Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia

BackgroundKrokodil, a homemade injectable opioid, gained its moniker from the excessive harms associated with its use, such as ulcerations, amputations and discolored scale-like skin. While a relatively new phenomenon, krokodil use is prevalent in Russia and the Ukraine, with at least 100,000 and around 20,000 people respectively estimated to have injected the drug in 2011. In this paper we review the existing information on the production and use of krokodil, within the context of the region's recent social history.MethodsWe searched PubMed, Google Advanced Search, Google Scholar, YouTube and the media search engine www.Mool.com for peer reviewed or media reports, grey literature and video reports. Survey data from HIV prevention and treatment NGOs was consulted, as well as regional experts and NGO representatives.FindingsKrokodil production emerged in an atypical homemade drug production and injecting risk environment that predates the fall of communism. Made from codeine, the active ingredient is reportedly desomorphine, but – given the rudimentary ‘laboratory’ conditions – the solution injected may include various opioid alkaloids as well as high concentrations of processing chemicals, responsible for the localized and systemic injuries reported here. Links between health care and law enforcement, stigma and maltreatment by medical providers are likely to thwart users seeking timely medical help.ConclusionA comprehensive response to the emergence of krokodil and associated harms should focus both on the substance itself and its rudimentary production methods, as well as on its micro and macro risk environments – that of the on-going syndemic of drug injecting, HIV, HCV, TB and STIs in the region and the recent upheaval in local and international heroin supply. The feasibility of harm reduction strategies for people who inject krokodil may depend more on political will than on the practical implementation of interventions. The legal status of opioid substitution treatment in Russia is a point in case.     

Housing and harm reduction: What is the role of harm reduction in addressing homelessness?

Homelessness and drug use often overlap and the harms of substance use are exacerbated by homelessness. Responding to the twin problems of homelessness and substance use is an important aspect of strategies to end homelessness. The introduction and development of ten year plans to end homelessness in North America heralds a new era of systemic responses to homelessness. Central to many of these plans is the adoption of ‘Housing First’ as a policy response. Housing First focuses directly on housing people regardless of current patterns of substance use. As such, harm reduction is a key principle of Housing First. In this paper, we examine Housing First as an example of the integration of housing and harm reduction and then put forth a community level policy framework to further promote the integration of harm reduction as part of a response to homelessness. Drawing on Rhodes’ risk environment framework and current evidence of Housing First and harm reduction, we describe four key policy areas for action: (1) social inclusion policies; (2) adequate and appropriate supply of housing; (3) on demand harm reduction services and supports and (4) systemic and organizational infrastructure. We conclude by identifying areas for future research.     

青少年健康危险行为研究现况及展望

随着我国经济结构的转型和＂十二五＂期间医药卫生体制改革的进展,对青少年健康危险行为的研究取得了显著成就,为进一步探讨监控青少年健康危险行为的适宜方法,控制其健康危险行为对青少年时期及其成年后的潜在身心威胁和负面影响,现对青少年健康危险行为流行状况进行综述,并展望未来研究方向。     

Worries about others’ substance use—Differences between alcohol,cigarettes and illegal drugs?

BackgroundWhile it is well documented that many experience harm from others’ substance use, little is known about the psychological strain associated with others’ use. The aims were: (1) to describe the prevalence of worries about others’ alcohol, cigarette and illegal drug use, (2) whose substance use people worry about, (3) the overlap in worries, and (4) to examine how worries about others’ use of each substance vary according to demographics, own substance use and experience of harm from others’ use.MethodsA population survey was conducted among 16–64 year old Norwegians (N = 1667). Respondents’ reported on worries about others’ alcohol, cigarette and illegal drug use, measures of experiences of harm from others’ use of the three substances, and own substance use.ResultsWorries about others’ drinking were most prevalent. Among those who worried, others’ cigarette and illegal drug use caused more frequent worry. While worry about cigarette use was mostly associated with family members’ use, worry about others’ alcohol and illegal drug use more often concerned friends’/acquaintances’ use. About half worried about others’ use of at least one substance. Across all three substances, experience of harm from others’ substance use was most strongly related to worries.ConclusionWorries about others’ substance use are common and reflect the prevalence of use of the substances in the population. In sum, the findings suggest that worry about others’ alcohol and illegal drug use is primarily related to acute harm while worry about others’ cigarette smoking is more related to chronic harm.     

