Drug misuse by patients in an inner-city hospital

AIM: To identify the prevalence of drug misuse (illicit, over-the-counter and prescribed) by patients at Bristol Royal Infirmary, an inner-city teaching hospital, and the problems encountered by ward staff in the management of these patients. METHOD: A prevalence survey was conducted in the A&E department of the hospital using an adapted version of the two-item conjoint screening test (TICS), a validated screening tool devised by Brown et al (1997). A qualitative survey of ward managers was used to identify the problems presented by drug misusers on the ward, and to gather suggestions for the role of a specialist substance misuse liaison worker. RESULTS: An 11 per cent prevalence of drug misuse was found among 64 patients attending the A&E department. In the survey of 18 ward managers, ten (55.5 per cent) wards admitted a minimum of one drug misuser each week and 15 wards (83 per cent) described negative behaviours among this patient group which had an effect on the management of the ward. CONCLUSION: Consideration should be given to routine screening for the presence of drug misuse among patients. Introduction of a specialist drug misuse liaison worker and guidelines for the management of this patient group would help to reduce the significant problems experienced by staff.     

Hazardous Drinking and HIV Sexual Risk Behaviors Among Injection Drug Users in Developing and Transitional Countries

Studies in North America and Western Europe have reported an association between hazardous drinking and HIV sexual risk behaviors among injection drug users (IDUs). However, we lack such studies from developing and transitional countries, where different cultural norms and contexts of drinking may change this association. We used a multi-site study using standard survey instruments and methods to examine whether hazardous drinking is associated with HIV sexual risk behaviors (defined as unprotected sex and having multiple sex partners) among IDUs in 12 cities across different developing and transitional countries. Data were collected from May 1999 to November 2003. In individual site analyses, hazardous drinking was associated with increased HIV risk behaviors in 10 cities. Mixed effects models of the multi-site data, also, showed an association of hazardous drinking and HIV sexual risk behaviors. These findings in the context of the high prevalence of drinking in many sites point to the importance of addressing alcohol use in HIV education and prevention policy for IDUs.     

Current and emerging research needs in studying the NYC HIV-drug use epidemic

As we begin the fourth decade of the epidemic, it is clear that, as demonstrated by the articles in this Special Issue, much has been learned about factors contributing to the decline in HIV prevalence among drug users in New York. However, there are a number of outstanding research questions that remain or are emerging. Following is a summary of some of the topics requiring further research. While this summary does not represent a comprehensive list, it is based on many of the questions raised in the articles in this Special Issue and identifies some of the directions to be investigated during the next decade.     

Symbiotic goals and the prevention of blood-borne viruses among injection drug users

A positive-deviance control-case life history study of injection drug users (IDUs) in New York City who had injected drugs for 8-15 years compared 21 IDUs who were antibody negative for both HIV and hepatitis C with 3 infected with both viruses and 11 infected with hepatitis C virus but not HIV. Eligible subjects were referred from other research studies and from community organizations that conduct testing for HIV and hepatitis C virus. Data were collected during 2005-2008 and were analyzed using life history and grounded theory approaches. They support grounded hypotheses that IDUs who are able to attain symbiotic goals like avoiding withdrawal and maintaining social support are assisted thereby in remaining uninfected with HIV or hepatitis C. These hypotheses should be tested using cohort studies and prevention trials to see if helping IDUs attain symbiotic goals reduces infection risk. The study's limitations are noted.     

HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.     

Geographic approaches to quantifying the risk environment: drug-related law enforcement and access to syringe exchange programmes

The concept of the "risk environment"--defined as the "space ... [where] factors exogenous to the individual interact to increase the chances of HIV transmission"--draws together the disciplines of public health and geography. Researchers have increasingly turned to geographic methods to quantify dimensions of the risk environment that are both structural and spatial (e.g., local poverty rates). The scientific power of the intersection between public health and geography, however, has yet to be fully mined. In particular, research on the risk environment has rarely applied geographic methods to create neighbourhood-based measures of syringe exchange programmes (SEPs) or of drug-related law enforcement activities, despite the fact that these interventions are widely conceptualized as structural and spatial in nature and are two of the most well-established dimensions of the risk environment. To strengthen research on the risk environment, this paper presents a way of using geographic methods to create neighbourhood-based measures of (1) access to SEP sites and (2) exposure to drug-related arrests, and then applies these methods to one setting (New York City [NYC]). NYC-based results identified substantial cross-neighbourhood variation in SEP site access and in exposure to drug-related arrest rates (even within the subset of neighbourhoods nominally experiencing the same drug-related police strategy). These geographic measures--grounded as they are in conceptualizations of SEPs and drug-related law enforcement strategies--can help develop new arenas of inquiry regarding the impact of these two dimensions of the risk environment on injectors' health, including exploring whether and how neighbourhood-level access to SEP sites and exposure to drug-related arrests shape a range of outcomes among local injectors.