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CORK Bibliography: Heroin

96 citations. July 2010 to present

Prepared: March 2011

Agorastos A; Zurhold H; Verthein U; Petridou A; Haasen C. Addiction services in Cyprus: Results of an EU Twinning Project. Drugs: Education, Prevention and Policy 18(5): 340-352, 2011. (38 refs.)

Introduction: This evaluation is part of a Twinning Project between Cyprus and Germany, aimed at evaluating the governmental drug services in Cyprus and promoting the improvement and introduction of new drug treatment services, in order to assist the new Member State in the implementation and harmonization with the European Community's legislation. Methods: A field investigation studied parameters as population in need, treatment demand and coverage, as well as high-risk patterns and their trend over the past years. Results: The main findings were a high level of problematic drug use, mainly high-risk intravenous heroin and cocaine use, and an increase treatment demand for women, adolescents and migrants. Expert interviews named gaps in treatment options, including a previous lack of maintenance treatment, insufficient harm reduction measures and inadequate treatment concepts to meet specific needs of problematic drug users. Discussion: Recommendations for improvement can be integrated into present services. Cypriot authorities have started implementing the suggestions, so that an overall improvement of services can be expected in the future.

Anticevic V; Britvic D; Sodic L. The personality traits and social characteristics of Croatian heroin addicts and cannabis users. Collegium Antropologicum 35(3): 701-707, 2011. (43 refs.)

The purpose of this study was to investigate differences in social characteristics (level of education, working and family status, and criminal record) between heroin addicts, cannabis users and a control group. Additional goal was to explore the possibility of discerning subjects of different addiction status (of both gender) based on their scores on Eysenck Personality Questionnaire (EPQ). In comparison to the control group, heroin addicts and cannabis users had lower level of education, were more frequently unemployed and with criminal record, and more often came from dysfunctional families. In cannabis users the frequency of these characteristics was generally lower than in heroin addicts. Proportion of correct classification of subjects in groups of different addiction status based on the EPQ scores was 23.3% for males (higher than by chance alone), and 30% for females.

Arendt M; Munk-Jorgensen P; Sher L; Jensen SOW. Mortality among individuals with cannabis, cocaine, amphetamine, MDMA, and opioid use disorders: A nationwide follow-up study of Danish substance users in treatment. Drug and Alcohol Dependence 114(2-3): 134- 139, 2011. (74 refs.)

This is a register-based cohort study of 20,581 individuals in treatment for illicit substance use disorders in Denmark between 1996 and 2006. All in all, 1441 deaths were recorded during 111,445 person-years of follow-up. Standardized mortality ratios (SMRs) associated with different primary substance types were calculated and Cox-regression analyses were performed in order to establish hazard ratios (HR) associated with injection drug use and psychiatric comorbidity. SMRs for primary users of specific substances were: cannabis: 4.9 (95% confidence interval (Cl): 4.2-5.8), cocaine: 6.4 (Cl: 3.9-10.0), amphetamine: 6.0 (Cl: 4.2-8.3), heroin: 9.1 (Cl: 8.5-9.8), and other opioids 7.7 (Cl: 6.6-8.9). For MDMA ('ecstasy') the crude mortality rate was 1.7/1000 person-years (Cl: 0.4-7.0) and the SMR was not significantly elevated. Injection drug use was associated with significantly increased hazard ratios in users of opioids and cocaine/amphetamine. Overall, psychiatric comorbidity was not associated with increased mortality (HR: 1.1 [Cl: 0.9-1.2], p = .28), but an association was found specifically among cocaine/amphetamine users (HR: 3.6 [Cl: 2.1-6.4], p <.001).

Bartlett N; Xin DM; Zhang H; Huang BM. A qualitative evaluation of a peer-implemented overdose response pilot project in Gejiu, China. International Journal of Drug Policy 22(4): 301-305, 2011. (30 refs.)

Background: A harm reduction NGO in southern Yunnan operating an emergency overdose response hotline service successfully reversed 76 overdoses through the administration of naloxone in one of the first interventions of its kind in China. Method: To explore local understandings of risk factors related to overdose, assess ongoing barriers to overdose response, and solicit client input on how to further reduce opiate overdose mortality in Gejiu, the authors conducted qualitative interviews with 30 clients, including 15 individuals who received naloxone injections to reverse an overdose and 15 individuals who called the hotline in response to the overdose of a peer. Results: Participants pointed to a number of local structural shifts in heroin use including the ageing of the opiate using population and drug mixing practises that contribute to the city's overdose toll. Concerns over medical professionals' willingness to treat drug users, protection of confidentiality, and financial costs associated with treatment frequently cause drug users to avoid contact with the city's emergency service providers. Participants suggest directly distributing naloxone to clients as one strategy to further reduce overdose mortality. Conclusion: The authors explore possible strategies, including targeted trainings and new partnerships with local hospitals, to further reduce opiate overdose mortality in this resource-poor setting.

Bell JAF Bell James. Commentary on Reimer et al. (2011): More work needed. (editorial). Addiction 106(9): 1656-1657, 2011. (3 refs.)

Bennett AS; Bell A; Tomedi L; Hulsey EG; Kral AH. Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. Journal of Urban Health 88(6): 1020-1030, 2011. (25 refs.)

Prevention Point Pittsburgh (PPP) is a public health advocacy organization that operates Allegheny County's only needle exchange program. In 2002, PPP implemented an Overdose Prevention Program (OPP) in response to an increase in heroin-related and opioid-related overdose fatalities in the region. In 2005, the OPP augmented overdose prevention and response trainings to include naloxone training and prescription. The objective of our study is to describe the experiences of 426 individuals who participated in the OPP between July 1, 2005, and December 31, 2008. of these, 89 individuals reported administering naloxone in response to an overdose in a total of 249 separate overdose episodes. of these 249 overdose episodes in which naloxone was administered, participants reported 96% were reversed. The data support findings from a growing body of research on similar programs in other cities. Community-based OPPs that equip drug users with skills to identify and respond to an overdose and prescribe naloxone can help users and their peers prevent and reverse potentially fatal overdoses without significant adverse consequences.

Bohnert ASB; Roeder KM; Ilgen MA. Suicide attempts and overdoses among adults entering addictions treatment: Comparing correlates in a US national study. Drug and Alcohol Dependence 119(1-2): 106-112, 2011. (55 refs.)

Background: Suicide attempts and non-fatal overdoses are both associated with substance use. The aim of the present study was to examine correlates of suicide attempts and non-fatal overdoses simultaneously among individuals seeking addictions treatment. Methods: A large U.S. national sample of individuals entering addictions treatment participated in a cross-sectional survey (n = 5892). Multinomial logistic regression modeling tested the adjusted associations of violence, injection drug use, specific substances, and depressive symptoms with a four-category outcome variable based on prior histories of suicide attempt and non-fatal overdose (neither, suicide attempt only, overdose only, both), adjusting for demographic and treatment characteristics. Results: Sexual and physical victimization was associated with suicide attempts with or without overdoses (ORs 1.25-2.84), while perpetrating violence was associated with having experienced either or both outcomes (ORs 1.25-1.56). Depressive symptoms had a stronger association with suicide attempts (OR = 3.05) than overdoses (OR = 1.29). Injection drug use was associated with overdoses with or without suicide attempts (ORs 2.65-3.22). Individuals seeking treatment for marijuana use were less likely have overdosed or attempted suicide (ORs 0.39-0.67), while individuals seeking treatment for heroin use were more likely to have overdosed (OR = 1.46). Seeking treatment for use of more than one substance was associated with overdose and overdose and suicide attempt (ORs 1.58-2.51), but not suicide attempt alone. Conclusions: The present findings indicate that suicide and overdose are connected yet distinct problems. Individuals who have had a history of both may be a group with particularly poor psychological functioning as well as more severe drug-related problems.

Bowen KJ; Dzuvichu B; Rungsung R; Devine AE; Hocking J; Kermode M. Life circumstances of women entering sex work in Nagaland, India. Asia-Pacific Journal of Public Health 23(6): 843-851, 2011. (15 refs.)

Background and objectives: The study objective was to enhance understanding of female sex workers' lives in Nagaland, India (one of the country's highest HIV prevalence states), to inform the development of interventions to reduce HIV transmission and assist women who want to leave sex work. Methods: A cross-sectional survey (n = 220) and semi-structured interviews (n = 30) were conducted with sex workers. Topics included the following: life situated currently and at time of initial engagement in sex work, circumstances of first sex work occasion, and current patterns of sex work. Results: Participants' lives at time of entry into sex work were socio-culturally and economically vulnerable as evidenced by the early age of sexual debut, low levels of education, unemployment, absence of protective male parents, and poor relationships with families. Participants experienced high levels of mobility, insecure accommodation, the need to financially support family, and the demand to give a portion of their income to others. The use of alcohol and other drugs, including heroin, was widespread. Discussion and conclusions: For these women, sex work can be seen as a pragmatic option for earning sufficient income to live. The women's lives would be improved by strategies to promote their health, ensure their safety, and protect their rights as long as they are engaging in sex work. This is likely to benefit not only the sex workers but also their children, their families, and the wider community. The development of alternative employment opportunities is vital to protect against entry into sex work and to support women who want to exit sex work.

Bowser BP; Lewis D; Dogan D. External influences on drug treatment interventions: East Palo Alto's Free-at-Last. Journal of Addiction Medicine 5(2): 115- 122, 2011. (25 refs.)

External influences on community-based drug treatment program outcomes have not been adequately accounted by either treatment providers or evaluators. In 2001-2003, a cohort of 197 African American and Latino crack cocaine and heroin users was interviewed at intake into the Free-at-Last's treatment program in East Palo Alto, California. Objective: The goal of this research was to identify, and then measure, the impact of a series of theory-based, hypothesized external influences on 3 client treatment outcomes: (1) program completers, (2) dropouts, and (3) referrals to more intensive inpatient treatment. Methods: All program clients were interviewed using the Government Performance and Results Act and the California Alcohol and Drug Data System questionnaires. Supplemental questions hypothesized the external influences and were based on prior research and staff focus groups. Results: There were statistically significant differences in treatment outcomes based on employment status, homelessness, living situation, and jail time. Regression analyses indicated that the strongest outcome predictors were treatment intensity, followed by prior crack use, homelessness, income, and number of illegal drugs used. Path analysis showed that former crack use and time in jail formed a particularly strong cluster of external influences on treatment outcomes. This cluster was the result of court-mandated treatment of arrested crack users who chose treatment over incarceration. If users failed treatment, they went back to jail. In a community such as East Palo Alto, court-mandated referrals had a powerful external influence on treatment and, therefore, need to be considered when evaluating a treatment program.

Braden M; McGowan IW; McLaughlin DF; McKenna HP; Keeney S; Quinn B. Users, carers and professionals experiences of treatment and care for heroin dependency: Implications for practice. A preliminary study. Journal of Substance Use 16(6): 452-463, 2011. (50 refs.)

Aim: This paper reports on the treatment and care experiences for heroin dependency in a Northern Ireland Healthcare Trust. Background: There is a dearth of multi-dimensional heroin dependency treatment perspectives in background qualitative peer-reviewed literature. This is surprising given the influence of "consumer evaluation" in service development. Method: Focus groups were undertaken with separate purposive samples of ex/current heroin users (n = 7), carers of ex/current heroin users (n = 4) and professionals involved in heroin dependency service provision (n = 4). Non-directive question schedules elicited collective phenomenological experiences. Focus groups were transcribed verbatim and content analyzed. Findings: Study participants shared mainly dehumanizing experiences of treatment and care provision often characterized by non-communicative and judgemental health professional conduct. Unpredictable prescribing protocol and limited treatment resources have overshadowed any beneficial experiences of substitute prescribing in our pilot study. Findings also showed that participants requested treatment choice and holistic care provision. Conclusions: Incoherent drug treatment policy and communication breakdown between treatment stakeholders has influenced a cyclical blame culture in this study.

Bretteville-Jensen AL. Illegal drug use and the economic recession: What can we learn from the existing research? International Journal of Drug Policy 22(5): 353-359, 2011. (59 refs.)

Background: Much research on the use of amphetamine, cocaine and heroin employs individual level data and analyses variations in drug use by factors like personal characteristics, socioeconomic factors, and the social environment. Less attention is given to how these individual responses inter-relate with key macroeconomic variables. From a drug policy perspective however, it is important to also understand the consequences for drug use and drug users of changes in the macroeconomic conditions. As the world is experiencing an economic recession one would like to know whether it will affect the number of drug users and/or consumption frequency and volume amongst established users. Methods: There are different channels through which a recession could influence drug consumption; here the main focus is on how an economic downturn may influence drug prices and drug users' incomes. We briefly refer to relevant economic theory before reviewing the research literature. Results: A fall in drug prices and income seem likely. Empirical studies confirm drug users' price responsiveness. Only a few studies have dealt with income elasticity amongst this group. Conclusion: As the price and the income effect may pull in opposite directions, the full effect on drug use is difficult to predict. Still, it seems likely that an economic downturn of the current magnitude could increase the use of drugs.

Bukten A; Skurtveit S; Stangeland P; Gossop M; Willersrud AB; Waal H et al. Criminal convictions among dependent heroin users during a 3-year period prior to opioid maintenance treatment.: A longitudinal national cohort study. Journal of Substance Abuse Treatment 41(4): 407-414, 2011. (42 refs.)

This study investigates frequency and types of criminal convictions among a national sample of heroin users during a 3-year period prior to opioid maintenance treatment (OMT). All heroin users (N = 3,789) in Norway who applied for and were eligible for OMT (1997-2003) were included. The OMT records were cross-linked to Norwegian crime statistics. During observation, 24,478 convictions were recorded among 60.9% of the sample. Differences of criminal convictions were found within the group; a large proportion (39.1%) had no convictions, whereas 10% of the sample was responsible for 37.8% of all convictions. Convictions for acquisitive crimes and drug crimes were the most common. Variations in the cohort's individual crime sequences were found. The heavy involvement of heroin users with the criminal justice system provides an opportunity to intervene with dependent offenders. Coordination between treatment providers and police or courts can play an important role in improving outcomes through better access to treatment.

Buster MCA; van den Brink W; van Brussel GHA; van Ree JM. Influence of treatment with inhalable heroin on pulmonary function. European Addiction Research 17(3): 136-138, 2011. (7 refs.)

This study aims to asses the influence of inhalable heroin on pulmonary function in chronic heroin-dependent patients treated with inhalable heroin. Among 32 patients (all cigarette smokers), a spirometric test was conducted at baseline and after an average period of 10 months of treatment with medically prescribed heroin. Patients showed a high frequency of pulmonary dysfunction at baseline [34%, with percentage of forced expiratory volume in 1 s (% FEV1) <80%]. However, after excluding those who started pulmonary treatment (n = 2) or who used heroin intravenously only (n = 2), no statistically significant differences in % FEV1 between baseline and follow-up were observed (n = 28; mean % FEV1 86% at baseline vs. 91% at follow-up; p = 0.09). This small and relatively brief study suggests that 10 months of co-prescribed inhalable heroine base does not seem to (further) deteriorate pulmonary function in chronic, cigarette smoking treatment refractory heroin addicts. Screening for and treatment of pulmonary dysfunction is recommended for methadone patients with and without co-prescribed heroin.

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The TEDS Report: The Length of Time from First Use to Adult Treatment Admission (September 29, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (4 refs.)

The findings in this report indicate that, on average, adult first-time treatment admissions an average of 15.6 years elapsed between first use and of the primary substance of abuse and entry into treatment. There were significant differences in duration of use by race/ethnicity, substance of abuse, and gender. The length of time between first use and treatment entry was longer for males than for females (16.5 vs. 13.8 years), and ranged from 13.3 years among Asian or Pacific Islander admissions to 17.4 years among American Indian/Alaska Native admissions. Non-Hispanic Black admissions had a longer length of time between first use and treatment entry than other race/ethnicities for primary cocaine abuse (17.0 vs. 14.5 years or less) and primary heroin abuse (21.1 vs. 15.2 years or less). Male admissions had a longer time between first use and treatment entry than female admissions for primary cocaine abuse (15.7 vs. 12.6 years), primary heroin abuse (13.4 vs. 10.0 years), and stimulants (13.0 vs. 10.6 years)The years between first use and treatment admission suggest that there may have been missed opportunities for intervention. Finally, there was a much shorter duration of use prior to first treatment for prescription drugs than for other substances.

