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CORK Bibliography: Heroin

119 citations. 2007 to present

Prepared: March 2008

Al-Adwani A; Nahata R. Heroin-assisted treatment: no difference in treatment retention. (letter). British Journal of Psychiatry 191: 458-458, 2007. (1 refs.)

Angelucci F; Ricci V; Pomponi M; Conte G; Mathe AA; Tonali PA et al. Chronic heroin and cocaine abuse is associated with decreased serum concentrations of the nerve growth factor and brain-derived neurotrophic factor. Journal of Psychopharmacology 21(8): 820-825, 2007. (49 refs.)

Chronic cocaine and heroin users display a variety of central nervous system (CNS) dysfunctions including impaired attention, learning, memory, reaction time, cognitive flexibility, impulse control and selective processing. These findings suggest that these drugs may alter normal brain functions and possibly cause neurotoxicity. Neurotrophins are a class of proteins that serve as survival factors for CNS neurons. In particular, nerve growth factor (NGF) plays an important role in the survival and function of cholinergic neurons while brain-derived neurotrophic factor (BDNF) is involved in synaptic plasticity and in the maintenance of midbrain dopaminergic and cholinergic neurons. In the present study, we measured by enzyme-linked immunosorbent assay (ELISA) the NGF and BDNF levels in serum of three groups of subjects: heroin-dependent patients, cocaine-dependent patients and healthy volunteers. Our goal was to identify possible change in serum neurotrophins in heroin and cocaine users. BDNF was decreased in heroin users whereas NGF was decreased in both heroin and cocaine users. These findings indicate that NGF and BDNF may play a role in the neurotoxicity and addiction induced by these drugs. In view of the neurotrophin hypothesis of schizophrenia the data also suggest that reduced level of neurotrophins may increase the risk of developing psychosis in drug users.

Arnold-Reed DE; O'Neil P; Holman CDJ; Bulsara MK; Rodiguez C; Gawthorne G et al. A comparison of mental health hospital admissions in a cohort of heroin users prior to and after rapid opiate detoxification and oral naltrexone maintenance. American Journal of Drug and Alcohol Abuse 33(5): 655-664, 2007. (20 refs.)

Mental health (MH) hospital admissions were investigated in a cohort (N 1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification ( ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.

Bailes M; Lowery C. Practical issues of program organization and operation. IN: Strain EC; Stitzer ML, eds. The Treatment of Opioid Dependence. Baltimore: Johns Hopkins University Press, 2006. pp. 178-209. (24 refs.)

This chapter addresses a number of practicual issues entailed in organizing and managing a methadone treatment clinic. These issues inlcude the physical organization of the clinic, staffing patterns, assessmentof patient eligibility for treatment, management of problemmatic behaviors, accreditation of the treatment clinic, and interactions between the clinic and surrounding community. These are interrelatead and all important for the management of a successful trehe uand other se of methdr program. adug tatmentFurther many of the herapies are also reviewed.

Bargagli AM; Faggiano F; Amato L; Salamina G; Davoli M; Mathis F; VEdeTTE Study Group. VEdeTTE, a longitudinal study on effectiveness of treatments for heroin addiction in Italy: Study protocol and characteristics of study population. Substance Use & Misuse 41(14): 1861-1879, 2006. (30 refs.)

The aim of this study was to provide a methodological overview of the study design of the national evaluation large-scale study VEdeTTE and a description of the VEdeTTE study population and to compare enrollments with refusals and the study population with the overall clients at the National Health System (NHS) treatment centers. VEdeTTE is a longitudinal study of heroin addicts recruited in 115 NHS treatment centers in Italy, 1998-2001; 11,903 people were enrolled, 3876 refused to participate; data were analysed on 10,454. Information from refusals was compared to enrollments. The characteristics of the cohort were compared to those of all patients treated in 1999 in Italy. Refusals had a lower educational level and less regular occupational status than those enrolled. Fourteen percent of enrolled patients were women; heroin users in the VEdeTTE study were older than patients attending all NHS treatment centers in Italy; incident cases were less represented. The majority of participants had more than 8 years of education, 33.5% were regularly employed, and only 2% did not have a fixed address. Injectors were 72.3%; 40.6% had a previous overdose, and 14.3% had been imprisoned for life; 15.7% shared injection equipment during the previous 6 months. The proportion of participants reporting heroin use approximately halved from the beginning of the current treatment to the time of the interview. The VEdeTTE study is the biggest cohort of heroin addicts attending treatment centers in Europe. The Italian heroin-addicted population under treatment seems to have low level of education but good social integration. Compared with men, women show a higher severity. Participants show a beneficial effect of treatment.

Bohatyrewicz M; Urasinska E; Rozanski J; Ciechanowski K. Membranous glomerulonephritis may be associated with heavy marijuana abuse. Transplantation Proceedings 39(10): 3054-3056, 2007. (18 refs.)

It is well documented that drug abuse can cause renal diseases. Nephropathy and proteinuria among heroin addicts has been recognized since the early 1970s. The predominant lesions in heroin-associated nephropathy are segmental glomerulosclerosis in African-Americans and membranous glomerulonephritis (MGN) in the Caucasian population. Cocaine may induce kidney damage, predominantly acute renal failure in the course of rhabdomyolysis. However, there are no case reports of nephropathy associated with marijuana smoking. We report a case of a marijuana-addicted 27-year-old Caucasian man after cadaveric kidney transplantation who developed de novo posttransplant MGN. The long period and high level of narcotic intoxication suggested that de novo MGN may have been associated with heavy marijuana abuse.

Bourgois P; Martinez A; Kral A; Edlin BR; Schonberg J; Ciccarone D. Reinterpreting ethnic patterns among white and African American men who inject heroin: A social science of medicine approach. PLoS Medicine 3(10): 1805-1815, article e452, 2006. (87 refs.)

Background: Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level. Methods and Findings We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its "War on Drugs.'' African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off "dopesickness'' rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories. Conclusions Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.

Boyd JJ; Kuisma MJ; Alaspaa AO; Vuori E; Repo JV; Randell TT. Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients. Acta Anaesthesiologica Scandinavica 50(10): 1266-1270, 2006. (14 refs.)

Background: In patients with presumed heroin overdose, the recommended time of observation after reversing heroin toxicity with naloxone varies widely. The aims of this study were to examine the incidence of recurrent opioid toxicity and the time interval in which it occurs after pre-hospital treatment in presumed heroin overdose patients. Methods: We undertook a retrospective study in Helsinki (population, 560,000). Records were reviewed from 1 January 1995 to 31 December 2000. Patients included were treated by the emergency medical service (EMS) for a presumed heroin overdose. Patients with known polydrug/alcohol use or the use of opioids other than heroin were excluded. The EMS records were compared with the cardiac arrest database and the medical examiners' records. Results: One hundred and forty-five patients were included. The median dose of pre-hospital administered naloxone was 0.4 mg. After pre-hospital care, 84 patients refused further care and were not transported to an emergency department (ED). Seventy-one received pre-hospital naloxone, and no life-threatening events were recorded during a 12-h follow-up period in these patients. After pre-hospital care, 61 patients were transported to an ED. Twelve patients received naloxone in the ED for respiratory depression. All had signs of heroin use-related adverse events within 1 h after receiving pre-hospital naloxone. Conclusions: Allowing presumed heroin overdose patients to sign out after pre-hospital care with naloxone is safe. If transported to an ED, a 1-h observation period after naloxone administration seems to be adequate for recurrent heroin toxicity.

Bravo MJ; Royuela L; Barrio G; de la Fuente L; Suarez M; Brugal MT. More free syringes, fewer drug injectors in the case of Spain. Social Science and Medicine 65(8): 1773-1778, 2007. (21 refs.)

International policy on the prevention of HIV and other health problems among drug users should be guided by scientific evidence. However, it has frequently been argued that Needle Exchange Programs (NEPs) have negative effects such as facilitation of injection of illicit drugs, without providing evidence to support this hypothesis. Since the early 1980s Spain has experienced a severe HIV epidemic among drug injectors. A delayed but comprehensive implementation of harm reduction programs has taken place since the early 1990s. This paper assesses trends between 1991 and 2004, both in the number of sterile syringes exchanged or delivered by NEPs or other programs to improve injectors' access to sterile injection material, and in the number of injectors admitted to first treatment for heroin or cocaine dependence, as a proxy for trends in the number of new drug injectors in Spain. The results show increased access to sterile syringes and a sharp decrease in the number of new drug injectors, suggesting that NEPs have not promoted drug injection. A positive overall transition from injecting to smoking was also observed in the most frequent route of heroin or cocaine administration.

Bretteville-Jensen AL. Drug demand: Initiation, continuation and quitting. De Economist 154(4): 491-516, 2006. (93 refs.)

As illicit drug use inflicts considerable harm on users, non-using persons and society, there is an urgent need to better understand demand. Unlawfulness and addictiveness separate the consumption of narcotic drugs from the consumption of other commodities. This paper reviews economic approaches to the task of analysing drug consumption and discusses some recent contributions to the field. We find it useful to apply a threefold division to a user's career: the initiation phase, the continuation phase and the quitting phase. First, however, we present an analysis of drug injectors' heroin demand based on a large set of personal interviews (n = 2882) and illustrate some of the problems affecting empirical studies in this field. An estimated price elasticity of -0.77 and income elasticity of 0.56 suggest a high level of responsiveness to economic incentives among heavy drug users.

Butler T; Boonwaat L; Hailstone S; Falconer T; Lems P; Ginley T et al. The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey. Australian and New Zealand Journal of Public Health 31(1): 44-50, 2007. (28 refs.)

Objectives: To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States. Design: Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected. Results: National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk. Conclusions: The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Byqvist S. Patterns of drug use among drug misusers in Sweden. Gender differences. Substance Use & Misuse 41(13): 1817-1835, 2006. (26 refs.)

The goal of the article is to provide information about polydrug abuse and drug misuse patterns in Sweden among women and men. The data has been taken from a 1998 national survey of "Heavy"/severe drug misuse in Sweden, project "MAX-98" (Olsson, Adamsson-Wahren, & Byqvist, 2001). The drug misusers were reported by various government agencies, including health services, social services, police, and correctional treatment facilities on a special form. One of the significant gender differences that emerged was that a greater percent of the women in the survey used and injected amphetamines, injected opiates, and used tranquilizers/sedatives, while a greater percent of the men smoked cannabis, smoked heroin, and misused alcohol. Furthermore, the most common combinations for both genders was amphetamines + cannabis, followed by amphetamines + heroin + cannabis. Alcohol played a large role for the narcotics users. Heroin as a primary drug has grown in the age groups under 35. The trends document that the use of ecstasy as well as chemical CNS-stimulating/hallucinogenic drugs has grown, that polydrug use has increased compared with earlier surveys, and that the methods of ingestion have changed. It is therefore more precise today to speak of different types of polydrug users than about users of exclusively one drug.

Carrieri MP; Amass L; Lucas GM; Vlahov D; Wodak A; Woody GE. Buprenorphine use: The international experience. Clinical Infectious Diseases 43(Supplement 4): s197-s215, 2006. (185 refs.)

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.

Centers for Disease Control. Unintentional deaths from drug poisoning by urbanization of area -- New Mexico, 1994-2003. MMWR. Morbidity and Mortality Weekly Report 54(35): 870-873, 2005. (9 refs.)

