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CORK Bibliography: Intravenous Use

67 citations. September January 2011 to present

Prepared: March 2012

Albertin P; Cubells J; Iniguez L. The social constructions of drug users in professional interventions. Journal of Social Work Practice 25(2): 217- 232, 2011. (40 refs.)

This qualitative study analyses the construction of a subject who uses drugs (injected drugs) so as to offer psychosocial proposals for social healthcare interventions within this collective, and thereby contribute to social healthcare policies that optimise treatment for drug use. The results indicate that identity is connected to positions that are activated in interactions and relationships between users and professionals in various day-to-day contexts of healthcare and treatment. We have labelled these activated positions: therapeutic, drug-sensory, consumerist, legal-repressive and group-community. Understanding them provides clues that may improve interventions in health and legal contexts. These clues include understanding the tensions between the subject and the substance, considering the stigmatised image and identity, and supporting the idea of the existence of dilemmas in users and professionals, as this may allow transformations to occur in the mutual relationships that are established.

Copyright 2011, Routledge

Arnaud S; Jeannin A; Dubois-Arber F. Estimating national-level syringe availability to injecting drug users and injection coverage: Switzerland, 1996-2006. International Journal of Drug Policy 22(3): 226-232, 2011. (38 refs.)

Background: Measuring syringe availability and coverage is essential in the assessment of HIV/AIDS risk reduction policies. Estimates of syringe availability and coverage were produced for the years 1996 and 2006, based on all relevant available national-level aggregated data from published sources. Methods: We defined availability as the total monthly number of syringes provided by harm reduction system divided by the estimated number of injecting drug users (IDU), and defined coverage as the proportion of injections performed with a new syringe, at national level (total supply over total demand). Estimates of supply of syringes were derived from the national monitoring system, including needle and syringe programmes (NSP), pharmacies, and medically prescribed heroin programmes. Estimates of syringe demand were based on the number of injections performed by IDU derived from surveys of low threshold facilities for drug users (LTF) with NSP combined with the number of IDU. This number was estimated by two methods combining estimates of heroin users (multiple estimation method) and (a) the number of IDU in methadone treatment (MT) (non-injectors) or (b) the proportion of injectors amongst LTF attendees. Central estimates and ranges were obtained for availability and coverage. Results: The estimated number of IDU decreased markedly according to both methods. The MT-based method (from 14,818 to 4809) showed a much greater decrease and smaller size of the IDU population compared to the LTF-based method (from 24,510 to 12,320). Availability and coverage estimates are higher with the MT-based method. For 1996, central estimates of syringe availability were 30.5 and 18.4 per IDU per month: for 2006, they were 76.5 and 29.9. There were 4 central estimates of coverage. For 1996 they ranged from 24.3% to 43.3%, and for 2006, from 50.5% to 134.3%. Conclusion: Although 2006 estimates overlap 1996 estimates, the results suggest a shift to improved syringe availability and coverage over time.

Copyright 2011, Elsevier Science

Bachireddy C; Bazazi AR; Kavasery R; Govindasamy S; Kamarulzaman A; Altice FL. Attitudes toward opioid substitution therapy and pre-incarceration HIV transmission behaviors among HIV-infected prisoners in Malaysia: Implications for secondary prevention. Drug and Alcohol Dependence 116(1-3): 151-157, 2011. (56 refs.)

Background: Pre-incarceration HIV transmission behaviors and current attitudes toward opioid substitution therapy (OST) among HIV-infected male prisoners in Malaysia have important implications for secondary HIV prevention efforts. Methods: In June 2007, 102 HIV-infected male prisoners within 6 months of community-release were anonymously surveyed in Kota Bharu, Malaysia. Results: Nearly all subjects (95%) met criteria for opioid dependence. Overall, 66% of participants reported sharing needles, and 37% reported unprotected sex in the 30 days prior to incarceration. During this period, 77% reported injection drug use, with 71% injecting daily and 65% injecting more than one substance. Injection of buprenorphine (28%), benzodiazepines (28%) and methamphetamines (49%) was reported. Nearly all (97%) of those reporting unprotected sex did so with someone not known to be HIV-infected. While 51% believed that opioid substitution therapy COST) would be helpful, only 33% believed they needed it to prevent relapse after prison release. Most participants (70%) expressed interest in learning more about OST. Those reporting the highest injection risks were more likely to believe OST would be helpful (p < 0.05), to believe that it was needed to prevent relapse post-release (p < 0.05), and to express interest in learning more about OST (p < 0.01). Conclusions: Secondary HIV prevention among prisoners in Malaysia is crucial to reduce community HIV transmission after release. Effectively reducing HIV risk associated with opioid injection will require OST expansion, including social marketing to improve its acceptability and careful monitoring. Access to sterile injection equipment, particularly for non-opioid injectors, and behavioral interventions that reduce sexual risk will also be required.

Copyright 2011, Elsevier Science

Backmund M; Meyer K; Schutz C; Reimer J. Factors associated with suicide attempts among injection drug users. Substance Use & Misuse 46(12): 1553-1559, 2011. (28 refs.)

Injection drug users (IDUs) entering an urban low-threshold opiate detoxification unit in Munich, Germany, between 1991 and 1997 were asked for lifetime suicide attempts and administered a questionnaire, including sociodemographic, IDU-related, and drug user treatment related variables. Among 1,049 participants, 20% had ever tried to commit suicide. In the logistic regression, female gender, older age, drug user treatment experience, lack of drug user counseling, and emergency treatment were associated with attempted suicide. Regular screening for suicidal behavior in IDUs should be undertaken with a special focus to mention risk factors. The study's limitations are noted. This study was partially sponsored by the German Ministry of Health.

Copyright 2011, Informa Healthcare

Balhara YPS; Jain R; Dhawan A; Mehta M. Assessment of abuse liability of pheniramine among opioid-dependent human subjects. Journal of Substance Use 16(6): 484-495, 2011. (44 refs.)

Background: Pheniramine is being used harmfully in combination with opiates and benzodiazepines through injecting route. However, the abuse liability of pheniramine has not been studied in humans. Aim: The present study is an attempt to analyze the abuse liability of pheniramine in human subjects. Materials and methodology: The study used a double-blind randomly allotted crossover design. The doses of the drugs used were placebo (normal saline) 2 mL, pheniramine maleate 45.5 mg and lorazepam 2 mg. The assessments were made at baseline and then at 15, 120 and 240 min. The subjects were assessed for the sociodemographic profile, drug-use history, physiological parameters (pulse rate, BP, respiratory rate), and Modified Single-Dose Questionnaire (MSDQ)/Morphine-Benzedrine Group Scale (MBG)/Pentobarbital-Chlorpromazine-Alcohol Group Scale (PCAG)/Visual Analog Scale (VAS)/Profile of Mood States (POMS) scale. Analysis: Analysis was carried out using SPSS version 10.0. In-between drug comparisons were done using one-way analysis of variance (ANOVA) (multiple comparisons). Results: MSDQ and PCAG showed comparable results between the two compounds. VAS and POMS scale had significant increase on the scale for both lorazepam and pheniramine. Conclusions: The findings suggest the possible abuse liability of pheniramine. These findings with the clinical observation of pheniramine abuse used in combination with injection buprenorphine and diazepam warrant the need of caution while prescribing the compound to individuals.

Copyright 2011, Informa Healthcare

Bazazi AR; Yokell M; Fu JJ; Rich JD; Zaller ND. Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users. Journal of Addiction Medicine 5(3): 175-180, 2011. (25 refs.)

Objectives: We examined the use, procurement, and motivations for the use of diverted buprenorphine/naloxone among injecting and noninjecting opioid users in an urban area. Methods: A survey was self-administered among 51 injecting opioid users and 49 noninjecting opioid users in Providence, RI. Participants were recruited from a fixed-site syringe exchange program and a community outreach site between August and November 2009. Results: A majority (76%) of participants reported having obtained buprenorphine/naloxone illicitly, with 41% having done so in the previous month. More injection drug users (IDUs) than non-IDUs reported the use of diverted buprenorphine/naloxone (86% vs 65%, P = 0.01). The majority of participants who had used buprenorphine/naloxone reported doing so to treat opioid withdrawal symptoms (74%) or to stop using other opioids (66%) or because they could not afford drug treatment (64%). More IDUs than non-IDUs reported using diverted buprenorphine/naloxone for these reasons. Significantly more non-IDUs than IDUs reported ever using buprenorphine/naloxone to "get high" (69% vs 32%, P < 0.01). The majority of respondents, both IDUs and non-IDUs, were interested in receiving treatment for opioid dependence, with greater reported interest in buprenorphine/naloxone than in methadone. Common reasons given for not being currently enrolled in a buprenorphine/naloxone program included cost and unavailability of prescribing physicians. Conclusions: The use of diverted buprenorphine/naloxone was common in our sample. However, many opioid users, particularly IDUs, were using diverted buprenorphine/naloxone for reasons consistent with its therapeutic purpose, such as alleviating opioid withdrawal symptoms and reducing the use of other opioids. These findings highlight the need to explore the full impact of buprenorphine/naloxone diversion and improve the accessibility of buprenorphine/naloxone through licensed treatment providers.

Copyright 2011, Lippincott, Williams & Wilkins

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

Bertoni N; Singer M; Silva CMFP; Scott Clair S; Malta M; Bastos FI. Knowledge of AIDS and HIV transmission among drug users in Rio de Janeiro, Brazil. Harm Reduction Journal 8: article 5, 2011. (39 refs.)

Background: Proper knowledge of HIV transmission is not enough for people to adopt protective behaviors, but deficits in this information may increase HIV/AIDS vulnerability. Objective: To assess drug users' knowledge of HIV/AIDS and the possible asg and unden beent questionnaires and testing for HIV (tween knowledge and HIV testing. Methodshuman immunodeficiency virus), syphilis and TB (tuberculosis). Random effects logistic regression was used to simultaneously model factors associated with five drug-related harms related to policing practices in the prior six months (i.e., police led them to rush injections; affected where they bought drugs; affected locations where they used drugs; feared that police will interfere with their drug use; receptive syringe sharing). Results: Of 727 IDUs, 85% were male; median age was 38 years. Within the last 6 months, 231 (32%) of IDUs reported that police had led them to rush injections, affected where they bought or used drugs or were very afraid police would interfere with their drug use, or shared syringes. Factors independently associated with drug-related harms related to policing within the last six months included: recent arrest, homelessness, higher frequencies of drug injection, use of methamphetamine, using the local needle exchange program and perceiving a decrease in the purity of at least one drug. Conclusions: IDUs who experienced drug-related harms related to policing were those who were most affected by other micro and macro influences in the physical risk environment. Police education programs are needed to ensure that policing practices do not exacerbate risky behaviors or discourage protective behaviors such as needle exchange program use, which undermines the right to health for people who inject drugs.

