Predictors of the degree of drug treatment coverage for injection drug users in 94 metropolitan areas in the United States of America

AimsA prior study concluded that drug treatment coverage, defined as the percentage of injection drug users in drug treatment, varied from 1 percent to 39 percent (median 9 percent) in 96 metropolitan statistical areas (MSAs) in the United States. Here, we determine which metropolitan area characteristics are associated with drug treatment coverage.MethodsWe conducted secondary analysis of official data, including the number of injection drug users in treatment and other variables, for 94 large US MSAs. We estimated the number of injection drug users in these metropolitan areas using previously described methods. We used lagged cross-sectional analyses where the independent variables, chosen on the basis of a Theory of Community Action, preceded the dependent variable (drug treatment coverage) in time. Predictors were determined using ordinary least squares multiple regression and confirmed with robust regression.ResultsIndependent predictors of higher drug treatment coverage for injectors were: presence of organisations that support treatment (unstandardized beta = 1.64; 95 percent CI .59 to 2.69); education expenditures per capita in the MSA (unstandardized beta = .12; 95 percent CI −.34 to 2.69); lower percentage of drug users in treatment who are non-injection drug users (unstandardized beta = −0.18; 95 percent CI −0.24 to −0.12); higher percentage of the population who are non-Hispanic White (unstandardized beta = .14; 95 percent CI .08 to .20); lower per capita long-term debt of governments in the metropolitan area (unstandardized beta = −0.93; 95 percent CI −1.51 to −0.35).ConclusionsIn conditions of scarce treatment coverage for drug injectors, an indicator of epidemiologic need (the per capita extent of AIDS among injection drug users) does not predict treatment coverage, and competition for treatment slots by non-injectors may reduce injectors’ access to treatment. Metropolitan finances limit treatment coverage. Political variables (racial structures, the presence of organisations that support drug treatment, and budget priorities) may be important determinants of treatment coverage for injectors. Although confidence in these results would be higher if we had used a longitudinal design, these results suggest that further research and action that address structural, political, and other barriers to treatment expansion are sorely needed.     

Using the health belief model to predict injecting drug users' intentions to employ harm reduction strategies

We examined whether perceived susceptibility to and severity of two injection-related health conditions (i.e., non-fatal overdose and bacterial infections), and perceived benefits of, barriers to, self-efficacy to, social acceptance of, and recent use of two harm-reduction behaviors (i.e., injecting test shots and pre-injection skin cleaning), predicted injecting drug users' near-term intentions to engage in these two strategies. Recent past use of these two behaviors consistently and positively predicted near-term intentions in each of four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, and with others). Perceived susceptibility to non-fatal overdose predicted intentions to do test shots, but only when participants imagined not being in withdrawal or injecting when alone. Perceived self-efficacy to clean one's skin predicted intentions to engage in this behavior, but only when participants imagined injecting while not in withdrawal. Participants' ratings of how often other injectors in their social network engage in pre-injection skin cleaning was also a significant positive predictor of intentions to clean one's skin, but only when they imagined being in withdrawal. Finally, length of time attending the needle exchange program was negatively associated with intention to engage in skin cleaning when not in withdrawal.     

High and low threshold service provision in drug-free settings: Practitioner views

BackgroundIn the United States, drug-free (non-drug substitution) treatment programmes are informed by an abstinence-only, disease model. Some critics believe this model hinders treatment service utilization and retention. An alternative public health model of harm reduction suggests that drug services should have a “low-threshold” for entry and retention such that they are offered with few or no conditions, such as abstinence from drug use.MethodsUsing semi-structured qualitative interviews with 15 practitioners from 9 outpatient drug-free agencies, this study examined beliefs about low threshold service provisions.ResultsRespondents identified certain conditions for drug services as clinically and programmatically appropriate and necessary to ensure safety. Factors relevant to outpatient services, drug use and client dynamics were also cited. Respondents tended to support service conditions to inform treatment planning and practices.ConclusionsPractitioners in these settings accept and support some threshold of imposed service conditions as useful in treatment and service planning. When outpatient services are terminated clinically appropriate services are offered instead. Concerns for service accessibility should focus on the availability of medically intensive services.     