New Mexico experienced an increase in poisoning deaths during the 1990s and in 2002 was the state with the highest death rate (14.1 per 100,000 population) from unintentional poisoning, more than twice the national rate (6.1). The majority of these unintentional poisoning deaths were caused by ingestion of drugs, including illicit, prescription, and over-the-counter drugs. New Mexico is geographically diverse, with communities ranging from urban centers to sparsely populated counties. Data from the New Mexico Medical Examiner was reviewed for 1994-2003, to ascertain any differences by the nature of the community. The analysis showed that deaths from illicit-drug poisoning were twice as likely to occur in metropolitan areas than nonmetropolitan areas. However, deaths from prescription-drug poisoning were most likely to occur in micropolitan areas. Decedent characteristics (e.g., sex, race/ethnicity, and drugs causing death) were analyzed, and age-adjusted drug-poisoning death rates per 100,000 population by urbanization of area were calculated for 1994--2003. Drugs causing death were categorized as illicit drugs (i.e., heroin, cocaine, or methamphetamine), over-the-counter drugs, or prescription drugs (i.e., methadone, other opioid painkiller, tranquilizer/muscle relaxant, antidepressant, barbiturate, or other prescription drug. During 1994--2003, a total of 1,982 drug-poisoning deaths were identified in New Mexico; data on four deaths did not include county of decedent residence. Statewide, 71.3% of decedents resided in metropolitan areas, 25.3% in micropolitan areas, and 3.4% rural. Compared with decedents from micropolitan and nonstatistical areas, a significantly larger proportion from metropolitan areas died from heroin overdose (52.6% versus 48.8% and 35.3%, respectively). However, a larger proportion from rural areas died from any prescription drug (50.0% versus 37.2% and 40.2%) or from opioid painkillers other than methadone (38.2% versus 19.6% and 22.8%). Illicit drug poisonings had the highest death rate (8.1 per 100,000 population), with a higher poisoning death rate from heroin than from cocaine or methamphetamine (5.8 versus 4.4 and 0.6). The death rate from any prescription drug was 4.4, with the highest rate among prescription drugs from opioid painkillers other than methadone (2.4). Metropolitan areas had the highest rates for all drug-poisoning deaths (12.6 versus 9.5 for micropolitan areas and 7.4 for nonstatistical areas), any illicit drug (9.0 versus 6.8 for micropolitan areas and 4.4 for nonstatistical areas), heroin (6.6 versus 4.7 for micropolitan areas and 2.6 for nonstatistical areas), and cocaine (4.8 versus 3.7 for micropolitan areas and 2.4 for nonstatistical areas). Metropolitan areas also had the highest death rates from methadone (1.6) and over-the-counter drugs (1.0). rural areas had the highest death rate from opioid painkillers other than methadone (2.8); micropolitan areas had the highest death rate from alcohol and drug cointoxication (3.7).

Public Domain

Centers for Disease Control and Prevention; Hoffman RS; Nelson LS; Chan GM; Halcomb SE; Bouchard NC; Ginsburg BY et al. Atypical reactions associated with heroin use -- Five States, January-April 2005. MMWR. Morbidity and Mortality Weekly Report 54(32): 793-796, 2005. (9 refs.)

Heroin use typically produces a well-recognized syndrome of euphoria, miosis, and respiratory and central nervous system depression; cardiovascular effects are not a common finding. In January 2005, a man aged 21 years in New Jersey was hospitalized with an atypical reaction (e.g., tachycardia and palpitations) after reported heroin use. During the next 3 months, 25 additional persons in five states were reported to poison control centers (PCCs) and local public health agencies with a similar reaction after reported heroin use; in all, 24 of 26 patients were hospitalized. This report describes four representative cases and summarizes the investigation by state and local health and law enforcement authorities and CDC into the 26 cases of atypical reactions after heroin use reported in five states. Clenbuterol is a b2 adrenergic receptor agonist with a rapid onset and long duration of action approved for limited veterinary use in the United States (2,3). Clenbuterol is also used illicitly as an alternative to anabolic steroids in humans and livestock because it can increase muscle mass (4,5). Most adverse health effects are related to its stimulation of b2 adrenergic receptors and clinical manifestations, including hypokalemia, hyperglycemia, hyperlactemia, agitation, tachycardia, and hypotension (6). Adverse human health effects have been reported previously in a case of clenbuterol ingestion (7) and from ingestion of meat from livestock fed clenbuterol (3). However, the 26 cases described in this report are the first published accounts of poisoning from clenbuterol associated with reported heroin use. Whether these cases represent adulteration of a single source of heroin before widespread distribution or adulteration of multiple sources is unknown. Also unclear is whether the substance used by each patient was heroin contaminated with clenbuterol or pure clenbuterol sold as heroin. The presence of adulterants in heroin is not uncommon.

Public Domain

Chassler D; Lundgren L; Lonsdale J. What factors are associated with high-frequency drug treatment use among a racially and ethnically diverse population of injection drug users? American Journal on Addictions 15(6): 440-449, 2006. (32 refs.)

This study explored the frequency of drug treatment utilization by 36,081 injection drug users (IDUs) in Massachusetts, 1996-2002. A number of multiple and logistic regression analyses examined the relationship between demographic characteristics, parental status, level of and type of drug use, history of mental health treatment use, types of drug treatment entered, and the number of times an IDU had entered drug treatment for the seven-year time period. Homelessness, using heroin as the primary drug of choice, and health insurance status were all associated with number of treatments entered. Logistic regression analysis identified that health insurance was a key factor associated with more frequent treatment: those with private health insurance were ten times more likely to be in the 90th percentile (12-107 entries) with respect to number of treatment entries.

Chiang S-C; Chan H-Y; Chang Y-Y et al. Psychiatric comorbidity and gender difference among treatment-seeking heroin abusers in Taiwan. Psychiatry and Clinical Neurosciences 61(1): 105-113, 2007. (39 refs.)

The objectives of the present study were to estimate the psychiatric comorbidity of Taiwanese heroin users seeking treatment and to identify the gender differences in psychiatric comorbidity and drug use behavior. Subjects were interviewed using a structured questionnaire on drug use behavior and the Mini International Neuropsychiatric Interview for psychiatric disorders. Of the subjects, 58.5% of the male and 62.5% of the female subjects had at least one non-substance-use axis I psychiatric disorder or antisocial personality disorder. Compared to male subjects, female subjects were younger, were less educated, had higher rates of unemployment and had earlier onset of illicit drug use. Female subjects were 11-fold more likely than male subjects to exhibit suicidal behavior. Among heroin abusers in the present study, female subjects were more widely exposed to unfavorable social factors and had substantially higher incidence of suicidal behavior than male subjects. Drug treatment centers should be aware of these gender differences and pay particular attention to comorbid depressive disorders and suicidal behavior of female heroin abusers.

Chiang SC; Chen SJ; Sun HJ; Chan HY; Chen WJ. Heroin use among youths incarcerated for illicit drug use: Psychosocial environment, substance use history, psychiatric comorbidity, and route of administration. American Journal on Addictions 15(3): 233-241, 2006. (49 refs.)

This study examines differences in psychosocial characteristics, substance use history, and psychiatric comorbidity in relation to heroin use among youths aged 15 to 22 incarcerated in 2003 for illicit drug use in northern Taiwan. Factors associated with heroin use included experiences of child abuse, having friends with illicit drug use, poor school attendance, polydrug use, and early age of drug initiation. Heroin users were found to have more severe clinical manifestation and experiences of conduct and anxiety disorders than non-heroin users; injection users tended to have a longer heroin history. This information may help guide future prevention programs to reduce heroin problems in youth.

Chiang SC; Chen CY; Chang YY; Sun HJ; Chen WJ. Prevalence of heroin and methamphetamine male users in the northern Taiwan, 1999-2002: capture-recapture estimates. BMC Public Health 7: e-article 292, 2007. (36 refs.)

Background: Illegal drug use and related problems have been emerging as an important public health issue in Taiwan. Via the capture-recapture approach, the present study aimed to offer insights into the size of heroin and methamphetamine male user population in the northern Taiwan during the period from 1999 to 2002. Methods: Annual lists of male subjects were collated from both judiciary and medical systems in Taoyuan County, Taiwan. A total of 2809, 2486, 1661, and 1440 local male illegal drug users aged 15 to 54 years were identified in Taoyuan County from 1999 to 2002, respectively. Results: An estimated number of 16192, 14532, 16844, and 11783 local male methamphetamine or heroin users were found in each of the four consecutive years in the region. From 1999 to 2002, the annual prevalence rate for heroin use was 0.27% (95% Cl = 0.20%, 0.38%), 0.33% ( 95% Cl = 0.25%, 0.44%), 0.63% ( 95% Cl = 0.44%, 0.92%), and 0.72% ( 95% Cl = 0.54%, 0.97%), respectively, suggesting a trend of significant increase (chi-square for linear trend = 1677.76, d.f. = 3, p < 0.0001). In contrast, a decreasing trend was found for methamphetamine (2.38%, 1.91%, 2.47%, and 1.24%), with a modest rebound in 2001. The prevalence rates of illegal drug use for male residents in Taoyuan County were approximately 2-3% during this period, and the scale of problem shows no sign of diminution. Conclusion: By taking advantage of existing datasets that were incomplete by each alone, the approach of capture-recapture model may be ultimately considered as a tool to estimate the scale of illegal drug use problems. The population of heroin-using males apparently is stably expanding in the northern part of Taiwan in the first years of 21(st) century.

Clatts MC; Giang LM; Goldsamt LA; Yi H. Novel heroin injection practices: Implications for transmission of HIV and other bloodborne pathogens. American Journal of Preventive Medicine 32(6, Supplement S): S226-S233, 2007. (22 refs.)

Background: This paper describes injection risk in an out-of-treatment population of young heroin users in Hanoi, Vietnam, including use of a soft-tissue portal known as a "cay ma" (injection sac). Methods: Data from a large cross-sectional survey (N=1270) are used to describe the prevalence of this practice and its association with disease. Additionally, data from an ethnographic substudy on injectors serve to elaborate injectors' rationales for this injection practice. Results: This practice was common in this sample, appearing soon after initiation of habitual injection. Injectors report that this allows rapid and reliable access to a vein; strategic advantages in a dense urban environment where rapid injection, typically in public settings, is necessary to avoid discovery or arrest. Additionally, this practice is believed to mitigate risk for vein damage from co-morbid promethazine hydrochloride injection. Conclusions: This practice may draw lymphocytes to injection sites, thereby increasing risk for transmission of bloodborne pathogens. Structural and behavioral interventions are needed for young heroin users in Vietnam.

Community Epidemiology Work Group, ed. Epidemiologic Trends in Drug Abuse. Volume I: Proceedings of the Community Epidemiology Work Group. Highlights and Executive Summary, June 2005. Bethesda MD: National Institute on Drug Abuse, 2006. (35 refs.)

Overview of Key Findings: Cocaine abuse indicators, particularly those for crack, continue to dominate in many CEWG areas and to have serious consequences for users, service providers, and law enforcement personnel. High levels of gang activity and violence are associated with cocaine trafficking. Indicator data, primarily for 2004, show that cocaine items reported by NFLIS exceeded those for other drugs in 12 CEWG areas, and crack accounted for 50 to more than 90 percent of primary cocaine treatment admissions in 15 of 16 reporting areas. eroin abuse indicators continued to be high in Baltimore and Newark and relatively high in Boston, Chicago, New York, Philadelphia, San Francisco, Seattle, and Washington, DC. arcotic Analgesic/Other Opiates abuse continued to cause concern in most CEWG areas. Treatment data indicate increases in admissions for primary opiate (other than heroin) abuse in 7 of the 14 CEWG areas in which treatment data for 2002 to 2004 were reported. Four CEWG participants reported that prescription-type narcotic drugs were being used with or in place of heroin. ethamphetamine abuse indicators continued at high levels in western and southwestern areas of the county. In 2004, indicators increased dramatically in Phoenix, and increasing levels were reported in Atlanta, Minneapolis/St. Paul, and St. Louis. Increasing numbers of Hispanics entered treatment for primary methamphetamine abuse in some CEWG areas. In Los Angeles, Hispanics represented 47 percent of all primary methamphetamine admissions in the second half of 2004. arijuana continues to be readily available and the most widely used drug in CEWG areas. In 2004, relatively high percentages of the items reported by forensic laboratories (NFLIS) contained marijuana in New Orleans, San Diego, Chicago, Boston, Detroit, St. Louis, Washington, DC, and Philadelphia. In 12 CEWG areas, 20-40 percent of 2004 illicit drug abuse admissions were for primary marijuana abuse. In four CEWG areas, primary marijuana treatment admissions (excluding alcohol) exceeded those for other illicit drugs: Seattle, Minneapolis/St. Paul, New Orleans, and Denver.