Copyright 2011, BioMed Central

Boodram B; Hershow RC; Cotler SJ; Ouellet LJ. Chronic hepatitis C virus infection and increases in viral load in a prospective cohort of young, HIV-uninfected injection drug users. Drug and Alcohol Dependence 119(3): 166-171, 2011. (47 refs.)

Background: Chronic hepatitis C (HCV) infection, defined as persistent RNA (viral load) for at least 6 months, accounts for up to 50% of all cirrhosis, end-stage liver disease and liver cancer cases. Moreover, elevated HCV viral load is consistently associated with high infectivity and poor therapy response. This study aims to identify modifiable behavioral correlates both chronic HCV infection and increases in viral load over time among injection drug users (IDUs). Methods: Cross-sectional and longitudinal analyses were performed using self-interview and serological data from a prospective cohort study (2002-2006) among young (age 18-35), HIV-negative, HCV therapy-naive IDUs (n = 113) from metropolitan Chicago, Illinois, USA. Results: After adjustment for age, gender and race/ethnicity, using drugs measured or mixed in someone else's syringe (odds ratio = 2.7, 95% confidence interval: 1.1, 6.7) was associated with chronic (n = 75.66%) versus resolved (n = 38, 34%) HCV infection status. Among chronically-infected IDUs, injecting with a new, sterile syringe infrequently (<1/2 half the time when injecting) compared to frequently (1/2 the time or more when injecting) was associated with increases in viral load over time after adjusting for age, gender, race/ethnicity and time effects. Conclusions: Reductions in risky injection-related practices among young IDUs may ameliorate both the burden of chronic HCV infection-related liver disease and elevated viral load-related poor treatment response.

Copyright 2011, Elsevier Science

Bourgois P; Hart LK. Commentary on Genberg et al. (2011): The structural vulnerability imposed by hypersegregated US inner-city neighborhoods: A theoretical and practical challenge for substance abuse research. (editorial). Addiction 106(11): 1975-1977, 2011. (7 refs.)

Chakrapani V; Newman PA; Shunmugam M; Dubrow R. Social-structural contexts of needle and syringe sharing behaviours of HIV-positive injecting drug users in Manipur, India: A mixed methods investigation. Harm Reduction Journal 8: article 9, 2011. (44 refs.)

Background: Few investigations have assessed risk behaviours and social-structural contexts of risk among injecting drug users (IDUs) in Northeast India, where injecting drug use is the major route of HIV transmission. Investigations of risk environments are needed to inform development of effective risk reduction interventions. Methods: This mixed methods study of HIV-positive IDUs in Manipur included a structured survey (n = 75), two focus groups (n = 17), seven in-depth interviews, and two key informant interviews. Results: One-third of survey participants reported having shared a needle/syringe in the past 30 days; among these, all the men and about one-third of the women did so with persons of unknown HIV serostatus. A variety of social-structural contextual factors influenced individual risk behaviours: barriers to carrying sterile needles/syringes due to fear of harassment by police and "anti-drug" organizations; lack of sterile needles/syringes in drug dealers' locales; limited access to pharmacy-sold needles/syringes; inadequate coverage by needle and syringe programmes (NSPs); non-availability of sterile needles/syringes in prisons; and withdrawal symptoms superseding concern for health. Some HIV-positive IDUs who shared needles/syringes reported adopting risk reduction strategies: being the 'last receiver' of needles/syringes and not a 'giver;' sharing only with other IDUs they knew to be HIV-positive; and, when a 'giver,' asking other IDUs to wash used needles/syringes with bleach before using. Conclusions: Effective HIV prevention and care programmes for IDUs in Northeast India may hinge on several enabling contexts: supportive government policy on harm reduction programmes, including in prisons; an end to harassment by the police, army, and anti-drug groups, with education of these entities regarding harm reduction, creation of partnerships with the public health sector, and accountability to government policies that protect IDUs' human rights; adequate and sustained funding for NSPs to cover all IDU populations, including prisoners; and non-discriminatory access by IDUs to affordable needles/syringes in pharmacies.

Copyright 2011, BioMed Central

Chatterjee S; Tempalski B; Pouget ER; Cooper HLF; Cleland CM; Friedman SR. Changes in the prevalence of injection drug use among adolescents and young adults in large US metropolitan areas. AIDS and Behavior 15(7): 1570-1578, 2011. (53 refs.)

Young injection drug users (IDUs) are at risk for acquiring blood-borne diseases like HIV and Hepatitis C. Little is known about the population prevalence of young IDUs. We (1) estimate annual population prevalence rates of young IDUs (aged 15-29) per 10,000 in 95 large U. S. metropolitan statistical areas (MSAs) from 1992 to 2002; (2) assess the validity of these estimates; and (3) explore whether injection drug use among youth in these MSAs began to rise after HAART was discovered. A linear mixed model (LMM) estimated the annual population prevalence of young IDUs in each MSA and described trends therein. The population prevalence of IDUs among youths across 95 MSAs increased from 1996 (mean = 95.64) to 2002 (mean = 115.59). Additional analyses of the proportion of young IDUs using health services suggest this increase may have continued after 2002. Harm reduction and prevention research and programs for young IDUs are needed.

Copyright 2011, Springer

Chikovani I; Bozicevic I; Goguadze K; Rukhadze N; Gotsadze G. Unsafe injection and sexual risk behavior among injecting drug users in Georgia. Journal of Urban Health 88(4): 736-748, 2011. (28 refs.)

Injection drug users (IDUs) are at risk for acquiring human immunodeficiency virus (HIV) through parenteral and sexual transmission. In this paper, we describe the prevalence and correlates of unsafe drug injecting and sexual behaviors among IDUs recruited across five cities in Georgia in 2009. IDUs were administered a questionnaire collecting information on demographics, drug use, sexual behaviors, and HIV testing behaviors. Correlates of risky injecting and sexual behaviors were determined using logistic regression. Of 1,127 IDUs, the majority (98.7%) were men, and the median duration of injecting drugs was 7 years. Unsafe injecting behavior at last injection was reported by 51.9% of IDUs, while 16.8% reported both unsafe injecting behavior and not using condoms with last occasional and/or commercial partner. In the multivariate analysis, independent correlates of unsafe injecting behavior at last injection were types of drugs injected [p = 0.0096; (for ephedrine, adjusted odds ratio (aOR) = 7.38; 95% CI, 1.50-36.26)] and not using condoms at last commercial sex (aOR = 2.29, 1.22-4.32). The following variables were significantly associated with unsafe injecting behavior at last injection and not using condoms at last sex with commercial and/or occasional partners in the multivariate analysis: marital status [p = 0.0002; (for divorced, widowed, and separated aOR = 2.62, 1.62-4.25; for single aOR = 1.61, 1.08-2.39)], being a member of a regular injecting group (aOR = 0.62, 0.44-0.88), types of drugs injected in the past month [p = 0.0024; (for buprenorphine aOR = 0.34, 0.18-0.63)], city of residence (p = 0.0083), and not receiving information on HIV (aOR = 1.82, 1.07-3.09). Though only ephedrine was injected by a smaller number of IDUs (9.1%), the vast majority of these (81.4%) reported unsafe injecting practices at last injection. High prevalence of unsafe injecting behaviors and diverse and at-risk sexual partnerships highlight the need to implement complex and targeted HIV interventions among IDUs in Georgia.

Copyright 2011, Springer

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.

Copyright 2011, Springer

Day C; Topp L. Commentary on Turner et al. (2011): Significant global scale-up of harm reduction interventions and pragmatic research approaches needed to prevent hepatitis C transmission. (editorial). Addiction 106(11): 1989-1990, 2011. (15 refs.)

DeBeck K; Wood E; Zhang R; Buxton J; Montaner J; Kerr T. A dose-dependent relationship between exposure to a street-based drug scene and health-related harms among people who use injection drugs. Journal of Urban Health 88(4): 724-735, 2011. (47 refs.)

While the community impacts of drug-related street disorder have been well described, lesser attention has been given to the potential health and social implications of drug scene exposure on street-involved people who use illicit drugs. Therefore, we sought to assess the impacts of exposure to a street-based drug scene among injection drug users (IDU) in a Canadian setting. Data were derived from a prospective cohort study known as the Vancouver Injection Drug Users Study. Four categories of drug scene exposure were defined based on the numbers of hours spent on the street each day. Three generalized estimating equation (GEE) logistic regression models were constructed to identify factors associated with varying levels of drug scene exposure (2-6, 6-15, over 15 hours) during the period of December 2005 to March 2009. Among our sample of 1,486 IDU, at baseline, a total of 314 (21%) fit the criteria for high drug scene exposure (> 15 hours per day). In multivariate GEE analysis, factors significantly and independently associated with high exposure included: unstable housing (adjusted odds ratio [AOR] = 9.50; 95% confidence interval [CI], 6.36-14.20); daily crack use (AOR = 2.70; 95% CI, 2.07-3.52); encounters with police (AOR = 2.11; 95% CI, 1.62-2.75); and being a victim of violence (AOR = 1.49; 95 % CI, 1.14-1.95). Regular employment (AOR = 0.50; 95% CI, 0.38-0.65), and engagement with addiction treatment (AOR = 0.58; 95% CI, 0.45-0.75) were negatively associated with high exposure. Our findings indicate that drug scene exposure is associated with markers of vulnerability and higher intensity addiction. Intensity of drug scene exposure was associated with indicators of vulnerability to harm in a dose-dependent fashion. These findings highlight opportunities for policy interventions to address exposure to street disorder in the areas of employment, housing, and addiction treatment.

Copyright 2011, Springer

Des Jarlais DC; Arasteh K; Friedman SR. HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years. Substance Use & Misuse 46(2-3): 131-139, 2011. (55 refs.)

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

Copyright 2011, Informa Healthcare

Des Jarlais DC; Hagan H; Arasteh K; McKnight C; Semaan S; Perlman DC. Can intranasal drug use reduce HCV infection among injecting drug users? Drug and Alcohol Dependence 119(3): 201-206, 2011. (35 refs.)

