both important to protecting first responders from these hazardous agents. To more fully characterize potential exposures, timely prospective toxicological evaluation of affected responders is recommended.     

Is peer injecting a form of intimate partner abuse? A qualitative study of the experiences of women drug users

Women are over-represented as the recipients of injections of illicit drugs and are often injected by their intimate partners. This study used qualitative research to explore women drug users' experiences of abuse from intimate partners when being injected with illicit drugs. In-depth interviews were conducted with 45 women drug users in the city of Leeds and the area of North Nottinghamshire, UK. The practice of peer injecting illicit drugs places women recipients at risk of physical, economic and emotional abuse from their male intimate partner injectors. However, this was not a universal feature. In trusting, supportive intimate partner relationships peer injecting took place through reciprocal arrangements. Moving away from peer injecting was technically and emotionally difficult for women and rarely straightforward. The implications of the work are discussed as clinicians and wider drug service staff should be aware of the possibility of abuse and enquire about peer injecting when consulting with women injecting drug users. However, clinicians should avoid working within a simplistic clinical framework that views all peer injecting as intrinsically abusive. More research is needed to provide evidence for best practice. Until then, generic principles of best practice management of intimate partner abuse could apply, including enhancing women's motivation to effect change in an abusive situation.     

A review of school drug policies and their impact on youth substance use

Youth substance use is an important social and health problem in the United States, Australia and other Western nations. Schools are recognized as important sites for prevention efforts and school substance use policies are a key component of health promotion in schools. The first part of this paper reviews the known status of school policies on tobacco, alcohol and other illicit drugs in a number of Western countries and the existing evidence for the effectiveness of school drug policy in preventing drug use. The review shows that most schools in developed countries have substance use policies but that there is substantial variation in the comprehensiveness of these policies (i.e. the breadth of people, places and times of day that are explicitly subject to policy prohibitions), and the orientation of their enforcement (e.g. punitive versus remedial), both across and within schools. The few studies of policy impact focus solely on tobacco policy and provide preliminary evidence that more comprehensive and strictly enforced school policies are associated with less smoking. The second part of the paper introduces the International Youth Development Study, a new longitudinal research project aimed at comparing school policies and the developmental course of youth drug use in the United States, where drug policies are abstinence-based, with Australia, which has adopted a harm minimization approach to drug policy.     

Web-Based Discussion and Illicit Street Sales of Tapentadol and Oxycodone in Australia: Epidemiological Surveillance Study

BackgroundOpioid use disorder and its consequences are a persistent public health concern for Australians. Web activity has been used to understand the perception of drug safety and diversion of drugs in contexts outside of Australia. The anonymity of the internet offers several advantages for surveilling and inquiring about specific covert behaviors, such as diversion or discussion of sensitive subjects where traditional surveillance approaches might be limited.ObjectiveThis study aims to characterize the content of web posts and compare reports of illicit sales of tapentadol and oxycodone from sources originating in Australia. First, post content is evaluated to determine whether internet discussion encourages or discourages proper therapeutic use of the drugs. Second, we hypothesize that tapentadol would have lower street price and fewer illicit sales than oxycodone.MethodsWeb posts originating in Australia between 2017 and 2019 were collected using the Researched Abuse, Diversion, and Addiction-Related Surveillance System Web Monitoring Program. Using a manual coding process, unstructured post content from social media, blogs, and forums was categorized into topics of discussion related to the harms and behaviors that could lead to harm. Illicit sales data in a structured format were collected through a crowdsourcing website between 2016 and 2019 using the Researched Abuse, Diversion, and Addiction-Related Surveillance System StreetRx Program. In total, 2 multivariable regression models assessed the differences in illicit price and number of sales.ResultsA total of 4.7% (28/600) of tapentadol posts discussed an adverse event, whereas 10.27% (95% CI 9.32-11.21) of oxycodone posts discussed this topic. A total of 10% (60/600) of tapentadol posts discussed unsafe use or side effects, whereas 20.17% (95% CI 18.92-21.41) of oxycodone posts discussed unsafe use or side effects. There were 31 illicit sales reports for tapentadol (geometric mean price per milligram: Aus $0.12 [US $0.09]) and 756 illicit sales reports for oxycodone (Aus $1.28 [US $0.91]). Models detected no differences in the street price or number of sales between the drugs when covariates were included, although the potency of the pill significantly predicted the street price (P<.001) and availability predicted the number of sales (P=.03).ConclusionsAustralians searching the web for opinions could judge tapentadol as safer than oxycodone because of the web post content. The illicit sales market for tapentadol was smaller than that of oxycodone, and drug potency and licit availability are likely important factors influencing the illicit market.     