Public Domain

Chekuri V; Gerber D; Brodie A; Krishnadas R. Premature ejaculation and other sexual dysfunctions in opiate dependent men receiving methadone substitution treatment. Addictive Behaviors 37(1): 124-126, 2012. (18 refs.)

A significant number of men with opiate misuse have sexual problems. Premature ejaculation (PE) occurs predominantly on discontinuation of the opiate but seems to persist in some cases. The aims of this study were to determine the rates of PE and other sexual dysfunctions in patients maintained on methadone; to determine the time of onset of PE in relation to onset of opiate misuse; and to look at the patients' perception of the effect of heroin and methadone on PE. Sixty five men attending a tertiary referral clinic for methadone maintenance treatment were assessed cross-sectionally using a semi-structured questionnaire, clinical interview, review of clinical records and the International Index of Erectile Function (IIEF). Thirty eight (58.5%) subjects reported a "lifetime" history of PE. Twenty (30.76%) of them reported "current" history of PE. Eleven (16.9%) people reported that PE preceded opiate misuse. Twenty four (63.2%) felt that heroin helped their PE and 7 (18.4%) felt that heroin worsened it. Fourteen (36.8%) felt that methadone helped PE, while 10 (26.3%) felt methadone worsened PE. Only 2 out of 65 (3.07%) reported that they had been asked about their sex life by the addiction services. Prevalence of "current" premature ejaculation was almost 3 times greater than reported in the general population. A significant number of patients perceived heroin to be beneficial on PE. Presence of sexual dysfunction could therefore be a risk factor for relapse into heroin misuse. Most clinicians avoid asking patients questions of a sexual nature. Nevertheless, managing sexual difficulties among patients with opiate misuse could be a significant step in relapse prevention.

Chekuri V; Gerber D; Brodie A; Krishnadas R. Premature ejaculation and other sexual dysfunctions in opiate dependent men receiving methadone substitution treatment. Addictive Behaviors 37(1): 124-126, 2012. (17 refs.)

Background: A significant number of men with opiate misuse have sexual problems. Premature ejaculation (PE) occurs predominantly on discontinuation of the opiate but seems to persist in some cases. The aims of this study were to determine the rates of PE and other sexual dysfunctions in patients maintained on methadone; to determine the time of onset of PE in relation to onset of opiate misuse; and to look at the patients' perception of the effect of heroin and methadone on PE. Methods: Sixty five men attending a tertiary referral clinic for methadone maintenance treatment were assessed cross-sectionally using a semi-structured questionnaire, clinical interview, review of clinical records and the International Index of Erectile Function (IIEF). Results: Thirty eight (58.5%) subjects reported a "lifetime" history of PE. Twenty (30.76%) of them reported "current" history of PE. Eleven (16.9%) people reported that PE preceded opiate misuse. Twenty four (63.2%) felt that heroin helped their PE and 7 (18.4%) felt that heroin worsened it. Fourteen (36.8%) felt that methadone helped PE, while 10 (26.3%) felt methadone worsened PE. Only 2 out of 65 (3.07%) reported that they had been asked about their sex life by the addiction services. Conclusion: Prevalence of "current" premature ejaculation was almost 3 times greater than reported in the general population. A significant number of patients perceived heroin to be beneficial on PE. Presence of sexual dysfunction could therefore be a risk factor for relapse into heroin misuse. Most clinicians avoid asking patients questions of a sexual nature. Nevertheless, managing sexual difficulties among patients with opiate misuse could be a significant step in relapse prevention.

Clatts MC; Goldsamt LA; Giang LM; Colon-Lopez V. Accelerated transition to injection among male heroin initiates in Hanoi, Vietnam: Implications for early harm reduction interventions. Journal of Community Health 36(6): 999-1003, 2011. (18 refs.)

This paper examines changes in the interval between first heroin smoking and onset of injection in a large, out-treatment sample of male heroin users in Hanoi, Vietnam (n = 1,115). Mean age at initiation of heroin use (smoking) was 18.4 and mean age of onset of heroin injection was 20.9 years. Full multivariate analysis indicates that the interval between first heroin use (smoking) and first heroin injection has been significantly attenuated among more recent heroin initiates (P = 0.0043), suggesting that heroin users in Vietnam may be at increased risk for exposure to HIV relatively soon after onset of heroin use, highlighting the need for behavioral interventions that target heroin smokers. Critical intervention goals include delaying the onset of injection and improved education about safer drug sharing and drug injection practices.

Cleland CM; Rosenblum A; Fong C; Maxwell C. Age differences in heroin and prescription opioid abuse among enrolees into opioid treatment programs. Substance Abuse Treatment Prevention and Policy 6(e-article 11), 2011. (20 refs.)

Background: In the United States, among those entering opioid treatment programs (OTPs), prescription opioid (PO) abusers tend to be younger than heroin users. Admissions of older persons to OTPs have been increasing, and it is important to understand typical patterns of use among those older enrolees. Methods: To disentangle the effect of age on recent heroin and PO abuse 29,114 enrolees into 85 OTPs were surveyed across 34 states from 2005-2009. OTPs where PO use was prevalent were oversampled. Results: Mean age was 34; 28% used heroin only. Younger enrolees had increased odds of using POs relative to using heroin only but mixed model analysis showed that much of the total variability in type of use was attributed to variation in age between OTPs rather than within OTPs. Conclusions: Organizational and cultural phenomena (e. g., OTP characteristics) must be examined to better understand the context of individual characteristics (e. g., age). If nesting of enrolees within OTPs is ignored, then associations that primarily operate at the OTP level may be misinterpreted as exclusively dependent on individuals.

Cohn SE; Jiang HY; McCutchan JA; Koletar SL; Murphy RL; Robertson KR et al. Association of ongoing drug and alcohol use with non-adherence to antiretroviral therapy and higher risk of AIDS and death: Results from ACTG 362. AIDS Care 23(6): 775- 785, 2011. (44 refs.)

Drug and alcohol use have been associated with a worse prognosis in short-term and cross-sectional analyses of HIV-infected populations, but longitudinal effects on adherence to antiretroviral therapy (ART) and clinical outcomes in advanced AIDS are less well characterized. We assessed self-reported drug and alcohol use in AIDS patients, and examined their association with non-adherence and death or disease progression in a multicenter observational study. We defined non-adherence as reporting missed ART doses in the 48 hours before study visits. The association between drug use and ART non-adherence was evaluated using repeated measures generalized estimating equation (GEE) models. The association between drug and alcohol use and time to new AIDS diagnosis or death was evaluated via Cox regression models, controlling for covariates including ART adherence. Of 643 participants enrolled between 1997 and 1999 and followed through 2007, at entry 39% reported ever using cocaine, 24% amphetamines, and 10% heroin. Ongoing drug use during study follow-up was reported by 9% using cocaine, 4% amphetamines, and 1% heroin. Hard drug (cocaine, amphetamines, or heroin) users had 2.1 times higher odds (p = 0.001) of ART non-adherence in GEE models and 2.5 times higher risk (p = 0.04) of AIDS progression or death in Cox models. Use of hard drugs was attenuated as a risk factor for AIDS progression or death after controlling for non-adherence during follow-up (HR = 2.11, p = 0.08), but was still suggestive of a possible adherence-independent mechanism of harm. This study highlights the need to continuously screen and treat patients for drug use as a part of ongoing HIV care.

de los Cobos JP; Sinol N; Trujols J; Banuls E; Batlle F; Tejero A. Drug-dependent inpatients reporting continuous absence of spontaneous drug craving for the main substance throughout detoxification treatment. Drug and Alcohol Review 30(4): 403-410, 2011. (43 refs.)

Introduction and Aims. Drug craving is considered to be an essential component of substance dependence. We aimed to characterise drug-dependent inpatients reporting continuous absence of subjective spontaneous drug craving. Design and Methods. This is a 3 year chart-review study designed to compare drug-dependent inpatients who did not report craving everyday (non-cravers) and their counterparts who did (cravers). All participants were recruited consecutively and completed a 14 day detoxification treatment. Craving was defined as a desire to use the main detoxification substance. This substance was chosen by patients, who completed a craving visual analogue scale, the Beck Depression Inventory and the State-Trait Anxiety Inventory daily. The Temperament and Character Inventory and the Addiction Severity Index were also used. Results. Of the 195 patients who completed the detoxification treatment, 45 (23.1%) were non-cravers and 32 (16.4%) were cravers. The main detoxification substances were alcohol, benzodiazepines, cannabis, cocaine, heroin and methadone. Non-cravers named methadone as the main detoxification substance more frequently than cravers, and benzoylecgonine was less frequently present in their urine at treatment entry. A decreased score on the Temperament and Character Inventory dimension of harm avoidance (i.e. trait anxiety) was the only independent predictor of absence of craving (odds ratio = 1.16, 95% confidence interval = 1.03-1.31). During admission, non-cravers had lower Beck Depression Inventory and State-Trait Anxiety Inventory scores than cravers. These differences were not accounted for by pharmacological treatment. Discussion and Conclusions. Drug-dependent inpatients who report absence of craving are characterised by relatively low levels of depression and anxiety throughout detoxification treatment, and relatively low levels of trait anxiety.

Deering KN; Shoveller J; Tyndall MW; Montaner JS; Shannon K. The street cost of drugs and drug use patterns: Relationships with sex work income in an urban Canadian setting. Drug and Alcohol Dependence 118(2-3): 430-436, 2011. (52 refs.)

Background: This study investigated the relationship between drug use and sex work patterns and sex work income earned among street-based female sex workers (FSWs) in Vancouver, Canada. Methods: We used data from a sample of 129 FSWs who used drugs in a prospective cohort (2007-2008), for a total of 210 observations. Bivariate and multivariable linear regression using generalized estimating equations was used to model the relationship between explanatory factors and sex work income. Sex work income was log-transformed to account for skewed data. Results: The median age of the sample at first visit was 37 years (interquartile range[IQR]: 30-43), with 46.5% identifying as Caucasian, 48.1% as Aboriginal and 5.4% as another visible minority. The median weekly sex work income and amount spent on drugs was $300 (IQR = $100-$560) and $400 (IQR = $150-$780), respectively. In multivariable analysis, for a 10% increase in money spent on drugs, sex work income increased by 1.9% (coeff: 0.20, 95% CIs: 0.04-0.36). FSWs who injected heroin, FSWs with higher numbers of clients and youth compared to older women (<25 versus 25+ years) also had significantly higher sex work income. Conclusions: This study highlights the important role that drug use plays in contributing to increased dependency on sex work for income among street-based FSWs in an urban Canadian setting, including a positive dose-response relationship between money spent on drugs and sex work income. These findings indicate a crucial need to scale up access and availability of evidence-based harm reduction and treatment approaches, including policy reforms, improved social support and economic choice for vulnerable women.

Dolan K; Salimi S; Nassirimanesh B; Mohsenifar S; Allsop D; Mokri A. Characteristics of Iranian women seeking drug treatment. Journal of Women's Health 20(11): 1687-1691, 2011. (40 refs.)

Background: In the west, men are twice as likely as women to develop a drug problem, but female users have higher rates of morbidity than male users. Iran has the world highest per capita opiate consumption, but little is known about female drug users. In 2007, we established a free methadone clinic with ancillary services for female drug users in South Tehran. The aim was to explore the characteristics of female drug users seeking treatment for heroin dependence in Iran. Clients were interviewed about demographic characteristics, drug use and treatment history, and drug-related health problems. Urine and blood samples were collected and tested for morphine, HIV, hepatitis C virus (HCV), and sexually transmitted infections (STIs). Methods: Between August 2007 and October 2008, 78 women completed a baseline interview. The median age was 37 years, the main ethnic background was Persian (65%), and half of the clients were married. Opium and heroin and opium use was reported by 69% (n = 54) and 87% (n = 68) of clients, respectively. The mean duration of heroin use problems was 10.5 years, and only 20% of women reported ever having received drug treatment. HIV and HCV seroprevalence was 5% and 24%, respectively. Forty percent were sexually active when interviewed, and one third tested positive for an STI. Women had poor social functioning, high levels of depression, and poor general health. Results and Conclusions: Our clients were dependent users with a multitude of problems who had little or no contact with treatment agencies before this study. Many clients had made a transition from using opium to using heroin, and some had commenced injecting, placing them at risk for HIV and HCV infection. More women-only drug treatment services are needed to facilitate women's entry into drug treatment.

dos Santos MML; Trautmann F; Kools JP. Rapid Assessment Response (RAR) study: Drug use and health risk - Pretoria, South Africa. Harm Reduction Journal 8: article 14, 2011. (27 refs.)

Background: Within a ten year period South Africa has developed a substantial illicit drug market. Data on HIV risk among drug using populations clearly indicate high levels of HIV risk behaviour due to the sharing of injecting equipment and/or drug-related unprotected sex. While there is international evidence on and experience with adequate responses, limited responses addressing drug use and drug-use-related HIV and other health risks are witnessed in South Africa. This study aimed to explore the emerging problem of drug-related HIV transmission and to stimulate the development of adequate health services for the drug users, by linking international expertise and local research. Methods: A Rapid Assessment and Response (RAR) methodology was adopted for the study. For individual and focus group interviews a semi-structured questionnaire was utilised that addressed key issues. Interviews were conducted with a total of 84 key informant (KI) participants, 63 drug user KI participants (49 males, 14 females) and 21 KI service providers (8 male, 13 female). Results. and Discussion: Adverse living conditions and poor education levels were cited as making access to treatment harder, especially for those living in disadvantaged areas. Heroin was found to be the substance most available and used in a problematic way within the Pretoria area. Participants were not fully aware of the concrete health risks involved in drug use, and the vague ideas held appear not to allow for concrete measures to protect themselves. Knowledge with regards to substance related HIV/AIDS transmission is not yet widespread, with some information sources disseminating incorrect or unspecific information. Conclusions: The implementation of pragmatic harm-reduction and other evidence-based public health care policies that are designed to reduce the harmful consequences associated with substance use and HIV/AIDS should be considered. HIV testing and treatment services also need to be made available in places accessed by drug users.

Dursteler-Macfarland KM; Kowalewski R; Bloch N; Wiesbeck GA; Kraenzlin ME; Stohler R. Patients on injectable diacetylmorphine maintenance have low bone mass. Drug and Alcohol Review 30(6): 577-582, 2011. (46 refs.)

Introduction and Aims. Risk factors for osteoporosis are prevalent in chronic heroin users who often start using opiates in their late teens. This study was the first to evaluate bone mineral density (BMD) in relatively young heroin-dependent patients on injectable heroin maintenance. Design and Methods. Using cross-sectional design, BMD was assessed in a convenience sample of 19 patients (mean age +/- SD = 33.9 +/- 5.4; 13 men) prescribed injectable diacetylmorphine for heroin dependence. BMD of the lumbar spine and proximal femur was measured by dual-energy X-ray absorptiometry. Substance use and menstrual history, psychopathology and risk factors for low BMD were assessed by questionnaire-based interviews. Results. According to World Health Organisation criteria almost three-quarters (74%) of the sample had osteopenia (n = 11) or osteoporosis (n = 3) at one or more sites of measurement. All patients showed multiple risk factors for bone loss, with pack-years of tobacco use and years of heroin use reaching marginally significant associations with spine Z-scores. Moreover, BMD Z-scores correlated significantly negatively with increasing age at all sites, indicating that the older the patient, the greater the BMD deviation from an age-controlled population. Discussion and Conclusions. Prolonged heroin dependence appears to be associated with lower-than-normal bone mass already at early age and these individuals might be at greater risk for fracture with advancing age. The negative correlation of age-adjusted Z-scores with increasing age suggests factors other than age for low BMD in this population (e. g. smoking, heroin use). Prospective studies are warranted to determine the necessity for diagnostic and preventive measures.

Frank D. The trouble with morality: The effects of 12-step discourse on addicts' decision-making. Journal of Psychoactive Drugs 43(3): 245-256, 2011. (41 refs.)

Since its development in the 1960s, researchers have extensively scrutinized methadone maintenance treatment (MMT) as a medical response to heroin addiction. Studies consistently find that MMT is more successful than other treatment models in the reduction of opiate/opioid misuse, the transmission of diseases like HIV/AIDS and hepatitis C, and criminal arrest and conviction rates. Nonetheless, a significant portion of active and former heroin addicts view MMT negatively and-perhaps as a result-MMT is vastly underused. This study examines the effects of 12-Step discourses on the opinions and treatment decisions of active heroin addicts, addicts in MMT, and addicts in 12-Step treatment programs. The study finds the abstinence/morality based discourse of drug addiction and treatment is pervasive among addicts and their non-drug using relations and peers alike; moreover, addicts have internalized this narrative, oftentimes despite their own knowledge of MMT's success and positive personal experiences. The findings suggest that the dominance of abstinence/morality narratives contributes to MMT's poor reputation among, and low use rate by current and former heroin addicts and that the power of the dominant discourse is such that it produces a desire to buy into its values and tenets even when it is against the individual's interests to do so.