Background: Preventing HCV infection among people who inject drugs is a difficult public health challenge. We examined the potential role of intranasal drug use in reducing HCV acquisition. Methods: Subjects were recruited from IDUs entering the Beth Israel drug detoxification program from 2005 to 2010. A structured interview was administered and serum samples were collected for HCV testing. Results: 726 active injecting drug users were recruited from 2005 to 2010. HCV prevalence was 71%, 90% reported recent heroin injection and 44% reported recent intranasal heroin use. In a multiple logistic regression analysis, being HCV seropositive was associated with more years injecting, Latino ethnicity, previous testing for HCV, and recent injection of speedball, and negatively associated with recent intranasal use of heroin (AOR = 0.52, 95% CI 0.33-0.82) and intranasal use of speedball (AOR = 0.41, 95% CI 0.31-0.80). The association between intranasal heroin use and lower HCV seroprevalance was observed among both new injectors and persons with long injecting histories (16+ years since first injection). Conclusion: Encouraging intranasal use as an alternative to injection among persons currently injecting drugs may be a viable strategy for reducing HCV transmission.

Copyright 2011, Elsevier Science

Dias AC; Araujo MR; Dunn J; Sesso RC; de Castro V; Laranjeira R. Mortality rate among crack/cocaine-dependent patients: A 12-year prospective cohort study conducted in Brazil. Journal of Substance Abuse Treatment 41(3): 273-278, 2011. (39 refs.)

Mortality is a significant outcome among Brazilian crack/cocaine-dependent patients yet not well understood and is under investigated. This study examined a range of mortality indicators within a cohort of 131 crack/cocaine-dependent patients admitted into treatment and meeting criteria for dependence of crack (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). After 12 years of treatment discharge, 107 individuals were reassessed and 27 death cases were confirmed by official records, wherein in its majority were caused by homicide (n = 16). In this group, survival rate was 0.77 (95% confidence interval [CI] = 0.74-0.81) and previous history of IV cocaine use was' identified as a predictor of mortality (2.5, 95% CI = 1.08-5.79). High mortality rates among Brazilian crack/cocaine-dependent patients, exposure to violence, and HIV/AIDS were topics discussed in this study. This research highlights the importance of ongoing programs to manage crack/cocaine use along with other treatment features within this population.

Copyright 2011, Elsevier Science

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.

Copyright 2011, Wiley-Blackwell

Fairbairn N; Kerr T; Milloy MJ; Zhang R; Montaner J; Wood E. Crystal methamphetamine injection predicts slower HIV RNA suppression among injection drug users. Addictive Behaviors 36(7): 762-763, 2011. (10 refs.)

We examined the impact of crystal methamphetamine injection on HIV RNA suppression among a prospective cohort of HIV-positive injection drug users initiating antiretroviral therapy. A multivariate Cox regression analysis found crystal methamphetamine injection to be negatively associated with viral load suppression (RH = 0.63 [95% CI: 0.40-0.98]; p=0.039). This study is the first to our knowledge to demonstrate an association between crystal methamphetamine use and HIV RNA suppression.

Copyright 2011, Elsevier Science

Furst RT; Curtis R; Balletto R. The transformation of drug markets and its impact on HIV outreach to injection drug users in New York City, 1987-2008. Substance Use & Misuse 46(2-3): 150-158, 2011. (25 refs.)

This oral history describes three periods of street outreach to injection drug users at risk for HIV in New York City: outreach in an era of public drug markets (1987-1993), outreach in an era of private markets (1993-2006), and network-driven outreach (2006-present). Individual interviews with administrators and supervisors of outreach workers are combined with field notes from the ethnographic research experiences of the first two authors to contextualize, compare, and contrast these distinct periods. The combination and triangulation of these sources of data allow for an analysis of both the specific and the wider social and cultural contexts in which outreach intervention efforts were situated. Through these lenses, the article examines some of the reasons why they were or were not successful and discusses prospects for the future.

Copyright 2011, Informa Healthcare

Genberg BL; Gange SJ; Go VF; Celentano DD; Kirk GD; Latkin CA et al. The effect of neighborhood deprivation and residential relocation on long-term injection cessation among injection drug users (IDUs) in Baltimore, Maryland. Addiction 106(11): 1966-1974, 2011. (45 refs.)

Aims To determine the incidence of long-term injection cessation and its association with residential relocation and neighborhood deprivation. Design ALIVE (AIDS Linked to the Intravenous Experience) is a prospective cohort with semi-annual follow-up since 1988. Multi-level discrete time-to-event models were constructed to investigate individual and neighborhood-level predictors of long-term injection cessation. Setting Baltimore, USA. Participants: A total of 1697 active injectors from ALIVE with at least eight semi-annual study visits. Measurements Long-term injection cessation was defined as 3 consecutive years without self-reported injection drug use. Findings: A total of 706 (42%) injectors achieved long-term cessation (incidence = 7.6 per 100 person-years). After adjusting for individual-level factors, long-term injection cessation was 29% less likely in neighborhoods in the third quartile of deprivation [hazard ratio (HR) = 0.71, 95% CI: 0.53, 0.95) and 43% less likely in the highest quartile of deprivation (HR = 0.57, 95% CI: 0.43, 0.76) compared to the first quartile. Residential relocation was associated with increased likelihood of long-term injection cessation (HR = 1.55, 95% CI: 1.31, 1.82); however, the impact of relocation varied depending on the deprivation in the destination neighborhood. Compared to those who stayed in less deprived neighborhoods, relocation from highly deprived to less deprived neighborhoods had the strongest positive impact on long-term injection cessation (HR = 1.96, 95% CI: 1.50, 2.57), while staying in the most deprived neighborhoods was detrimental (HR = 0.76, 95% CI: 0.63, 0.93). Conclusions Long-term cessation of injection of opiates and cocaine occurred frequently following a median of 9 years of injection and contextual factors appear to be important. Our findings suggest that improvements in the socio-economic environment may improve the effectiveness of cessation programs.

Copyright 2011, Society for the Study of Addiction

Ghanem A; Little SJ; Drumright L; Liu L; Morris S; Garfein RS. High-risk behaviors associated with injection drug use among recently HIV-infected men who have sex with men in San Diego, CA. AIDS and Behavior 15(7): 1561-1569, 2011. (38 refs.)

The contribution of injection drug use to HIV risk among men who have sex with men (MSM) is understudied. MSM infected with HIV within the prior 12 months completed a questionnaire assessing sociodemographic, sexual, drug use, and social factors. Analyses were performed to identify factors associated with lifetime history of injection drug use. Among 212 participants, the mean age was 33.8 years, 72% were White, 89% had attended college, and 9.4% reported ever injecting drugs. In multivariable logistic regression analysis, ever trading sex and using methamphetamine during sex with at least one of their last three partners were associated with injection drug use. Adjusting for these variables, in separate models, ever perpetrating violence against others (Adjusted Odds Ratio [AOR] = 3.16), having physically abusive sexual partners (AOR = 3.08), or physically abusing sexual partners (AOR = 10.17) were significantly (P < 0.05) associated with injection drug use. These findings suggest that violence is more common among MSM who inject drugs, which should be considered in HIV prevention efforts.

Copyright 2011, Springer

Gibbie TM; Hides LM; Cotton SM; Lubman DI; Aitken C; Hellard M. The relationship between personality disorders and mental health, substance use severity and quality of life among injecting drug users. Medical Journal of Australia 195(3, supplement): S16-S21, 2011. (21 refs.)

Objective: To determine the relationship between personality disorders (PDs) and substance use severity, mental health symptoms and disorders and quality of life (QoL) among injecting drug users (IDUs). Design, setting and participants: A cross-sectional study of 103 IDUs accessing a needle and syringe program and a primary health centre in Melbourne, Australia. Main outcome measures: Presence of PDs was assessed using the International Personality Disorder Examination ICD-10 Screener. Axis I mental health disorders, psychological distress and QoL were also assessed. Results: Ninety per cent of participants scored positive for one or more PD. Having a Cluster A or Cluster B PD was associated with greater severity of substance use. The. presence of a current mental health disorder was associated with all types of PD except dissocial PD. Only Cluster C PDs were associated with self-reported levels of psychological distress. Cluster C PDs were more strongly associated with substance use, mental health and QoL variables than Cluster A or B, although the number of PDs present had the strongest associations with these variables. Conclusions: IDUs had high rates of PD symptoms, which were associated with the presence of concurrent mental health disorders, more severe levels of psychological distress and substance use and low perceived QoL. IDUs require comprehensive models of care, including access to mental-health practitioners with expertise in co-occurring disorders.

Copyright 2011, Australasian Medical Publishing

Gowing L; Farrell MF; Bornemann R; Sullivan LE; Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. (review). Cochrane Database of Systematic Reviews 8: e-article CD004145, 2011. (176 refs.)

Background: Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour Objectives: To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections. Search strategy: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO toMay 2011. We also searched reference lists of articles, reviews and conference abstracts Selection criteria Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion Data collection and analysis Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author. Main results: Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated. Authors' conclusions: Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Copyright 2011, Wiley-Blackwell

Grady B; van den Berg C; van der Helm J; Schinkel J; Coutinho R; Krol A et al. No impact of hepatitis C virus infection on mortality among drug users during the first decade after seroconversion. Clinical Gastroenterology and Hepatology 9(9): 786-U107, 2011. (31 refs.)

Background & Aims: Most studies of progression of chronic hepatitis C virus (cHCV) infection were conducted in hospital settings and were therefore biased for patients with severe disease. We evaluated the long-term outcomes of hepatitis C virus (HCV) infection among injecting drug users, recruited from outside the hospital setting, and examined the effect of cHCV on mortality after seroconversion. Methods: We studied data from 106 seroconverters with a documented or estimated date of HCV seroconversion. Cox proportional hazards analysis was used to determine the effect of HCV persistence, compared with HCV clearance, on survival after HCV seroconversion. The median follow-up time was 14.8 years (interquartile range, 7.8 -19.6). Results: cHCV infection developed in 71 of the subjects (67%; 95% confidence interval [CI], 57%-76%); 33 subjects died. One HCV-related death was observed 23 years after HCV seroconversion. Most causes of death were non-natural (n = 12) or acquired immune deficiency syndrome-related (n = 8). The effect of cHCV on mortality was nonproportional over time. When survival time was analyzed separately for 0-5 years, >5-10 years, and >10 years after HCV seroconversion, the age-adjusted hazard ratios for cHCV were 0.59 (95% CI, 0.16-2.20), 1.76 (95% CI, 0.36-8.53), and 8.28 (95% CI, 1.10-64.55), respectively, compared with resolved HCV infection. Conclusions: cHCV infection does not affect overall mortality in the first decade after seroconversion, compared with individuals who resolve HCV infection; however, during the second decade after infection, individuals with cHCV have an increased risk for all-cause mortality. Mortality from liver-related causes was low but might have been masked by competing mortality.

Copyright 2011, Elsevier Science

Gu J; Lau JTF; Chen HY; Tsui HY; Ling WH. Prevalence and factors related to syringe sharing behaviours among female injecting drug users who are also sex workers in China. International Journal of Drug Policy 22(1): 26-33, 2011. (39 refs.)