Public Domain

Conroy E; Degenhardt L; Day C. Impact of drug market changes on substance-using pregnant women in three key Sydney drug markets. Women & Health 44(4): 93-105, 2006. (27 refs.)

Introduction: In 2001 the supply of heroin was substantially reduced across Australia. Given the child protection concerns associated with the use of substances hy pregnant women, it was pertinent to examine how the reduction in the supply of heroin affected this community of users. This paper aimed to assess the extent of any drug-related problems among pregnant women associated with the reduction in heroin supply in New South Wales (NSW). Method: Two sources of data were used: (1) Data on hospital visits in NSW in which drug and alcohol problems were noted as complicating the pregnancy; and (2) Key informant reports from services targeting substance-using pregnant women across the three main Sydney drug markets. Results: The shortage did not affect the number of hospital separations for substance-using pregnant women, nor the number of women referred to services for substance use in pregnancy. Key informants reported an increase in the use of cocaine among pregnant women and achange in injection sites for some women (including into breast tissue). No substantial change in adverse outcomes was observed to be associated with this change in patterns of drug use. Discussion: The reduction in heroin Supply appeared to have limited impact on the number of substance-using pregnant women as assessed by hospital episodes and key informant reports. The evidence suggested an increase in the injecting of cocaine by pregnant women using drug treatment services, similar to the changes in drug use patterns observed among other groups of injecting drug users. The lack of change observed in the qualitative and statistical data regarding adverse health consequences associated with cocaine injecting suggests the potentially negative impact of maternal cocaine use on infant health may be difficult to detect and monitor.

Crum RM. Epidemiology of opioid use, abuse, and dependence. IN: Strain EC; Stitzer ML, eds. The Treatment of Opioid Dependence. Baltimore: Johns Hopkins University Press, 2006. pp. 43-55. (22 refs.)

This chapter reviews the nonmedical use, abuse, and dependence of prescription opioids, including a discussion of the epidemiology of heroin use and related disorders. The chapter focuses upon U.S. data, because it provides information on trends over time using similar methodological approaches.

Dabby R; Djaldetti R; Gilad R; Herman O; Frand J; Sadeh M et al. Acute heroin-related neuropathy. Journal of the Peripheral Nervous System 11(4): 304-309, 2006. (16 refs.)

Heroin-related peripheral nervous injury has scarcely been reported, mostly as compressive neuropathy. Rarely, other types of peripheral nervous system (PNS) injury have been recognized, such as plexopathy, polyradiculopathy, mononeuropathy, and rhabdomyolysis. These complications are usually not related to local trauma, but the nature of nerve injury remains unknown. Immunologic mechanisms have been proposed, although generally there is no laboratory evidence of inflammation and usually there is no improvement following steroid therapy. We describe six patients who developed acute PNS injury following intravenous or intranasal heroin self-administration with no evidence of compression injury or inflammation. Four patients had plexopathy (two lumbosacral and two brachial), and two had symmetric distal axonal sensorimotor neuropathy affecting the lower extremities. Of the six patients, five had concomitant rhabdomyolysis (creatine kinase, CK: 5,000-100,000 U/l) and one patient with brachial plexopathy had normal CK levels. The neurological deficit was noticed 3-36 h after heroin administration. Electromyography in five patients was consistent with sensorimotor axonal loss either confined to the affected plexus or with a diffuse distribution in the legs in the two patients with neuropathy. We propose that a toxic mechanism may be responsible for non-compression cases of acute neuropathy following heroin abuse.

Daini S; Tonioni F; Barra A; Lai C; Lacerenza R; Sgambato A et al. Serum magnesium profile in heroin addicts: According to psychiatric comorbidity. Magnesium Research 19(3): 162-166, 2006. (17 refs.)

Psychiatric comorbidity in heroin addiction can modify both the biological pattern and clinical course of this disorder. Because of the role of magnesium in neurotransmission and its specific patterns in some psychiatric conditions, such as depression and schizophrenia, we studied a sample of heroin dependent subjects, with and without psychiatric comorbidity. A sample of 162 drug addicts (123 men and 39 women, mean age 32.3 +/- 6.7) was diagnosed for the presence of psychiatric comorbidity with DSM W criteria. They were subsequently divided in 4 subgroups: No comorbidity, Anxiety Disorders, Mood Disorders, Personality Disorders. Differences in serum magnesium level between the groups were analysed with the Anova method, with age as covariate. Results show that seritin Mg++ levels are significantly higher in patients with heroin dependence and personality disorders compared to patients with depression comorbidity and without comorbidity. Psychiatric codiagnosis significantly modifies Mg++ levels in this drug dependent sample. Gender modifies Mg levels in no comorbid subjects so that females show significantly lower Mg++ levels compared to males. The presence of psychiatric comorbidity abates this difference.

Darke S; Havard A; Ross J; Williamson A; Mills KL; Teesson M. Changes in the use of medical services and prescription drugs among heroin users over two years. Drug and Alcohol Review 26(2): 153-159, 2007. (25 refs.)

The study aimed to determine patterns of use of medical services and prescriptions for pharmaceuticals among 438 heroin users interviewed for the Australian Treatment Outcome Study ( ATOS) at baseline, 12 and 24 months. Drug use declined markedly, and there were significant improvements in health. There were declines in the proportion of participants who had attended a general practitioner (GP) (baseline: 60%, 12 months: 53%, 24 months: 52%), who had an ambulance attendance (11%, 7%, 5%), and who were treated in an accident and emergency department (11%, 6%, 5%). While there was no decrease in the proportion who obtained a prescription (47%, 45%, 46%), there was a decrease in the mean number of reported prescriptions obtained (2.3, 1.0, 0.9). There were also differences across follow- up in the reported types of medications obtained, with a significant decrease in the proportion obtaining psychotropic medications (38%, 21%, 19%). In particular, there were large declines in the proportion who reported benzodiazepines (30%, 12%, 10%) or narcotic analgesics (8%, 3%, 4%) on prescription. While ATOS participants continued to be frequent users of health services, the cohort reported reduced levels of drug-seeking and risk commensurate with their reductions in drug use.

Darke S; Ross J; Williamson A; Mills KL; Havard A; Teesson M. Borderline personality disorder and persistently elevated levels of risk in 36-month outcomes for the treatment of heroin dependence. Addiction 102(7): 1140-1146, 2007. (27 refs.)

Aims: To determine the effects of borderline personality disorder (BPD) on 36-month outcomes for the treatment of heroin dependence. Design: Longitudinal cohort study. Setting Sydney, Australia. Participants A total of 429 heroin users enrolled in the Australian Treatment Outcome Study, interviewed at 36-month follow-up. Findings: The BPD group enrolled in significantly more different treatment episodes across follow-up, but there was no difference in the cumulative number of treatment days received. At 36 months, there were no group differences in sustained or current heroin abstinence, daily heroin use or level of polydrug use. BPD patients maintained significantly higher levels of crime, injection-related health problems, heroin overdose, major depression and poorer global mental health. In contrast to 12-month follow-up, at 36 months there were no group differences in the proportions who attempted suicide over the preceding 12 months or had recently borrowed used injection equipment. Conclusions The clinical picture provided some cause for optimism since 12-month follow-up. Despite this, BPD patients maintained elevated risk levels across a number of domains. The fact that these risks were maintained indicates that this is a group that requires specific clinical attention for BPD-related risks.

Darke S; Ross J; Williamson A; Mills KL; Havard A; Teesson M. Patterns and correlates of attempted suicide by heroin users over a 3-year period: Findings from the Australian treatment outcome study. Drug and Alcohol Dependence 87(2/3): 146-152, 2007. (35 refs.)

In order to determine patterns and correlates of attempted suicide amongst heroin users across 3 years, a cohort of 387 heroin users (134 entering maintenance treatment, 134 entering detoxification, 81 entering residential rehabilitation and 38 not entering treatment) were interviewed about suicide attempts at baseline, 12, 24 and 36 months. Across the follow-up period, 11.6% attempted suicide. There were declines in the proportion who attempted suicide each year amongst both males and females and significant declines in Major Depression, suicidal ideation and current suicide plans. Despite this, levels of attempted suicide, suicidal ideation and Major Depression in the cohort remained higher than in the general population. Those who had made a previous suicide attempt were five times more likely to make an attempt across follow-up and there was a strong association between an attempt in any I year and increased probability of an attempt in the subsequent year. A quarter of those who reported suicidal ideation at baseline made an attempt across follow-up. At each interview point, current suicidal ideation was strongly associated with increased risk of a suicide attempt in the following year. Independent predictors of a suicide attempt across follow-up were a lifetime suicide history, baseline suicidal ideation, social isolation and the extent of baseline polydrug use. Given the strong predictive value of suicidal ideation and previous attempts, regular brief screening would appear warranted to identify those at greatest risk.

Darke S; Ross J; Teesson M. The Australian Treatment Outcome Study (ATOS): What have we learnt about treatment for heroin dependence? Drug and Alcohol Review 26(1): 49-54, 2007. (31 refs.)

Opioids make the single largest contribution to illicit drug related mortality and morbidity worldwide In this paper we reflect upon what has been learnt regarding treatment outcome and the natural history of heroin use from the Australian Treatment Outcome Study (ATOS). We focus on what we knew prior to ATOS, what A TOS revealed that is novel, and the implications for research, practice and policy. ATOS provided strong evidence for sustained improvement attributable to treatment across the three years of the study. It is argued that treatment for heroin dependence is money well spent, and leads to clear and sustained benefits to both heroin users and society.

Darke S; Williamson A; Ross J; Mills KL; Havard A; Teesson M. Patterns of nonfatal heroin overdose over a 3-year period: Findings from the Australian Treatment Outcome Study. Journal of Urban Health 84(2): 283-291, 2007. (22 refs.)

To determine annual patterns and correlates of nonfatal heroin overdose across 3 years, data were analyzed on 387 heroin users recruited for the Australian Treatment Outcome Study (ATOS), interviewed at 12, 24, and 36 months. A heroin overdose across follow-up was reported by 18.6%, and naloxone bad been administered to 11.9%. Annual rates of overdose declined between baseline and 12 months and then remained stable. Previous overdose experience was strongly related to subsequent overdose. Those with a history of overdose before ATOS were significantly more likely to overdose during the study period. In particular, there was a strong association between overdose experience in any 1 year and increased overdose risk in the subsequent year. This is the first study to examine long-term annual trends in nonfatal heroin overdose. While overdose rates declined after extensive treatment, substantial proportions continued to overdose in each year, and this was strongly associated with overdose history.

Darke S; Williamson A; Ross J; Teesson M. Residential rehabilitation for the treatment of heroin dependence: Sustained heroin abstinence and drug-related problems 2 years after treatment entrance. Addictive Disorders and their Treatment 5(1): 9-18, 2006. (27 refs.)

To determine levels of sustained heroin abstinence, current drug use, and drug-related problems of residential rehabilitation (RR) admissions 24 months after entering treatment. Longitudinal cohort study of 100 heroin users admitted to short-term (1 month) or long-term (3-6 months or longer) RR. Separation in the first week was uncommon in both short-term (7%) and long-term (16%) programs. Eighteen percent successfully graduated, 47% self-discharged, and 30% were expelled. Postindex treatment exposure was widespread (82%), with additional RR the most common treatment. At 24 months, 71% were heroin abstinent over the month preceding interview, and 18% reported heroin abstinence over the entire follow-up period. There had been large declines in levels of recent needle borrowing, crime, psychopathology, and improvements in global and injection-related health. Independent predictors of continuous heroin abstinent were female sex (odds ratio [OR] 5.00), successful graduation from the index program (OR 9.05), and post-treatment MT exposure (OR 0.08). The study confirms the effectiveness of RR and highlights and the impact of program graduation.

Davoli M; Bargagli AM; Perucci CA; Schifano P; Belleudi V; Hickman M; VEdeTTE Study Group. Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study. Addiction 102(12): 1954-1959, 2007. (27 refs.)