Geng LN; Jiang T; Han D. Relationships among self-esteem, self-efficacy, and faith in people in Chinese heroin abusers. Social Behavior and Personality 39(6): 797-806, 2011. (29 refs.)

The relationships among self-esteem, self-efficacy, and faith in people in Chinese heroin abusers were investigated. We used 3 rating scales to survey a sample of 200 heroin abusers: the Self-esteem Scale (Rosenberg, 1965), the Self-efficacy Questionnaire for Chinese Drug Users (Geng & Han, 2008), and the Faith in People Scale (Rosenberg, 1956). A correlation analysis and a regression analysis were employed to analyze the data. The correlations among self-esteem, self-efficacy, and faith in people were significantly positive. Self-efficacy and faith in people results were found to be predictive of the self-esteem level of participants at a statistically significant level.

Geng LN; Qian BJ. Implicit and explicit cognition of Chinese heroin abusers. Social Behavior and Personality 39(4): 433-443, 2011. (25 refs.)

Sixty-five heroin abusers receiving Methadone Maintenance Treatment (MMT), 38 heroin abusers not receiving MMT, and 30 nonusers of drugs participated in this investigation of cognition in heroin and methadone users. Heroin users were measured for both implicit and explicit cognition, while the control group of nonusers was measured only for implicit cognition. The results demonstrate that implicit cognition can influence the development of addictive behaviors, and that implicit and explicit cognition of heroin were separate and independent constructs. Based on the results of Implicit Association Tests (IAT; Greenwald, McGhee, & Schwartz, 1998) MMT appears to be a valid method for opiate withdrawal treatment as it reverses the implicit desire for heroin in heroin abusers.

Grella CE; Lovinger K. 30-year trajectories of heroin and other drug use among men and women sampled from methadone treatment in California. Drug and Alcohol Dependence 118(2-3): 251-258, 2011. (48 refs.)

Background: This study examines 30-year trajectories of heroin and other drug use among men and women who were in methadone maintenance treatment in California in the late 1970s and interviewed in 1978-1981. Methods: Nearly half (N = 428; 46.8%) of the original study sample (N = 914) was deceased. Of the remaining 486 subjects, 343 (44.3% female) completed a follow-up interview in 2005-2009 (70.6% of those not deceased). Average age at follow-up was 58.3 (SD = 4.9) years for males and 55.0 (SD = 4.1) years for females. Longitudinal data was obtained on their drug use, treatment participation, and criminal justice status over the follow-up period. Trajectory group modeling was used to identify distinctive trajectory groups based on monthly averages of heroin and other drug use per year; group differences were examined. Results: Four heroin and five alcohol and other drug (AOD) trajectory groups were identified. A greater proportion of women (60%) were in the "rapid decrease" heroin group (odds of use less than 10% by 10 years following initiation of use) as compared with the other groups. More rapid decrease of heroin use was associated with increases in AOD use, whereas a gradual decrease in heroin use was associated with a gradual decrease in AOD use. More school problems and earlier age at onset of heroin use and first arrest were associated with more persistent heroin use. Conclusion: Heroin-use trajectories were linked with changes in AOD use. Childhood antecedents of heroin-use trajectories were identified as well as gender differences.

Hadland SE; Marshall BDL; Kerr T; Qi JZ; Montaner JS; Wood E. Depressive symptoms and patterns of drug use among street youth. Journal of Adolescent Health 48(6): 585- 590, 2011. (40 refs.)

Purpose: Rates of depression among street youth are poorly characterized, particularly as they pertain to concurrent drug use. We sought to assess associations between drug type and degree of depression in this population. Methods: Between October 2005 and November 2007, data were collected from a cohort of street-recruited youth aged 14-26 residing in Vancouver, Canada, for the At-Risk Youth Study. Active drug users were classified by predominant substance of use: daily marijuana use, weekly cocaine/crack use, weekly crystal methamphetamine use, or weekly heroin use. Adjusted mean number of depressive symptoms (measured by the Center for Epidemiology Studies Depression [CES-D] scale) was compared among the four groups using multiple linear regression. Logistic regression was also used to assess adjusted odds of CES-D score >= 22. Results: Among 447 youth, mean CES-D score was the highest among heroin users (adjusted mean: 22.7; standard deviation [SD]: 1.2), followed by crystal methamphetamine users (adjusted mean: 21.8; SD: 1.1), then cocaine and/or crack users (adjusted mean: 19.1; SD: 1.0), and finally, marijuana users (adjusted mean: 18.3; SD: 1.1), resulting in a difference that was significant among groups (p < .001). When compared with daily marijuana users, odds of CES-D score >= 22 were higher among heroin users (adjusted odds ratio [AOR]: 2.64; 95% confidence interval [CI]: 1.39-4.99) and crystal methamphetamine users (AOR: 1.88; 95% CI: 1.04-3.42), but not among cocaine/crack users (AOR: 1.41; 95% CI: .79-2.52). Conclusion: To our knowledge, this is the first report of drug use typologies and depression among street youth. Policymakers might heed the apparent vulnerability of heroin and crystal methamphetamine users to even greater degrees of depression than their peers.

Havens JR; Oser CB; Knudsen HK; Lofwall M; Stoops WW; Walsh SL et al. Individual and network factors associated with non-fatal overdose among rural Appalachian drug users. Drug and Alcohol Dependence 115(1-2): 107- 112, 2011. (43 refs.)

Background: Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States - especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users. Methods: Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses. Results: Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network. Conclusions: Rural drug users with history of overdose were more likely to have injected with prescription opioids - which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.

Herrero MJ; Domingo-Salvany A; Brugal MT; Torrens M. Incidence of psychopathology in a cohort of young heroin and/or cocaine users. Journal of Substance Abuse Treatment 41(1): 55-63, 2011. (35 refs.)

A prospective study was carried out in Barcelona, Spain, to determine the incidence of mental disorders including substance use disorders (SUDs). From a cohort of 288 young adult (aged 18-30 years) cocaine and/or heroin users recruited in nonclinical settings, 158 were reinterviewed 18 months later using the Psychiatric Research Interview for Substance and Mental Disorders. During follow-up, 18% of subjects presented a new SUD, and nearly 11% a new non-SUD Axis 1 disorder. Incidence was highest for mood disorders (8%). Being a woman, a lower frequency of substance use at baseline, a younger age of heroin first use, and a worsening of SUD were associated with a higher likelihood of presenting a new Axis 1 disorder. Having received drug treatment ever (at baseline) or during follow-up was not associated with progress of SUD. An overall improvement in the psychiatric status of these young substance users was observed.

Horton A. Heroin users: The need for improved treatment for incarcerated women. Social Work in Public Health 26(2): 176-188, 2011. (21 refs.)

This paper addresses the use of drugs, specifically heroin, by women. While women's rate of incarceration in the nation have dramatically increased, tripling in the last decade, prisons have not kept pace with the growth of the number of women in prison and the need for drug treatment and recovery for this population. This paper examines one programmatic effort to provide services to this most vulnerable population in the state of Illinois. The continuum of care model is considered in light of the challenges of high recidivism rates, particularly in the state of Illinois. It identifies a need for more effective evidence-based services at the state level for prison inmates before and after discharge. Effective program evaluation has not been a priority in some states, and perhaps Illinois correction is prototypical. More effective intervention may requiremore community involvement post-release for ex-offenders. Barriers to healthcare, employment and housing, are just as evident with female drug offenders as in the male population.

Huang KC; Zhang LN; Liu JH. Drug problems in contemporary China: A profile of Chinese drug users in a metropolitan area. International Journal of Drug Policy 22(2): 128- 132, 2011. (14 refs.)

Background: Drug problems are reemerging in China since the nation implemented economic reform and an "open door" policy in the early 1980s. This is causing both national and international concern. However, knowledge and understanding of the Chinese drug problem is fairly limited because of the nation's unique social and political history. In response to this shortage of information, our study presents a profile of Chinese drug users. Methods: Data were collected from a survey of drug users attending mandatory treatment centres in a large city in 2009. We present a demographic profile of the drug users, describe their patterns of drug use, their access to drugs and their history of drug treatment. Results: Chinese drug users, like those from the U.S., are likely to be unemployed and have a low level of education. However, they are more likely than those in the U.S. to use heroin, Bingdu (methamphetamine) and Maguo (a derivative of methamphetamine), and they pay less for their drugs. Conclusion: This profile of drug users is informative and valuable for drug prevention, intervention, and treatment in the Chinese setting because knowing and understanding the drug population is essential for effective control.

Hughes CE; Lancaster K; Spicer B. How do Australian news media depict illicit drug issues? An analysis of print media reporting across and between illicit drugs, 2003-2008. International Journal of Drug Policy 22(4): 285-291, 2011. (35 refs.)

Background: Media reporting on illicit issues has been frequently criticised for being sensationalised, biased and narrow. Yet, there have been few broad and systematic analyses of the nature of reporting. Using a large sample and methods commonly adopted in media communications analysis this paper sought to identify the dominant media portrayals used to denote illicit drugs in Australian newspapers and to compare and contrast portrayals across drug types. Methods: A retrospective content analysis of Australian print media was carried out over the period 2003-2008 from a sample comprised of 11 newspapers. Articles that contained one or more mention of five different drugs (or derivatives) were identified: cannabis, amphetamines, ecstasy, cocaine and heroin. A sub-sample of 4397 articles was selected for media content analysis (with 2045 selected for full content analysis) and a large number of text elements coded for each. Key elements included topic, explicit or implicit messages about the consequences of drugs/use and three value dimensions: overall tone, whether drugs were portrayed as a crisis issue and moral evaluations of drugs/use. Results: The dominant media portrayals depicted law enforcement or criminal justice action (55%), but most articles were reported in a neutral manner, in the absence of crisis framings. Portrayals differed between drugs, with some containing more narrow frames and more explicit moral evaluations than others. For example, heroin was disproportionately framed as a drug that will lead to legal problems. In contrast, ecstasy and cocaine were much more likely to emphasise health and social problems. Conclusion: Media reporting on illicit drugs is heavily distorted towards crime and deviance framings, but may be less overtly sensationalised, biased and narrowly framed than previously suggested. This is not to suggest there is no sensationalism or imbalance, but this appears more associated with particular drug types and episodes of heightened public concern.

Ilic G; Gligorijevic J; Karadzic R; Antovic A; Kostic-Banovic L; Stojanovic J et al. Myocardial damage in heroin abuse: Immunohistochemical investigations with LCA, CD68, and CD45R0. Romanian Journal of Legal Medicine 19(2): 89-94, 2011. (38 refs.)

Background. Myocardial insufficiency is suspected to be implicated in fatal lung edema complicating heroin-overdosage. The pathogenetic mechanism is not fully understood, but defects in myocardial contractility were proposed. Methods. The qualification and quantification of leukocytes, monocytes, and T-lymphocytes was done on the myocardial samples from 13 heroin/morphine related deaths, compared to six controls by histological and immunohistochemical examination. The quantification of cell types was done by counting speciffic cell type of 30 high power fealds in each myocardial sample. Mean values were then tested by Student t-test. Results. The results showed that the control group had a higher mean number of observed leukocyte common antigen (LCA) and CD45R0 positive white blood cells, without significant difference. The mean number of CD68 positive white blood cells was significantly lower in drug addicts group than in the control group (p=0.013, Cohen's d=1.41, power 0.86). Conclusions. Deterioration of immune cell function in heroin abusers will produce in time left ventricular disfunction and susceptibility to lung edema complicating heroin-overdose.

Ilic G; Karadzic R; Kostic-Banovic L; Antovic A; Milic M; Stojanovic I. The reduction of glycogen in the liver induced by chronic intravenous heroin abuse. Romanian Journal of Legal Medicine 19(4): 259-264, 2011. (12 refs.)

Introduction. The liver plays a key role in the removal of lipophyllic substances from the plasma, including both morphine and its derivative heroin. Intravenous heroin abuse leads to liver damages, so that the effects of heroin intake are the most marked and characteristic in the liver. Objective. A histochemical and ultastructural study of the liver, particularly hepatocyte glycogen content, should provide a precise insight into the type and degree of liver damage induced by intravenous heroin abuse. Methods. The study included the analysis of 50 autopsies, 40 from the group of intravenous heroin abusers and 10 control autopsies. Paraffin sections, 5 gm thick, were stained by PAS method for deposited glycogen staining. The ultrastructural investigation was performed on transmission electron microscope. Results. Glycogen amount was reduced proportionally to the severity and distribution of degenerative and necrotic hepatocytic lesions. Regarding deposited glycogen depletion in particular acinar zones, glycogen was most preserved in zone 1 (30% of studied cases), then in zone 3 (preserved in 25%), while the depletion was most significant in intermediary zone (preserved in 5%). In the intravenous heroin abusers group of up to 2 years glycogen was preserved in the acinar zones 1,2 and 3 in 43%, 30% and 57%, respectively; in the group of over 10 years glycogen preservation in zone 1 was 25% and in other zones 0%. Conclusion. Intravenously administered heroin directly influences glycogen reduction in the hepatocytes, and the effect is potentiated by morphologic changes in the liver due to intravenous heroin abuse. Glycogen depletion in the hepatocytes reduces energy reserves in these cells and causes cell death, which is an important segment of general liver injury in intravenous heroin abusers. The degree of reduction of glycogen depositions is proportional to the duration of intravenous heroin abuse

Jimenez-Trevino L; Saiz PA; Garcia-Portilla MP; Diaz-Mesa EM; Sanchez-Lasheras F; Buron P et al. A 25-year follow-up of patients admitted to methadone treatment for the first time: Mortality and gender differences. Addictive Behaviors 36(12): 1184-1190, 2011. (50 refs.)

Introduction: We conducted a follow-up study to evaluate the outcome of a heroin-dependent population 25 years after their first enrollment in methadone maintenance treatment (MMT). We assessed mortality in the sample plus actual drug use, treatment, and medical factors associated with drug dependence, focusing on possible gender differences. Methods: Prospective follow-up study of 214 heroin-dependent patients consecutively admitted for MMT between 1980 and 1984 in the Asturias Public Health Service. The standardized mortality ratio (SMR) and 95% confidence interval (Cl) were calculated. An ad-hoc protocol on drug misuse and treatment, drug-related morbidity and Clinical Global Impression (CGI) scores were assessed in the survivors' sample. Results: Information was received on 159 subjects, 106 of whom were deceased. Men accounted for 76.2% of the study cohort. Over the 25-year follow-up period, the SMR was 22.51 (95% CI = 22.37-22.64). In the survivors sample, 39.6% were still enrolled in MMT; human immunodeficiency virus (HIV) was diagnosed in 47.2% and hepatitis B/C in 81.1%; current heroin use was reported by 22.6%. There were no gender differences in mortality or HIV and hepatitis B/C status. None of the female survivors were using heroin at the 25-year follow-up compared with 31.1% of males. Conclusions: This study confirms the high mortality of heroin addicts even after enrollment in MMT. Severity of the addiction in terms of mortality was similar in both genders. Women who survived the 25-year follow-up were more likely to have stopped using heroin than men.

Jones AW; Holmgren A. Concentration ratios of free-morphine to free-codeine in femoral blood in heroin-related poisoning deaths. Legal Medicine 13(4): 171-173, 2011. (15 refs.)

The concentrations of free-morphine (Mo), free-codeine (Co) and 6-monoacetyl morphine (6-MAM) were determined in femoral blood in N = 747 heroin-related deaths. The opiates were determined by isotope dilution gas chromatography-mass spectrometry after solid-phase extraction. The median blood concentrations of 6-MAM, free-morphine and free-codeine were 0.01 mg/L, 0.24 mg/L and 0.02 mg/L, respectively. The mean and median Mo/Co concentration ratios were 13.2 and 11.0, respectively with a range from 0.2 to 124. Despite the fact that all victims had taken heroin, there were eight cases (1.1%) with a Mo/Co ratio less than one and 18 cases (2.4%) with a ratio less than two. The free-morphine concentration in blood did not depend on the Mo/Co ratio; median 0.29 mg/L (Mo/Co < 2.0) and median 0.25 mg/L (Mo/Co ratio > 2.0). By contrast, the concentration of free-codeine in blood was highly dependent on the Mo/Co ratio; median 0.75 mg/L (Mo/Co < 1.0) and median 0.30 mg/L (Mo/Co ratio < 2.0). A Mo/Co ratio in post-mortem (PM) femoral blood >1.0 is compelling evidence that the deceased had taken illicit heroin. However, finding a low Mo/Co ratio (<1.0 or <2.0) does not preclude use of heroin because such low ratios are possible if a person had co-ingested heroin along with use or abuse of codeine medication.

