Evaluation of heroin maintenance in controlled trial.

Ninety-six confirmed heroin addicts requesting a heroin maintenance prescription were randomly allocated to treatment with injectable heroin or oral methadone. Progress was monitored throughout the next 12 months by research workers operating independently of the clinic. Heroin can be seen as maintaining the status quo, with the majority continuing to inject heroin regularly and to supplement their maintenance prescription from other sources; it was associated with a continuing intermediate level of involvement with the drug subculture and criminal activity. Refusal to prescribe heroin while offering oral methadone constituted a more confrontational response and resulted in a higher abstinence rate, but also a greater dependence on illegal sources of drugs for these who continued to inject. Those offered oral methadone tended to polarize toward high or low categories of illegal drug use and involvement with the drug subculture, and were more likely to be arrested during the 12-month follow-up. There was no difference between the two groups in terms of employment, health, or consumption of nonopiate drugs. Refusal to prescribe heroin resulted in a significantly greater drop out from regular treatment.

Opiates: prevalence and demographic factors.

This paper focuses on the prevalence and profile of opiate use, primarily heroin, in the United States and Europe. Methods include representative population surveys, which understate prevalence, and targeted approaches, which reflect more problematic use. In the United States and Europe, the lifetime prevalence of opiate use reported in surveys remained stable over the 1980s (around 1%), though young adults report higher rates. Estimates for the early 1990s suggest that the prevalence of problematic heroin use in the United States was double the average for western Europe. However, in a few European countries prevalence is now approaching that of the United States. Rates in major cities are considerably higher, especially in the north-east and south-west of the United States. Higher prevalence is often, although not always, associated with socio-economic deprivation. An important trend away from injecting is observed, notably in some European countries. Heroin availability and use, as well as serious heroin-related consequences, are increasing again in many European countries after an apparent pause in the mid-1980s. They are also increasing in parts of the United States. Heroin remains a public health priority, especially among vulnerable populations, including young people in central and eastern Europe.

Opiate and cocaine consumers attending Barcelona emergency rooms: a one year survey (1989).

Due to the limitations of standard epidemiological methods, indirect indicators have often been used to describe the characteristics of drug abusing populations and to assess prevalence trends in illegal drug use. In Barcelona (Spain), a study of emergency room (ER) attendance was carried out to describe the population of opiate/cocaine consumers across the whole city who use this service. Three thousand four hundred and five consumers of opiates and/or cocaine, aged 15-44 years, who attended ERs during 1989, were identified. They accounted for 6807 episodes in the hospitals surveyed. Their mean age was 26 years, men (73%) being 1 year older than women (25.2 years). The drug of abuse was specified in the clinical records of 60% of individuals, heroin being the most frequently specified (56%). The main reason for attendance was 'other medical condition' (OMC) (55% of episodes), followed by withdrawal (34%) and overdoses (6%). Seventy-one percent of individuals were residents of Barcelona city, yielding a rate of 3.2 opiate/cocaine consumers attending ERs per thousand Barcelona residents aged 15-44. The geographical distribution of the rates in the city showed a very large difference between districts, the most deprived ones having a higher rate of consumers attending ERs. ER data can provide valuable insights into the nature and dimensions of drug abuse problems.

A small area analysis estimating the prevalence of addiction to opioids in Barcelona, 1993.

STUDY OBJECTIVE: To determine the distribution of opioid use prevalence in small areas and its relation with socioeconomic indicators. DESIGN: Capture-recapture was applied using data from the Barcelona Drug Information System for 1993 (treatment demands, hospital emergency room visits, deaths from heroin acute adverse reaction and pre-trial prison admissions). To avoid dependence between sources, a log-linear regression model with interactions was fitted. For small neighbourhoods, where capture-recapture estimates were not obtainable, the Heroin Problem Index (HPI) was used to predict prevalence rates from a regression model. The correlation between estimated opioid use prevalence by neighbourhoods and their socioeconomic level was computed. MAIN RESULTS: The city's estimated prevalence was 12.9 opioid addicts per 1000 inhabitants aged 15 to 44 years (95% CI: 10.1, 17.2), which represents 9176 persons. The highest rate was found in the inner city neighbourhood. Comparing rates obtained for each neighbourhood with their unemployment rates, a high correlation coefficient was obtained (r = 0.80, p < 0.001). CONCLUSION: The main contribution of this study is that of combining capture-recapture with the HPI to produce small area prevalence estimates, which would not have been possible using only one method. Areas with higher socioeconomic status showed proportionally low addiction prevalences, but in depressed areas, prevalences varied widely.