Background: Female injecting drug users who are sex workers (IDUFSWs) are at high risk of contracting HIV. They may bridge HIV transmissions from injecting drug users to clients of female sex workers. Methods: A total of 216 non-institutionalised IDUFSWs were recruited by snowball sampling methods. Anonymous face-to-face interviews were conducted to collect data. Univariate, multivariate and hierarchical logistic regression models were fitted to investigate the associations between background characteristics, cognitive variables, psychological stress and syringe sharing behaviours among IDUFSWs. Results: Respectively 33.8% and 27.8% of the respondents injected drugs with others' used syringes and gave used syringes to others for drug injection in the last month. These two syringe sharing behaviours were significantly associated with inconsistent condom use during commercial sex (OR=5.00 and 1.92, p<0.05). Over 90% of the respondents reported at least one type(s) of psychological distress included in this study. Adjusting for significant background variables, all variables that are related to the Theory of Planned Behaviour (attitude, norm, perceived control and behavioural intention) and psychological distress (except for depression) were significantly associated with injecting drugs with others' used syringes (adjusted OR=2.08-6.25, p < 0.05), whilst variables related to perceived control, behavioural intention and insomnia were significantly associated with providing used syringes to others for injection (adjusted OR = 2.00-3.56, p<0.05). In two separate summary multivariate models, variables related to the Theory of Planned Behaviours and psychological distress were independently associated with injecting drugs with others' used syringes (OR = 1.98-4.02, p<0.05) and giving used syringes to others for injection (OR = 2.06-3.59, p<0.05). Conclusions: Syringe sharing behaviours were prevalent among IDUFSWs and were associated with cognitive and psychological factors. Effective integrative intervention programmes targeting IDUFSWs are warranted.

Copyright 2011, Elsevier Science

Gyarmathy VA; Neaigus A. The association between social marginalisation and the injecting of alcohol amongst IDUs in Budapest, Hungary. International Journal of Drug Policy 22(5): 393-397, 2011. (26 refs.)

Background: Alcohol injecting may cause intense irritation, serious vein damage, and additional risks. What little is known about alcohol injecting points to the potential role of social marginalisation. Methods: Injecting drug users (N=215) were recruited between October 2005 and December 2006 in Budapest, Hungary from non-treatment settings. Multivariate logistic regression models identified correlates of lifetime alcohol injecting. Results: About a quarter (23%) reported ever injecting alcohol-only 3% reported injecting alcohol in the past 30 days. In multivariate analysis, six variables were statistically significantly associated with ever injecting alcohol: male gender, being homeless, ever sharing cookers or filters and injecting mostly in public places showed a positive association, whilst Roma ethnicity and working at least part time showed a negative association. Conclusions: Our study suggests that alcohol injecting is more of a rare event than a so far undiscovered research and prevention priority. Still, providers of harm reduction services should be aware that alcohol injecting happens, albeit rarely, especially amongst socially marginalised IDUs, who should be counselled about the risks of and discouraged from alcohol injecting.

Copyright 2011, Elsevier Science BV

Hadland SE; Marshall BDL; Kerr T; Zhang R; Montaner JS; Wood E. A comparison of drug use and risk behavior profiles among younger and older street youth. Substance Use & Misuse 46(12): 1486-1494, 2011. (48 refs.)

Among 559 street youth recruited between 2005 and 2007 in Vancouver, Canada, young drug users (<21 years of age) were compared with older drug users (>= 21 years) with regard to recent drug use and sexual practices using multiple logistic regression. Older youth were more likely to be male and of Aboriginal ancestry, to have more significant depressive symptoms, to have recently engaged in crack smoking, and to have had a recent history of injection drug use. Young drug users, by contrast, were more likely to have engaged in recent binge alcohol use. Efforts to reduce drug use-related harm among street youth may be improved by considering the highly prevalent use of "harder" drugs and risk for depression among older youth.

Copyright 2011, Informa Healthcare

Hagan H; Perlman DC; Des Jarlais DC. Sexual risk and HIV infection among drug users in New York City: A pilot study. Substance Use & Misuse 46(2-3): 201-207, 2011. (28 refs.)

Measures of sexual health were assessed during 2008-2009 in a New York City sample of 102 injection and noninjection users of heroin, cocaine, or crack. There was considerable overlap and transitioning between crack smoking and injecting. Crack users were also significantly more likely to be gay, lesbian, or bisexual than other drug users. In multivariate analysis, HIV infection was independently associated with crack use and with being gay or bisexual. In New York City, HIV prevention for drug users has focused on syringe access, safe injection, and drug user treatment, but further progress in HIV control will require strategies to address sexual health among people who use drugs. The study's limitations are noted.

Copyright 2011, Informa Healthcare

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.

Copyright 2011, Elsevier Science

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

Copyright 2011, Romanian Legal Medical Society

Jackson LA; Dykeman M; Gahagan J; Karabanow J; Parker J. Challenges and opportunities to integrating family members of injection drug users into harm reduction efforts within the Atlantic Canadian context. International Journal of Drug Policy 22(5): 385-392, 2011. (54 refs.)

Background: This paper explores injection drug users' (IDUs) relationships with non-drug using family members in order to understand the potential opportunities for, and challenges to, having these family members provide harm reduction services (e.g., clean syringes). Methods: The qualitative data for this paper were drawn from a larger study of IDUs' relationships with key individuals in their lives (e.g., friends, family members). Interviews were conducted with 115 IDUs from across Atlantic Canada living in both urban and rural areas. Results: IDUs report that their relationships with family members are variable and dynamic, often changing over time. IDUs and family members engage in a variety of strategies to protect themselves from the multiple harms associated with drug use. Several strategies of self-protection (e.g., discontinuing all contact) are antithetical to the provision of harm reduction supports by family members. However, other strategies are based on continued contact, providing a potential opportunity for the integration of harm reduction approaches. Some family members not only have contact but provide supports (e.g., emotional support, housing) thus potentially facilitating the integration of harm reduction. In a few instances, family members already provide harm reduction supports (e.g., safe space to use). Conclusions: Conceptualizing addictions as a health and social justice issue, and providing appropriate interventions, may reduce some of the harms experienced by users and family members thus encouraging sustained relationships and greater integration of harm reduction approaches into the relationship. Targeted education to family members about harm reduction may also further encourage their involvement in such efforts. Likewise, supporting family members who are already providing harm reduction supports will likely assist in the scaling-up of harm reduction efforts.

Copyright 2011, Elsevier Science BV

Keijzer L; Imbert E. The filter of choice: Filtration method preference among injecting drug users. Harm Reduction Journal 8: article 20, 2011. (24 refs.)

Background: Injection drug use syringe filters (IDUSF) are designed to prevent several complications related to the injection of drugs. Due to their small pore size, their use can reduce the solution's insoluble particle content and thus diminish the prevalence of phlebitis, talcosis. Their low drug retention discourages from filter reuse and sharing and can thus prevent viral and microbial infections. In France, drug users have access to sterile cotton filters for 15 years and to an IDUSF (the Sterifilt(r)) for 5 years. This study was set up to explore the factors influencing filter preference amongst injecting drug users. Methods: Quantitative and qualitative data were gathered through 241 questionnaires and the participation of 23 people in focus groups. Results: Factors found to significantly influence filter preference were duration and frequency of injecting drug use, the type of drugs injected and subculture. Furthermore, IDU's rationale for the preference of one type of filter over others was explored. It was found that filter preference depends on perceived health benefits (reduced harms, prevention of vein damage, protection of injection sites), drug retention (low retention: better high, protective mechanism against the reuse of filters; high retention: filter reuse as a protective mechanism against withdrawal), technical and practical issues (filter clogging, ease of use, time needed to prepare an injection) and believes (the conviction that a clear solution contains less active compound). Conclusion: It was concluded that the factors influencing filter preference are in favour of change; a shift towards the use of more efficient filters can be made through increased availability, information and demonstrations.

Copyright 2011, BioMed Central

Khosla N; Juon HS; Kirk GD; Astemborski J; Mehta SH. Correlates of non-medical prescription drug use among a cohort of injection drug users in Baltimore City. Addictive Behaviors 36(12): 1282-1287, 2011. (39 refs.)

Despite reports of increasing non-medical prescription drug use, relatively few studies have systematically evaluated the prevalence and correlates of non-medical prescription drug use, particularly in populations that might be especially vulnerable (e.g., injection drug users [IDUs]). We examined factors associated with non-medical prescription drug use among a community-based cohort of current and former IDUs in Baltimore (The ALIVE Study). We conducted a cross-sectional analysis of data from cohort participants that responded to a survey that included questions on non-medical prescription drug use between 2005-06 (n = 1320). Nonmedical prescription drug use was considered to be use of any of the following: Opiates (Oxycontin, Percocet), Benzodiazepines or Clonidine, purchased on the street and taken orally within the last six months. Data on other covariates of interest (e.g., demographics, substance use, general health) was obtained through a standardized interview. The median age was 46 years; 66% were male, 85% were African-American. Twenty one percent reported any non-medical prescription drug use; 12% reported using more than one drug. Nonmedical use of opiates was most common (17%). In multivariate analysis, non-medical prescription drug use was significantly associated with Caucasian race (prevalence ratio [PR]: 1.79), self-reported bodily pain (PR: 1.58), hazardous alcohol use (PR: 1.47), marijuana use (PR: 1.65), non-injection cocaine/heroin use (PR: 1.70), diverted use of buprenorphine (PR: 1.51) or methadone (PR: 2.51), and active injection drug use (PR: 3.50; p<0.05 for all). The association between bodily pain and non-medical prescription drug use was stronger among persons that were not using substances (marijuana, injecting drugs, snorting/smoking heroin, cocaine, using crack) as compared to those using these substances. The high prevalence of non-medical prescription drug use among this population warrants further research and action. Information on the risks of nonmedical prescription drug use especially overdose, should be incorporated into interventions targeted at IDUs.

Copyright 2011, Elsevier Science

Kidorf M; King VL; Peirce J; Kolodner K; Brooner RK. A treatment reengagement intervention for syringe exchangers. Journal of Substance Abuse Treatment 41(4): 415-421, 2011. (34 refs.)