Kahan M; Srivastava A; Conway B. Is there a need for heroin substitution treatment in Vancouver's downtown eastside? Canadian Journal of Public Health 102(2): 84- 86, 2011. (17 refs.)

The North American Opiate Medication Initiative (NAOMI) was a randomized controlled trial conducted in Vancouver and Montreal comparing heroin substitution treatment (HST) to methadone treatment (MT) for heroin addicts. The HST group had a higher treatment retention rate and lower illicit heroin use than the MT group. Despite the rigour with which the study was designed, systematic flaws have affected the interpretation of the results. In the MT arm, the dose was titrated slowly, contributing to the high early dropout rate. The mean maintenance dose was suboptimal. The investigators did not calculate on-treatment retention rates; by the end of the trial, more subjects were on MT than HST. Life-threatening events were more common in the HST than the MT group. Overall, the only clear advantage of HST over MT was its greater initial treatment attractiveness, resulting in more early drop-outs in the MT group. HST is intended for treatment-refractory addicts who have no other option but to use street heroin. Yet for most NAOMI subjects, the safest and most cost-effective approach is comprehensive MT or buprenorphine with optimal dosing, flexible program policies, and the provision of integrated primary care and social services. These proven strategies, currently lacking in Vancouver's Downtown Eastside, should be implemented before diverting already insufficient resources to HST, given its risks, cost and uncertain efficacy.

Khan U; Nicell JA. Refined sewer epidemiology mass balances and their application to heroin, cocaine and ecstasy. Environment International 37(7): 1236-1252, 2011. (153 refs.)

The detection of illicit drugs in environmental matrices may be a cause for concern, both from the perspective of their potential environmental impacts and the fact that their presence in detectable concentrations would be an indicator of significant drug use. The primary goal behind recent studies on this subject has been to use measured influent concentrations of selected illicit drugs or their in vivo metabolites in the environment as a means of estimating the abuse level of these drugs and patterns of consumption. Thus-far, such calculations have hinged on the use of solitary excretion estimates from single studies of limited scope and/or studies of limited applicability. Therefore, the need exists to conduct a comprehensive meta-analysis of metabolic disposition studies to construct excretions profiles for the various illicit drugs and their in vivo metabolites. The constructed excretory profiles should not only provide mean excretion values but also indicate the expected variations in excreted fractions that arise due to differences not only in the metabolic capacity of users but also in the efficiencies of various routes of administration for a given illicit drug. Therefore, the primary goal of the research presented here was to refine sewer epidemiology extrapolation mass balances for various illicit drugs of interest by constructing their excretory profiles segregated by route-of-administration. After conducting such a study with a multi-national scope on illicit drugs including cocaine, heroin and ecstasy, the results obtained clearly indicate that extrapolation factors currently being used in literature for these drugs to enumerate prevalence of abuse required significant refinement to increase their reliability.

Kuramoto SJ; Bohnert ASB; Latkin CA. Understanding subtypes of inner-city drug users with a latent class approach. Drug and Alcohol Dependence 118(2-3): 237-243, 2011. (51 refs.)

Aims: We empirically identified subtypes of inner-city users of heroin and cocaine based on type of drug used and route of administration. Method: The sample was recruited from the communities in Baltimore, MD (SHIELD study) and consisted of 1061 participants who used heroin and or cocaine in the past 6 months on a weekly basis or more. Latent class analysis (LCA) was used to identify subtypes of drug users based on type of drug and route of administration. Logistic regression was used to compare the subtypes on depressive symptoms, injection risk and drug network compositions. Findings: Inner-city drug users were classified into five subtypes: three subtypes of injection drug users (IDUs) [heroin injecting (n = 134: 13%), polydrug and polyroute (n = 88, 8%), and heroin and cocaine injecting (n = 404, 38%)], and two subtypes with low proportions of IDUs (LIDUs) [heroin snorting (n = 275, 26%) and crack smoking (n = 160; 14%)]. The polydrug and polyroute subtype had the highest depressive symptoms risk among all subtypes. Injection risk was lowest in the heroin injecting subtype and significantly differed from heroin and cocaine injecting subtype. The IDU subtypes also varied in the drug network compositions. The LIDU subtypes had similar depressive symptoms risk but vastly differed in the drug network compositions. Conclusions: Subgroups of inner-city cocaine and heroin users based on type and route of administration differed in their depressive symptoms, injection risk and drug network compositions. Future studies should longitudinally examine factors associated with transitioning across these subtypes to better inform prevention and treatment efforts.

Li L; Sangthong R; Chongsuvivatwong V; McNeil E; Li JH. Multiple substance use among heroin-dependent patients before and during attendance at methadone maintenance treatment program, Yunnan, China. Drug and Alcohol Dependence 116(1-3): 246-249, 2011. (24 refs.)

Background: Multiple substance use is a common problem among heroin users. This study aims to describe patterns of multiple substance use one year before and during attendance at methadone maintenance treatment (MMT) programs and associated variables of continued heroin use in MMT clinics in Yunnan, China. Methods: The study was conducted among 168 heroin addicts who had received treatment for at least one year at two MMT clinics in Kunming city. A structured questionnaire, a medical record, and computer database were used to obtain history of substances use, significant clinical information, and treatment details, respectively. Results: Heroin, tobacco, and alcohol were the most commonly used substances both before and during MMT. After one year in MMT, use of heroin, alcohol, tramadol, and triazolam significantly decreased whereas use of ephedrine increased. Simultaneous substance use was halved but the decrease was not statistically significant. The proportion of injecting users was reduced from 61% to 43%. History of heroin use in the preceding 6 months during MMT increased the odds of continued heroin use (OR = 5.8, 95% Cl =12.9-11.3]). An average 10 mg higher methadone dose increment was associated with a reduced odds of heroin use by 10%. Conclusion: MMT did not reduce the number of substances used, but the number of injecting heroin users after the first year of treatment decreased. Heroin use in the preceding.6 months during MMT treatment and lower methadone dose were associated with continued heroin use in MMT.

Li L; Zhang X; Levine B; Li GH; Zielke HR; Fowler DR. Trends and pattern of drug abuse deaths in Maryland teenagers. Journal of Forensic Sciences 56(4): 1029-1033, 2011. (29 refs.)

The Office of the Chief Medical Examiner of Maryland recorded a total of 149 drug abuse deaths of teenagers aged 13-19 years between 1991 and 2006. Of these deaths, 96 (64.4%) were caused by the use of narcotic drugs only, 29 (19.5%) by both narcotics and cocaine, four (2.7%) by both narcotics and methylenedioxymethamphetamine, six (4.0%) by cocaine only, and 14 (9.4%) by volatile substances (e.g., butane, Freon, nitrous oxide, and propane). The annual death rate from drug abuse for teenagers increased from 1.4 deaths per 100,000 population in 1991 to 2.7 deaths per 100,000 population in 2006 (chi-square test for time trend, p < 0.01). The increase in teenager drug abuse deaths occurred in 1999 and since has remained at a higher rate. Further analysis revealed that the increase in drug abuse deaths was attributable to a large degree to narcotic drugs, particularly heroin / morphine and methadone, and was confined to teenagers residing in the suburban and rural areas.

Li T; Yu SY; Du J; Chen HH; Jiang HF; Xu K et al. Role of novelty seeking personality traits as mediator of the association between COMT and onset age of drug use in Chinese heroin dependent patients. PLoS ONE 6(8): e22923, 2011. (51 refs.)

Background: Personality traits such as novelty seeking (NS) are associated with substance dependence but the mechanism underlying this association remains uncertain. Previous studies have focused on the role of the dopamine pathway. Objective: Examine the relationships between allelic variants of the catechol-O-methlytransferase (COMT) gene, NS personality traits, and age of onset of drug use in heroin-dependent subjects in China. Methods: The 478 heroin dependent subjects from four drug rehabilitation centers in Shanghai who were genotyped for eight tagging single nucleotide polymorphisms (SNP) on the COMT gene completed the NS subscale from the Temperament and Character Inventory. Multivaritate analyses were used to assess the potential mediating role of NS personality traits in the association between COMT gene variants and the age of onset of heroin use. Principal Findings and Conclusions: In the univariate analysis the COMT rs737866 gene variants were independently associated with both NS and age of onset of drug use: those with the TT genotype had higher NS subscale scores and an earlier onset age of heroin use than individuals with CT or CC genotypes. In the multivariate analysis the inclusion of the NS subscore variable weakened the relationship between the COMT rs737866 TT genotype and an earlier age of onset of drug use. Our findings that COMT is associated with both NS personality traits and with the age of onset of heroin use helps to clarify the complex relationship between genetic and psychological factors in the development of substance abuse.

Liao YH; Tang JS; Liu TQ; Chen XG; Liu XB; Hao W. A pilot study of life events and mood disorders: Self-report survey in Chinese heroin-dependent individuals. American Journal on Addictions 20(4): 337-342, 2011. (23 refs.)

An understanding of the relationship among life events, anxiety, depression, and heroin abuse may benefit the prevention and early treatment of heroin dependence. The objective of this study was to assess self-reported life events, anxiety, and depression in patients with heroin dependence. In this survey, Chinese heroin-dependent patients (n = 139) were asked to conduct a battery of self-reported questionnaires. A total of 76.26% of heroin-dependent patients reported the occurrence of major lifestyle pattern (dietary and sleep) changes as negative life events. Financial problems from family, unemployment, and poor interpersonal relationships were also frequently reported as negative events. Heroin-dependent patients experienced overwhelmingly more negative life events than positive life events. Those negative life events positively correlated with depression and anxiety. They also exhibited high levels of anxiety (Self-Rating Anxiety Scale, mean 44.42 +/- 8.27) and depression (Self-Rating Depression Scale, mean 47.28 +/- 8.54). Although preliminary, findings from this study suggest the need for further investigation of life events, anxiety, and depression in a generalized large sample, which may benefit community-based psychosocial intervention and prevention of relapse in heroin-dependent subjects.

Liu JL; Zhang TL. Global behaviour of a heroin epidemic model with distributed delays. Applied Mathematics Letters 24(10): 1685-1692, 2011. (12 refs.)

In this paper, we study a heroin epidemic model with distributed time delays. The basic reproduction number R-0 for the model is identified and the threshold property of R-0 is established. It is shown that drug-free equilibrium is globally asymptotically stable if R-0 < 1. When R-0 > 1, there is a disease endemic equilibrium which is locally asymptotically stable, it is proved that the disease is uniformly persistent in the population, and explicit formulae are obtained by which the eventual lower bound of the drug user individuals can be computed.

Liu JX; Qin W; Yuan K; Li J; Wang W; Li Q et al. Interaction between dysfunctional connectivity at rest and heroin cues-induced brain responses in male abstinent heroin-dependent Individuals. PLoS ONE 6(10): e23098, 2011. (51 refs.)

Background: The majority of previous heroin cue-reactivity functional magnetic resonance imaging (fMRI) studies focused on local function impairments, such as inhibitory control, decision-making and stress regulation. Our previous studies have demonstrated that these brain circuits also presented dysfunctional connectivity during the resting state. Yet few studies considered the relevance of resting state dysfunctional connectivity to task-related neural activity in the same chronic heroin user (CHU). Methodology/Principal Findings: We employed the method of graph theory analysis, which detected the abnormality of brain regions and dysregulation of brain connections at rest between 16 male abstinent chronic heroin users (CHUs) and 16 non-drug users (NDUs). Using a cue-reactivity task, we assessed the relationship between drug-related cue-induced craving activity and the abnormal topological properties of the CHUs' resting networks. Comparing NDUs' brain activity to that of CHUs, the intensity of functional connectivity of the medial frontal gyrus (meFG) in patients' resting state networks was prominently greater and positively correlated with the same region's neural activity in the heroin-related task; decreased functional connectivity intensity of the anterior cingulate cortex (ACC) in CHUs at rest was associated with more drug-related cue-induced craving activities. Conclusions: These results may indicate that there exist two brain systems interacting simultaneously in the heroin-addicted brain with regards to a cue-reactivity task. The current study may shed further light on the neural architecture that supports craving responses in heroin dependence.

Liu S-h. Passage to Manhood: Youth Migration, Heroin, and AIDS in Southwest China. Stanford CA: Sandford University Press, 2011

This book based on the author's field work describes the circumstances of Nuosu youth of a rural, poor farming community in southwest China. This community was defined by the post-revolutionary Chinese governmental as a "minority" community. Historically, the Nuosu had very limited with the Han, the majority population in China. Since the late 1980s, young Nuosu men became engaged in a circular migratory pattern, generally spending between two and four months at a time in Chinese cities attempting to make money before returning home.� Often lacking fluency in Mandarin, educational opportunities and social networks in the urban centers, many young migrant Nuosu workers supplement unsteady day labor jobs with participation in theft and other illicit activities. Before long, not only the young men who travelled to the cities, but also their families at home became involved in the consumption and distribution of heroin.�The heroin trade appears to have been one of the few sectors of the rural economy that improved the material quality of life in Limu during the Reform era. With the rise in heroin use, HIV and AIDS also became a growing problem in these communities. The author describes the toll on individuals, families and community relationships. Beyond the stigma arising from the minority status, the further stigma of HIV/AIDS was introduced in the process of governmental efforts at public health education. An unfortunate result was the fraying of kinship relationships which had provided a supportive network for AIDS patients. The author traces several themes, the impetus of youth to migrate as a means of improving their life circumstances; the fraying of community life, the inability of this minority population to reap the benefits accruing to the broader population. Due to high mortality rates, the numbers of heroin users has declined. Youth however have turned to newer drugs, namely ecstasy and methamphetamine.

Liu SH. A precarious rite of passage in post-reform China: Heroin use among Nuosu youths on the move. Medical Anthropology Quarterly 25(3): 395-411, 2011. (45 refs.)

This article employs the rite of passage concept to analyze why and how heroin use and a subsequent HIV/AIDS epidemic have taken hold among minority Nuosu (Yi) young men in Southwest China. It juxtaposes structural inequalities and sociocultural particularities in social suffering among Nuosu youths as they attempt to create meaningful lives in China's market reform era. Since the 1980s, young Nuosu have ventured out to Han-dominant cities in search of fun and opportunities. This movement has become a new foray into manhood and inadvertently set up their encounter with heroin and the subsequent introduction of HIV into their hometowns. The article is based on my 20-month ethnographic fieldwork in Limu, a mountainous Nuosu community in Liangshan Yi Autonomous Prefecture, Sichuan Province, between 2002 and 2009.

Lovrecic B; Semerl JS; Tavcar R; Maremmani I. Sociodemographic and clinical differences among deceased and surviving cohort members of opioid maintenance therapy. Heroin Addiction and Related Clinical Problems 13(3): 39-47, 2011. (27 refs.)

This study aimed to analyse the differences found among surviving and deceased heroin addicts in opioid maintenance treatment in the years 2004-2006 in Slovenia in terms of their sociodemographic and clinical characteristics. 3,950 heroin addicts entered our retrospective cohort study; of these, 69 had died by the end of the study. Mean age as recorded at entry into treatment was significantly higher among those who had died by the end of the study than among survivors. Men and those who had undergone more than one treatment died significantly more frequently than women and those in their first treatment. In addition, those who were unemployed or had had fewer years of education proved to be more likely to die. Heroin was the main drug in both groups; among its users death rates were significantly higher than among those taking other widely used addictive drugs. This is the first cohort study that has taken the step of recording indirect deaths. Further studies are now needed to acquire a better understanding of the phenomenon.

Mactier H. The management of heroin misuse in pregnancy: Time for a rethink? (review). Archives of Disease in Childhood. Fetal and Neonatal Edition 96(6): F457-F460, 2011. (42 refs.)