Background: Specialist drug treatment is critical to overdose prevention; methadone maintenance is effective, but we lack evidence for other modalities. We evaluate the impact of a range of treatments for opiate dependence on overdose mortality. Methods: Prospective cohort study of 10 454 heroin users entering treatment 1998-2001 in Italy followed-up for 10,208 person-years in treatment and 2,914 person-years out of treatment. Standardized overall mortality ratios (SMR) estimate excess mortality risk for heroin users in and out of treatment compared to the general population. Cox models compare the hazard ratio (HR) of overdose between heroin users in treatment and out of treatment. Results: There were 41 overdose deaths, 10 during treatment and 31 out of treatment, generating annual mortality rates of 0.1% and 1.1% and SMRs of 3.9 [95% confidence interval (CI) 2.8-5.4] and 21.4 (16.7-27.4), respectively. Retention in any treatment was protective against overdose mortality (HR 0.09 95% CI 0.04-0.19) compared to the risk of mortality out of treatment, independent of treatment type and potential confounders. The risk of a fatal overdose was 2.3% in the month immediately after treatment and 0.77% in the subsequent period; compared to the risk of overdose during treatment the HR was 26.6 (95% CI 11.6-61.1) in the month immediately following treatment and 7.3 (3.3-16.2) in the subsequent period. Conclusions: We demonstrate that a range of treatments for heroin dependence reduces overdose mortality risk. However, the considerable excess mortality risk in the month following treatment indicates the need for greater health education of drug users and implementation of relapse and overdose death prevention programmes. Further investigation is needed to measure and weigh the potential benefits and harms of short-term therapies for opiate use.

De Jong CAJ; Roozen HG; van Rossum LGM; Krabbe PFM; Kerkhof JFM. High abstinence rates in heroin addicts by a new comprehensive treatment approach. American Journal on Addictions 16(2): 124-130, 2007. (35 refs.)

In this multi-center, naturalistic study, the effectiveness of naltrexone maintenance combined with the Community Reinforcement Approach (CRA) was investigated in detoxified, opioid-dependent patients (N = 272). Patients were recruited from methadone maintenance programs. With intention-to-treat analysis, 10 months of treatment yielded abstinence rates of 28% and 32% at 10 and 16 months after detoxification. The cumulative abstinence rate at 16 months was 24%. Quality of life, craving, general psychopathology, use of other psychoactive substances, and addiction severity of the abstinent group significantly improved when compared to the relapsed group. This abstinence-oriented approach appears to be a feasible goal, and remains an important option next to long-term methadone maintenance in the management of opioid dependence.

de la Fuente L; Toro C; Brugal MT; Vallejo F; Soriano V; Barrio G et al. Poor validity of self-reported HBV vaccination among young heroin users in Spain supports the policy "don't ask, draw a blood sample, vaccinate and try to schedule another visit". Journal of Clinical Virology 38(1): 87-90, 2007. (14 refs.)

Objectives: To assess the validity of self-reported hepatitis B virus vaccination status in young heroin users. Study design: Cross-sectional study among 949 street-recruited young injection heroin users (IHUs) and non-injection heroin users (NIHUs) in Madrid, Barcelona and Seville. Face-to-face interviews and dried blood spot tested for anti-HBc and anti-HBs. The validity of self-reported vaccination status was assessed comparing with the serological status. The percentage of agreement with the kappa (K) statistic and the positive predictive value were calculated. Results: The percentage of agreement between self-reported and serologic vaccination status was 51.9% overall, with little difference by city (53.1% in Barcelona, 49.0% in Madrid and 51.5% in Seville) or between IHUs (51.3%) and NIHUs (53.0%). All the K scores were lower than 0.1. The positive predictive value of self-reports was less than 25% in all categories analysed, except in the city of Barcelona (37%). Among those who indicated that they had been vaccinated, 31% were actually susceptible. Conclusions: In areas with a high prevalence of infection and rising coverage of vaccination the policy "don't ask, take a blood sample, give a dose of vaccine and try to schedule another visit" should be recommended in clinical practice.

De Leon G; Jones HE; Stitzer ML. Medication-free treatment of opioid dependence. IN: Strain EC; Stitzer ML, eds. The Treatment of Opioid Dependence. Baltimore: Johns Hopkins University Press, 2006. pp. 323-345. (78 refs.)

Therapeutic communities are the most widely known and studied form of medication-free treatment. This chapter begins by reviewing what is known about this approach, including the salient features, their use in treatment, and treatment outcomes. Beyond describing the classical model, there is consideration of new innovations, including the incorporation of methadone treatment in the program. The second half of the chapter reviews issues related to other forms of other drug-free treatment. As part of this discussion is attention to reinforcement based therapy, these include incentives integrated into a relatively rich set of treatment services.

De P; Cox J; Boivin JF; Platt RW; Jolly AM. Rethinking approaches to risk reduction for injection drug users - Differences in drug type affect risk for HIV and hepatitis C virus infection through drug-injecting networks. JAIDS. Journal of Acquired Immune Deficiency Syndromes 46(3): 355-361, 2007. (55 refs.)

Objective: To identify and compare the drug-injecting network characteristics of cocaine and heroin injectors associated with a risk of HIV and hepatitis C virus (HCV). Methods: Active injectors were recruited from syringe exchange and methadone programs. Characteristics of all participants and their social networks were elicited. Regression analysis using generalized estimating equations examined the network characteristics of injection drug users (IDUs) relative to cocaine or heroin use in the past 6 months. Results: Of 282 IDUs, 228 (81%) used cocaine and 54 (19%) used heroin as their primary injected drug. In analyses adjusted for age and gender, cocaine injectors compared with heroin injectors were more likely to live in unstable housing (odds ratio [OR] = 3.55, 95% confidence interval [CI]: 1.49 to 8.40), self-report HCV infection (OR = 4.69, 95% CI: 2.14 to 10.31), and have a greater number of IDUs in their social network (OR = 1.61, 95% CI: 1.14 to 2.28) and were less likely to be polydrug users (OR = 0.06, 95% CI: 0.02 to 0.16) and to have social support (OR = 0.97, 95% CI: 0.95 to 0.99). The injecting networks of cocaine users were more likely to have members who were older (OR = 1.08, 95% CI: 1.04 to 1.12), had a history of shooting gallery use (OR = 2.27, 95% CI: 1.08 to 4.76), and had shorter relationships with the subject (OR = 0.91, 95% CI: 0.85 to 0.97). Conclusions: Beyond personal behaviors, HIV and HCV infection risk seems to be linked to social network traits that are determined by drug type. Prevention efforts to control the spread of bloodborne viruses among IDUs could benefit from tailoring interventions according to the type of drug used.

Degenhardt L; Gilmour SD; Hall W. The "lessons" of the Australian "heroin shortage." (commentary). Substance Abuse Treatment, Prevention, and Policy 1: article 11, 2006. (48 refs.)

Heroin use causes considerable harm to individual users including dependence, fatal and nonfatal overdose, mental health problems, and blood borne virus transmission. It also adversely affects the community through drug dealing, property crime and reduced public amenity. During the mid to late 1990s in Australia the prevalence of heroin use increased as reflected in steeply rising overdose deaths. In January 2001, there were reports of an unpredicted and unprecedented reduction in heroin supply with an abrupt onset in all Australian jurisdictions. The shortage was most marked in New South Wales, the State with the largest heroin market, which saw increases in price, dramatic decreases in purity at the street level, and reductions in the ease with which injecting drug users reported being able to obtain the drug. The abrupt onset of the shortage and a subsequent dramatic reduction in overdose deaths prompted national debate about the causes of the shortage and later international debate about the policy significance of what has come to be called the "Australian heroin shortage". In this paper we summarise insights from four years' research into the causes, consequences and policy implications of the "heroin shortage".

Druid H; Strandberg JJ; Alkass K; Nystrom I; Kugelberg FC; Kronstrand R. Evaluation of the role of abstinence in heroin overdose deaths using segmental hair analysis. Forensic Science International 168(2-3): 223-226, 2007. (22 refs.)

In the body heroin is rapidly metabolized to 6-acetylmorphine and morphine. Victims of lethal heroin overdose often present with fairly low blood concentrations of morphine. Reduced tolerance due to abstinence has been proposed to account for this finding. The aim of the present study was to examine the role of abstinence in drug-related deaths by comparing recent and past exposure to opioids using segmental hair analysis with the postmortem blood morphine concentrations in deceased heroin users. The study included 60 deceased drug addicts in the Stockholm area, Sweden. In 32 cases, death was not related to heroin intake. In 18 of the 28 heroin fatalities, opioids were absent in the most recent hair segment, suggesting a reduced tolerance to opioids. However, the blood morphine levels were similar to those found in the 10 subjects that showed continuous opioid use. Hair and blood analysis disclosed an extensive use of additional drugs that directly or indirectly may influence the opioid system. The results suggest that abstinence is not a critical factor for heroin overdose death. Obviously tolerant subjects die after intake of similar doses. Other factors, particularly polydrug use, seem to be more causally important for these deaths.

Dubois-Arber F; Benninghoff F; Jeannin A. Typology of injection profiles of clients of a supervised drug consumption facility in Geneva, Switzerland. European Addiction Research 14(1): 1-10, 2008. (31 refs.)

The use of a supervised drug consumption room (DCR) in a newly established low threshold facility in Geneva, Switzerland, in 2002 is analyzed. Two sources of routine data were used: data collected at the first visit by any new client (entry questionnaire) which included some personal details, and data collected on the substances injected at each visit to the DCR. A typology of injection profiles was constructed. Overall, the mean number of injections and days of visits per client over the year was low and cocaine was the main substance injected. However, an important heterogeneity in the use of the DCR was found and five types of clients identified: 1-day clients; standard clients; heroin-oriented clients; high cocaine consumption clients, and newcomers. Typology was associated with some characteristics at the first visit and the drug consumption pattern in the month preceding the first visit was in accordance with the subsequent use of the DCR. This heterogeneity in the use of the DCR highlights the diverse roles of the DCRs in harm reduction.

Dunbar NM; Harruff RC. Necrotizing fasciitis: Manifestations, microbiology and connection with black tar heroin. Journal of Forensic Sciences 52(4): 920-923, 2007. (17 refs.)

A 10-year review of records of the King County Medical Examiner's Office found 87 deaths due to necrotizing fasciitis and related necrotizing soft tissue infections. In 64 of these cases there were sufficient details to provide an analysis of the manifestations, microbiology, and source of infection. One half (32) of the cases were due to injection of black tar heroin, the nearly exclusive form of heroin in the Northwest United States. Of those due to black tar injection, 24 were clostridial infections with various species represented, eight of which were Clostridium sordellii. Of the 32 cases not associated with drug injection, streptococcal species predominated, with Streptococcus pyogenes isolated in 14 cases. Only three of 32 cases not associated with injection drug use were clostridial infections. These differences were statistically significant. Staphylococcus aureus was isolated from 14 cases; two were methicillin-resistant strains. Overall, 28 of the 64 cases were polymicrobial infections, 15 due to black tar injection and 13 not associated with drug injection. This study supports the conclusion that necrotizing fasciitis due to black tar heroin injection is predominantly a clostridial disease, and in this way differs significantly from necrotizing fasciitis due to other causes.

Ebejer KA; Winn J; Carter JF; Sleeman R; Parker J; Korber F. The difference between drug money and a "lifetime's savings"'. Forensic Science International 167(2-3): 94-101, 2007. (18 refs.)

In many countries, monies suspected of being associated with drug trafficking can be seized by the authorities. One of the ways of investigating this association is through the analysis of seized banknotes for traces of controlled drugs. We report three studies which may assist the expert in assessing whether banknotes contaminated with diamorphine are part of the general population of notes in circulation or whether they show unusual contamination patterns which require explanation. Study 1 is based on three plausible contamination scenarios as they may occur during the various stages of an illicit drug transaction and seizure. It shows that notes which have been in direct contact with visible traces of diamorphine show significantly higher contamination to those in more indirect contact with the drug. Study 2 investigates the transfer of diamorphine from one highly contaminated note to other notes in a bundle over a period of 10 weeks with and without agitation. It was found that the total amount of drug transferred was smaller than 6% and no more than 4 out of a bundle of 10 previously clean notes became lightly contaminated. Based on extensive background data, study 3 proposes a probabilistic model to assess whether an observed proportion of diamorphine bearing banknotes is likely to have been contaminated by chance. The model predicts that there is only a 0.3% chance that a bundle of 100 notes from the general banknote population contains more than six contaminated specimens. Jointly, the three studies give useful indications for the spread of contamination throughout a sample and the amounts of heroin which may be expected given plausible contamination scenarios.