Poor sustained treatment engagement limits the effectiveness of all modalities of substance abuse treatment. This study evaluated the efficacy of a novel treatment reengagement intervention for a subset of syringe-exchange program (SEP) participants (N = 113) that had enrolled in treatment as part of a 4-month clinical trial (M. Kidorf et al., 2009). Three reengagement conditions for participants leaving treatment were compared. Motivational referral condition (MRC) participants (n = 31) could attend group sessions that focused on renewing treatment interest. MRC plus incentive (M RC + I) participants (n = 49) could receive modest monetary incentives for attending these sessions and reenrolling in treatment. Standard referral condition participants (n = 33) could not attend groups or receive incentives. Across a 1-year observation window, almost all study participants (86%) were discharged from treatment. M RC + I participants attended more group sessions than MRC participants and were considerably more likely to reenroll in treatment than participants in the other study conditions. Reengagement strategies can further enhance the public health benefits of SEPs by increasing rates of treatment participation over time.

Copyright 2011, Elsevier Science

Ko NY; Hsu ST; Chen CH; Lee HC; Ko WC. Heroin dependence and bloodborne virus transmission behaviors for HIV infection among newly incarcerated injection drug users in Taiwan. Substance Use & Misuse 46(5): 591-598, 2011. (29 refs.)

The purpose of the study was to determine heroin dependence and risky behaviors associated with human immunodeficiency virus (HIV) infection among newly incarcerated injection drug users (IDUs). Three self-administrated questionnaires were collected among 450 newly incarcerated male heroin users during 2005-2007. Inmates were categorized as heroin-dependent if they met three or more of the six ICD-10 criteria. Heroin-dependent inmates had higher scores of bloodborne virus transmission risk than non-dependent IDUs (12.8 +/- 16.0 vs. 7.2 +/- 11.5, p < 0.001). Multiple logistic regression analysis indicated that heroin dependence was a significant moderator of the association between risky injection behaviors and HIV infection. It is crucial to integrate substance treatment with behavioral interventions into harm reduction programs to prevent bloodborne virus transmission among IDUs.

Copyright 2011, Informa Healthcare

Koram N; Liu HJ; Li JH; Li J; Luo J; Nield J. Role of social network dimensions in the transition to injection drug use: Actions speak louder than words. AIDS and Behavior 15(7): 1579-1588, 2011. (43 refs.)

The objective of this study was to examine the influences of social network factors, particularly social support and norms, in the transition from non-injection heroin and/or opiate use to heroin-injection, which is one of the leading causes of the spread of HIV/AIDS in China. Respondent-driven sampling was used to recruit young heroin and/or opiate users in an egocentric network study in Yunnan, China. Multivariate logistic regression using hierarchical combinations of candidate variables was used to analyze network factors for the injection transition. A total of 3,121 social network alters were reported by 403 egos with an average network size of eight. Fifty-eight percent of egos transitioned to heroin-injection from non-injection. This transition was associated with having a larger sex network size, a larger number of heroin injectors in one's network, and a higher network density. The findings enhance our understanding of the influence of social network dimensions on the transition to injection drug use. Accordingly, the development of interventions for heroin and/or opiate users in China should consider social network characteristics.

Copyright 2011, Springer

Kostnapfel T; Svab I; Rotar DP. A qualitative exploration of travel-related risk behaviours of injection drug users from two Slovene regions. Harm Reduction Journal 8: article 8, 2011. (36 refs.)

This qualitative study of travel-related risk behaviours of Slovene injection drug users was based on interviews with individuals enrolled in drug addiction treatment programmes run by three regional centres for prevention and treatment of drug addiction. The primary objective of the study was to analyse behaviour patterns and practices of injection drug users during travel. Methods: Travel-related problems of Slovene injection drug users were identified on the basis of data obtained by 25 in-depth interviews. A semi-structured questionnaire with 13 open-ended questions was developed after a preliminary study and review of the literature, and on the basis of experience with the treatment of drug addiction in Slovenia. Results: The sample comprised 25 individuals, 18 men and seven women, aged 25 to 53 years. The interviews were 10 to 30 minutes long. The results obtained were presented as identified risk behaviours. Five categories were generated, providing information on the following topics: procurement of illicit drugs, criminal acts/environment, HIV and hepatitis B and C infections, storage and transport of substitution medication and pre-travel health protection. The first three categories comprise the injection drug users' risk behaviours that are most frequently explored in the literature. The other two categories - storage and transport of medication across the border and pre-travel health protection - reflect national specificities and the effectiveness of substitution treatment programmes. The majority of participants denied having shared needles and other injecting equipment when travelling. Participants who had no doctor's certificate had recourse to various forms of risk behaviour, finding a number of ways to hide the medication at the border. Conclusion: This qualitative study provides insight into potential travel-related risk behaviour of injection drug users from two Slovene regions - central and coastal. The potential value of this qualitative study is primarily in the identification of potential risk behaviour of Slovene injection drug users travelling abroad. The study shows that injection drug users' experiences can contribute to better and more efficient treatment of drug addiction in Slovenia.

Copyright 2011, Biomedical Central

Larance B; Degenhardt L; Lintzeris N; Bell J; Winstock A; Dietze P et al. Post-marketing surveillance of buprenorphine-naloxone in Australia: Diversion, injection and adherence with supervised dosing. Drug and Alcohol Dependence 118(2-3): 265-273, 2011. (69 refs.)

Background: These studies compared the diversion and injection of buprenorphine-naloxone (BNX), buprenorphine (BPN) and methadone (MET) in Australia. Methods: Surveys were conducted with regular injecting drug users (IDUs) (2004-2009, N = 881-943), opioid substitution treatment (OST) clients (2008, N = 440) and authorised OST prescribers (2007, N = 291). Key outcome measures include the unsanctioned removal of supervised doses, diversion, injection, motivations, drug liking and street price. Levels of injection among IDUs were adjusted for background availability of medications. Doses not taken as directed by OST clients were adjusted by total number of daily doses dispensed. Results: Among regular IDUs, levels of injection were lower for BNX relative to BPN, but comparable to those for MET, adjusting for background availability. Among OST clients, fewer BNX clients (13%) reported recently injecting their medication, than BPN (28%) and MET clients (23%). Fewer MET clients (10%) reported removal of supervised doses, than BPN (35%) and BNX clients (22%). There were no differences in prevalence of recent diversion (28% of all OST clients). Adjusting for the total doses dispensed, more BPN was injected (10%), removed (12%) and diverted (5%), than MET (5%, <1% and 2% respectively) and BNX (5%, 9% and <1% respectively). In 2009, the median street price of BNX was equivalent to that for BPN. Conclusions: BNX was less commonly and less frequently injected than BPN, but both sublingual medications were diverted more than liquid MET.

Copyright 2011, Elsevier Science

Lashkarizadeh MR; Ashrafganguie M; Ashrafganguie M. Surgical management of femoral artery pseudoaneurysms secondary to drug abuse. Journal of the College of Physicians and Surgeons Pakistan 21(11): 672-675, 2011. (22 refs.)

Objective: To assess the outcome of surgical management of mycotic false aneurysms due to local injury after intravenous injection of drugs. Study Design: Case series. Place and Duration of Study: Department of Surgery, Kerman Medical School of Sciences, Kerman, Iran, from July 2001 to June 2009. Methodology: Twenty one consecutive patients presenting with infected femoral artery pseudoaneurysms (IFAPs) secondary to parenteral drug abuse treated in our department were studied. Data analyzed included demographic characteristics, modes of presentation, side of involvement, management and outcome. Results: All patients were male with mean age of 32.2 +/- 5.2 years. All presented with pain and swelling in the groin. Five patients presented with significant hemorrhage. The locations were the left side in 9 cases and the right side in 12 cases. The injured artery was the common femoral artery and its bifurcation. In 14 patients (64%), ligation-excision was carried out. In 5 patients (26%), primary repair of the artery with over-sewing was done. In 2 patients (10%), revascularization with saphenous interposition was carried out. Below-knee amputation was necessary in 1 patient who underwent ligation-excision. One patient died due to severe septicemia. Conclusion: Ligation of IFAPs is an effective, safe and simple option. Primary repair with preservation of the native vessel is suggested if infection is limited.

Copyright 2011, College of Physicians & Surgeons Pakistan

Latkin C; Yang C; Srikrishnan AK; Solomon S; Mehta SH; Celentano DD et al. The relationship between social network factors, HIV, and Hepatitis C among injection drug users in Chennai, India. Drug and Alcohol Dependence 117(1): 50-54, 2011. (24 refs.)

Objective: The purpose of this study was to examine whether social network factors predict HIV and Hepatitis C (HCV) serostatus after controlling for individual-level factors at baseline among a cohort of male injection drug users in Chennai, India. Methods: The sample, which was recruited through street outreach, consists of 1078 males who reported having injected drugs in the last 6 months. Results: The participants reported 3936 social support and risk network members. HIV and HCV positive serostatus were negatively associated with network member providing emotional support, and positively associated with network member providing material support. In addition, HCV positivity was associated with network member being an active drug user known for more than 10 years and network member being male kin networks, even after adjusting for individual demographic factors and risk behaviors. Conclusions: These findings suggest that social network factors are significantly linked to HIV and HCV status among IDUs in Southern India and highlight the mixed effects of social capital on health. Future HIV/HCV prevention efforts should incorporate IDU peers to alter drug network injection risk norms. For drug users who have minimal network support, support groups and other informal and formal support mechanisms may be need to help them with health care and psychological support needs for dealing with HIV/HCV.

Copyright 2011, Elsevier Science

Lemstra M; Rogers M; Thompson A; Moraros J; Buckingham R. Risk indicators of depressive symptomatology among injection drug users and increased HIV risk behaviour. Canadian Journal of Psychiatry 56(6): 358-366, 2011. (25 refs.)

Objectives: In 2009, the annual incidence of positive human immunodeficiency virus (HIV) test reports for people in the Saskatoon Health Region (SHR) was 31.3 per 100,000, when the national average was only 9.3 per 100,000. The first objective was to determine the prevalence of depressive symptomatology among injection drug users (IDUs) in the SHR. The second objective was to determine the unadjusted and adjusted risk indicators associated with depressive symptomatology among IDUs. The third objective was to determine if depressive symptomatology was associated with HIV risk behaviours. Methods: From September 2009 to April 2010, 603 current IDUs were surveyed with validated instruments; this sample represents 76.6% of known IDUs in the SHR. Results: Among the respondents, 81.4% reported depressive symptomatology, whereas 57.7% reported more severe depressive symptomatology. After multivariate analysis, the 4 covariates that had an independent association with depressive symptomatology included sexual assault as an adult, sexual assault as a child, attending a residential school, and having an annual income of less than $10 000 Depressive symptomatology was initially associated with 7 HIV risk behaviours. After multivariate analysis, depressive symptomatology was associated with giving sex to get money, giving drugs to get sex, and with more frequently sharing injecting equipment. Conclusions: This study found that depressive symptomatology was strongly associated with injection drug use.