Heroin use in pregnancy is a worldwide problem. Methadone maintenance treatment has definite advantages for the mother and is currently recommended in the UK. There is, however, increasing evidence of adverse effects upon developing cortical and visual function in children of treated heroin-addicted mothers. The longer-term implications of this are not yet clear, and are confounded by poly-drug misuse and ongoing social deprivation. There is a paucity of evidence regarding outcome for infants who require pharmacological treatment for neonatal abstinence syndrome compared to those who have only mild symptoms. Well-controlled studies of the treatment of heroin misuse in pregnancy that take account of both neonatal and longer term outcomes for the child are urgently required.

Madden ME; Shapiro SL. The methadone epidemic: Methadone-related deaths on the rise in Vermont. American Journal of Forensic Medicine and Pathology 32(2): 131- 135, 2011. (29 refs.)

The prevalence of methadone-related overdose deaths is increasing worldwide and has been a topic of recent debate. Methadone-related deaths, to this point, have not been systematically reviewed in the state of Vermont. All of the methadone-related fatalities from 2001 to 2006 (total, 76 cases), which were examined by the Vermont Office of the Chief Medical Examiner were retrospectively reviewed. The mean age of the decedents was 36 years (range, 16-74 years), and 72% were male. The manners of death were classified as follows: 84% accident, 12% undetermined, and 4% suicide. The mean level of methadone was 457 ng/mL (range, 50-3793 ng/mL). The substances causing death were determined to be methadone alone in 26 (34%), methadone with only other prescribed medications in 29 (38%), methadone with only illicit drugs (excluding tetrahydrocannabinol) in 13 (17%), methadone with both illicit and prescribed medications in 5 (7%), and methadone with ethanol in 3 (4%). The methadone was obtained by illegal diversion (sale, gift, or theft) in 67% of cases. In the remaining cases (33%), the methadone was obtained by physician's prescription for chronic pain (60%), acute pain or injury (8%), methadone maintenance therapy for heroin dependence (8%), and unknown reasons (24%). The number of overdose deaths has increased 4-fold from 2001 (17 deaths) to 2006 (79 deaths). The proportion of methadone-related deaths has increased by 300% from 2001 (0.6% of reported deaths, 12% of overdose deaths) to 2006 (3% of reported deaths, 37% of overdose deaths). Methadone maintenance therapy for heroin dependence in our population comprises an insignificant number of the methadone-related deaths (3% of the decedents). In Vermont, the populations most at risk are those taking methadone for chronic pain and those obtaining diverted methadone for abuse. Education of clinicians regarding the increasing number of methadone-related deaths, the potential for abuse and diversion, and the pharmacokinetics of methadone may help halt this epidemic and reduce the number of fatalities from this drug.

Martin M; Vanichseni S; Suntharasamai P; Sangkum U; Chuachoowong R; Mock PA et al. Enrollment characteristics and risk behaviors of injection drug users participating in the Bangkok Tenofovir Study, Thailand. PLoS ONE 6(9): e25127, 2011. (44 refs.)

Background: The Bangkok Tenofovir Study was launched in 2005 to determine if pre-exposure prophylaxis with tenofovir will reduce the risk of HIV infection among injecting drug users (IDUs). We describe recruitment, screening, enrollment, and baseline characteristics of study participants and contrast risk behavior of Tenofovir Study participants with participants in the 1999-2003 AIDSVAX B/E Vaccine Trial. Methods: The Bangkok Tenofovir Study is an ongoing, phase-3, randomized, double-blind, placebo-controlled, HIV pre-exposure prophylaxis trial of daily oral tenofovir. The Tenofovir Study and the Vaccine Trial were conducted among IDUs at 17 drug-treatment clinics in Bangkok. Tenofovir Study sample size was based on HIV incidence in the Vaccine Trial. Standardized questionnaires were used to collect demographic, risk behavior, and incarceration data. The Tenofovir Study is registered with ClinicalTrials.gov, number-NCT00119106. Results: From June 2005 through July 2010, 4094 IDUs were screened and 2413 enrolled in the Bangkok Tenofovir Study. The median age of enrolled participants was 31 years (range, 20-59), 80% were male, and 63% reported they injected drugs during the 3 months before enrollment. Among those who injected, 53% injected methamphetamine, 37% midazolam, and 35% heroin. Tenofovir Study participants were less likely to inject drugs, inject daily, or share needles (all, p<0.001) than Vaccine Trial participants. Discussion: The Bangkok Tenofovir Study has been successfully launched and is fully enrolled. Study participants are significantly less likely to report injecting drugs and sharing needles than participants in the 1999-2003 AIDSVAX B/E Vaccine Trial suggesting HIV incidence will be lower than expected. In response, the Bangkok Tenofovir Study enrollment was increased from 1600 to 2400 and the study design was changed from a defined 1-year follow-up period to an endpoint-driven design. Trial results demonstrating whether or not daily oral tenofovir reduces the risk of HIV infection among IDUs are expected in 2012.

Maxwell JC. The prescription drug epidemic in the United States: A perfect storm. Drug and Alcohol Review 30(3): 264- 270, 2011. (32 refs.)

Introduction and Aims. Abuse of prescription analgesics in the USA is increasing. The epidemic has been driven by many factors, including marketing strategies, incorrect prescribing practices, a variety of legal and illegal drug sources, belated governmental responses and increases in the number of prescriptions written. Design: and Methods. Data sources including surveys, emergency room visits, treatment admissions, overdose deaths, toxicology laboratory findings and journal articles were examined to identify trends. Results. The surveys and emergency department visits show use lowest among young teenagers and highest among older teenagers and young adults, with significant increases among those aged 55 and older. The length of time between initial use of an opioid other than heroin and admission to treatment is shortening. Mortality data and toxicology exhibits confirm the increases and show the variation in the prevalence of various drugs across the. Discussion and Conclusions. Abuse is increasing, with varying patterns of use by high-risk groups and different geographic preferences. Prescription drug monitoring programs are being developed in each of the US states to deter 'doctor shopping'; the Food and Drug Administration has increased authority over manufacturers; and options for proper disposal of leftover medications exist. There is increased emphasis on responsible prescribing including risk assessments, prescribing agreements, treatment plans, and training for clinicians, as well as monitoring the interactions with benzodiazepines. However, unless these efforts decrease diversion, abuse and addiction, clinicians may lose the ability to use some of these opioids for effective pain management or so many barriers will be raised that pain will go undertreated or untreated.

McCabe I; Acree M; O'Mahony F; McCabe J; Kenny J; Twyford J et al. Male street prostitution in Dublin: A psychological analysis. Journal of Homosexuality 58(8): 998-1021, 2011. (48 refs.)

This study assessed the mental health characteristics of 12 male street prostitutes (MSPs) in Dublin, with particular regard to issues of homelessness, substance abuse, depression, suicidal ideation, and self-esteem. Participants completed five psychometric tests, which indicated that all of the participants had above average levels of depression and suicidal ideation and low levels of self-esteem. This study found that candidates likely to become MSPs are young males with a combination of factors, including a background of childhood sexual or physical abuse, leaving school early, running away from home, and a dependence on heroin.

Molinaro S; Siciliano V; Curzio O; Denoth F; Salvadori S; Mariani F. Illegal substance use among italian high school students: Trends over 11 years (1999-2009). PLoS ONE 6(6): e20482, 2011. (29 refs.)

Purpose: To monitor changes in habits in drug use among Italian high school students. Methods: Cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD) carried out in Italy annually for 11 years (1999-2009) with representative samples of youth attending high school. The sample size considered ranges from 15,752 to 41,365 students and response rate ranged from 85.5% to 98.6%. Data were analyzed to obtain measures of life-time prevalence (LT), use in the last year (LY), use in the last 30 days (LM), frequent use. Comparisons utilized difference in proportion tests. Tests for linear trends in proportion were performed using the Royston p trend test. Results: When the time-averaged value was considered, cannabis (30% LT) was the most, and heroin the least (2%) frequently used, with cocaine (5%), hallucinogens (2%) and stimulants (2%) in between. A clear gender gap is evident for all drugs, more obvious for hallucinogens (average M/F LY prevalence ratio 2, range 1.7-2.4, p<0.05), less for cannabis (average M/F LY prevalence ratio 1.3, range 1.2-1.5, p<0.05). Data shows a change in trend between 2005 and 2008; in 2006 the trend for cannabis use and availability dropped and the price rose, while from 2005 cocaine and stimulant use prevalence showed a substantial increase and the price went down. After 2008 use of all substances seems to have decreased. Conclusions: Drug use is widespread among students in Italy, with cannabis being the most and heroin the least prevalent. Girls are less vulnerable than boys to illegal drug use. In recent years, a decrease in heroin use is overbalanced by a marked rise in hallucinogen and stimulant use.

Neale J; Nettleton S; Pickering L. What is the role of harm reduction when drug users say they want abstinence? International Journal of Drug Policy 22(3): 189-193, 2011. (24 refs.)

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

Nettleton S; Neale J; Pickering L. Techniques and transitions: A sociological analysis of sleeping practices amongst recovering heroin users. Social Science & Medicine 72(8): 1367- 1373, 2011. (34 refs.)

This paper seeks to make sense of the sleeping practices of people who are recovering from heroin use. It brings together two hitherto unrelated literatures: the sociology of sleep and studies on heroin use and recovery. Conceptual resources developed within the sociology of sleep are deployed to facilitate the analysis of interview data generated as part of a qualitative investigation into the everyday lives of recovering heroin users living in England. Twenty one men and 19 women were interviewed with 37 of the 40 being interviewed twice, giving a corpus of 77 interviews. Without exception all the participants in the research experienced extensive sleeping problems that were not only exacerbated by the pharmacological effects of heroin, but were made worse by the way of life that accompanied their using. Irregular and anarchic sleeping practices mirrored the study participants' disrupted and difficult lives. Attempts to establish sleep routines, and normative sleeping patterns, constitutes an important marker of recovery, but after years, and for some decades, of chaotic, intermittent and irregular sleeping, cultivating sleep presents a series of difficult challenges. Their embodied biographies of heroin use constrain the promotion of sleep, and attempts to develop rituals and routines to restore sleeping patterns are confounded by the involuntary aspects of sleep and their recalcitrant bodies. These findings are significant because not only is the quality of sleep critical to health outcomes but it also forms an important but hitherto relatively overlooked aspect of recovery from heroin use.

Nielsen S; Bruno R; Lintzeris N; Fischer J; Carruthers S; Stoove M. Pharmaceutical opioid analgesic and heroin dependence: How do treatment-seeking clients differ in Australia? Drug and Alcohol Review 30(3): 291- 299, 2011. (34 refs.)

Introduction and Aims. Non-prescribed use of pharmaceutical opioid analgesics (POA) has been escalating internationally. In Australia, few studies have examined if POA users have similar characteristics and treatment needs to heroin users. The aim of this study was to compare those presenting for treatment where heroin versus POA were the primary drugs of concern. Design: and Methods. A convenience sample of 192 treatment entrants were recruited from alcohol and drug treatment services in four Australian jurisdictions. A structured interview collected data on demographic characteristics, substance use, self-perceived mental and physical health, crime and harms resulting from drug use. Multivariate analyses were performed to identify characteristics which may differentiate those seeking treatment for heroin compared with POA. Results. Most treatment entrants sampled reported a history of injection drug use and use of both heroin and POA. However, those with primary POA problems were less likely to report an overdose history (adjusted odds ratio 0.90, 95% confidence interval 0.81-0.99) and more likely to initiate opioid use for pain (adjusted odds ratio 2.52, 95% confidence interval 1.04-6.12) than those with primary heroin problems. Latent Class Analysis found that, while most of the POA group were similar to heroin users in demographics, health and injecting drug use, there was a small, distinct group of primary POA problem users that did not typically inject and who commonly initiated opioid use for pain and also experienced elevated physical and mental health disability. Discussion and Conclusions. While some differences existed, this study of Australian treatment seekers found many similar characteristics between those with primary problems with heroin and POA. Few non-injecting POA were recruited in this sample. This finding contrasts with reports of a growing population of opioid-dependent people with characteristics that are distinct from traditional opioid-dependent populations, which may reflect the orientation of current treatment systems in Australia towards injection drug users.

Nikolov MA; Beltcheva O; Galabova A; Ljubenova A; Jankova E; Gergov G et al. No evidence of association between 118A > G OPRM1 polymorphism and heroin dependence in a large Bulgarian case-control sample. Drug and Alcohol Dependence 117(1): 62-65, 2011. (31 refs.)

The mu-opioid receptor is the primary site of action of most opioids. The 118A>G (rs1799971) polymorphism in exon 1 of the mu-opioid receptor gene (OPRM1) leads to an Asn40Asp amino acid change that affects a putative N-glycosylation site. It has been widely investigated for association with alcohol and drug dependence and pain sensitivity, with mixed results. The aim of the current study was to examine whether this polymorphism was associated with heroin dependence in a large Bulgarian cohort of 1842 active users and 1451 population controls. SNP genotyping was done using Real-Time PCR TaqMan technology. Association analyses were conducted, separately for Roma and non-Roma participants. Our results suggest that there is no direct effect of 118A>G genotype on the risk for heroin dependence among active heroin users.

Peles E; Schreiber S; Sason A; Adelson M. Earning "take-home" privileges and long-term outcome in a methadone maintenance treatment program. Journal of Addiction Medicine 5(2): 92-98, 2011. (13 refs.)

Objectives: This observational prospective study aimed to determine whether duration to the earning of privileges of "take-home" methadone doses (as a part of behavioral enforcement) reflects long-term outcome of patients in methadone maintenance treatment (MMT). Methods: All 657 former heroin addicts admitted to our MMT clinic between June 1993 and June 2008 were prospectively studied and followed up. Duration from admission to first take-home dose (until October 2008), to leaving (retention, until June 2009), and to dying (survival, until June 2008) was calculated. Results: Most patients (n = 435; 66.2%) ever achieved take-home privileges. Retention was longest (10 years, 95% confidence interval [CI]: 8.8 to 11.2) for 110 patients who achieved their first take-home dose after 3 to 6 months, followed by 9 years (95% CI: 7.7 to 10.3) for 98 patients who achieved it after >6 months and <= 1 year, and 8.3 years (95% CI: 7.2 to 9.4) for 127 patients who managed to achieve it only after >1 year. Retention was lower among patients who were given exceptional take-home doses (not respecting policy regulations) <3 months since admission: 5.1 years (95% CI: 3.4 to 7.8) for 30 patients (who got it for medical reasons), 9 years (95% CI: 6.7 to 11.3) for 14 patients admitted from another MMT, and 6.3 years (95% CI: 5 to 7.6) for 56 patients who got it for unjustified (mistakes) reasons. The shortest retention in MMT was 2.2 years (95% CI: 1.8 to 2.7, P < 0.0005) for 222 patients who never managed to achieve any take-home privileges. Survival was longer among patients who ever versus never received take-home privileges (13.2 years [95% CI: 12.8 to 13.6] vs 12.3 years [95% CI: 11.5 to 13.1], respectively; P = 0.04) and longest (14.1 years [95% CI: 13.4 to 14.7]) among those who received take-home privileges after 3 to 6 months. Conclusions: The group with the shortest time (3 to 6 months) to the achievement of first take-home dose had the best outcome. Further studies are needed to characterize this group.

Perron BE; Bohnert ASB; Monsell SE; Vaughn MG; Epperson M; Howard MO. Patterns and correlates of drug-related ED visits: Results from a national survey. American Journal of Emergency Medicine 29(7): 704-710, 2011. (28 refs.)

Purpose: Drug treatment can be effective in community-based settings, but drug users tend to underuse these treatment options and instead seek services in emergency departments (EDs) and other acute care settings. The goals of this study were to describe prevalence and correlates of drug-related ED visits. Basic Procedures: This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions, which is a nationally representative survey of 43,093 US residents. Main Findings: The overall prevalence of drug-related ED visits among lifetime drug users was 1.8%; for those with a lifetime drug use disorder, 3.7%. Persons with heroin dependence and inhalant dependence had the highest rates of ED visits, and marijuana dependence was associated with the lowest rates. Multivariate analyses revealed that being socially connected (ie, marital status) was a protective factor against ED visits, whereas psychopathology (ie, personality or mood disorders) was a risk factor. Conclusions: Significant variability exists for risk of ED use for different types of drugs. These findings can help inform where links between EDs with local treatment programs can be formed to provide preventive care and injury-prevention interventions to reduce the risk of subsequent ED visits.

Preston KL; Epstein DH. Stress in the daily lives of cocaine and heroin users: Relationship to mood, craving, relapse triggers, and cocaine use. Psychopharmacology 218(1, special issue): 29-37, 2011. (33 refs.)