Elifson KW; Klein H; Sterk CE. Predictors of sexual risk-taking among new drug users. Journal of Sex Research 43(4): 318-327, 2006. (78 refs.)

We studied predictors of HIV-related sexual risk-taking among individuals who initiated the use of heroin or methamphetamine during the past 5 years. Many studies have linked drug use to HTV risk, but most research has been based on samples of users with long-established drug careers. We conducted face-to-face interviews with 153 adult new drug users in Atlanta, GA. Drug use was not a statistically significant predictor of sexual risk, but gender, age, race, homelessness status, childhood neglect, level of paranoia, and level of (dys)functionality in handling disagreements were associated with frequency of sexual risk-taking. We discuss the need to incorporate new drug users in HIV/AIDS and other health-related prevention and intervention programs.

Exley C; Ahmed U; Polwart A; Bloor RN. Elevated urinary aluminium in current and past users of illicit heroin. Addiction Biology 12(2): 197-199, 2007. (12 refs.)

The use of illicit heroin is associated with aberrant neurology of unknown aetiology and various psychiatric illnesses. Aluminium, which is a proven neurotoxin, is present in significant amounts in illicit heroin and may also be volatilized and inhaled following the vaporization of heroin off aluminium foil ('Chasing the Dragon'). The purpose of this study was to establish if the use of illicit heroin was associated with an increase in the body burden of aluminium. We have used graphite furnace atomic absorption spectrometry to measure the aluminium and iron contents of the urine of current and past users of illicit heroin and used these data to estimate body burdens of aluminium. Urinary excretion of aluminium is the most effective non-invasive indicator of the body burden of aluminium and was found to be significantly (P < 0.001) higher in users of illicit heroin, range 14-3382 nmol/mmol creatinine (mean +/- SD; 222 +/- 491 nmol/mmol creatinine), than in a normal non-drug abusing control population, range 23-74 nmol/mmol creatinine (mean +/- SD; 43 +/- 19 nmol/mmol creatinine). Exposure to aluminium from the use of illicit heroin may be of particular significance because the urinary excretion of iron, another major contaminant of illicit heroin, in users (mean +/- SD; 53 +/- 63 nmol/mmol creatinine) was not significantly different (P > 0.05) from the control population (mean +/- SD; 38 +/- 18 nmol/mmol creatinine). We have shown for the first time that the use of illicit heroin may be a significant contributor to the body burden of aluminium. Further research will be required to determine if adventitious aluminium has a role in heroin use-related neuropathology and neurology.

Farrell M; Marsden J. Acute risk of drug-related death among newly released prisoners in England and Wales. Addiction 103(2): 251-255, 2008. (18 refs.)

Aims: To investigate drug-related deaths among newly released prisoners in England and Wales. Design Database linkage study. Participants National sample of 48 771 male and female sentenced prisoners released during 1998-2000 with all recorded deaths included to November 2003. Findings There were 442 recorded deaths, of which 261 (59%) were drug-related. In the year following index release, the drug-related mortality rate was 5.2 per 1000 among men and 5.9 per 1000 among women. All-cause mortality in the first and second weeks following release for men was 37 and 26 deaths per 1000 per annum, respectively (95% of which were drug-related). There were 47 and 38 deaths per 1000 per annum, respectively, among women, all of which were drug-related. In the first year after prison release, there were 342 male deaths (45.8 were expected in the general population) and there were 100 female deaths (8.3 expected in the general population). Drug-related deaths were attributed mainly to substance use disorders and drug overdose. Coronial records cited the involvement of opioids in 95% of deaths, benzodiazepines in 20%, cocaine in 14% and tricyclic antidepressants in 10%. Drug-related deaths among men were more likely to involve heroin and deaths among women were more likely to involve benzodiazepines, cocaine and tricyclic antidepressants. Conclusions: Newly released male and female prisoners are at acute risk of drug-related death. Appropriate prevention measures include overdose awareness education, opioid maintenance pharmacotherapy, planned referral to community-based treatment services and a community overdose-response using opioid antagonists.

Fischer B; Rehm J. Illicit opioid use in the 21st century: Witnessing a paradigm shift? (review). Addiction 102(4): 499-501, 2007. (26 refs.)

The authors of this editorial note the historical emphasis upon heroin as "the" illicit drug of concern, and a virtual caricature of the nature of the drug problem, and review the treatment approaches, particularly the emergence of drug substitution therapy. It is noted that increasingly heroin use is declining, with prescription opioids now being more widely used which in turn also changes the face of the drug trade. Questions are raised as how to best tackle the misuse of these prescription medications without placing the legitimate use for pain management at risk.

Gallagher J; McKeganey N. Should we prescribe heroin? A current Scottish debate. (editorial). Scottish Medical Journal 52(4): 2-4, 2007. (15 refs.)

There have been recent calls from within both Scotland and England for the wider prescription of heroin to heroin addicts as a way of coping with our burgeoning drug problem and as a route to reducing drug related criminality. But how feasible is heroin prescribing in this context? This paper considers some of the existing research evidence relating to heroin prescribing and looks also at the ethics and practicalities of prescribing heroin to heroin addicts in Scotland. We conclude that whilst the evidence on the benefits of heroin prescribing is far from clear cut there is a case for mounting a Scottish trial of heroin prescribing. Such a trial would need to be tightly controlled and rigorously evaluated. It would need to show that heroin prescribing was associated not only with a comparable level of harm reduction, as methadone prescribing: but that it was also an effective route towards drug users' eventual recovery and drug cessation.

Galldiks N; Nolden-Hoverath S; Kosinski CM; Stegelmeyer U; Schmidt S; Dohmen C et al. Rapid geographical clustering of wound botulism in Germany after subcutaneous and intramuscular injection of heroin. Neurocritical Care 6(1): 30-34, 2007. (16 refs.)

Background: Wound infections due to Clostridium botulinum in Germany are rare and occur predominantly in heroin injectors, especially after subcutaneous or intramuscular injection of heroin ("skin popping"), which is; contaminated with spores of C. botulinum. We report a rapid geographical clustering of cases in Germany in a region between Cologne, Bonn, and Aachen with wound botulism and consecutive systemic C. botulinum intoxication in intravenous drug users (IDUs) within 6 weeks in October and November 2005. Patients: A group of 12 IDUs with wound botulism after "skin popping." Results: Clinical data were available in 11 (92%) of 12 patients; in 7 (58%) of the 12 cases, there was cranial nerve involvement including mydriasis, diplopia, dysarthria, and dysphagia, followed by progressing symmetric and flaccid paralysis of proximal muscles of the neck, arms, trunk, and respiratory muscles. Mechanical respiratory support was necessary. Five of the IDUs were treated with antitoxin, but mechanical respiratory support could not be avoided. The mean ventilation duration was 27.4 days (range 6-77 days). In 4 patients (33%), mechanical ventilation could be avoided; two were treated with antitoxin. Conclusions: This report describes rapid geographical clustering of wound botulism with severe respiratory complications in IDUs after "skin popping," which has not previously been reported either in Germany or any other European country. Based on these observations and those in other European countries, we conclude that there is a trend towards "skin popping," suggesting a change in injection practices in IDUs. Secondly, we conclude that the total number of cases with wound botulism is likely to increase because "skin popping" is the main risk factor.

George S. The curious incident of methadone in dog's urine. (letter). Acta Psychiatrica Scandinavica 114(6): 446-446, 2006. (0 refs.)

Ghitza UE; Epstein DH; Preston KL. Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients. Addictive Behaviors 32(5): 938-949, 2007. (30 refs.)

Underreporting of drug use is common and influenced by multiple factors. Cannabis (THC) use nonreporting and its relationship to heroin and cocaine use were investigated in 690 patients enrolled in 25-to 29-week clinical trials of contingency management plus methadone maintenance. Urine specimens and self-reports of drug use were collected 3 times/week. Potential predictors of THC use nonreporting were analyzed by multiple logistic regression; relationships between THC use nonreporting and % cocaine- and opiate-positive urines were analyzed by multiple regression. Compared to non-THC users (n = 317), patients with THC-positive urines (n = 373) were more likely to be male and have more years of THC use, but were not different on other characteristics. Nonreporting to user ratios were: THC 191/373 (51.2%); opiates 17/686 (2.5%); cocaine 21/681 (3.1%). Predictors of THC use nonreporting were low rate of THC-positive urines during treatment, fewer days of THC use in the last 30 before treatment, African-American race, and absence of antisocial personality disorder. Nonreporting of THC use was associated with significantly greater opiate and cocaine use. Contingency management decreased cocaine use in THC nonreporters to the level of reporters. Nonreporting of THC use is a significant predictor of greater cocaine and heroin use. This association can be eliminated with contingency management therapy.

Ghosheh FR; Kathuria SS. Intraorbital heroin injection resulting in orbital cellulitis and superior ophthalmic vein thrombosis. Ophthalmic Plastic and Reconstructive Surgery 22(6): 473-475, 2006. (6 refs.)

A 47-year-old man with decreased vision, ophthalmoplegia, proptosis, and chemosis of his right eye admitted to injecting heroin directly into his orbit. He was placed on intravenous antibiotics for orbital cellulitis, and computed tomography and magnetic resonance imaging were performed. Superior ophthalmic vein thrombosis (SOVT) was noted on magnetic resonance imaging. The patient responded well to intravenous antibiotics, and his symptoms resolved with minimal deficits. Steroids and anticoagulants were not administered. We review the pathogenesis of septic SOVT and briefly discuss the role of anticoagulants and steroids in this setting.

Grau LE; Dasgupta N; Harvey AP; Irwin K; Givens A; Kinzly ML; Heimer R. Illicit use of opioids: Is OxyContin (R) a "Gateway drug''? American Journal on Addictions 16(3): 166-173, 2007. (42 refs.)

This study examines whether individuals who engage in illicit, non-medical use of OxyContin((R)) are distinguishable from other non-medical users of opioids and whether OxyContin serves as a "gateway'' to heroin and/or injection drug use. The study sample included active non-medical users of opioids, who are 16 years or older and residents of Cumberland County, Maine. Possible associations between type of opioid used and behavioral and descriptive variables were assessed. The study sample was predominantly urban-dwelling, male, Caucasian, and economically disadvantaged. OxyContin users could only be distinguished from heroin users (non-heroin opioid users). Polyopioid use within the first year of initiation was associated with quicker progression to heroin and injection drug use.

Guyer S; Kosel M; Altrichter S; El-Koussy M; Haemmig R; Fisch HU et al. Pattern of regional cerebral blood-flow changes induced by acute heroin administration - a perfusion MRI study. Journal of Neuroradiology 34(5): 322-329, 2007. (31 refs.)

Purpose. - Although both the subjective and physiological effects of abused psychotropic substances have been characterized, less is known about their effects on brain function. We examined the actions of intravenous diacetylmorphine (heroin), the most widely abused opioid, on regional cerebral blood flow (rCBF), as assessed by perfusion-weighted MR imaging (PWI) in a double-blind and placebo-controlled setting. Material and Methods. - Eight mate subjects dependent of diacetylmorphine (mean age 36 years, range: 26 to 44 years), who had participated in a clinical diacetylmorphine maintenance program, underwent PWI with gadolinium injection. At two sessions separated by 27 days, the participants were examined 80 s after intravenous administration of either diacetylmorphine or saline. rCBF in four regions of interest (amygdala, vermis of the cerebellum, anterior cingulated cortex and thalamus) was compared with heroin versus placebo. Results. - In the cerebellum, thalamus and cingulated cortex, there were no significant differences in perfusion values between diacetylmorphine and placebo. In the amygdala, perfusion values were 0.8 +/- 0.4 and 0.5 +/- 0.2 on the left, and 0.9 +/- 0.4 and 0.6 +/- 0.3 on the right, with diacetylmorphine and with placebo, respectively (t-test results were P=0.044 and P = 0.033 on the left and right sides, respectively). Other differences in perfusion values between the drug and placebo did not reach statistical significance. Conclusion. - Perfusion MRI demonstrated differences in brain hemodynamics induced by drug intake.