An epidemiologic review of smokeless tobacco health effects and harm reduction potential

A systematic review of the epidemiologic literature on the health effects of smokeless tobacco (ST) and its relevance to the harm reduction model for smoking was undertaken. Published epidemiologic studies, from the US and European countries, meeting defined inclusion criteria and assessing the health effects of smokeless tobacco products were examined. ST use showed evidence of a slightly increased risk for all-cause mortality. Little evidence was found to support a causal relationship between ST use and risk of oral, pancreatic or lung cancer. ST use was not associated with an increased risk of cardiovascular disease or stroke incidence, but evidence suggested ST use was associated with increased mortality from these diseases. Clinical trials evaluating the effectiveness of ST products in smoking cessation have been sparse, and no standardized method for measuring ST dependence has been used, limiting the assessment of their relationship to ST use. Several studies have examined if ST use increases the risk of smoking initiation, but few have modeled this complex behavior appropriately. Overall, epidemiologic studies have not shown strong evidence of elevated tobacco-related disease risks with ST use. More research is necessary to assess the smoking behavioral consequences of ST use prior to its consideration as a harm reduction tool.     

What is the role of harm reduction when drug users say they want abstinence?

Quantitative survey data indicate that most drug users starting treatment want abstinence rather than harm reduction (McKeganey et al., 2004). This finding has been seized upon by those seeking ‘evidence’ that abstinence is the bedrock of recovery and harm reduction is a negative and oppositional philosophy. However, all research involves questions of meaning, definition and value and an alternative research paradigm and different study design can provide important additional insights into treatment aspirations, including the desire for abstinence. Qualitative interviews conducted with 30 recovering heroin users (15 males and 15 females) in Southern England in 2009 confirm that those starting treatment often report a desire for abstinence. Nonetheless, drug users are frequently uncertain about their ability to achieve this and can have very different and inconsistent understandings of what being abstinent means. We suggest that the work of the critical theorist [Habermas, 1970] and [Habermas, 1991] could improve our understanding of abstinence and is consistent with recent efforts to achieve a working definition of recovery. Importantly, our qualitative data also reveal that drug users have treatment aspirations that extend far beyond their drug consumption. They additionally want to improve relationships, engage in meaningful activities, acquire material possessions, and achieve better mental and physical health. Moreover, these broader life goals are often inextricably linked to their drug taking. From this, we conclude that both abstinence and harm reduction discourses should more routinely prioritise the many diverse ‘wellness’ goals that so clearly motivate treatment clients. The harm reduction field will then likely find that it has more in common with abstinence-oriented services and the broader recovery agenda than it might otherwise have imagined.     

Drug policy, harm and human rights: a rationalist approach

Background

It has recently been argued that drug-related harms cannot be compared, so making it impossible to choose rationally between various drug policy options. Attempts to apply international human rights law to this area are valid, but have found it difficult to overcome the problems in applying codified human rights to issues of drug policy.

Method

This article applies the rationalist ethical argument of Gewirth (1978) to this issue. It outlines his argument to the ‘principle of generic consistency’ and the hierarchy of basic, nonsubtractive and additive rights that it entails. It then applies these ideas to drug policy issues, such as whether there is a right to use drugs, whether the rights of drug ‘addicts’ can be limited, and how different harms can be compared in choosing between policies.

Result

There is an additive right to use drugs, but only insofar as this right does not conflict with the basic and nonsubtractive rights of others. People whose freedom to choose whether to use drugs is compromised by compulsion have a right to receive treatment. They retain enforceable duties not to inflict harms on others. Policies which reduce harms to basic and nonsubtractive rights should be pursued, even if they lead to harms to additive rights.

Conclusion

There exists a sound, rational, extra-legal basis for the discussion of drug policy and related harms which enables commensurable discussion of drug policy options.     

Harm reduction intensity-Its role in HAART adherence amongst drug users in Amsterdam

Background

Opioid substitution treatment seems to improve adherence to highly active antiretroviral therapy (HAART) in drug users (DU). DU in Amsterdam receive methadone within a harm reduction programme. We hypothesized that not only receiving methadone, but joining this complete comprehensive programme would improve HAART adherence.

Methods

Included were 102 HIV-positive DU attending the Amsterdam Cohort Study (ACS), reporting HAART use at multiple visits between 1999 and 2009. Non-adherence was defined as taking less than 95% of medication in the past 6 months (self-reported). Harm reduction intensity (HR) was measured by combining injecting drug use, methadone dosage and needle exchange, in different levels of participation, ranging from no/incomplete HR, complete HR to low or no dependence on HR. We studied the association between non-adherence and harm reduction intensities with logistic regression models adjusted for repeated measurements.

