Amphetamine Prescribing as a Harm Reduction Measure: A Preliminary Study

The study evaluated prescribing dexamphetamine for injecting primary amphetamine users. Subjects were prescribed dexamphetamine, up to 40mg daily, dispensed up to six times weekly. The treatment group were those 63 clients who had been prescribed dexamphetamine and fulfilled the study criteria. The control group comprised all 25 clients who fulfilled the same criteria but who had attended the service before dexamphetamine prescribing began. Three questions were addressed: does prescribing amphetamine attract high risk users, does it retain them in contact with the service and does it change behaviour. There were statistically significant increases in the number and proportion of amphetamine users attending the service and in the duration of contact with the treatment group. There were statistically significant reductions in the quantity and frequency of illicit amphetamine use, benzodiazepine use, money spent on drugs, injecting, needle sharing and track marks among the treatment group. Dexamphetamine prescribing merits further study.     

Deficit models and divergent philosophies: Service providers' perspectives on barriers and incentives to drug treatment

Aims: To ascertain service providers' views on barriers and incentives to illicit drug users accessing or remaining in treatment.

Methods: Interviews with service providers in Australia were conducted.

Results: Two main themes were explored. Service providers suggested that the perception of a person seeking treatment was strongly associated with the image of that person as deficient, defective or lacking, and that this could impede treatment. Service providers also suggested that differing treatment philosophies and their related treatment goals were at the core of many barriers to treatment. We argue that it is important to find a balance between a model of treatment which works and is responsive to clients' needs while also avoiding the potential for feeding stigma of those who seek treatment for drug dependence.

Conclusion: Our results suggest that knowledge and understanding of treatment philosophies are important for people seeking treatment so that clients can find services that match their needs and treatment goals.     

Drug replacement treatments: is amphetamine substitution a horse of a different colour?

Advocates of amphetamine substitution therapy argue that needle sharing by amphetamine users, and associated infectious disease risk, outweigh the risks associated with oral dexamphetamine substitution prescribing, and that substitution can allow stabilization and gradual withdrawal of patients, or maintenance. Others note that amphetamine users are not generally physically dependent, dexamphetamine prescribing can lead to increased drug use and psychosis, and that there are possible neurotoxic effects from prolonged chronic exposure to amphetamines. Research on the impact of amphetamine and cocaine prescribing on drug use, injecting, social adjustment and criminal involvement is lacking apart from a small number of retrospective case reports. Early experience in the United Kingdom leads to the view that amphetamine maintenance was a therapeutic failure. More recently, clinicians have expressed confidence that the approach has merit, and while their claims should not be discounted there remains no empirical basis to support them. Although dexamphetamine substitution therapy has been heralded as an important intervention to reduce injecting behaviour and associated infectious disease risk, there is very little research which attests to its success in reaching this goal. Indeed, what is known regarding patterns of amphetamine use and the effects of prolonged use of the drug raise serious doubts as to the efficacy of amphetamine maintenance. There is an urgent need for randomized or case-controlled trails of the efficacy of these procedures. Until such empirical comparative research is available, the benefits to be gained from dexamphetamine substitution therapy remain speculative and opinion-based.     

Exchange, deceit, risk and harm: The consequences for women of receiving injections from other drug users

Aims: To explore the consequences for women of being injected with illicit drugs.

Methods: In-depth interviews with 45 women injecting drug users who have been injected by other people.

Findings: Women's reliance on others to administer injections meant they had less control over their drug use. Exchanging drugs as currency for being injected was common and women had little choice but to provide the injector with drugs. Being injected by others often caused the recipient physical harm. Previous experience of deception and harm meant women became more knowledgeable about their injector's intentions and subsequently tried to reduce future damage when being injected. Women appeared to be confused about the risks associated with being injected and the perceived risks were often complex and polarized. Understanding the context and nature of being injected is important for services when working with injection recipients.