Copyright 2011, Canadian Psychiatric Association

Li J; Liu HJ; Li JH; Luo J; Des Jarlais D; Koram N. Role of sexual transmission of HIV among young noninjection and injection opiate users: A respondent-driven sampling study. Sexually Transmitted Diseases 38(12): 1161-1166, 2011. (30 refs.)

Background: Sexual transmissibility of HIV among young drug users in China has been investigated in few studies. The objective of this study was to examine the role of sexual transmission on HIV infection among injection drug users (IDUs) and noninjection drug users (NIDUs). Methods: Respondent-driven sampling (RDS) was used to recruit 426 young heroin/opium drug users in Yunnan, China. Logistic regression modeling was performed to examine interrelationships among risky sexual behaviors, drug-use modes, and drug-use practices. Results: Substantial proportions of NIDUs and IDUs reported engagement in risky sexual behaviors including: (1) multiple sexual partners (42% of NIDUs vs. 37% of IDUs), (2) concurrent sexual partnerships (48% vs. 46%), (3) commercial sex partners (23% vs. 24%), and sex partners who were NIDUs (14% vs. 17%). Both NIDUs and IDUs reported low levels of condom use with nonregular partners (48% vs. 42%) and regular partner (24% vs. 27%), and having a history of recent methamphetamine use (21% vs. 18%). Compared to IDUs, NIDUs reported having had fewer sex partners who were IDUs, fewer IDU network peers, more NIDU network peers, and having lower levels of HIV knowledge and self-perceived HIV risk. Conclusions: Generalization of the HIV epidemic from high-risk groups to the general population may be driven by risky sexual behavior among drug users. Reducing sexual transmission of HIV among both IDUs and NIDUs is the next major challenge for HIV intervention among drug users in China.

Copyright 2011, Lippincott, Williams & Wilkins

Marshall BDL; Galea S; Wood E; Kerr T. Injection methamphetamine use is associated with an increased risk of attempted suicide: A prospective cohort study. Drug and Alcohol Dependence 119(1-2): 134-137, 2011. (35 refs.)

Background: Methamphetamine (MA) use is a growing public health concern in many settings around the world. While some physical and mental health effects associated with injection MA use have been well described, little is known about the relationship between injecting MA and suicidal behavior. We sought to determine whether MA injection was associated with an increased risk of attempting suicide among a prospective cohort of injection drug users (IDUs) in Vancouver, Canada. Methods: Between 2001 and 2008, eligible participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) completed semi-annual questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems including suicidal behavior. We used Cox proportional hazards models with time-dependent covariates to determine whether self-reported MA injection was an independent predictor of attempting suicide at subsequent time points. Results: of 1873 eligible participants, 149 (8.0%) reported a suicide attempt, resulting in an incidence density of 2.5 per 100 person-years. Participants who attempted suicide were more likely to be younger (median: 35 vs. 40, p < 0.01), female (48.3% vs. 35.1%, p < 0.01), and of Aboriginal ancestry (43.6% vs. 31.3%, p < 0.01). In a Cox proportional hazards model, MA injection was associated with an 80% increase in the risk of attempting suicide (adjusted hazard ratio = 1.80, 95% CI: 1.08-2.99, p = 0.02). Conclusions: These findings suggest that IDUs who inject MA should be monitored for suicidal behavior. Improved integration of mental health and suicide prevention interventions within harm reduction and drug treatment programs may be fruitful.

Copyright 2011, Elsevier Science

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, 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.

Copyright 2011, Public Library of Science

McAdam-Marx C; McGarry LJ; Hane CA; Biskupiak J; Deniz B; Brixner DI. All-cause and incremental per patient per year cost associated with chronic hepatitis C virus and associated liver complications in the United States: A managed care perspective. Journal of Managed Care Pharmacy 17(7): 531-546, 2011. (44 refs.)

BACKGROUND: Approximately 3.2-3.9 million U.S. residents are infected with the hepatitis C virus (HCV). Total annual costs (direct and indirect) in the United States for HCV were estimated to be $5.46 billion in 1997, and direct medical costs have been predicted to increase to $10.7 billion for the 10-year period from 2010 through 2019, due in part to the increasing number of HCV patients developing advanced liver disease (AdvLD). OBJECTIVE: To quantify in a sample of commercially insured enrollees (a) total per patient per year (PPPY) all-cause costs to the payer, overall and by the stage of liver disease, for patients diagnosed with HCV; and (b) incremental all-cause costs for patients diagnosed with HCV relative to a matched non-HCV cohort. METHODS: This retrospective, matched cohort study included patients aged at least 18 years and with at least 6 months of continuous enrollment in a large managed care organization (MCO) claims database from July 1, 2001, through March 31, 2010. Patients with a diagnosis of HCV (ICD-9-CM codes 070.54, 070.70) were identified and stratified into those with and without AdvLD, defined as decompensated cirrhosis (ICD-9-CM codes 070.44, 070.71, 348.3x, 456.0, 456.1, 456.2x, 572.2, 572.3, 572.4, 782.4, 789.59); hepatocellular carcinoma (HCC, ICD-9-CM code 155); or liver transplant (ICD-9-CM codes V42.7, 50.5 or CPT codes 47135, 47136). For patients without AdvLD, the index date was the first HCV diagnosis date observed at least 6 months after the first enrollment date, and at least 6 months of continuous enrollment after the index date were required. HCV patients without AdvLD were stratified into those with and without compensated cirrhosis (ICD-9-CM codes 571.2, 571.5, 571.6). For patients with AdvLD, the index date was the date of the first AdvLD diagnosis observed at least 6 months after the first enrollment date, and at least 1 day of enrollment after the index date was required. Cases were matched in an approximate 1:10 ratio to comparison patients without an HCV diagnosis or AdvLD diagnosis who met all other inclusion criteria based on gender, age, hospital referral region state, pre-index health care costs, alcoholism, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and a modified Charlson Comorbidity Index. For the HCV and comparison patient cohorts, PPPY all-cause costs to the payer were calculated as total allowed charges summed across all patients divided by total patient-days of follow-up for the cohort, multiplied by 365, inflation-normalized to 2009 dollars. Because the calculation of PPPY cost generated a single value for each cohort, bootstrapping was used to generate descriptive statistics. Incremental PPPY costs for HCV patients relative to non-HCV patients were calculated as between-group differences in PPPY costs. T-tests for independent samples were used to compare costs between case and comparison cohorts. RESULTS: A total of 34,597 patients diagnosed with HCV, 78.0% with HCV without AdvLD, 4.4% with compensated cirrhosis, 12.3% with decompensated cirrhosis, 2.8% with HCC, and 2.6% with liver transplant, were matched to 330,435 comparison patients. Mean (SD) age of all HCV cases was 49.9 (8.5) years; 61.7% were male. Incremental mean (SD) PPPY costs in 2009 dollars for all HCV patients relative to comparison patients were $9,681 ($176) PPPY. Incremental PPPY costs were $5,870 ($157) and $5,330 ($491) for HCV patients without liver disease and with compensated cirrhosis, respectively. Incremental PPPY costs for patients with AdvLD were $27,845 ($965) for decompensated cirrhosis, $43,671 ($2,588) for HCC, and $93,609 ($4,482) for transplant. Incremental prescription drug costs, including the cost of antiviral drugs, were $2,739 ($37) for HCV patients overall, $2,659 ($41) for HCV without liver involvement, and $3,102 ($157) for HCV with compensated cirrhosis. These between-group differences were statistically significant at P<0.001. CONCLUSIONS: Based on a retrospective analysis of data from a large, MCO claims database, patients diagnosed with HCV had annual all-cause medical costs that were almost twice as high as those of enrollees without a diagnosis of HCV. Health care costs increased dramatically with AdvLD. Data from this study may help MCOs project future HCV costs and facilitate planning for HCV patient management efforts. [Note. HCV is associated with injecting drug use.]

Copyright 2011, Academy of Managed Care Pharmacy

Millet JP; Orcau A; Rius C; Casals M; de Olalla PG; Moreno A et al. Predictors of death among patients who completed tuberculosis treatment: A population-based cohort study. PLoS ONE 6(9): e25315, 2011. (44 refs.)

Background: Mortality among patients who complete tuberculosis (TB) treatment is still high among vulnerable populations. The objective of the study was to identify the probability of death and its predictive factors in a cohort of successfully treated TB patients. Methods: A population-based retrospective longitudinal study was performed in Barcelona, Spain. All patients who successfully completed TB treatment with culture-confirmation and available drug susceptibility testing between 1995-1997 were retrospectively followed-up until December 31, 2005 by the Barcelona TB Control Program. Socio-demographic, clinical, microbiological and treatment variables were examined. Mortality, TB Program and AIDS registries were reviewed. Kaplan-Meier and a Cox regression methods with time-dependent covariates were used for the survival analysis, calculating the hazard ratio (HR) with 95% confidence intervals (CI). Results: Among the 762 included patients, the median age was 36 years, 520 (68.2%) were male, 178 (23.4%) HIV-infected, and 208 (27.3%) were alcohol abusers. Of the 134 (17.6%) injecting drug users (IDU), 123 (91.8%) were HIV-infected. A total of 30 (3.9%) recurrences and 173 deaths (22.7%) occurred (mortality rate: 3.4/100 person-years of follow-up). The predictors of death were: age between 41-60 years old (HR: 3.5; CI: 2.1-5.7), age greater than 60 years (HR: 14.6; CI: 8.9-24), alcohol abuse (HR: 1.7; CI: 1.2-2.4) and HIV-infected IDU (HR: 7.9; CI: 4.7-13.3). Conclusions: The mortality rate among TB patients who completed treatment is associated with vulnerable populations such as the elderly, alcohol abusers, and HIV-infected IDU. We therefore need to fight against poverty, and promote and develop interventions and social policies directed towards these populations to improve their survival.

Copyright 2011, Public Library of Science

Mravcik V; Skarupova K; Orlikova B; Zabransky T; Karachaliou K; Schulte B. Use of gelatine capsules for application of methamphetamine: A new harm reduction approach. International Journal of Drug Policy 22(2): 172- 173, 2011. (10 refs.)