Hser YI; Huang D; Chou CP; Anglin MD. Trajectories of heroin addiction: Growth mixture modeling results based on a 33-year follow-up study. Evaluation Review 31(6): 548-563, 2007. (39 refs.)

This study investigates trajectories of heroin use and subsequent consequences in a sample of 471 male heroin addicts who were admitted to the California Civil Addiction Program in 1964-1965 and followed over 33 years. Applying a two-part growth mixture modeling strategy to heroin use level during the first 16 years of the addiction careers since first heroin use, the authors identified three groups with distinctive profiles: stably high-level heroin users (n = 278), late decelerated users (n = 149), and early quitters (n = 44). Study findings empirically demonstrate the chronic nature of heroin addiction and subsequent adverse consequences including mortality, mental health, and employment.

Isralowitz R; Reznik A. Gender differences among Israeli adolescents in residential drug treatment. Drugs: Education, Prevention and Policy 14(2): 167-172, 2007. (17 refs.)

Aims: The use of licit and illicit drugs is considered to be primarily a male problem. Numerous studies, however, question the extent of gender differences. This article reports on last 30 day drug use and related problem behaviour among male and female youth prior to residential treatment. Methods: Self-report data were collected from 95 male and female adolescents, age 13 to 18 years, at intake for treatment. Findings: Gender was not a factor differentiating the youth for cigarette, alcohol, cannabis, ecstasy, inhalant, and amphetamine use. Males were more likely to report hashish use. Females, however, were more likely to report use of prescription drugs, cocaine and heroin. No gender differences were found for binge drinking, driving a car after drinking or being a passenger in a car after the driver had been drinking, selling drugs, deterioration of relations with friends and family, gambling, taking loans or using personal money to buy drugs. Conclusion: Drug use and related behaviour among adolescents in residential treatment does not appear to be predominately a male problem. Further research is needed to understand the role of gender status in relation to what drugs are used and how for prevention, treatment and public health purposes.

Isralowitz R; Reznik A; Spear SE; Brecht ML; Rawson RA. Severity of heroin use in Israel: Comparisons between native Israelis and former Soviet Union immigrants. Addiction 102(4): 630-637, 2007. (20 refs.)

Aims: This study examined drug use patterns and severity among native-Israeli and former Soviet Union (FSU) immigrants in Israel who reported heroin use. Design, setting and participants: A total of 272 native Israelis and 300 FSU heroin users were interviewed from 2002 to 2006 as part of a large drug use surveillance study in Israel. Individuals were sampled at an intake centre, a methadone clinic and a day-treatment facility in the Negev region of Israel. Participants were assessed using the Addiction Severity Index, fifth edition. Native Israeli and FSU users were compared within two groups: those interviewed at intake and those interviewed in treatment. Findings Overall, ASI composite scores suggested generally comparable levels of addiction severity between the two ethnic groups. Native-born Israelis reported more years of heroin use; however, the FSU immigrants reported longer use of other opiates. The FSU reported significantly more heroin use by injection, and a significantly higher rate of hepatitis C and other chronic medical problems. Comparisons by gender within each group revealed higher drug severity scores for females (native-born Israeli and FSU combined). Females in the intake group had significantly higher severity scores in the areas of employment and psychiatric status when compared to individuals who had been in treatment for some time. Conclusions: Except for higher levels of alcohol use, the FSU did not have more severe drug problems than the native Israelis as measured by ASI severity scores. Injection use among FSU, however, is a critical public health problem, especially given the well-established link between injection drug use, hepatitis C and HIV/AIDS.

Jones HE; Tuten M; Keyser-Marcus L; Svikis DS. Specialty treatment for women. IN: Strain EC; Stitzer ML, eds. The Treatment of Opioid Dependence. Baltimore: Johns Hopkins University Press, 2006. pp. 455-484. (110 refs.)

This chapter covers two related topics. The first section deals with gender differences in drug abuse prevalence, in drug abuse-related comorbidities, and in treatment outcomes. These are important because they provide guidance for the type of treatment which can most benefit women. The second section deals with the critically important topic of treatment for drug-dependent pregnant women. Pregnancy may bring women into the care system, and it is important to have services available to respond. Tone and other se of methdr program. adug tatmentFurther many of the herapies are also reviewed.

Kidorf M; King VL; Brooner RK. Counseling and psychosocial services. IN: Strain EC; Stitzer ML, eds. The Treatment of Opioid Dependence. Baltimore: Johns Hopkins University Press, 2006. pp. 119-150. (87 refs.)

The aim of this chapter is to review the evidence of effectiveness of counseling and psychosocial services in treatment for opiate dependence and receiving methadone. The issue of adherence to nonpharmacologic components of treatment is a common difficulty in methadone programs. The second goal of this chapter is describe a service delivery system designed to encourage patients to attend counseling sessions consistently. The model is termed as "motivated step care" and involves the integration of counseling with verbal-expressive forms of therapy as well as behavioral interventions along with methadone.

Kinlock TW; Gordon MS; Schwartz RP; O'Grady KE. A study of methadone maintenance for male prisoners. Criminal Justice and Behavior 35(1): 34-47, 2008. (54 refs.)

This study examined benefits of methadone maintenance among prerelease prison inmates. Incarcerated males with preincarceration heroin dependence (n = 197) were randomly assigned to (a) group educational counseling (counseling only); (b) counseling, with opportunity to begin methadone maintenance on release (counseling + transfer); or (c) counseling and methadone maintenance in prison, with opportunity to continue methadone maintenance on release (counseling + methadone). At 90-day follow-up, counseling + methadone participants were significantly more likely than counseling-only and counseling + transfer participants to attend drug treatment (p = .0001) and less likely to be reincarcerated (p = .019). Counseling + methadone and counseling + transfer participants were significantly less likely (all ps < .05) to report heroin use, cocaine use, and criminal involvement than counseling-only participants. Follow-up is needed to determine whether these findings hold over a longer period.

Kovas AE; McFarland BH; McCarty DJ; Boverman JF; Thayer JA. Buprenorphine for acute heroin detoxification: Diffusion of research into practice. Journal of Substance Abuse Treatment 32(2): 199-206, 2007. (48 refs.)

Buprenorphinc has been approved for heroin detoxification, but little is known about its impact on everyday practice. Concerns about buprenorphine include expense, limited knowledge about its use, patient limits, and social and clinical attitudes regarding opioid treatment for heroin dependence. On the other hand, randomized clinical trials suggest that buprenorphine is superior to clonidine with regard to withdrawal symptom relief In June 2004, a community-based residential medical detoxification center switched from clonidine to buprenorphine treatment for all new and returning heroin clients. This study is a retrospective chart review of subject outcomes with clonidine (n = 100) versus buprenorphine (n = 100). Bivariate analysis suggested few cohort differences in pretreatment demographics and client characteristics. In contrast, buprenorphine was significantly associated with increased length of stay and treatment completion. The positive associations between buprenorphine and both treatment completion and length of stay persisted and were slightly enhanced after regression analysis adjusted for potential confounders. Additionally, clinical staff reported better subject engagement in treatment and psychosocial group sessions. This single-site study is an example of successful integration of an evidence-based treatment into community-based practice.

Krupitsky EM; Burakov AM; Dunaevsky IV; Romanova TN; Slavina TY; Grinenko AY. Single versus repeated sessions of ketamine-assisted psychotherapy for people with heroin dependence. Journal of Psychoactive Drugs 39(1): 13-19, 2007. (13 refs.)

A prior study found that one ketamine-assisted psychotherapy session was significantly more effective than active placebo in promoting abstinence (Krupitsky et al. 2002). In this study of the efficacy of single versus repeated sessions of ketamine-assisted psychotherapy in promoting abstinence in people with heroin dependence, 59 detoxified inpatients with heroin dependence received a ketamine-assisted psychotherapy (KPF) session prior to their discharge from an addiction treatment hospital, and were then randomized into two treatment groups. Participants in the first group received two addiction counseling sessions followed by two KPT sessions, with sessions scheduled on a monthly interval (multiple KPT group). Participants in the second group received two addiction counseling sessions on a monthly interval, but no additional ketamine therapy sessions (single KPT group). At one-year follow-up, survival analysis demonstrated a significantly higher rate of abstinence in the multiple KPT group. Thirteen out of 26 subjects (50%) in the multiple KPT group remained abstinent, compared to 6 out of 27 subjects (22.2%) in the single KPT group (p < 0.05). No differences between groups were found in depression, anxiety, craving for heroin, or their understanding of the meaning of their lives. It was concluded that three sessions of ketamine-assisted psychotherapy are more effective than a single session for the treatment of heroin addiction.

Kruptisky EM; Burakov AM; Tsoy MV; Egorova VY; Slavina TY; Grinenko AY et al. Overcoming opioid blockade from depot naltrexone (Prodetoxon((R))). Addiction 102(7): 1164-1165, 2007. (0 refs.)

Aim: To describe a situation in which an opioid-dependent patient overcame naltrexone blockade. Design, case report, setting Addiction treatment center in St Petersburg, Russia. Participant Patient with naltrexone implant. Intervention Detoxification. Measurements: Clinical observations. Conclusions: It is possible, but very difficult, to overcome naltrexone blockade by using large doses of heroin.

Laudet AB; White WL. Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Substance Use & Misuse 43(1): 27-54, 2008. (85 refs.)

Many recovering persons report quitting their drug use because they are "sick and tired" of the drug life. Recovery is the path to a better life, but that path is often challenging and stressful. There has been little research on the millions of recovering persons in the United States, and most research has focused on substance use outcomes rather than on broader functioning domains. This study builds on our previous cross-sectional findings that recovery capital (social supports, spirituality, religiousness, life meaning, and 12-step affiliation) enhances the ability to cope with stress and enhances life satisfaction. This study (a) tests the hypothesis that higher levels of recovery capital prospectively predict sustained recovery, higher quality of life, and lower stress one year later, and (b) examines the differential effects of recovery capital on outcomes across the stages of recovery. Recovering persons (N = 312), mostly inner-city ethnic minority members whose primary substance had been crack or heroin, were interviewed twice at a one-year interval in New York City between April 2003 and April 2005. Participants were classified into one of four baseline recovery stages: under 6 months, 6-18 months, 18-36 months, and over 3 years. Multiple regression findings generally supported the central hypothesis and suggested that different domains of recovery capital were salient at different recovery stages. The study's limitations are noted and implications of findings for clinical practice and for future research are discussed, including the need for a theoretical framework to elucidate the recovery process.

Levy MS. An exploratory study of OxyContin use among individuals with substance use disorders. Journal of Psychoactive Drugs 39(3): 271-276, 2007. (13 refs.)

This study surveyed 422 individuals being treated in a substance abuse treatment program that offers various levels of care in order to learn about OxyContin (R) use among this population. Focus areas included exposure and use of OxyConfin, how this medication was obtained, reasons for initial use, and whether users of OxyContin were drug naive or experienced users of opiate or non-opiate drugs. Whether OxyContin users who previously had never used opiates would report migrating to heroin was also explored. Findings revealed that 48% of the population had used OxyContin and of this population, only 1 % had no history of prior substance use. Seventy percent of this sample obtained them from friends and 14% obtained them directly from physicians. Many reported that their friends obtained their OxyContin from physicians, bringing the percentage of people who directly or indirectly obtained OxyContin through a physician to 37%. While most users of OxyConfin had a history of past opiate use, a small percentage had not, and of this later group, 73% migrated to using heroin. The majority of individuals who obtained OxyContin from a physician had a history of recreational or problematic opiate or non-opiate drug use. Finally, over time, 90% had stopped using this drug, although other drug use continued.