Harm reduction in hospitals: is it time?

Among persons who inject drugs (IDU), illicit drug use often occurs in hospitals and contributes to patient expulsion and/or high rates of leaving against medical advice (AMA) when withdrawal is inadequately managed. Resultant disruptions in medical care may increase the likelihood of several harms including drug resistance to antibiotics as well as costly readmissions and increased patient morbidity. In this context, there remains a clear need for the evaluation of harm reduction strategies versus abstinence-based strategies with respect to addressing ongoing issues related to substance use among addicted hospitalized patients. While hospitalization can be used to stabilize addicted patients as they recover from their acute illness and help them to achieve abstinence, patients unable to maintain abstinence should not be penalized for failing to do so at the expense of their health. This article describes harm reduction activities within hospitals and areas for future investigation.     

Infant Birth Outcomes Among Substance Using Women: Why Quitting Smoking During Pregnancy is Just as Important as Quitting Illicit Drug Use

Poor birth outcomes are associated with illicit drug use during pregnancy. While prenatal cigarette exposure has similar effects, cessation of illicit drug use during pregnancy is often prioritized over cessation of smoking. The study goal was to examine the impact of pregnancy tobacco use, relative to use of illicit drugs, on birth outcomes. Women were recruited at entry to prenatal care, with background and substance use information collected during pregnancy. Urine drug screens were performed during pregnancy, and the final sample (n = 265) was restricted to infants who also had biologic drug testing at delivery. Participants were classified by pregnancy drug use: no drugs/no cigarettes, no drugs/cigarette use, illicit drugs/no cigarettes, and illicit drugs/cigarette use. Groups differed significantly on infant birthweight, but not gestational age at delivery after control for confounders including background and medical factors. Among women who smoked, the adjusted mean birthweight gain was 163 g for those not using hard illicit drugs, while marijuana use had no effect on birth weight beyond the effect of smoking cigarettes. Women who used hard illicit drugs and did not smoke had an adjusted mean birthweight gain of 317 g over smokers. Finally, women who refrained from hard illicit drugs and smoking had a birthweight gain of 352 g. Among substance using pregnant women, smoking cessation may have a greater impact on birthweight than eliminating illicit drug use. Intervention efforts should stress that smoking cessation is at least as important to improving pregnancy outcomes as abstaining from illicit drug use.     

Medicare Drug Price Negotiation in the United States: Implications and Unanswered Questions

The United States is a relatively free-pricing market for pharmaceutical manufacturers to set list prices at the product launch. Few drug price controls exist, and federal price negotiation as a policy has historically been politically untenable. After decades of debate on whether the federal government, specifically the Medicare program, should more actively manage drug prices, the US Congress passed legislation authorizing Medicare to directly negotiate prices with manufacturers. The purpose of this article is to describe elements and implementation of the price negotiation provisions and then comment on the potential impacts on payers, innovations, and the pharmaceutical industry. While impacting only a few drugs each year in the beginning, price negotiation in the Medicare program will have secondary and long-term effects in the US market and beyond. It is clear that in the United States, the Medicare market for drugs will no longer be a free-pricing environment in the industry.