Background: In order to reduce injecting drug use, low-threshold facilities in the Czech Republic have started to distribute empty gelatine capsules as an oral alternative of drug application for those injecting methamphetamine. This report reviews implementation of this intervention and its possible benefits and limitations. Methods: Between December 2008 and January 2009,109 low-threshold facilities were asked to complete a questionnaire about the capsule programmes. Two focus groups were conducted, one with professionals involved in distribution and one with peer outreach workers who were interviewed on their experience of using the capsules. Results: A total of 50 facilities (46%) responded to the questionnaire; 16 (32%) distributed the capsules regularly and 19(38%) were planning to introduce this practice. The main target groups were injecting users of methamphetamine whose veins had been damaged, and methamphetamine users wishing to reduce injecting. The advantages of capsules, as perceived by service staff and peer outreach workers, were their easy use and the satisfactory effect of the oral application; health risks related to the oral use of methamphetamine were considered drawbacks. Conclusion: Capsule distribution is a promising harm reduction approach for injectors of methamphetamine or other stimulants; nonetheless its benefits and limitations should be further analysed in an in-depth longitudinal study.

Copyright 2011, Elsevier Science

Neira-Leon M; Barrio G; Bravo MJ; Brugal MT; de la Fuente L; Domingo-Salvany A et al. Infrequent opioid overdose risk reduction behaviours among young adult heroin users in cities with wide coverage of HIV prevention programmes. International Journal of Drug Policy 22(1): 16-25, 2011. (59 refs.)

Background: Opioid overdose risk reduction behaviours include some preventive behaviours to avoid overdoses (PB) and others to avoid death after overdose, such as never using heroin while alone (NUA). Few studies have examined the prevalence and predictors of these behaviours. Aim: To establish the prevalence and predictors of PBs and NUA among heroin users, both injectors and non-injectors, in three Spanish cities. Methods: 516 injecting and 475 non-injecting heroin users aged 18-30 were street-recruited in 2001-2003 and interviewed by face-to-face computer-assisted interview. PBs and NUA in the last 12 months were explored using open-ended and precoded questions, respectively. Specific predictors for three PB categories were investigated: control of route of drug administration, control of quantity or type of heroin used, and control of co-use of other drugs. Bivariate and logistic regression methods were used. Results: Overall, the most prevalent PBs were: using a stable and not excessive amount of heroin (12.7%), injecting or using the whole heroin dose slowly or dividing it into smaller doses (12.4%), reducing or stopping heroin injection (8.3%), and not mixing heroin with tranquillisers (5.1%). Most PBs were significantly more prevalent among injectors than non-injectors. No one mentioned reducing the amount of heroin after an abstinence period. Some 36.2% had NUA. In multiple regression analysis, knowledge of risk factors for opioid overdose was a predictor of specific PBs, although this was not always the case. Use of syringe exchange programmes was a predictor of PB among injectors. However, attending methadone maintenance treatment (MMT) or other drug-dependence treatment was not a predictor of any opioid overdose reduction behaviour. Only ever having witnessed or experienced an overdose predicted PB in both injectors and non-injectors. Conclusions: The proportion of heroin users with opioid overdose risk reduction behaviours is very low. Additional specific measures to prevent overdose are needed, as well as increased emphasis on reducing the risk of overdose in programmes to prevent HIV and other blood-borne infections in heroin injectors.

Copyright 2011, Elsevier Science

Okwen MP; Ngem BY; Alomba FA; Capo MV; Reid SR; Ewang EC. Uncovering high rates of unsafe injection equipment reuse in rural Cameroon: validation of a survey instrument that probes for specific misconceptions. Harm Reduction Journal 8: article 4, 2011. (75 refs.)

Background: Unsafe reuse of injection equipment in hospitals is an on-going threat to patient safety in many parts of Africa. The extent of this problem is difficult to measure. Standard WHO injection safety assessment protocols used in the 2003 national injection safety assessment in Cameroon are problematic because health workers often behave differently under the observation of visitors. The main objective of this study is to assess the extent of unsafe injection equipment reuse and potential for blood-borne virus transmission in Cameroon. This can be done by probing for misconceptions about injection safety that explain reuse without sterilization. These misconceptions concern useless precautions against cross-contamination, i.e. "indirect reuse" of injection equipment. To investigate whether a shortage of supply explains unsafe reuse, we compared our survey data against records of purchases. Methods: All health workers at public hospitals in two health districts in the Northwest Province of Cameroon were interviewed about their own injection practices. Injection equipment supply purchase records documented for January to December 2009 were compared with self-reported rates of syringe reuse. The number of HIV, HBV and HCV infections that result from unsafe medical injections in these health districts is estimated from the frequency of unsafe reuse, the number of injections performed, the probability that reused injection equipment had just been used on an infected patient, the size of the susceptible population, and the transmission efficiency of each virus in an injection. Results: Injection equipment reuse occurs commonly in the Northwest Province of Cameroon, practiced by 44% of health workers at public hospitals. Self-reported rates of syringe reuse only partly explained by records on injection equipment supplied to these hospitals, showing a shortage of syringes where syringes are reused. Injection safety interventions could prevent an estimated 14-336 HIV infections, 248-661 HBV infections and 7-114 HCV infections each year in these health districts. Conclusions: Injection safety assessments that probe for indirect reuse may be more effective than observational assessments. The autodisable syringe may be an appropriate solution to injection safety problems in some hospitals in Cameroon. Advocacy for injection safety interventions should be a public health priority.

Copyright 2011, BioMed Central

Qian HZ; Stinnette SE; Rebeiro PF; Kipp AM; Shepherd BE; Samenow CP et al. The relationship between injection, and noninjection drug use and HIV disease progression. Journal of Substance Abuse Treatment 41(1): 14-20, 2011. (30 refs.)

Background: Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression. Methods: We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005. Results: There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43-2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92-1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period (n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09-3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81-1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use. Conclusions: This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.

Copyright 2011, Elsevier Science

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.

Copyright 2011, Society for the Study of Addiction to Alcohol and Other Drugs

Ropelewski LR; Mancha BE; Hulbert A; Rudolph AE; Martins SS. Correlates of risky injection practices among past-year injection drug users among the US general population. Drug and Alcohol Dependence 116(1-3): 64-71, 2011. (61 refs.)

Background: With an estimated 1 million active injection drug users (IDUs), injection drug use continues to be a public health concern in the United States. Risky injection practices have been associated with the transmission of HIV, Hepatitis B and C, as well as other skin and soft tissue infections. Methods: We used data from 463 respondents, aged 18 and older, who were past-year IDUs in the 2005-2008 National Survey of Drug Use and Health (NSDUH). We investigated correlates of risky injection behavior among these recent IDUs. Results: Older age (>= 35 versus 18-25) was associated with reusing one's own needle at last injection (aOR = 1.80 [1.02-3.17], as were past year heroin (aOR = 2.59 [1.18-5.66]) and cocaine injection (aOR = 2.17 [1.13-4.15]). Past year crack cocaine use was positively associated with not cleaning needles with bleach (aOR = 2.18 [1.10-4.33]). Past year cocaine injection was associated with obtaining needles in a risky manner (aOR = 2.29 [1.23-4.25]). Methamphetamine injection was associated with obtaining needles in less risky ways (aOR = 0.41 [0.20-0.84]). Conclusion: Our findings indicate that some IDUs are continuing to engage in high risk injection behaviors. The identification of potential at-risk populations of IDUs may have implications for harm reduction interventions and HIV prevention programs.

Copyright 2011, Elsevier Science

Sarin E; Samson L; Sweat M; Beyrer C. Human rights abuses and suicidal ideation among male injecting drug users in Delhi, India. International Journal of Drug Policy 22(2): 161- 166, 2011. (56 refs.)

Background: Human rights abuses, denial of care, police surveillance, and violence directed at IDUs have been found to impact HIV prevention efforts due to decreased attendance in harm reduction programs. The association of mental health status with rights abuses has not been examined extensively among drug users. In India, drug control laws are often in conflict with harm reduction policies, thus increasing the likelihood of rights abuses against IDUs. The purpose of this study was to describe human rights abuses occurring among IDUs in Delhi and examine their association with suicidal ideation. Methods: 343 IDUs were recruited in two research sites in Delhi through respondent driven sampling and were interviewed with a cross sectional survey questionnaire that included items on human rights and socio demographics. Results: IDUs in the study experienced many human rights abuses. Notably among these were denial of admission into hospital (38.5%), denial of needles and syringes (20%), police arrests for carrying needles and using drugs (85%), verbal abuse (95%) and physical abuse (88%). Several human rights abuses were associated with suicidal ideation. These include being denied needles and syringes (OR: 7.28, 95% CI: 3.03-17.49); being arrested by police for carrying needles and using drugs (OR: 2.53,95% CI: 1.06-6.03), and being physically abused (OR: 1.66, 95% CI: 1.05-2.23). The likelihood of suicidal ideation is also strongly related to the cumulative number of abuses. Conclusions: These findings demonstrate that there is a high prevalence of human rights abuses among IDUs in Delhi. Given the alarming rate of suicidal ideation and its close relationship with human rights abuses it is essential that IOU interventions are executed within a rights-based framework.

Copyright 2011, Elsevier Science

Semaan S; Fleming P; Worrell C; Stolp H; Baack B; Miller M. Potential role of safer injection facilities in reducing HIV and Hepatitis C infections and overdose mortality in the United States. (review article). Drug and Alcohol Dependence 118(2-3): 100-110, 2011. (206 refs.)

Background: Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States. Method: We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs. Results: SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data. Conclusions: SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.

Copyright 2011, Elsevier Science

Senbanjo R; Strang J. The needle and the damage done: Clinical and behavioural markers of severe femoral vein damage among groin injectors. Drug and Alcohol Dependence 119(3): 161-165, 2011. (27 refs.)

Aim: To identify factors associated with severe femoral vein (FV) damage among groin injectors (GIs) on oral opioid substitution treatment. Design: A cohort study. Setting: Drug treatment centres in South East England. Participants: GIs attending an ultrasound 'health-check' clinic. Measures: Femoral ultrasonography and clinical grading of venous disease in each leg. Method: Comparison of 67 GIs with severely damaged FV and 86 GIs with minimal/moderate damage. Findings: The majority were men (69.3%) and the mean age was 36.2 years with mean duration of injecting drug use (IDU) of 13.3 years. There were no significant between-group differences in age, gender or duration of IDU. Severe FV damage was associated with longer duration of groin injecting (GI; P < 0.005), use of thick needles (blue-hub, 23G; or green-hub, 21G; P < 0.001), benzodiazepine injection (P < 0.005), history of deep vein thrombosis (DVT, P < 0.001) and recurrent DVT (P < 0.001), presence of depressed groin scar (P < 0.001) and chronic venous disease (CVD, P < 0.001). Logistic regression analysis revealed needle size (beta 1.2, Wald 4.9, P < 0.05) and DVT(beta 3.3, Wald 38.5, P < 0.001) as the main predictors of severe FV damage. Conclusion: Needle and syringe exchange services should consider only supplying appropriate lengths of orange-hub needle (25G) on request from GIs. Early cessation of GI, avoidance of benzodiazepine injection and prompt diagnosis and treatment of DVT might also reduce the prevalence of severe FV damage among GIs and the associated healthcare burden. Routine examination of injecting sites among these patients should include an assessment of severity of venous disease in each leg.