Patterns of harm reduction service utilization and HIV incidence among people who inject drugs in Ukraine: A two-part latent profile analysis

BackgroundProgram utilization patterns are described within a large network of harm reduction service providers in Ukraine. The relationship between utilization patterns and HIV incidence is determined among people who inject drugs (PWID) controlling for oblast-level HIV incidence and treatment/syringe coverage.MethodsData were extracted from the network’s monitoring and evaluation database (January 2011–September 2014, n = 327,758 clients). Latent profile analysis was used to determine harm reduction utilization patterns using the number of HIV tests received annually and the number of condoms, syringes, and services (i.e., information and counseling sessions) received monthly over a year. Cox proportional hazards regression determined the relations between HIV seroconversion and utilization class membership.ResultsIn the final 4-class model, class 1 (34.0% of clients) received 0.1 HIV tests, 1.3 syringes, 0.6 condom and minimal counseling and information sessions per month; class 2 (33.6%) received 8.6 syringes, 3.2 condoms, and 0.5 HIV tests and counseling and information sessions; class 3 (19.1%) received 1 HIV test, 11.9 syringes, 4.3 condoms, and 0.7 information and counseling sessions; class 4 (13.3%) received 1 HIV test, 26.1 syringes, 10.3 condoms, and 1.8 information and 1.9 counseling sessions. Class 4 clients had significantly decreased risk for HIV seroconversion as compared to those in class 1 after controlling for oblast-level characteristics.ConclusionInjection drug use continues to be a major mode of HIV transmission in Ukraine, making evaluation of harm reduction efforts in reducing HIV incidence among PWID critical. These analyses suggest that receiving more syringes and condoms decreased risk of HIV. Scaling up HIV testing and harm reduction services is warranted.     

心房颤动的形成机制、危害及治疗

心房颤动的发生机制目前主流的观点是触发活动和折返机制,其次还有钾＂离子通道＂＂失控＂和多种因素协同机制.对炎症和氧化应激的干预治疗是一种新的方向,未来可能成为心律失常治疗学中的一大亮点.随着老年人口不断增多,房颤已成为发病人数排在高血压、冠心病之后的第三位心血管疾病.房颤的治疗,归纳起来是两大策略：一是药物治疗,二是非药物治疗.近年来导管射频消融技术的开展,为房颤的治疗带来了革命性变化.     

A high proportion of users of low-threshold facilities with needle exchange programmes in Switzerland are currently on methadone treatment: implications for new approaches in harm reduction and care

Background

Increasingly, patients receiving methadone treatment are found in low threshold facilities (LTF), which provide needle exchange programmes in Switzerland. This paper identifies the characteristics of LTF attendees receiving methadone treatment (MT) compared with other LTF attendees (non-MT).

Methods

A national cross-sectional survey was conducted in 2006 over five consecutive days in all LTF (n = 25). Attendees were given an anonymous questionnaire, collecting information on socio-demographic indicators, drug consumption, injection, methadone treatment, and self-reported HIV and HCV status. Univariate analysis and logistic regression were performed to compare MT to non-MT. The response rate was 66% (n = 1128).

Results

MT comprised 57.6% of the sample. In multivariate analysis, factors associated with being on MT were older age (OR: 1.38), being female (OR: 1.60), having one's own accommodation (OR: 1.56), receiving public assistance (OR: 2.29), lifetime injecting (OR: 2.26), HIV-positive status (OR: 2.00), and having consumed cocaine during the past month (OR: 1.37); MT were less likely to have consumed heroin in the past month (OR: 0.76, not significant) and visited LTF less often on a daily basis (OR: 0.59). The number of injections during the past week was not associated with MT.

Conclusions

More LTF attendees were in the MT group, bringing to light an underappreciated LTF clientele with specific needs. The MT group consumption profile may reflect therapeutic failure or deficits in treatment quality and it is necessary to acknowledge this and to strengthen the awareness of LTF personnel about potential needs of MT attendees to meet their therapeutic goals.