Conclusions: This work uncovered ideas about a complex area and highlights the importance for those working with drug users to pay attention to this. Increased training and awareness for drug-service staff about factors influencing being injected and the potential associated risks is recommended. Reinforcing current harm-reduction messages and providing related advice to injection recipients is also important. In improving the knowledge and awareness about being injected, women recipients may gain increased choice and agency in the injection process.     

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.     

Alcohol, other drug use, and gambling among Australian Capital Territory (ACT) workers in the building and related industries

Aims: To describe the prevalence of alcohol, drug, and gambling problems among building and related workers in the ACT.

Methods: Workers at 9 major construction and maintenance sites in the ACT received self-administered questionnaires, which they completed on site and returned to researchers.

Findings: Workers returned 254 usable questionnaires. Response rates varied by location but were between 70 and 80% on larger sites. They reported high levels of tobacco, cannabis and amphetamine use and 19% reported self-diagnosed alcohol problems, 11.5% gambling problems and 18% problems in their family life.

Conclusions: This study found high levels of alcohol, and other drug use among building and related workers and high levels of self-diagnosed problems associated with this use and with gambling. While an existing union-led program aims to reduce harm on the worksite, the levels of self-reported family and gambling problems found in this study suggest that more needs to be done for workers and their families off worksites.     

Involving drug users in treatment decisions: An exploration of potential problems

Aims: This paper explores the problems that can arise when trying to involve illicit drug users in decisions about their own treatment.

Methods: Semi-structured interviews (n = 187) were conducted in two specialist community prescribing agencies and two residential rehabilitation agencies. Seventy-nine new treatment clients were interviewed, and 59 of these were re-interviewed three months later. Interviews were also conducted with 27 agency staff and 22 individuals who had referred the drug users into treatment.

Findings: Difficulties in implementing user involvement in drug treatment decision making could be grouped under five broad headings: (1) the perceived characteristics, needs and expectations of drug users; (2) the attitudes of professionals; (3) the dynamics of treatment encounters; (4) treatment programme design; and (5) structural factors affecting service provision.

Conclusions: While involving drug users in treatment decisions is achievable, the problems can be substantial and complex. More financial resources to increase the availability and accessibility of treatment options; improved communication between service providers and their clients; and an investment in education, training and skills development can all potentially promote client participation. Nonetheless, some constraints to full involvement in decision making are likely to be inevitable and even necessary.     

Chiral analysis of amphetamines in hair by liquid chromatography–tandem mass spectrometry: compliance‐monitoring of attention deficit hyperactivity disorder (ADHD) patients under Elvanse® therapy and identification after controlled low‐dose application

Amphetamine (AMP) is used as an illicit drug and also for the treatment of attention deficit hyperactivity disorder (ADHD). Respective drugs most often contain the enantiomer (S)‐AMP as active compound or (S)‐AMP is formed from the prodrug lisdexamfetamine (Elvanse®) whereas the illicit drug is usually traded as racemate ((R/S)‐AMP). A differentiation between the use of the medically prescribed drug and the abuse of illicit street amphetamine is of great importance, for example in retrospective consumption monitoring by hair analysis. A liquid chromatography–tandem mass spectrometry (LC–MS/MS) method for the chiral separation and quantitation of (S)‐ and (R)‐AMP in hair was developed. For this purpose, 20 mg hair was extracted and derivatized with N‐(2,4‐dinitro‐5‐fluorophenyl)‐L(S)‐valinamide L(S)‐(DNPV) to yield amphetamine diastereomers. Baseline separation of the resulting diastereomers was achieved on a high‐pressure liquid‐chromatography system (HPLC) coupled to a Sciex QTRAP® 5500 linear ion trap quadrupole mass spectrometer. The method was successfully validated. Analysis of hair samples from nine Elvanse® patients revealed only (S)‐AMP in eight cases; one subject showed both enantiomers indicating a (side‐) consumption of street amphetamine. The analysis of the 16 amphetamine users' samples showed only racemic amphetamine. Furthermore, it could be shown in a controlled study that (S)‐AMP can be detected after administration of even very low doses of lisdexamfetamine and dexamphetamine, which can be of interest in forensic toxicology and especially in drug‐facilitated crime (DFC). The method now enables the retrospective compliance‐monitoring of ADHD patients and the differentiation between medically prescribed intake of (S)‐amphetamine and abuse of illicit street amphetamine.     