Results

Non-adherence was reported in 11.9% of ACS visits. Non-injecting DU with low dependence on HR were less adherent than DU with complete HR (aOR 1.78; CI 95% 1.00-3.16), although there was no overall effect of HR. No difference was demonstrated in adherence between DU with complete HR and incomplete HR. Unsupervised housing (no access to structural support at home) (aOR 2.58; CI 95% 1.40-4.73) and having a steady partner (aOR 0.48; CI 95% 0.24-0.96) were significantly associated with respectively more and less non-adherence.

Conclusions

In Amsterdam, still-injecting DU who are exposed to systematic and integrated care, although not practising complete harm reduction, can be just as adherent to HAART as DU who make use of complete harm reduction and non-injecting DU with no dependence on harm reduction. These findings suggest the importance of a systematic and comprehensive support system including supervised housing and social and medical support to increase HAART adherence rates amongst all HIV-infected DU. When such programmes are introduced in settings where injecting drug use is highly prevalent, access to HAART for drug users in these settings can and should be increased.     

Hepatitis elimination by 2030: Progress and challenges

Globally, over 300 million people are living with viral hepatitis with approximately 1.3 million deaths per year. In 2016, World Health Assembly adopted the Global Health Sector Strategy on viral hepatitis to eliminate hepatitis by 2030. Different World Health Organization member countries are working on hepatitis control strategies to achieve hepatitis elimination. So far, only 12 countries are on track to achieve hepatitis elimination targets. The aim of the study was to give an update about the progress and challenges to achieving hepatitis elimination by 2030. According to the latest data, 87% of infants had received the three doses of hepatitis B virus (HBV) vaccination in the first year of their life and 46% of infants had received a timely birth dose of HBV vaccination. There is a strong need to improve blood and injection safety. Rates of hepatitis B and C diagnosis are very low and only 11% of hepatitis B and C cases are diagnosed. There is a dire need to speed up hepatitis diagnosis and find the missing millions of people living with viral hepatitis. Up to 2016, only 3 million hepatitis C cases have been treated. Pricing of hepatitis C virus drugs is also reduced in many countries. The major hurdle to achieve hepatitis elimination is lack of finances to support hepatitis programs. None of the major global donors are committed to invest in the fight against hepatitis. It will be very difficult for the low and middle-income countries to fund their hepatitis control program. Hepatitis elimination needs strong financial and political commitment, support from civil societies, and support from pharmaceutical and medical companies around the globe.     

Temperament Affects Sympathetic Nervous Function in a Normal Population

Objective

Although specific temperaments have been known to be related to autonomic nervous function in some psychiatric disorders, there are few studies that have examined the relationship between temperaments and autonomic nervous function in a normal population. In this study, we examined the effect of temperament on the sympathetic nervous function in a normal population.

Methods

Sixty eight healthy subjects participated in the present study. Temperament was assessed using the Korean version of the Cloninger Temperament and Character Inventory (TCI). Autonomic nervous function was determined by measuring skin temperature in a resting state, which was recorded for 5 minutes from the palmar surface of the left 5th digit using a thermistor secured with a Velcro® band. Pearson''s correlation analysis and multiple linear regression were used to examine the relationship between temperament and skin temperature.

Results

A higher harm avoidance score was correlated with a lower skin temperature (i.e. an increased sympathetic tone; r=-0.343, p=0.004) whereas a higher persistence score was correlated with a higher skin temperature (r=0.433, p=0.001). Hierarchical linear regression analysis revealed that harm avoidance was able to predict the variance of skin temperature independently, with a variance of 7.1% after controlling for sex, blood pressure and state anxiety and persistence was the factor predicting the variance of skin temperature with a variance of 5.0%.

Conclusion

These results suggest that high harm avoidance is related to an increased sympathetic nervous function whereas high persistence is related to decreased sympathetic nervous function in a normal population.     

A Multidimensional Model for the Research and Treatment of Alcoholism

It was thought that several motivational theories might explain heroin use and account for the heterogeneity of personality traits found in the addict population. Greaves' existential theory and McClelland et al.'s conceptualization of the power motive were examined. These theories were operationalized and then compared with groups of addicts, alcoholics, and medical patients in a VA hospital. None of the hypotheses derived from the existential theory were supported. The power motivation theory gained considerable support in that addicts exhibited greater power concerns than the medical patients. It was found that addicts manifested an avoidance style of power concerns while the alcoholics showed more impulsive power strivings.