Quantitative real-time data on the stress experienced by drug misusers in their daily lives may provide additional insight into stress's role in drug use. The purpose of this study is to evaluate stress in relation to craving, mood, relapse-trigger exposure, and cocaine use in cocaine-dependent outpatients. Methadone-maintained cocaine- and heroin-abusing outpatients (N = 114) provided ecological momentary assessment data on handheld computers. Ratings of stress were compared to those of craving and mood and past-hour exposure to putative drug-use triggers in randomly prompted entries and in the 5 h prior to participant-initiated cocaine use reports. Stress had significant positive relationships with current ratings of craving for cocaine, heroin, and tobacco and with ratings of tiredness, boredom, and irritation, and had significant negative relationships with ratings of happiness and relaxation. Stress was significantly greater in entries in which participants also reported past-hour exposure to negative-mood triggers, most of the drug-exposure triggers, or any trigger involving thoughts about drugs (e.g., tempted out of the blue). The linear increase in stress during the 5-h preceding individual episodes of cocaine use was not significant (p = 0.12), though there was a trend for such an increase before the use episodes that participants attributed to stressful states when they occurred (p = 0.87). The findings suggest a complex role of stress in addiction. Stress reported in real time in the natural environment showed strong cross-sectional momentary relationships with craving, mood, and exposure to drug-use trigger. However, the prospective association between stress ratings and cocaine-use episodes was, at best, weak.

Reddon H; Wood E; Tyndall M; Lai C; Hogg R; Montaner J; Kerr T. Use of North America's first medically supervised safer injecting facility among HIV-positive injection drug users. AIDS Education And Prevention 23(5): 412-422, 2011. (49 refs.)

The objective of this study was to examine supervised injecting facility (SIF) use among a cohort of 395 HIV-positive injection drug users (IDUs) in Vancouver, Canada. The correlates of SIF use were identified using generalized estimating equation analyses. In multivariate analyses, frequent SIF use was associated with homelessness (adjusted odds ratio [AOR] = 1.90), daily heroin injection (AOR = 1.56), and daily cocaine injection (AOR = 1.59). The reasons given for not using the SIF included a preference for injecting at home and already having a safe place to inject. The SIF services most commonly used were needle exchange and nursing services. The SIF appears to have attracted a high-risk subpopulation of HIV-positive IDUs; this coverage perhaps could be extended with the addition of HIV-specific services such as disease monitoring and the provision of antiretroviral therapy.

Reimer J; Verthein U; Karow A; Schafer I; Naber D; Haasen C. Physical and mental health in severe opioid-dependent patients within a randomized controlled maintenance treatment trial. Addiction 106(9): 1647-1655, 2011. (33 refs.)

Aims To evaluate physical and mental health and compare treatment outcomes in opiate-dependent patients substituted either with heroin or methadone. Design: Twelve-month open-label randomized controlled trial. Setting Out-patient substitution clinics in seven German cities. Participants: A total of 1015 opiate-dependent individuals. Measurements Opiate Treatment Index-Health Scale Score (OTI), Body Mass Index (BMI), serology for infectious diseases such as hepatitis B, C and human immunodeficiency virus as well as tuberculosis, Karnofsky Performance Scale (KPS), electrocardiogram (ECG), echocardiogram, Symptom Checklist 90-R (SCL-90-R), Global Assessment of Functioning (GAF), Modular System for Quality of Life and study medication-related serious adverse events (SAE). Findings: Improvements were found in both heroin and methadone substituted patients regarding OTI, BMI, KPS, SCL-90-R, and GAF, but they were more pronounced for the heroin group (analysis of variance, all P = 0.000). The frequency of pathological echocardiograms decreased in the heroin group and increased in the methadone group (chi(2) test, < 0.05). Markers for infectious diseases and frequencies of pathological ECGs did not differ between baseline and 12 months, or between treatment groups. Studymedication-related serious adverse events, all of which were treated successfully, occurred 2.5 times more often in the heroin group. The majority of heroin-related SAEs (41 of 58) occurred within a few minutes of the injections. Conclusions: The integration of severe injection drug users either in methadone or heroin-assisted maintenance treatment has positive effects on most physical and mental change-sensitive variables, with heroin showing superior results. Due to medication-related adverse events, patients should be observed for 15 minutes after a heroin injection.

Roddy J; Steinmiller CL; Greenwald MK. Heroin purchasing is income and price sensitive. Psychology of Addictive Behaviors 25(2): 358-364, 2011. (31 refs.)

Semi-structured interviews were used to assess behavioral economic drug demand in heroin dependent research volunteers. Findings on drug price, competing purchases, and past 30-day income and consumption, established in a previous study, are replicated. We extended these findings by having participants indicate whether hypothetical environmental changes would alter heroin purchasing. Participants (n = 109) reported they would significantly (p < .005) decrease heroin daily purchasing amounts (DPA) from past 30-day levels (M = $60/day) if: (a) they encountered a 33% decrease in income (DPA = $34), (b) family/friends no longer paid their living expenses (DPA = $32), or (c) they faced four-fold greater likelihood of police arrest at their purchasing location (DPA = $42). Participants in higher income quartiles (who purchase more heroin) show greater DPA reductions (but would still buy more heroin) than those in lower income quartiles. For participants receiving government aid (n = 31), heroin purchasing would decrease if those subsidies were eliminated (DPA = $28). Compared to participants whose urine tested negative for cocaine (n = 31), cocaine-positive subjects (n = 32) reported more efficient heroin purchasing, that is, they live closer to their primary dealer; are more likely to have heroin delivered or walk to obtain it (and less likely to ride the bus), thus reducing purchasing time (52 vs. 31 min, respectively); and purchase more heroin per episode. These simulation results have treatment and policy implications: Daily heroin users' purchasing repertoire is very cost-effective, more so for those also using cocaine, and only potent environmental changes (income reductions or increased legal sanctions) may impact this behavior.

Roncero C; Fuste G; Barral C; Rodriguez-Cintas L; Martinez-Luna N; Eiroa-Orosa FJ et al. Therapeutic management and comorbidities in opiate-dependent patients undergoing a replacement therapy programme in Spain: the PROTEUS study. Heroin Addiction and Related Clinical Problems 13(3): 5-16, 2011. (57 refs.)

The aim of this study was to comprehensively describe the clinical comorbidities, concomitant treatments and the current therapeutic management of opiate-dependent patients undergoing a replacement therapy programme (RTP). This is an observational, cross-sectional, multicentre, epidemiological study conducted in 74 healthcare centres for drug users. Patients were diagnosed with Opiate Dependence (OD), and enrolled in a RTP in Spain (N=624). Most patients were men (84%); they received methadone (94%) at a mean dose of 61.52mg/day during the maintenance phase, orally (95%) with take-home doses (76%). High rates of infectious (59%) and psychiatric comorbidities (67%) were found. Patients infected by HIV, HCV or coinfected by HIV/HCV were given significantly higher methadone doses (p<0.0001).

Rudolph AE; Latkin C; Crawford ND; Jones KC; Fuller CM. Does respondent driven sampling alter the social network composition and health-seeking behaviors of illicit drug users followed prospectively? PLoS ONE 6(5): e19615, 2011. (56 refs.)

Respondent driven sampling (RDS) was originally developed to sample and provide peer education to injection drug users at risk for HIV. Based on the premise that drug users' social networks were maintained through sharing rituals, this peer-driven approach to disseminate educational information and reduce risk behaviors capitalizes and expands upon the norms that sustain these relationships. Compared with traditional outreach interventions, peer-driven interventions produce greater reductions in HIV risk behaviors and adoption of safer behaviors over time, however, control and intervention groups are not similarly recruited. As peer-recruitment may alter risk networks and individual risk behaviors over time, such comparison studies are unable to isolate the effect of a peer-delivered intervention. This analysis examines whether RDS recruitment (without an intervention) is associated with changes in health-seeking behaviors and network composition over 6 months. New York City drug users (N = 618) were recruited using targeted street outreach (TSO) and RDS (2006-2009). 329 non-injectors (RDS = 237; TSO = 92) completed baseline and 6-month surveys ascertaining demographic, drug use, and network characteristics. Chi-square and t-tests compared RDS- and TSO-recruited participants on changes in HIV testing and drug treatment utilization and in the proportion of drug using, sex, incarcerated and social support networks over the follow-up period. The sample was 66% male, 24% Hispanic, 69% black, 62% homeless, and the median age was 35. At baseline, the median network size was 3, 86% used crack, 70% used cocaine, 40% used heroin, and in the past 6 months 72% were tested for HIV and 46% were enrolled in drug treatment. There were no significant differences by recruitment strategy with respect to changes in health-seeking behaviors or network composition over 6 months. These findings suggest no association between RDS recruitment and changes in network composition or HIV risk, which supports prior findings from prospective HIV behavioral surveillance and intervention studies.

Sawyer-Kurian KM; Browne FA; Carney T; Petersen P; Wechsberg WM. Exploring the intersecting health risks of substance abuse, sexual risk, and violence for female South African teen dropouts. Journal of Psychology in Africa 21(1): 15- 25, 2011. (41 refs.)

The study sought to better understand the cultural contexts of the risks for adolescent females who have dropped out of school. Focus groups were conducted with 37 Black and Coloured females aged 13 to 17 in Cape Town, South Africa. Data were analysed using content analysis. Methamphetamine, cannabis, and alcohol were used by both, however, Black teens also used methaqualone and Coloured teens used heroin and ecstasy. Some teens traded sex for drugs and others did so at the request of their drug-addicted mothers. Teens revealed high rates of violence, including rape, and many myths and barriers about condom use, revealing risky sex behaviours. Conclusion: Cultural nuances between the two groups will help inform the adaptation of an HIV prevention intervention.

Schechter MT; Kendall P. Is there a need for heroin substitution treatment in Vancouver's Downtown Eastside? Yes there is, and in many other places too. Canadian Journal of Public Health 102(2): 87- 89, 2011. (9 refs.)

The prescription of medically-supervised diacetylmorphine, the active ingredient in heroin, to individuals with treatment-refractory opioid dependence is a controversial and often politically charged subject. Just as methadone maintenance was opposed in the 1960s by some treatment providers who preferred abstinence-based therapies, heroin-assisted therapy is now being opposed by some methadone treatment providers this despite the fact that the effectiveness of heroin-assisted treatment has been demonstrated in no less than six randomized trials in Switzerland, the Netherlands, Spain, Germany, Canada and the UK. The North American Opiate Medication Initiative (NAOMI) trial in Canada clearly showed heroin-assisted therapy to be superior to methadone in individuals with chronic, treatment-refractory heroin addiction both in terms of retention in addiction treatment and clinical response. An international internal review panel, three Research Ethics Boards, the CIHR RCT review panel, the Therapeutic Products Directorate of Health Canada, and several journal peer-reviewers reviewed the NAOMI trial. Nevertheless, authors of a commentary in this issue of CJPH find fault with the trial in terms of methadone prescribing, use of intention-to-treat analysis, safety and cost. We take this opportunity to respond to the numerous misconceptions and errors in their commentary.

Schneider S; Meys F. Analysis of illicit cocaine and heroin samples seized in Luxembourg from 2005-2010. Forensic Science International 212(1-3): 242-246, 2011. (21 refs.)

This article discusses drug purity, frequency of appearance and concentration ranges of adulterants of 471 illicit cocaine and 962 illicit heroin samples seized in Luxembourg from January 2005 to December 2010. For cocaine samples the mean concentration was lowest in 2009 (43.2%) and highest in 2005 (54.7%) but no clear trend could be observed during the last 6 years. 14 different adulterants have been detected in cocaine samples, from which phenacetin has been the most abundant in terms of frequency of appearance and concentration until 2009. In 2010 the veterinary antihelminthic drug levamisole has become the most abundant adulterant detected in cocaine samples, its concentrations however remained low (1.5-4.1%). The mean heroin concentration was 26.6% in 2005, a decline has been observed in 2006 and the concentrations have been relatively stable since then (15.8-17.4%). Paracetamol and caffeine were by far the most abundant adulterants detected in heroin samples.

Sherman SG; Reuben J; Chapman CS; Lilleston P. Risks associated with crack cocaine smoking among exotic dancers in Baltimore, MD. Drug and Alcohol Dependence 114(2-3): 249- 252, 2011. (20 refs.)

Background: There is a dearth of research focusing on sex work in exotic dance clubs. We conducted a cross-sectional study to examine the prevalence and correlates of crack cocaine smoking among a sample of exotic dancers. Methods: The "block," a historical red-light district in downtown Baltimore, MD, is comprised of 30 adult-entertainment establishments. Between 01/09 and 08/09, we conducted a survey with exotic dancers (N = 98). The survey explored demographic, and drug and sexual/drug risk behaviors. Bivariate and multivariate analysis was conducted using Poisson regression with robust variance estimates to examine correlates of current crack smoking. Results: Crack cocaine smokers compared to non-crack cocaine smokers were significantly more likely to report: older age (29 vs. 23 years, respectively, p < 0.0001); being White (79% vs. 50%, respectively, p = 0.008); having been arrested (93% vs. 67%, respectively, p = 0.008); daily alcohol consumption (36% vs. 17%, p = 0.047); current heroin injection (57% vs. 13%, p < 0.001); and current sex exchange (79% vs. 30%, p < 0.001). In the presence of other variables, crack cocaine smokers compared to non-crack cocaine smokers were significantly older, more likely to report current heroin injection, and more likely to report current sex exchange. Discussion: We found high levels of drug use and sexual risk behaviors as well as a number of risks behaviors associated with crack cocaine smoking among this very under-studied population. Targeted interventions are greatly needed.

Simonsen KW; Hansen AC; Rollmann D; Kringsholm B; Muller IB; Johansen SS et al. Drug-related death in Denmark in 2007. Danish Medical Bulletin 58(8): a4307, 2011. (14 refs.)

Introduction: We investigated fatal poisonings among drug addicts in 2007. The cause of death, abuse pattern and geographic differences are presented. MATERIAL AND METHODS: All drug-related deaths examined at the three forensic medicine institutes in Denmark in 2007 were evaluated. RESULTS: The number of drug-related deaths in 2007 was 226. Methadone deaths had increased since 1997 while heroin/morphine deaths decreased. In earlier studies, very few deaths from central stimulants like cocaine and amphetamines occurred (1-1.5%), but in 2007 6% of the deaths were caused by these drugs. Multiple drug use was common. Heroin/morphine, cocaine, amphetamine, cannabis, methadone, benzodiazepines and alcohol were included in the poly-drug use. Conclusion: This investigation shows stabilization in the number of fatal poisonings in drug addicts. Geographic differences were observed. Methadone was the most frequent cause of fatal poisoning and there was a continuous decrease in heroin/morphine deaths. Fatal deaths from cocaine and amphetamine have increased considerably. Multiple drug use was common.

Smyth BP; Fagan J; Kernan K. Outcome of heroin-dependent adolescents presenting for opiate substitution treatment. Journal of Substance Abuse Treatment 42(1): 35-44, 2012. (34 refs.)

Because the outcome of methadone and buprenorphine substitution treatment in adolescents is unclear, we completed a retrospective cohort study of 100 consecutive heroin-dependent adolescents who sought these treatments over an 8-year recruitment period. The participants' average age was 16.6 years, and 54 were female. Half of the patient group remained in treatment for over 1 year. Among those still in treatment at 12 months, 39% demonstrated abstinence from heroin. The final route of departure from the treatment program was via planned detox for 22%, dropout for 32%, and imprisonment for 8%. The remaining 39% were transferred elsewhere for ongoing opiate substitution treatment after a median period of 23 months of treatment. Males were more likely to exit via imprisonment (p < .05), but other outcomes were not predicted by gender. There were no deaths during treatment among these 100 patients who had a cumulative period of 129 person years at risk. Our findings suggest that this treatment delivers reductions in heroin use and that one fifth of patients will exit treatment following detox completion within a 1- to 2-year time frame.

Sordo L; Chahua M; Bravo MJ; Barrio G; Brugal MT; Domingo-Salvany A et al. Depression among regular heroin users: The influence of gender. Addictive Behaviors 37(1): 148-152, 2012. (28 refs.)