Levy R; Zelkowicz A. Efficiency evaluation of a police operation to fight the drug plague: Distribution unit weight as an objective index. Journal of Forensic Sciences 52(4): 909-912, 2007. (6 refs.)

Lod, a city near Tel-Aviv, is considered the main drug distribution center in Israel. A major police undercover operation in Lod, lasting close to a year, was terminated in May 2003. The success or failure of such an operation is frequently measured by the number of arrests made, the hierarchical level of the dealers arrested, the number of drug stations closed down, and the decrease in heroin seizures following the operation. In this work we suggest using an additional parameter, which has a scientific, objective basis, namely, comparing the changes in the average user weight unit ("dose") before and after the operation. We found that prior to the operation the average weight per unit was 1.1 g. Three months after the operation terminated the average weight per unit had decreased to 0.8 g and remained there for at least 4 months before rising again.

Li M; Lee S; Gan Z; Tan Y; Meng J; He M. Achieving a high coverage: The challenge of controlling HIV spread in heroin users. Harm Reduction Journal 4: article 8, 2007. (8 refs.)

In China, the national plan to open 1000 methadone clinics over a five-year period provides a unique opportunity to assess the impacts of harm reduction in a country with concentrated HIV epidemic amongst heroin users. To track the progress of this public health response, data were collected from the first methadone clinic in Liuzhou, Guangxi, a province with a high HIV prevalence. In the first 15 months of its operation, a cumulative total of 488 heroin users, 86% of which male, had joined the programme. The first dose of methadone was given efficiently at a median of 2 days after registration. Of the 240 heroin users attending the clinic in August 2006, 61% took methadone for four days or more each week. The number of active methadone users, however, leveled off at around 170 after the first two months, despite the availability of capacity to deliver more services. The reasons for this observation are: firstly, the provision of one single service that may not be convenient to all heroin users; and secondly, concerns of heroin users who may feel insecure to come forward. As broad coverage is essential in ultimately reducing HIV risk, a low threshold approach is crucial, which should be supported by the removal of social obstacles and a refinement of the administrative procedures.

Maher L; Li J; Jalaludin B; Wand H; Jayasuriya R; Dixon D et al. Impact of a reduction in heroin availability on patterns of drug use, risk behaviour and incidence of hepatitis C virus infection in injecting drug users in New South Wales, Australia. Drug and Alcohol Dependence 89(2/3): 244-250, 2007. (59 refs.)

In early 2001, Australia experienced a sudden and dramatic reduction in the availability of heroin. Research examining the impact of the reduction on drug-related harms has yielded a conflicting picture. The current study uses data from a prospective cohort study of anti-HCV negative injecting drug users (IDU) (n = 368) to examine patterns of injecting drug use, risk behaviours and HCV incidence before and after the reduction. The proportion of participants mainly injecting heroin declined sharply from 74% to 47% after the onset of the reduction and continued throughout 2001. There was marked shift to other drugs, mainly cocaine and amphetamine. Cocaine injectors had the highest risk profile and the highest incidence of HCV (82.6 per 100 person years, 95% CI 52.0-131.0). While HCV seroconversions increased by year, this increase was not statistically significant. We observed a reduction in heroin injection and a concomitant increase in cocaine injection and a significant association between cocaine injection and incident HCV infection during a period of reduced heroin availability. Results suggest that attempts to suppress drug markets by manipulating availability may result in collateral damage in the form of drug-related harms, indicating a need for more sophisticated understandings of the potential trade-offs involved in attempting to suppress the supply of illicit drugs.

Maremmani I; Pani PP; Mellini A; Pacini M; Marini G; Lovrecic M et al. Alcohol and cocaine use and abuse among opioid addicts engaged in a methadone maintenance treatment program. Journal of Addictive Diseases 26(1): 61-70, 2007. (42 refs.)

Alcohol and cocaine abuse result in unsatisfactory treatment outcomes for heroin and illicit opioid addicts engaged in Methadone Maintenance Treatment Programs (MMTPs). This study aims to clarify the impact of MMT, which focuses on cessation of opioid abuse and diminishing psychopathology to acceptable levels (stabilization) on alcohol and cocaine abuse. Of specific interest was whether reduction of polysubstance abuse and associated psychopathological complications diminished illicit opioid abuse and/or increased retention in treatment. Changes in cocaine and alcohol use that occurred in 53 heroin addicts who had been stabilized were monitored. A control group was composed of patients terminated from treatment due to noncompliance with treatment recommendations, poor attendance, or failure to have opioid abuse stabilized, within a year. The association of psychiatric severity with alcohol and cocaine abuse in these methadone maintained patients was assessed. Cessation of illicit opioid abuse and retention in treatment are positively correlated with decrease in alcohol and cocaine abuse and the absence of the psychosocial complications associated with such abuse.

McKetin R; Kelly E. Socio-demographic factors associated with methamphetamine treatment contact among dependent methamphetamine users in Sydney, Australia. Drug and Alcohol Review 26(2): 161-168, 2007. (28 refs.)

Australia has a sizable population of dependent methamphetamine users, the majority of whom do not receive treatment for their drug use. The aim of the current study was to identify socio- demographic factors related to not having received treatment for methamphetamine use among dependent users of the drug in Sydney, Australia. A cross-sectional survey of methamphetamine users in Sydney was used to identify a sample of dependent methamphetamine users (n = 173). Dependence was defined as a score of four or greater on the Severity of Dependence Scale. Dependent methamphetamine users who had received treatment for their methamphetamine use (n = 57) were compared with those who had never received treatment for their methamphetamine use (n = 116) on socio- demographic characteristics and drug use. After adjusting for severity of methamphetamine dependence, socio- demographic factors that were predictive of not having received methamphetamine treatment included being female, being born outside Australia and being in full-time employment. Methamphetamine smokers were less likely to receive treatment than people who took the drug via other routes of administration, while primary heroin users who were concurrently dependent on methamphetamine were unlikely to receive treatment for their methamphetamine use. Further research is needed to understand the barriers to receiving methamphetamine treatment among these subgroups of dependent methamphetamine users.

Mills KL; Teesson M; Ross J; Darke S. The impact of post-traumatic stress disorder on treatment outcomes for heroin dependence. Addiction 102(3): 447-454, 2007. (36 refs.)

Aims: To examine the impact of post-traumatic stress disorder ( PTSD) on 2-year treatment outcomes for heroin dependence. Design: Prospective longitudinal study. Participants Data were obtained from a predominantly treatment seeking sample of 615 dependent heroin users who were followed-up at 3, 12 and 24 months (follow-up rates: 89%, 81% and 76%, respectively). Measurements: Outcomes examined include treatment retention and exposure, substance use, general physical and mental health and employment. Findings Despite improvements in substance use, PTSD was associated with continued physical (beta - 1.69, SE 0.61, P < 0.01) and mental disability (beta - 2.07, SE 0.66, P < 0.01), and reduced occupational functioning ( OR 0.67, 95% CI: 0.48-0.93) throughout the 2-year follow-up. Conclusions: Although conventional treatment services are successful in producing improvements in substance use and associated disability, the disability associated with PTSD remains. An intervention targeting both heroin dependence and PTSD may help to improve the outcomes of those with PTSD.

Millson P; Challacombe L; Villeneuve PJ; Strike CJ; Fischer B; Myers T et al. Reduction in injection-related HIV risk after 6 months in a low threshold methadone treatment program. AIDS Education and Prevention 19(2): 124-136, 2007. (41 refs.)

This study assessed injection-related HIV risk behavioral changes among opioid users 6 months after enrollment in low-threshold (harm reduction based) methadone maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subcohort); and those who continued to inject drugs (injecting subcohort). In this prospective observational cohort study, an interviewer-administered questionnaire examining injection-related HIV risk behaviors was administered to 183 study participants at entry to treatment and 6 months later. Changes in risk behaviors were analyzed using conditional logistic regression which took into account the paired nature of the data. We found that the proportion of participants injecting drugs, sharing needles, sharing drug equipment, indirectly sharing and using shooting galleries declined with follow-up for the whole cohort. Within the drug-using subcohort, there was a decrease in the proportion of individuals who injected drugs, while within the injecting subcohort the sharing of injection equipment and the use of shooting galleries declined. Our findings suggest that low-threshold MMT programs can reduce the risk of HIV without the enforcement of abstinence-based policies.

Monga N; Rehm J; Fischer B; Brissette S; Bruneau J; El-Guebaly N et al. Using latent class analysis (LCA) to analyze patterns of drug use in a population of illegal opioid users. Drug and Alcohol Dependence 88(1): 1-8, 2007. (62 refs.)

Background: The objective of this paper is to empirically determine a categorization of illegal opioid users in Canada in order to describe and analyze drug use patterns within this population. Methods: Drug use patterns of 679 eligible illegal opioid users outside treatment from the OPICAN study, a pan-Canadian cohort (recruited March to December, 2002) involving the cities of Toronto, Montreal, Vancouver, Edmonton and Quebec City, were empirically examined using latent class analysis. These latent classes were then further analyzed for associations using chi-square and t-test statistics. Findings: The opioid and other drug user sample surveyed were categorized into three latent classes. Class I (N=256) was characterized by the use of Tylenol 3 and benzodiazepines along with high levels of depression and self-reported pain. Class 2 (N=68) was described by the non-injection use of both heroin and crack while having a high level of homelessness. Class 3 (N=344) was shown to consist of injection drug users of heroin and cocaine exhibiting the highest levels of HIV and Hepatitis C infections amongst the classes. Conclusions: Using latent class analysis we found distinct patterns of drug use amongst illegal opioid users differing in terms of type of drugs co-used, social context, and co-morbid pathologies. These data may be useful as the empirical basis for the planning of specific prevention and treatment interventions.

Moore TJ. Australian illicit drug market data: Sources and issues. Australian Economic Review 39(4): 442-452, 2006. (34 refs.)

This article provides a brief overview of Australian data sources on illicit drug markets. In Australia, there are several datasets that may be useful for economists interested in conducting research into illicit drug markets. The aim of this article is to describe these data sources and discuss some of the issues that should be considered when using them. To be clear, the focus here is on markets for psychoactive substances completely proscribed by law, rather than substances subject to restrictions (such as prescription medicines, alcohol and tobacco). These are most commonly cannabis, opiates (including heroin), stimulants (including cocaine, amphetamine and methamphetamine) and hallucinogens (including ecstasy/MDMA, LSD and ketamine) (Australian Crime Commission 2006; Australian Institute of Health and Welfare (AIHW) 2005). Three types of information are discussed in turn. The first is price data, which are necessary for any economic analysis of illicit drug markets. The second is consumption and participation data. While occasionally people are asked how much of an illicit drug they consumed, more often they are asked about whether they were a consumer (that is, a participant) within a recent period of time (for example, whether they used a particular drug over the past year, past month or past week). The third type of data is those that measure characteristics related to drug markets, such as health outcomes and criminal activity.

Morgan OW; Johnson H; Rooney C; Seagroatt V; Griffiths C. Changes to the daily pattern of methadone-related deaths in England and Wales, 1993-2003. Journal of Public Health 28(4): 318-323, 2006. (21 refs.)

Previous studies suggest that fatal poisoning deaths involving methadone occur more frequently on the weekends. We assessed changes in the daily pattern of mortality because of methadone poisoning following a review of drug misuse services in 1996 and publication of revised clinical guidelines in 1999. We also compared this to the daily pattern of deaths involving heroin/morphine. The Office for National Statistics provided data on all deaths in England and Wales between 1993 and 2003 for which methadone and heroin/morphine were mentioned on the coroner's certificate of death registration after inquest, with or without alcohol or other drugs. There were 3098 deaths involving methadone. The death rate increased up to 1997 and then declined. Initially, there was a marked excess of deaths occurring on Saturdays. The rate of decline was greatest for deaths occurring on Saturdays. As a result, the Saturday peak disappeared (P = 0.006). There were 6328 deaths involving heroin/morphine. No change in the daily pattern of heroin/morphine deaths was observed during the study period. Although the marked change in the epidemiology of methadone deaths coincided with recommendations for service redevelopment and clinical management of methadone treatment, the contribution of improved prescribing practice or treatment services is unclear.