Copyright 2011, Elsevier Science

Todd CS; Nasir A; Stanekzai MR; Fiekert K; Rasuli MZ; Vlahov, D. et al. Prevalence and correlates of HIV, syphilis, and hepatitis B and C infection and harm reduction program use among male injecting drug users in Kabul, Afghanistan: A cross-sectional assessment. Harm Reduction Journal 8: article 22, 2011. (31 refs.)

Background: A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population. Methods: IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use. Results: Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58-22.38 and AOR = 2.33, 95% CI: 1.38-3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22-5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16-2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06-2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08-1.82). Conclusions: HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.

Copyright 2011, BioMed Central

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.

Copyright 2011, Sage Publications

Treloar C; Valentine K; Fraser S. Social inclusion and hepatitis C: Exploring new possibilities for prevention. Expert Review of Anti-Infective Therapy 9(4): 397- 404, 2011. (72 refs.)

In Western countries, people who inject drugs experience a disproportionate burden of hepatitis C as a result of effective transmission of the virus via the sharing of used injection equipment. With a hepatitis C prevalence of 60% and higher in many areas, previous and current prevention efforts focusing on the availability of sterile injecting equipment along with education, have had only limited effect on incidence rate. Little attention has been paid to the broader social and political positions that drug use and people who use drugs hold in these societies. Insights from social research provide opportunities to broaden the possibilities for prevention efforts. We will review the social inclusion literature to provide some examples of how hepatitis C prevention may be approached in innovative ways.

Copyright 2011, Expert Reviews

Turner KME; Hutchinson S; Vickerman P; Hope V; Craine N; Palmateer N et al. The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: Pooling of UK evidence. Addiction 106(11): 1978-1988, 2011. (46 refs.)

Aims To investigate whether opiate substitution therapy (OST) and needle and syringe programmes (NSP) can reduce hepatitis C virus (HCV) transmission among injecting drug users (IDUs). Design: Meta-analysis and pooled analysis, with logistic regression allowing adjustment for gender, injecting duration, crack injecting and homelessness. Setting Six UK sites (Birmingham, Bristol, Glasgow, Leeds, London and Wales), community recruitment. Participants: A total of 2986 IDUs surveyed during 2001-09. Measurement Questionnaire responses were used to define intervention categories for OST (on OST or not) and high NSP coverage (>= 100% versus <100% needles per injection). The primary outcome was new HCV infection, measured as antibody seroconversion at follow-up or HCV antibody-negative/RNA-positive result in cross-sectional surveys. Findings: Preliminary meta-analysis showed little evidence of heterogeneity between the studies on the effects of OST (I(2) = 48%, P = 0.09) and NSP (I(2) = 0%, P = 0.75), allowing data pooling. The analysis of both interventions included 919 subjects with 40 new HCV infections. Both receiving OST and high NSP coverage were associated with a reduction in new HCV infection [adjusted odds ratios (AORs) = 0.41, 95% confidence interval (CI): 0.21-0.82 and 0.48, 95% CI: 0.25-0.93, respectively]. Full harm reduction (on OST plus high NSP coverage) reduced the odds of new HCV infection by nearly 80% (AOR = 0.21, 95% CI: 0.08-0.52). Full harm reduction was associated with a reduction in self-reported needle sharing by 48% (AOR 0.52, 95% CI: 0.32-0.83) and mean injecting frequency by 20.8 injections per month (95% CI: -27.3 to -14.4). Conclusions: There is good evidence that uptake of opiate substitution therapy and high coverage of needle and syringe programmes can substantially reduce the risk of hepatitis C virus transmission among injecting drug users. Research is now required on whether the scaling-up of intervention exposure can reduce and limit hepatitis C virus prevalence in this population.

Copyright 2011, Society for the Study of Addiction

Vlahov D; Ompad DC; Fuller CM; Nandi V. Comparison of HIV risk by duration of injection drug use. Substance Use & Misuse 46(2-3): 181-191, 2011. (58 refs.)

Early studies documented an inverse association between the HIV risk and duration of injection among injection drug users (IDUs). Results from subsequent studies have been inconsistent. To examine this issue, we conducted interviews with 395 street-recruited active IDUs from 38 neighborhoods in New York City during 2005 and 2008. We observed no significant differences in drug or risky sex behaviors by duration of drug use among these IDUs. Despite this, continuing to tailor HIV prevention programs for these recent-onset IDUs is prudent. The study's limitations are noted.

Copyright 2011, Informa Healthcare

Volkmann T; Lozada R; Anderson CM; Patterson TL; Vera A; Strathdee SA. Factors associated with drug-related harms related to policing in Tijuana, Mexico. Harm Reduction Journal 8: article 7, 2011. (41 refs.)

Objective: To assess factors associated with drug-related harms related to policing among injection drug users (IDUs) in Tijuana, Mexico. Methods: IDUs who were over 18 years old and had injected drugs within the last six months were recruited via respondent-driven samplinrwsociation beent questionnaires and testing for HIV (tween knowledge and HIV testing. Methodshuman immunodeficiency virus), syphilis and TB (tuberculosis). Random effects logistic regression was used to simultaneously model factors associated with five drug-related harms related to policing practices in the prior six months (i.e., police led them to rush injections; affected where they bought drugs; affected locations where they used drugs; feared that police will interfere with their drug use; receptive syringe sharing). Results: Of 727 IDUs, 85% were male; median age was 38 years. Within the last 6 months, 231 (32%) of IDUs reported that police had led them to rush injections, affected where they bought or used drugs or were very afraid police would interfere with their drug use, or shared syringes. Factors independently associated with drug-related harms related to policing within the last six months included: recent arrest, homelessness, higher frequencies of drug injection, use of methamphetamine, using the local needle exchange program and perceiving a decrease in the purity of at least one drug. Conclusions: IDUs who experienced drug-related harms related to policing were those who were most affected by other micro and macro influences in the physical risk environment. Police education programs are needed to ensure that policing practices do not exacerbate risky behaviors or discourage protective behaviors such as needle exchange program use, which undermines the right to health for people who inject drugs.

Copyright 2011, BioMed Central

Volkow ND; Montaner J. The urgency of providing comprehensive and integrated treatment for substance abusers with HIV. Health Affairs 30(8): 1411-1419, 2011. (69 refs.)

Substance abuse is linked to many new cases of HIV infection. Barriers such as the myth that drug users cannot adhere to HIV/AIDS treatment block progress in curbing the spread of HIV in that population. In this article we explain the need to aggressively seek out high-risk, hard-to-reach substance abusers and to offer them HIV testing, access to treatment, and the necessary support to remain in treatment-both for HIV and for substance abuse. We summarize evidence showing that injection drug users can successfully undergo HIV treatment; that many substance abusers adhere to antiretroviral therapy as well as do people who don't inject drugs; and that injection drug users who undergo substance abuse treatment are more likely to obtain and stay in treatment for their HIV infection. This evidence makes a strong case for integrating substance abuse treatment with HIV treatment programs and providing substance abusers with universal access to HIV treatment. But an integrated strategy will require changes in the health care system to overcome lingering obstacles that inhibit the merging of substance abuse treatment with HIV programs.

Copyright 2011, Project Hope

Walton G; Co SJ; Milloy MJ; Qi JZ; Kerr T; Wood E. High prevalence of childhood emotional, physical and sexual trauma among a Canadian cohort of HIV-seropositive illicit drug users. AIDS Care 23(6): 714- 721, 2011. (43 refs.)

Background. The psychosocial impacts of various types of childhood maltreatment on vulnerable illicit drug-using populations remain unclear. We examined the prevalence and correlates of antecedent emotional, physical and sexual abuse among a community-recruited cohort of adult HIV-seropositive illicit drug users. Methods. We estimated the prevalence of childhood abuse at baseline using data from the Childhood Trauma Questionnaire, a 28-item validated instrument used to retrospectively assess childhood maltreatment. Logistic regression was used to estimate relationships between sub-types of childhood maltreatment with various social-demographic, drug-using and clinical characteristics. Results. Overall, 233 HIV-positive injection drug users (IDU) were included in the analysis, including 83 (35.6%) women. Of these, moderate or severe emotional childhood abuse was reported by 51.9% of participants, emotional neglect by 36.9%, physical abuse by 51.1%, physical neglect by 46.8% and sexual abuse by 41.6%. In multivariate analyses, emotional, physical and sexual abuses were independently associated with greater odds of recent incarceration. Emotional abuse and neglect were independently associated with a score of >= 16 on the Centre for Epidemiology Studies Depression Scale. There was no association between any form of childhood maltreatment and clinical HIV variables, including viral load, CD4+ count and history of antiretroviral therapy use. Conclusion. These findings underscore the negative impact of childhood maltreatment on social functioning and mental health in later life. Given the substantial prevalence of childhood maltreatment among this population, there is a need for evidence-based resources to address the deleterious effect it has on the health and social functioning of HIV-positive IDU.

Copyright 2011, Routledge

Washington TA; Brocato J. Exploring the perspectives of substance abusing Black men who have sex with men and women in addiction treatment programs: A need for a human sexuality educational model for addiction professionals. American Journal of Men's Health 5(5): 402-412, 2011. (75 refs.)

This study examined the perspectives of African American male injection drug users who have sex with both men and women (IDU-MSM/W) and who are involved in sex trade regarding the need for a human sexuality educational model (HSEM) for addiction professionals. Focus groups were conducted involving an exploratory sample (N = 105) of men who met the following parameters: aged 18 to 40 years, African American, engage in injection drug using behavior, have sex with male and female partners, and who frequent parks and other sex working areas in Baltimore City and surrounding areas. Data suggest that an HSEM may be useful for addiction professionals who work with substance abusing Black MSM/W. Moreover, the model should include opportunities for addiction professionals to (a) identify their personal biases about homosexuality in general (acknowledging personal biases so not to allow those personal biases to influence service); (b) understand the diversity within the Black MSM/W community (e.g., challenge assumptions that all Black MSM/W self-identify as gay); (c) understand how to, and the need for, assessing sexual trauma in Black MSM/W; and (d) understand the need to incorporate risk factors and safer sex practices that may be of concern to a subpopulation of Black MSM/W, such as "barebacking." These findings suggest the need for, and topics to include in, an HSEM that assists professionals with exploring their biases about sexuality and MSM/W and better prepares counselors to address HIV prevention and risky behavior using language that is appropriate for the Black IDU-MSM/W population.

Copyright 2011, Sage Publications