The aim of this study was to determine the prevalence of recent (last 12months) depression in regular young heroin users and to ascertain factors associated with depression in this population, broken down by gender. A sample of 561 participants completed a cross-sectional survey. Eligibility criteria were: age 30years or younger, and having used heroin for at least 12days in the last 12months and at least one day in the last 3months. Participants were recruited outside of health-care facilities in the cities of Barcelona, Madrid and Seville by targeted sampling and chain referral methods. Depression was assessed using the World Mental Health Composite International Diagnostic Interview. The prevalence of recent depression was 22.3% (35.2% among women and 17.3% among men, p<0.001). In the multivariate analysis, the factors positively associated with recent depression in the whole sample were female gender, age 25 or less, inability to work due to health problems and high risk consumption of alcohol. Among woman, the related variables were age 25 or less, cocaine dependence in the last 12months, and alcohol consumption in that period. Among men, employment status was the only related variable. Analysis of an overall sample without the gender breakdown may hide important differences in the factors associated with depression in men and women. Both prevention and treatment of depression should rely on specific gender analysis.

Sordo L; Chahua M; Bravo MJ; Barrio G; Brugal MT; Domingo-Salvany A et al. Depression among regular heroin users: The influence of gender. Addictive Behaviors 37(1): 148-152, 2012. (28 refs.)

The aim of this study was to determine the prevalence of recent (last 12 months) depression in regular young heroin users and to ascertain factors associated with depression in this population, broken down by gender. A sample of 561 participants completed a cross-sectional survey. Eligibility criteria were: age 30 years or, younger, and having used heroin for at least 12 days in the last 12 months and at least one day in the last 3 months. Participants were recruited outside of health-care facilities in the cities of Barcelona, Madrid and Seville by targeted sampling and chain referral methods. Depression was assessed using the World Mental Health Composite International Diagnostic Interview. The prevalence of recent depression was 22.3% (35.2% among women and 17.3% among men, p<0.001). In the multivariate analysis, the factors positively associated with recent depression in the whole sample were female gender, age 25 or less, inability to work due to health problems and high risk consumption of alcohol. Among woman, the related variables were age 25 or less, cocaine dependence in the last 12 months, and alcohol consumption in that period. Among men, employment status was the only related variable. Analysis of an overall sample without the gender breakdown may hide important differences in the factors associated with depression in men and women. Both prevention and treatment of depression should rely on specific gender analysis.

Susnjara IM; Gojanovic MD; Vodopija D; Capkun V; Smoljanovic A. Influence of war on quantitative and qualitative changes in drug-induced mortality in Split-Dalmatia County, Croatia. Croatian Medical Journal 52(5): 629-636, 2011. (54 refs.)

Aim: To study drug-induced mortality and characteristics of overdose deaths in the war (1991-1995), pre-war (1986-1990), and post-war period (1996-2000) in Split-Dalmatia County. Methods: We retrospectively searched through Databases of the Department of Forensic Medicine, University Hospital Split, the national register of death records, the archives of the Split-Dalmatia County Police, and the Register of Treated Drug Addicts of the Croatian National Institute of Public Health, covering the period from 1986 to 2000, according to drug poisoning codes IX and X of the International Classification of Diseases. The indicators were statistically analyzed. Results There were 146 registered drug-induced deaths, with 136 (93%) deceased being men. The median age of all cases was 27 years (interquartile range 8). Most of them were single (70.6%), unemployed (44.6%), and secondary school graduates (69.2%). In the war period, there were 4.8 times more deaths than in the pre-war period (P = 0.014), and in the post-war period there were 5.2 times more deaths than in the pre-war period (P = 0.008). The most common site of death was the deceased person's home. The toxicological analyses showed that 59 (61%) deaths were heroin related, alcohol use was found in 62 cases (42.5%), and multi-substance use was found in more than a half of the cases. In 133 (91.1%) cases, deaths were classified as unintentional, whereas 13 (8.9%) were classified as suicides. Conclusion: The war, along with other risk factors, contributed to unfavorable developments related to drug abuse in Split-Dalmatia County, including the increase in the drug-induced mortality rate.

Susnjara IM; Smoljanovic A; Gojanovic MD. Drug related deaths in the Split-Dalmatia County 1997-2007. Collegium Antropologicum 35(3): 823-828, 2011. (40 refs.)

Drug overdoses are a major cause of mortality for drug users and, in many countries, are the leading cause of death in this group. The aim of the present study is to explore the frequency of all drug related deaths in the Split-Dalmatia County in the period between 1997 and 2007 and to analyze some of the characteristics of these deaths to help target preventive policies. The data on drug related deaths were collected using records from the Department of Forensic Medicine, Clinical Hospital Centre Split, University of Split, School of Medicine. There were 190 drug related deaths in the observed period of 11 years. Statistically significant difference (p=0.004, chi(2)-test for trend) was found in the number of deaths in 1997 in comparison with the number of deaths in 2007. The majority of 105 (55%) the decedents were 25-34 years old, and 92.1% (175) of them were male. There was a 94% higher probability of mortality in the 25-34 years group (chi(2)=5.55, p=0.064). Average age of all dead people was 31.01 +/- 7.59 years (median 31.0 years; range 18-49). Almost three quarters of the decedents were single and more than three fifths hadn't been employed. The most common location of death was at home. Approximately, 80% were autopsied followed by full histological and toxicological analyses. Out of all examined cases, the majority of drug related deaths (93 or 60.8%) were attributed to heroin. Heroin was the sole cause of death in 35(22.9%) cases. Methadone was cause of death in 24 (15.7%) cases. 3.4-methylenedioxy-methamphetamine (MDMA) deaths were rare (3.3%). Cocaine deaths were also rare (1.3%). Three fifths (55.6%) of the cases involved includes multi-substance use. During the investigation there was an evident trend towards multi-substance abuse patterns. These data suggest that interventions to prevent drug related mortality should address the use of drugs such as heroin and alcohol in combination.

Tanner GR; Bordon N; Conroy S; Best D. Comparing methadone and Suboxone in applied treatment settings: the experiences of maintenance patients in Lanarkshire. Journal of Substance Use 16(3): 171- 178, 2011. (13 refs.)

Background. Although there is evidence that buprenorphine is more effective than placebo in suppressing heroin use, and is a recommended treatment for opioid dependence, methadone remains the dominant maintenance treatment. However, this may have adverse consequences in increased dependence liability and greater withdrawal effects. Rationale. The study assessed the experiences of clients in Lanarkshire who had experienced both substances to report on the strengths and weaknesses of each. Method. Two phases of opportunistic data were collected - open narrative accounts of those successfully detoxifying from Suboxone (a buprenorphinenaloxone combination) and structured interviews with clients comparing Suboxone and methadone. Results. Consistently, clients reported more clarity of thinking while on Suboxone. However, this was not always perceived positively as increased clarity necessitated more psychosocial therapeutic support than was needed on methadone. Suboxone was associated with increased confidence and lower stigma than methadone. Concerns were expressed about the antagonistic effect of Suboxone, with several reports of ""use on top"". Conclusion. Participants made clear distinctions between methadone and Suboxone, with the strongest difference being increased clarity of thinking on Suboxone. Suboxone has significant potential for staged use within a ""recovery journey"" but only if prescribed within an appropriate package of psychosocial care.

Todorovic MS; Mitrovic S; Aleksandric B; Mladjenovic N; Matejic S. Association of pulmonary histopathological findings with toxicological findings in forensic autopsies of illicit drug users. Vojnosanitetski Pregled 68(8): 639-642, 2011. (11 refs.)

Background/Aim. Drug abuse remains a significant social problem in many countries. The aim of the study was to estimate association between pulmonary histopathological changes and results of toxicological analyses in forensic autopsies of illicit drug users. Methods. This investigation was performed in the Institute of Forensic Medicine, Belgrade, and in the Clinical Center, Department of Forensic Medicine, Kragujevac, from 2000 to 2004, and included 63 medicolegal autopsies of heroin or other drug consumers who suddenly died. Autopsies, postmortem toxicological examination of drugs and serological analyses of anti-HIV/HBV/HCV antibodies were performed. Results. The deceased persons were mostly male, 46/63 (73.01%), ranged in age from 19 to 49 years (mean 31 years) and all were whites. Postmortem toxicological examination was performed on all of the deceased persons and drugs in the fatal range were identified in only eight of them (12.7%), in the toxic range in ten (15.87%), and in minimal concentrations in 35 (55.56%) of the deceased persons. Drugs identified in the fatal, toxic or minimal range included heroin-morphine (38/53), cocaine (4/53), tramadol (3/53), and lorazepam (1/53). In the 7 remaining subjects, ethanol in combination with heroin was found in 4 cases, and diazepam in combination with heroin in 3 cases. Dominant pathomorphological changes were findings in the lung tissue. Most common histological changes observed in drug users were pulmonary edema - 55/63 (87.3%), acute alveolar hemorrhages - 49/63 (77.78%), hemosiderin-laden macrophages (siderophages) - 52/63 (82,54%), and emphysematous changes - 51/63 (80,95%). Conclusion. Pulmonary edema is the frequent non-specific autopsy finding which is associated with virtually all routes of drug administration. The histopathological study is necessary to determinate a cause of death when a deceased person has the history of dependence or abouse of psychoactive drugs with negative toxicological results.

Torchalla I; Strehlau V; Li K; Krausz M. Substance use and predictors of substance dependence in homeless women. Drug and Alcohol Dependence 118(2-3): 173-179, 2011. (43 refs.)

Objective: : To examine lifetime and current prevalence rates of substance use disorders and the demographic and clinical correlates of current drug dependence in a sample of homeless women. Methods: : A cross-sectional study of 196 homeless women in three Canadian cities was done. Each subject was assessed using structured clinical interviews. A multivariate regression model was applied to determine predictors of substance use. Results: : The mean age of the sample was 35.3 years, 54.4% identified as Aboriginal, 46.4% lived on the street Crack cocaine (58%) was the most common substance used, followed by alcohol (53%), cannabis (41%), and heroin (30%). Overall, 82.4% of the sample had at least one type of current substance use disorder, of which 70.5% had drug dependence and 37.8% had alcohol dependence. 58.3% had concurrent substance use and mental health disorders. 76.7% of those individuals with current alcohol dependence had concurrent drug dependence. Only 24.6% of those who had recovered from alcohol dependence had no current substance use disorder. Multivariate analyses showed that younger age, living on the street, engaging in sex work, and having ever attempted suicide were associated with current drug dependence. Conclusion: : Prevalence rates for alcohol and especially drug dependence were exceptionally high in this sample. Innovative programs need to be developed which are accessible and tailored to meet the needs of this specific population, accounting for high problem severity, polysubstance dependence, and high rates of psychiatric comorbidity.

Torres LR; Kaplan C; Valdez A. Health consequences of long-term injection heroin use among aging Mexican American men. Journal of Aging and Health 23(6): 912-932, 2011. (67 refs.)

Objectives: Research on the health consequences of long-term injection drug use (IDU) is limited. This article examines these consequences among aging, male Mexican American injecting heroin users. Concern for this group is crucial, given its health disparities and the association of IDU with disease transmission. Method: Aging, male Mexican American IDUs (N = 227) were recruited through intensive outreach. Participants self-reported health status, medical and substance use history, and completed behavioral and psychometric health scales. Results: are compared to Hispanic national samples. Results: Participants had significantly poorer self-rated health and negative health conditions. Selected medical conditions not associated with the heroin-use lifestyle (i.e., hypertension, diabetes, arthritis) were lower relative to the comparison samples. Discussion: This population has a complex profile of health consequences linked to a heroin-using lifestyle. The study concludes that routine screening of infectious diseases and medical and behavioral conditions among aging substance using populations may contribute to reducing Hispanic health disparities.

Uddin M; Maskrey V; Holland R. A study to validate a self-reported version of the ONS drug dependence questionnaire. Journal of Substance Use 16(4): 273-281, 2011. (15 refs.)

Aim: A prospective study to establish the reliability of a self-completion version of the Office for National Statistics (ONS) questionnaire for assessing drug dependence of substance misuse clients. Method: A total of 47 treatment seeking opioid-dependent clients completed the self-complete version of the ONS questionnaire (ONS-sc) followed by the interviewer-administered ONS questionnaire (ONS-ia) at a single clinic appointment. Scores for four Class A drugs (heroin, methadone, speed and crack/cocaine) from both formats were compared. Results: The observed agreement was 87% or more and Cohen's kappa was 0.7 (p < 0.001) or more for all four Class A drugs. Sensitivity for each Class A drugs was 56% or higher and specificity was 87% or higher. Sensitivity for severe heroin dependency was 98% (CI 89-100%). There was a 100% correlation between the ONS-sc and positive urine analysis for heroin use. However, methadone and crack/cocaine drug use appeared under reported. Conclusion: ONS-sc is a feasible, practical and time-saving alternative to a detailed interview on drug dependence. Further research with a larger sample size and non-opiate-dependent clients are needed, as this could prove a useful tool for monitoring clients in everyday practice, or for survey purposes where interviews are impractical.

Valdez A; Neaigus A; Kaplan C; Cepeda A. High rates of transitions to injecting drug use among Mexican American non-injecting heroin users in San Antonio, Texas (never and former injectors). Drug and Alcohol Dependence 114(2-3): 233- 236, 2011. (29 refs.)

Objective: To assess the incidence and rate of transition to injecting among Mexican American noninjecting heroin users. Methods: in a prospective cohort study of street-recruited MA-NIU in San Antonio, Texas, 2002-2005, participants were administered structured interviews and tested for Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). The analysis sample comprised former injection drug users (last injected >6 months ago, n = 47) and those who had never injected drugs and tested HCV negative (n = 219). A transition to injecting was defined as the first injection of illicit drugs since baseline interview. Transition rates were based on person-years at-risk (PYAR). Proportional hazards regression was used to estimate crude and adjusted (for significant differences between former and never injectors) hazard ratios and 95% confidence intervals of injecting history on transitioning to injecting. Results: Sixty-three (24%) participants transitioned to injecting at a rate of 22.3/100 PYAR (95% Cl: 17.2-28.2). Former-injectors were significantly more likely to transition than never injectors (43% or 20/47 vs. 20% or 43/219; p<0.001), and did so at a faster rate (40.4/100 PYAR, 95% Cl: 24.6-60.0 vs. 18.5/100 PYAR, 95% Cl: 13.4-24.4), with the crude HR = 1.931 (95% Cl: 1.116, 3.341) and adjusted HR = 2.263 (95% Cl: 1.192-4.294). Conclusions: The rate of transitioning to injecting was high and greater among former injectors. Of particular concern is the high rate of injecting initiation among never injectors. Future analyses will examine factors associated with injecting initiation, including individual susceptibility and behaviors, social networks, and the cultural and drug market context.

Vassileva J; Georgiev S; Martin E; Gonzalez R; Segala L. Psychopathic heroin addicts are not uniformly impaired across neurocognitive domains of impulsivity. Drug and Alcohol Dependence 114(2-3): 194- 200, 2011. (78 refs.)

Background: Impulsivity is a hallmark characteristic of drug addiction and a prominent feature of externalizing disorders such as psychopathy that are commonly comorbid with drug addiction. In a previous study (Vassileva et al., 2007) we have shown that psychopathic heroin addicts evidence more impulsive decision-making on the Iowa Gambling Task relative to non-psychopathic heroin addicts. The goal of the current study was to investigate whether the observed impulse-control deficits in psychopathic heroin addicts would generalize to other neurocognitive domains of impulsivity, such as delay discounting and behavioral inhibition among a group of relatively "pure" heroin addicts in Bulgaria who participated in our previous study. Methods: We tested 92 currently abstinent male heroin addicts, classified as psychopathic or non-psychopathic based on the Hare Psychopathy Checklist - Revised (PCL-R). We administered two neurocognitive tasks of impulsivity: (1) Delayed Rewards Discounting Task, a measure of temporal discounting of rewards; and (2) Passive Avoidance Learning Task, a measure of behavioral inhibition. Results: Psychopathic heroin addicts were not impaired relative to non-psychopathic heroin addicts on the Delayed Rewards Discounting Task and the Passive Avoidance Learning Task, on the latter of which they showed better attentional capacity. Conclusions: These results indicate that psychopathic heroin users are not uniformly impaired across neurocognitive domains of impulsivity. Combined with our previous findings, results suggest that the presence of psychopathy may exacerbate decision-making deficits in psychopathic heroin addicts, but it may not have significant effect on other neurocognitive domains of impulsivity in this population.

Viana M; Postigo C; Querol X; Alastuey A; de Alda MJL; Barcelo D et al. Cocaine and other illicit drugs in airborne particulates in urban environments: A reflection of social conduct and population size. Environmental Pollution 159(5, special issue): 1241- 1247, 2011. (12 refs.)