Mouzos J; Smith L; Hind N. Drug Use Monitoring in Australia: 2005 Annual Report on Drug Use among Polic Detainees. Research and Public Policy Series No. 70. Canberra Australia: Australian Institute of Criminology, 2006. (22 refs.)

The Drug Use Monitoring in Australia (DUMA) program, established in 1999, is a quarterly collection of information from police detainees in seven sites (police states or watchhouses) across Australia. There are two parts to the information collected: a questionnaire, which is conducted with a trained interviewer independent from the police, and a urine sample, which is tested for six different classes of drugs. Information collected from the questionnaire includes basic demographic data, drug use history, drug market information, treatment history and information on prior contact with the criminal justice system. The seven DUMA sites represent a range of community configurations: two sites represent the urban conurbation of a major state capital; three cover a metropolitan city area; one the outer suburbs of a major state capital; and the last covers a major tourist and retirement destination. This report presents both self-report and urinalysis data from 3,786 participating detainees for 2005. It includes an overview of the characteristics of detainees at each site, including self-reported drug use, prior criminal behaviour and treatment history. In addition to tracking changes in local drug markets, DUMA collects additional information on key strategic issues in a timely manner. Since its inception a number of addendums have been run as part of the DUMA questionnaire. In 2005, the following different addendums were run at the sites: quarter one: diversion (all sites but specific to each state); quarter two: drug driving (all sites); quarter three: domestic violence (all sites); and quarter four: stolen goods (all sites). This annual report, relying on provides the results for seven sites. There were a total of 3,685 persons. Almost 42% of the detainees reported using drug prior to their arrest. Thirty-seven reported having sold drugs at some point in their lives, but only 10% said they were looking for drugs at the time of arrest. Drugs identified were benzodiazepines, 17% or males and 33% of females; marijuana, 54% of males and females, but concentrated in younger detainees; cocaine,1%; heroin, 12% of males, and 17% of females; methyl methamphetamine, 26% of males, 39% of females, as marijuana, also higher in younger age groups. Ecstasy was uncommon, less than 3%. Data is also presented on injecting use patterns, methods of securing drugs, and the proportion who paid cash and the locus of purchase, crime attributed to drug use, age of first drug use and drug arrest, history of drug treatment, estimates of dependence levels, and data organized by site.

Neale J; Bloor M; McKeganey N. How do heroin users spend their spare time? Drugs: Education, Prevention and Policy 14(3): 231-246, 2007. (24 refs.)

Aims: Data from a national longitudinal study of drug users entering treatment in Scotland are used to undertake an exploratory investigation of how heroin users like to spend their spare time. Specific aims are to explore heroin users' self-reported interests at two time points; their continuity of interests over time; and demographic and behavioural factors associated with having at least one non-drug pastime. Methods: 606 heroin users (70% males; 30% females) were interviewed using structured questionnaires at treatment entry and again 33 months later. Univariate analyses were undertaken using chi-square tests and independent t-tests. Multivariate analyses were undertaken using stepwise logistic regression. Findings: 359 respondents (59%) reported at least one leisure interest at treatment entry and 521 (86%) reported at least one leisure interest 33 months later. Sport was the most common type of interest reported, but fifteen other hobby categories were identified. Many respondents reported multiple interests and 214 reported at least one same interest at both time points. The most consistent variables associated with having a spare time interest were being male and sleeping well. Conclusions: The study provides further evidence that many problem drug users participate in ordinary daily activities. Enjoying these is a positive aspect of everyday life and a behavioural pattern that should be supported and encouraged by service providers whenever possible.

Nunes EV; Sullivan MA; Carpenter KM; Kleber HD. Behavioral therapy to augment oral naltrexone for opioid dependence: A ceiling on effectiveness? American Journal of Drug and Alcohol Abuse 32(4): 503-517, 2006. (42 refs.)

The effectiveness of antagonist maintenance with oral naltrexone for opioid dependence has been limited by high dropout rates. Behavioral Naltrexone Therapy (BNT) was developed to improve retention on oral naltrexone by integrating voucher incentives, Motivational and Cognitive Behavioral therapies, and a significant other for monitoring medication adherence. In a 6-month, randomized, controlled trial in heroin dependent patients, BNT (N = 36) improved retention in treatment compared to a standard treatment control (Compliance Enhancement (CE); N = 33) (log rank = 4.28; p = .04). Most patients retained beyond 3 months achieved abstinence from opioids, but retention at 6 months was only 22% on BNT and 9% on CE. A systematic review of related controlled trials revealed similar effect sizes in the small to medium range, and substantial dropout. There may be a limit on the extent to which behavioral therapy can overcome poor adherence to oral naltrexone. Future research should consider combinations of behavioral methods with new long-acting injectable or implantable naltrexone formulations.

O'Brien S; Mattick RP; White J; Breen C; Kimber J; Ritter A et al. Maintenance pharmacotherapy for opioid dependence and SF-36 health status: A comparison with general population norms and other chronic disorders. Addictive Disorders and their Treatment 5(4): 155-164, 2006. (31 refs.)

OBJECTIVES: To assess the health status of heroin users starting and following 3 months of pharmacotherapy for opioid dependence, and to compare outcomes to a range of other chronic medical illnesses treated with maintenance medication. METHODS: The study uses pooled data from 6 clinical trials included in an Australian National Evaluation of Pharmacotherapies for Opioid Dependence. Participants received maintenance pharmacotherapy (oral naltrexone treatment, methadone, or buprenorphine) for the treatment of heroin dependence. Participants' health status was measured using the Short Form 36 health survey completed before treatment and at 3-month follow-up. Baseline data from 326 heroin-dependent participants starting maintenance treatment, and 3-month follow-up data for the 117 participants retained in trial treatment are presented. RESULTS: Heroin users at entry into pharmacotherapy for opioid dependence were in very poor psychological and physical health in relation to Australian population norms. For the 117 participants retained in treatment, clinically and statistically significant improvements in physical health, and emotional and social health were observed in just 3 months. Importantly, the health status of treated heroin users improves to a comparable or greater degree than that observed with other chronic illnesses treated with maintenance medication. CONCLUSIONS: Existing, evidence-based pharmacotherapies should be used in the treatment of heroin dependence with the same long-term care and medical monitoring strategies currently used in the treatment of other chronic illnesses.

Office of Applied Studies. The New DAWN Report. Opiate-related Drug Misuse Deaths in Six States: 2003. Issue 19. Rockville MD: Substance Abuse and Mental Health Services Administration, 2006. (3 refs.)

The 2004 National Survey on Drug and Use and Health found that an estimated 4.4 miilion people aged 12 or older had used opiate pain medications nonmedically in the prior month. In 2004, an estimated 158,281 emergency department visits were related to opiate prescription pain medications. This report examines the involvement of opiates in deaths resulting from drug misuse in six states: Maine, New Hamphsire, Vermont, Maryland, Utah, and New Mexico. These states vary in population and portion of the population living in metropolitan versus rural areas. Among the major findings are that the rates of opiate-related drug misuse deaths in 2003 ranged from 7.2 per 100,000 population (New Hampshire) to 11.6 persons per 100,000 in New Mexico. In each of these states, most opiate-related drug misuse deaths involved multiple drugs. In five of the six states, the age group with the highest rate of opiate-related deaths was among those ages 35-54. In the remaining state (Maine), the highest rate was for adults ages 21-34. States varied in respect to which opiate medication was involved in deaths. Oxycodone was involved in 30% of deaths in Vermont, but less than half of that in Maryland (14%) and New Mexico (13%). Hydrocodone involvement ranged from 3% (Maryland) to 17% Utah). In all states but Vermont, methadone deaths outnumbered deaths associated with oxycodone or hydocodone. Information is also provided in respect to demographic characteristics, death rates per age group, and poly- versus single drug involvement.

Paoli L; Rabkov I; Greenfield VA; Reuter P. Tajikistan: The rise of a narco-state. Journal of Drug Issues 37(4): 951-+, 2007. (71 refs.)

Since the collapse of the Soviet Union in 1991, Tajikistan has experienced an extraordinary and devastating expansion of opiate trafficking and consumption. While heroin was virtually unknown in the country up to the mid-1990s and opium was produced and consumed locally only to a modest degree, in less than a decade Tajikistan has become a key transit country for Afghan opiates bound north- and westwards, at the same time as it has witnessed a rapid growth of domestic heroin use. Tajikistan now rivals Afghanistan for the unenviable title of the country most dependent on the illicit drug industry, with the opiate industry adding at least 30% to the recorded gross domestic product. The opiate trade is so important economically that it corrupts the whole political system. This article therefore argues that since the mid-1990s Tajikistan has become a narco-state, in which leaders of the most powerful trafficking groups occupy high-ranking government positions and misuse state structures for their own illicit businesses.

Peles E; Bodner G; Kreek MJ; Rados V; Adelson M. Corrected-QT intervals as related to methadone dose and serum level in methadone maintenance treatment (MMT) patients: A cross-sectional study. Addiction 102(2): 289-300, 2007. (43 refs.)

Aims: To determine and evaluate OTc intervals in electrocardiograms (ECGs) of former heroin addicts, currently in methadone maintenance treatment (MMT), as previous reports suggest that methadone may prolong QTc intervals, thus possibly increasing the risk for Torsade de pointes (TdP). Design: Cross-sectional study. Setting Between January 2003 and September 2004, patients on a steady dose of methadone for at least 2 weeks were studied. Participants This study is a subset of 15 3 patients, of whom 15 1 patients participated in a study of high methadone doses and serum levels. A total of 138 patients in MMT for a minimum of 100 days up to 10.7 years, receiving 40-290 mg/day methadone dose, participated. Measurements Patients had an ECG at the time when blood was drawn for determination of serum methadone levels at around 24 hours after the last oral methadone dose. Corrected-QT intervals (QTc) were calculated using the Bazett formula. Findings Of 13 8 patients studied, 9 8 (71%) were male. Mean OTc interval was 418.3 +/- 32.8 milliseconds (ms). Mean methadone dose was 170.9 +/- 50.3 mg/day and mean serum methadone level was 708.2 +/- 363.1 ng/ml. Methadone dose and serum levels did not correlate with QTc. Three patients had QTC intervals above 500 ms ('prolonged'). After 2 +/- 0.4 years of follow-up, two patients died; they were two of three patients with very prolonged QTc. Causes of death were not attributed to cardiac origin. An additional 19 patients had QTc intervals of between 450 and 499 ms ('possibly prolonged'). None of these QTc >= 450 ms patients had any cardiac problems. Methadone doses of all 22 patients were > 120 mg/day. Conclusions: Methadone maintenance is generally safe; however, the possible toxicity of high dose I(> 120 mg/day) should be monitored for QTc.

Peles E; Schreiber S; Naumovsky Y; Adelson M. Depression in methadone maintenance treatment patients: Rate and risk factors. Journal of Affective Disorders 99(1-3): 213-220, 2007. (39 refs.)

Background: Depression is widely prevalent among former heroin addicts in methadone maintenance treatment (MMT). The risk factors for depression among MMT patients that have not been well characterized, was studied. Methods: In a cross-sectional study (January, 2004-August, 2005), 90 MMT patients were evaluated for depression by the 21-item Hamilton Rating Scale for Depression (21-HAM-D) and the Brief Psychiatric Rating scale (BPRS). To study possible induction of depression by drug abuse, urine samples tested for, opiates, cocaine metabolite (benzoylecgonine), benzodiazepines (BDZ), cannabis (THC), amphetamines and methadone metabolite during I month preceding study entry: a drug was defined as being positive if at least one sample was positive. Results: The 21-HAM-D and BPRS scores were significantly correlated (Pearson R=0.76, p < 0.0005). Fifty percent were found to be suffering from depression (21-HAM-D, scored 18). Fifteen new patients in MMT had better scores (5.1 +/- 5.7) than continuous patients (17.7 +/- 6.2, p < 0.0005), independent of treat