Predictors of neurotic symptom severity among female drug users in Glasgow, Scotland

Aims: The prevalence and predictors of neurotic symptom severity among 266 female drug users recruited from three services in Glasgow, Scotland, is described.

Methods: The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms. Questions on abuse and eating disorders were adapted from the Female European Addiction Severity Index.

Findings: In their lifetime, 71% (184/260) had been emotionally abused, 65% (168/260) physically abused and 50% (129/259) sexually abused. In addition, 85% (227/266) met threshold for a neurotic disorder (CIS-R ≥ 12) and 71% (188/266) reported a severity of current neurotic symptoms likely to need treatment (CIS-R ≥ 18). Stepwise multiple logistic regression found that ever suffering from bulimia, anorexia and/or binge eating (OR 4.10, 95% CI 1.76-9.58), adult emotional abuse (OR 2.98, 95% CI 1.57-5.65), being prescribed psychiatric medication in the last 30 days (OR 2.95, 95% CI 1.18-7.38), and 12-month dependence on illicit tranquillizers (OR 2.51, 95% CI 1.29-4.89) were associated with CIS-R ≥ 18. Results were compared for participants attending each of the three services.

Conclusions: The findings demonstrate the multiple and complex needs of female drug users that may require medical, mental health and drug use treatment.     

Treatment retention in the Drug Intervention Programme: Do primary drug users fare better than primary offenders?

Aims: The Drug Intervention Program (DIP) was set up to reduce drug-related crime by engaging drug-using offenders in treatment. However, the limited evidence that exists would suggest that reconviction rates are high, and are linked to failure to complete the treatment programme. This study examined completion rates in one DIP programme by crime behaviours and drug use.

Method: A retrospective case-note method based on all files opened over a three-month window, examining outcomes three months after the last case was opened. A total of 123 files were examined.

Results: While less than 5% of cases were successfully completed, some form of positive outcome was reported in 14% of cases, 57% had negative outcomes (such as breaching the requirements of the order or failure to attend) and 29% were still open 6 months after the start of the programme. Negative outcomes were associated with more intensive criminal histories and lower levels of drug use in the month prior to intake to DIP. Open cases were typically associated with fewer previous incarcerations but higher levels of current drug use.

Conclusions: Relatively few cases had positive outcomes, although treatment retention exceeded expectations in around one quarter of cases. The analysis provides tentative support for the suggestion that drug users accessing treatment through the criminal justice system can be broadly split into drug-using offenders and offending drug users, and these two groups have differing outcomes in criminal justice treatment interventions.     

Substance misuse training among psychiatric doctors, psychiatric nurses, medical students and nursing students in a South London psychiatric teaching hospital

Background: Health professionals play an important role in the detection and subsequent management of individuals who misuse substances.

Aim: This article aimed to assess self-reported levels of training received by psychiatric doctors, nurses, medical students and nursing students in a South London psychiatric teaching hospital.

Method: Self-completion questionnaire assessing key aspects of training.

Findings: We found low overall levels of reported training in substance misuse. Of the reported training received, most was theoretical rather than clinical. The highest level of reported training was in alcohol misuse compared to illicit drug and tobacco misuse. High numbers of respondents reported feeling responsible for helping individuals with substance misuse difficulties but low numbers actually felt skilled to do so, indicating high levels of awareness without the requisite training.

Conclusion: Our findings suggest that more resources should be focused on teaching psychiatric doctors, nurses, medical students and nursing students the key issues in substance misuse, and that this training should be clinically grounded, to alleviate the perceived low levels of reported clinical training in this study and the resulting lack of confidence.