Maintaining low HIV seroprevalence in populations of injecting drug users.

OBJECTIVES: To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (< 5%) during at least 5 years. DESIGN AND SETTING: A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs. PARTICIPANTS: Injecting drug users recruited from both drug treatment and non-treatment settings in each city. INTERVENTIONS: A variety of HIV prevention activities for IDUs had been implemented in each of the five cities. RESULTS: There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections. CONCLUSIONS: In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.

HIV prevention among injecting drug users: three years of experience from a syringe exchange program in Sweden.

Exchange of syringes and needles has for the last 3 years been offered to injecting drug users as part of an HIV prevention project in a small university town in south Sweden. The program at the local hospital has been visited by 979 drug users, of which 182 have participated on a more regular basis. The typical participant is a 30-year-old male who has injected amphetamine or heroin for at least 10 years. The seroprevalence for HIV among drug users in south Sweden has been maintained at approximately 1% in contrast to up to 60% in subpopulations from other Scandinavian regions with a comparable drug problem. No project participant has become HIV infected during the study period and a reduction in risk behavior has been noted among local drug injectors. The HIV prevention project has attracted many individuals with no previous contact with drug rehabilitation programs; for a number of drug users, the syringe exchange has served as an introduction to such treatment efforts.

Fatal outcome in drug addiction.

A sample of 524 young drug addicts consecutively treated at a special hospital ward has been followed by registers for an average of 10 years. A total of 62 were found to have died drug-related deaths at an average age of 28 years; 19 of them had committed suicide. Representativeness of the sample is investigated. Sex and choice of drugs were predictive factors behind fatal outcome: male opiate addicts died 5.4 times and male amphetamine abusers 2.5 times as often as expected. The males were exposed to greater risk than the females. Those who committed suicide had an hereditary disposition for mental disturbances, especially affective disorders. Lethal substances proved to be opiates, barbiturates and alcohol and/or other psychotropic preparations. Signs of heart disease were often found in the overdose cases. Most of the addicts who died were in a compulsive stage of the drug career, but some were abstaining or trying to abstain from drugs. A critical period seems to be at 26-28 years of age, a period when the abuse seems to be most intense and compulsive, the suicide risk is high and the efforts to abstain from drugs most serious and hazardous.

Psychiatric aspects of cannabis use in adolescents and young adults.

A review of the psychiatric symptoms connected with cannabis use in adolescents and young adults is presented. Use of cannabis among teenagers can be perceived as a way of escaping from different kinds of conflicts in life. Cannabis use may be a way to provoke the parents. At the same time it is self-destructive and risky. Anxiety reactions, psychotic breakdowns may follow use. Heavy cannabis use may cause an 'amotivational syndrome'. The effects on the CNS seem to be reversible.

Regional cerebral blood flow in long-term heavy cannabis use.

Regional cerebral blood flow (rCBF) was measured by the 133Xenon inhalation method in nine male chronic cannabis users. The rCBF level in cannabis users was significantly (11%) lower than that of age- and sex-matched healthy controls. Four of the subjects were reexamined after 9-60 days of detoxification and showed a significant (12%) increase of the CBF level at followup. No significant regional flow abnormalities were noted. The global CBF reduction seen in the early phase of detoxification is most likely the consequence of the dysfunction of the central nervous system accompanying chronic cannabis use.

Psychiatric effects of cannabis use.

That cannabis use may provoke mental disturbances is well known to Scandinavian psychiatrists today. A review of the psychiatric aspects of cannabis use is given, and the clinical signs of 70 cases of cannabis psychoses collected in Sweden are described. The bluntness and "amotivation" following chronic cannabis use are discussed. Anxiety reactions, flashbacks, dysphoric reactions and an abstinence syndrome are all sequels of cannabis use. Three risk groups begin to emerge: a) Young teenage cannabis users who lose some of their capacity to learn complex functions and who flee from reality to a world of dreams. With its sedative effect, cannabis could modify such emotions as anger and anxiety and slow down the liberation process of adolescence. b) Heavy daily users, often persons who cannot cope with depression or their life circumstances. c) Psychiatric patients whose resistance to relapses into psychotic reactions might be diminished according to the psychotropic effects of cannabis.

Assaultive alcoholics 20 years later.

In a consecutive series of 257 alcoholics from an out-patient department 53 were judged as assaultive and 38 as suicidally inclined at the clinical examination 20 years ago. At the follow-up the assaultive alcoholics had a 3.3 times increased mortality rate, the suicidally inclined 1.9 times and the others 1.7 times compared with the general population. The assaultive alcoholics had an increased rate of suicides, intoxications and other alcohol-related deaths compared with other alcoholics. Repeated assaultive behaviour was uncommon. It is concluded that a skilled psychiatric evaluation of assaultive behaviour in alcoholism has an important predictive value.

Drug careers in perspective.

This paper reports the results of a 10-year follow-up of a pioneer group of 36 opiate addicts treated at a detoxification unit at St Lars Hospital in Lund in the years 1971-72. Sixteen of them are now ex-addicts. Their way out of addiction is described. The results show that there exists a turning process during which some kind of therapeutic action could be of considerable value. The ex-addicts go through a period in which they show signs of an identity conflict. During this period women seem more inclined to relapse than men. This stresses the importance of long-term therapeutic strategies.

Cannabis psychoses in south Sweden.

Eleven patients with a psychosis in connection with cannabis abuse admitted to two mental hospitals during 1 year were examined. Patients with a pre-existent psychosis or a mixed abuse were excluded. The patients were divided into three groups: acute, subacute and chronic. The features of the disease were essentially similar in all patients, with a mixture of affective and schizophrenia-like symptoms, confusion and a pronounced aggressiveness. The course as a rule was self-limiting leaving no residual symptoms. There was almost no heredity of severe mental disease. The symptoms were very similar to those seen in cycloid psychosis, and a possible relationship between the two diseases is discussed. As regards the widespread abuse of cannabis we conclude that psychosis is a rare complication but that in unclear psychotic states it is recommended to actively search for a cannabis psychosis.

An extrapyramidal choreiform syndrome caused by amphetamine addiction.

Four cases are described to demonstrate the extrapyramidal clinical syndrome sometimes appearing in chronic amphetamine users. The symptoms are dominated by choreiform or athetoid movements, ataxia and disturbances of gait. The syndrome develops during amphetamine abuse and may be observed also during abstinence. The symptoms usually disappear within a week when the drug is discontinued, but may remain for years.