Levels of cocaine and other psychoactive substances in atmospheric particulate matter (PM) were determined in urban environments representing distinct social behaviours with regard to drug abuse: night-life, university and residential areas. Three cities (with population >1 million and <0.3 million inhabitants) were selected. Mean daily levels of drugs in PM were 11-336 pg/m(3) for cocaine, 23-34 pg/m(3) for cannabinoids, and 5-90 pg/m(3) for heroin. The highest levels were recorded on weekends, with factors with respect to weekdays of 1-3 for cocaine, 1-2 for cannabinoids and 1.1-1.7 for heroin. Higher levels were detected in the night-life areas, pointing towards consumption and trafficking as major emission sources, and possibly ruling out drug manufacture. The similarities in temporal trends at all sites suggested a city-scale transport of psychoactive substances. Correlations were detected between cocaine and amphetamine consumption (r(2) = 0.98), and between heroin and cannabinoids (r(2)>0.82).

Walter M; Degen B; Treugut C; Albrich J; Oppel M; Schulz A et al. Affective reactivity in heroin-dependent patients with antisocial personality disorder. Psychiatry Research 187(1-2): 210- 213, 2011. (48 refs.)

The Antisocial personality disorder (ASPD), one of the most common co-morbid psychiatric disorders in heroin-dependent patients, is associated with a lack of affective modulation. The present study aimed to compare the affect-modulated startle responses of opioid-maintained heroin-dependent patients with and without ASPD relative to those of healthy controls. Sixty participants (20 heroin-dependent patients with ASPD, 20 heroin-dependent patients without ASPD, 20 healthy controls) were investigated in an affect-modulated startle experiment. Participants viewed neutral, pleasant, unpleasant, and drug-related stimuli while eye-blink responses to randomly delivered startling noises were recorded continuously. Both groups of heroin-dependent patients exhibited significantly smaller startle responses (raw values) than healthy controls. However, they showed a normal affective modulation: higher startle responses to unpleasant, lower startle responses to pleasant stimuli and no difference to drug-related stimuli compared to neutral stimuli. These findings indicate a normally modulated affective reactivity in heroin-dependent patients with ASPD.

Wang W; Li QA; Wang YR; Tian J; Yang WC; Li W et al. Brain fMRI and craving response to heroin-related cues in patients on methadone maintenance treatment. American Journal of Drug and Alcohol Abuse 37(2): 123-130, 2011. (57 refs.)

Objective: To investigate the subjective craving and brain response to heroin-related cues in former heroin addicts on long-term methadone maintenance treatment. Methods: Fourteen participants completed an event-related functional magnetic resonance imaging task including heroin-related and nonheroin-related (neutral) cues. Craving self-reports were collected before and after the task. Results: Although no significant craving changes were associated with the task, blood oxygen-level dependence intensity was significantly greater during exposure to heroin-related cues, compared to neutral cues in brain areas studied. Conclusions and Scientific Significance: The results indicate that the learned brain response of former heroin addicts to drug-related stimuli may persist despite long-term methadone maintenance treatment.

Wilkins C; Sweetsur P; Griffiths R. Recent trends in pharmaceutical drug use among frequent injecting drug users, frequent methamphetamine users and frequent ecstasy users in New Zealand, 2006-2009. Drug and Alcohol Review 30(3): 255- 263, 2011. (22 refs.)

Aims. To examine the rates of pharmaceutical drug use, and level of prescription use and injection of pharmaceutical drugs, by frequent injecting drug users (IDU), frequent methamphetamine users and frequent ecstasy users in New Zealand for 2006-2009. Design: and method. The paper draws on findings from the 2006, 2007, 2008 and 2009 Illicit Drug Monitoring System (IDMS). The IDMS interviews three groups of frequent illegal drug users (i.e. IDU, methamphetamine users and ecstasy users) from the three main cities of New Zealand using purposive sampling and 'snowballing'. Results. Pharmaceutical morphine rather than heroin was the principal opioid used by the IDU. Few of the IDU or frequent methamphetamine users had prescriptions to use morphine. A lower proportion of the IDU had a prescription to use morphine in 2009 compared to 2008. The injection of methadone by IDU and methamphetamine users was common. A higher proportion of the IDU had injected methadone in 2009 compared to previous years. A higher proportion of the IDU had used oxycodone in 2009 compared to 2008 and prescription use of oxycodone by IDU was very low. All three groups of frequent drug users were involved in the extra-medical use of methylphenidate and benzodiazepines. Discussion and conclusion. Extra-medical use of pharmaceuticals occurred among all three groups of frequent illegal drug users to varying degrees. Differences between the three groups in the level and type of extra-medical pharmaceutical drug use suggest that different control strategies may be effective for each group.

Witteck A; Schmid P; Hensel-Koch K; Thurnheer MC; Bruggmann P; Vernazza P. Management of hepatitis C virus (HCV) infection in drug substitution programs Comparison of HCV treatment uptake and success rate with Swiss hepatitis C cohort study (SCCS) and Swiss HIV cohort study (SHCS) data. Swiss Medical Weekly 141: ew13193, 2011. (48 refs.)

BACKGROUND: In Switzerland, intravenous drug use (IDU) accounts for 80% of newly acquired hepatitis C virus (HCV) infections. Early HCV treatment has the potential to interrupt the transmission chain and reduce morbidity/mortality due to decompensated liver cirrhosis and hepatocellular carcinoma. Nevertheless, patients in drug substitution programs are often insufficiently screened and treated. OBJECTIVE/METHODS: With the aim to improve HCV management in IDUs, we conducted a cross sectional chart review in three opioid substitution programs in St. Gallen (125 methadone and 71 heroin recipients). Results were compared with another heroin substitution program in Bern (202 patients) and SCCS/SHCS data. RESULTS: Among the methadone/heroin recipients in St. Gallen, diagnostic workup of HCV was better than expected: HCV/HIV-status was unknown in only 1% (2/196), HCV RNA was not performed in 9% (13/146) of anti-HCV-positives and the genotype missing in 15% (12/78) of HCV RNA-positives. In those without spontaneous clearance (two thirds), HCV treatment uptake was 23% (21/91) (HIV-: 29% (20/68), HIV+: 4% (1/23)), which was lower than in methadone/heroin recipients and particularly non-IDUs within the SCCS/SHCS, but higher than in the, mainly psychiatrically focussed, heroin substitution program in Bern (8%). Sustained virological response (SVR) rates were comparable in all settings (overall: 50%, genotype 1: 35-40%, genotype 3: two thirds). In St. Gallen, the median delay from the estimated date of infection (IDU start) to first diagnosis was 10 years and to treatment was another 7.5 years. CONCLUSIONS: Future efforts need to focus on earlier HCV diagnosis and improvement of treatment uptake among patients in drug substitution programs, particularly if patients are HIV-co-infected. New potent drugs might facilitate the decision to initiate treatment.

Wurst FM; Thon N; Yegles M; Halter C; Weinmann W; Laskowska B et al. Optimizing heroin-assisted treatment: Assessment of the contribution of direct ethanol metabolites in identifying hazardous and harmful alcohol use. Drug and Alcohol Dependence 115(1-2): 57- 61, 2011. (40 refs.)

Background: Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites. Method: Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair. Results: Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake. Conclusions: The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.

Yang C; German D; Webster D; Latkin C. Experiencing violence as a predictor of drug use relapse among former drug users in Baltimore, Maryland. Journal of Urban Health 88(6): 1044-1051, 2011. (30 refs.)

The purpose of this study was to examine experiencing violence as a predictor of subsequent drug relapse among a sample of former crack, cocaine, and heroin users in Baltimore, MD, USA. The sample consists of 228 former drug users in Baltimore who were recruited through street outreach. Mixed-effects models were used to examine experiencing violence as a predictor of drug relapse at follow-up after adjusting for clustering of responses among participants living in the same census block. Using longitudinal data, we found that experiencing violence in the past year predicted drug relapse at 2-year follow-up among former drug users. Results indicate experiencing violence is a determinant of drug use relapse and highlight the importance of addressing the fundamental issues of violence experienced in inner-city communities. Addressing the extent of recent violence among drug treatment participants, providing coping skills, and reducing community violence are strategies that may address the link between violence and drug relapse.

Yemen H; Aydin Y; Yilmaz S; Onder E; Guclum E; Ozturk O. Recurrent and assive life threatening epistaxis due to nasal heroin usage. Clinical and Experimental Otorhinolaryngology 4(3): 159-161, 2011. (12 refs.)

Epistaxis, active bleeding from the nose, is a common ear nose and throat emergency, and can be severe or even fatal. We report a severe life threatening recurrent massive nasal bleeding caused by intranasal heroin use that has not hitherto been reported in the English literature. A 24-year-old male who took heroin several times nasally presented with massive nasal bleeding. A blood transfusion and an operation to halt nasal bleeding were required. The patient did not experience a bleeding attack 2 months following cessation of nasal heroin use.

Yen CN; Wang CSM; Wang TY; Chen HF; Chang HC. Quality of life and its correlates among heroin users in Taiwan. Kaohsiung Journal of Medical Sciences 27(5): 177- 183, 2011. (54 refs.)

The aims of this study were to compare the quality of life (QOL) between subjects with and without heroin use and to examine the association of QOL with sociodemographic characteristics, characteristics of heroin use, family support, and depression among heroin users at entry to a methadone maintenance treatment program. A group of 123 heroin users who visited an outpatient addiction treatment clinic in southern Taiwan for methadone maintenance treatment were recruited into this study. We also recruited 106 subjects who had never used heroin as the control group. Their QOL status was assessed by the short form of the Taiwan Version of the World Health Organization Questionnaire on Quality of Life (the WHOQOL-BREF Taiwan version). The level of QOL between subjects with and without heroin use was compared, and the correlates of QOL among heroin users were examined. Heroin users had poorer QOL than nonusers in the physical, psychological, and social relationship domains but not the environment domain of the WHOQOL-BREF after controlling for the influences of other factors. In addition, heroin users with obvious depression had poorer QOL in all four domains than those without obvious depression. Also, heroin users who perceived higher family support had better QOL in the social relationship and environment domains. Heroin users had poorer QOL than nonusers in multiple domains. Relief of depressive symptoms and enhancement of family support should be important strategies to improve QOL in heroin users.

Zhang M; Zhu HY; Li XY; Shui RD; Shen MW. Biased number perception of schematic expressions in abstinent heroin abusers compared to normal controls. Journal of Behavior Therapy and Experimental Psychiatry 43(1): 602-606, 2012. (22 refs.)

Background and objectives: Drug-dependent people exhibit biases when evaluating discrete emotional facial expressions. Little is known about how drug abusers process multiple expressions presented simultaneously. The present study investigated the number perception of schematic emotional expressions by abstinent heroin abusers. Methods: Eighty-four heroin abstainers with varied lengths of abstinence (short-term, mid-term, and long-term) and twenty healthy controls were examined. A method of limits was deployed to obtain estimates (points of subjective equality) of perceived numbers of schematic faces (expressing positive, neutral, or negative emotion). Results: Major results include the following: 1) heroin-abstinent participants showed significantly lower points of subjective equality for negative and neutral faces, but not for positive faces, compared to control participants: 2) heroin-abstinent participants showed lower points of subjective equality for negative faces and higher ones for positive faces when compared to neutral faces, while no such differences were found in control participants. Conclusion: Heroin abusers demonstrate an exaggerated perception of number when exposed to negative expressions, even after a period of abstinence as long as 10 months. In addition, the current results could also reflect an underestimated perception of number during exposure to positive expressions and a heightened baseline for neutral expressions, or the attribution of negative valence to neutral expressions by heroin abusers.

Zhang XL; Shi J; Zhao LY; Sun LL; Wang J; Wang GB et al. Effects of stress on decision-making deficits in formerly heroin-dependent patients after different durations of abstinence. American Journal of Psychiatry 168(6): 610-616, 2011. (41 refs.)

Objective: Drug abuse is associated with substantial impairments in decision making. However, little is known about the time course of changes in decision-making ability after abstinence or about the effects of stress on decision making in individuals recovering from heroin dependence after different durations of abstinence. Method: First, the authors assessed decision-making performance with the original card version of the Iowa Gambling Task in formerly heroin-dependent patients who had been abstinent for 3, 7, 15, or 30 days or 3, 6, 12, or 24 months. Second, patients who had been abstinent from heroin for 15 or 30 days or 3, 12, or 24 months were challenged with acute stress induced by the Trier Social Stress Test. Third, the beta-adrenoceptor antagonist propranolol (40 mg) was administered 1 hour before stress to those who had been abstinent for 30 days or 12 or 24 months. Results: The short-term abstinence groups (3-30 days) performed worse on the Iowa Gambling Task compared with the long-term abstinence groups (3-24 months). Psychosocial stress unmasked a latent impairment in decision making in the 24-month abstinence group, which seemed to perform identically to healthy comparison subjects in the absence of stress. Propranolol blocked the stress-induced impairment of decision making, which was seen only in the formerly heroin-dependent patients. Conclusions: Stress can exacerbate an already existing impairment of decision making or unmask a latent one in individuals recovering from heroin dependence. The beta-adrenergic blockade reduces this effect and might hold promise for treatment of substance use disorders.

Zhao LY; Sun LL; Shi J; Li P; Zhang Y; Lu L. Effects of beta-adrenergic receptor blockade on drug-related memory reconsolidation in abstinent heroin addicts. Drug and Alcohol Dependence 118(2-3): 224-229, 2011. (49 refs.)

Rationale and objective: The reactivation of a consolidated memory can return it to a labile state, a process referred to as reconsolidation. A previous study showed that oral administration of the beta-adrenergic receptor antagonist propranolol before memory reactivation in humans erased the behavioral expression of the fear memory 24 h later. In this study, we investigated whether propranolol impairs the drug-related memory by disrupting the reconsolidation process in heroin addicts. Methods: Seventy abstinent heroin addicts learned a word list (including 10 heroin-related positive words, 10 heroin-related negative words, and 10 neutral words) on day 1. Participants orally administered the beta-adrenergic receptor antagonist propranolol or placebo before retrieval of the word list on day 2. Free recall of the word list and other psychological and physical responses were assessed on day 3. Results: Oral administration of propranolol before reactivation of the word list impaired reconsolidation of drug-related positive and negative but not neutral words in abstinent heroin addicts, and these impairments critically depended on reactivation of the word list. Conclusions: This study extends earlier reports that a p-adrenergic receptor antagonist affects the drug-related memory reconsolidation process. Our findings may have important implications for the understanding and treatment of persistent and abnormal drug-related memories in abstinent heroin addicts.

Zuccato E; Castiglioni S; Tettamanti M; Olandese R; Bagnati R; Melis M et al. Changes in illicit drug consumption patterns in 2009 detected by wastewater analysis. Drug and Alcohol Dependence 118(2-3): 464-469, 2011. (27 refs.)

Background: Wastewater analysis can provide estimates of illicit drug (ID) consumption in local communities. Methods: We used repeated raw wastewater analysis in urban wastewater treatment plants to estimate loads of cocaine, heroin, methamphetamine, and cannabis consumed daily by the inhabitants of two cities in Northern Italy, Milan and Como, from 2005 to 2009. Results: Daily cocaine loads did not change in Milan from 2005 to 2008 but fell 45% in 2009 (ANOVA, p < 0.001, followed by Tukey-Kramer HSD test [2009 vs. others], p < 0.05), and there was a similar drop in Como (41%, p < 0.0001. t-test). Heroin also fell from 2008 to 2009 in Milan (66%, ANOVA, p < 0.001, followed by Tukey-Kramer [2009 vs. others], p < 0.05) and Como (26%, p = 0.017, t-test). However, methamphetamine, which had risen in Milan from 2005 to 2008, rose further in 2009 (Kruskal-Wallis test, p < 0.001, followed by Steel-Dwass [2009 or 2008 vs.-previous], p < 0.05), and cannabis, which was falling from 2005 to March 2009, rose again in September 2009 (40%, p = 0.027, t-test). Conclusions: Results suggest a trend toward a decrease in consumption of costly ID, such as cocaine and heroin. This might be due to a reduction in the number of consumers and/or to a change in their behaviour since there was also an increase in the consumption of less expensive ID. This itself might reflect a drop in consumers' money supply, caused by the economic crisis. Wastewater analysis was useful to estimate ID consumption levels in local communities in real time and promptly identify changes in trends.