Non-pharmacological factors in drug abuse.

This paper examines the relevance of laboratory models of drug abuse to drug taking in human societies, and discusses their significance relative to other explanatory frameworks. It argues that self-administration models are poor predictors of the prevalence of drug taking, and offer an inadequate basis for both explanation and intervention. Non-pharmacological factors that may be of greater importance derive from social perspectives (notably economic and market factors, socio-economic conditions, and cultural and subcultural processes) and psychological approaches (individual, social learning, cognitive and developmental). It is concluded that drug abuse should be understood within the same framework of explanation as other human behaviour and sentiment, having major cultural, social and cognitive dimensions as well as the strictly behavioural and pharmacological.

Epidemiological approaches to drug misuse in Britain.

Most surveys in Britain are carried out at local level, though some indicators are monitored at national level. An example of a successful multi-source and multiple method model used in local studies is described. The importance of integrating both quantitative and qualitative approaches is stressed. The emphasis is on the value of local research, and of comparative studies between localities (e.g., cities). National surveys offer a useful baseline against which to set local studies. They are also used to inform broad policies, though it is argued that they are often misused and that their contribution at national policy level is overrated. Most service delivery and prevention activities occur at local level. It is here that research can be interpreted in the local context, thus giving richer and more relevant insights. It is important that a range of methods and sources are used, since any one approach is partial and can easily lead to bias. The strengths and weaknesses of different methods are discussed.

Food supply, grazing activity and growth rate in the limpet Patella vulgata L.: a comparison between exposed and sheltered shores.

The limpet Patella vulgata L. is an important microphagous grazer on intertidal rocky shores of north-west Europe, occurring across the wave exposure gradient. Groups of P. vulgata were selected at mid-tide level of two exposed shores and two sheltered, fucoid dominated shores on the Isle of Man, British Isles, and manipulated to equivalent densities and population structure. The level of grazing activity and growth rate were determined over a 1-year period. At the same time, the abundance of epilithic microalgae, measured as the concentration of chlorophyll a, was determined as an estimate of food supply. Microagal abundance showed a seasonal pattern in both exposed and sheltered conditions, with higher levels in winter compared to summer. In both seasons, the microalgal resource was more abundant on the sheltered shore studied. The level of grazing activity in P. vulgata showed a seasonal pattern on the exposed but not the sheltered shores. Averaged over the year, grazing activity on the exposed shores was over double that on sheltered shores. Thus, in sheltered conditions, food supply for limpets was high and grazing activity low; in exposed conditions, food supply was low and grazing activity high. The growth rate of P. vulgata, measured as increase in shell length, showed no significant difference between exposed and sheltered shores. Growth rate was also determined in P. vulgata at natural densities. Although the overall density declined with decreasing exposure to wave action, the density per unit area of grazeable substance was higher in shelter. In these populations, the mean growth rate was over twice as high on exposed compared to sheltered shores.

Psychosocial considerations for the prevention of HIV infection in injecting drug users.

In this article, the authors discuss a study that investigated the meaning that injecting drug users attribute to risk behaviors linked to HIV transmission, especially through the use of nonsterile syringes or the failure to use condoms. To do this, social discourses with respect to the prevention of HIV infection are evaluated. The discussion focuses on how these discourses affect the daily practices of heroin users, practices that in turn influence discourses. Ethnography was used to observe 78 heroin users and 35 people following a methadone treatment program. Observation was carried out in a central district of Barcelona, Spain, with a low socioeconomic level. The results are a useful starting point for generating strategies aimed at preventing HIV transmission among this population on personal, community, and sociostructural levels.

Seasonal variations in activity concentrations of 99Tc and 137Cs in the edible meat fraction of crabs and lobsters from the central Irish Sea.

Discharges of most radionuclides into the Irish Sea from the BNFL site at Sellafield have decreased over the past 20 years or so. For a few radionuclides, however, discharges have peaked more recently. Notably, operation of the Enhanced Actinide Removal Plant (EARP) since 1994 has led to an increase in discharges of (99)Tc, as a result of the treatment of previously stored waste, with consequent increases in (99)Tc activity concentrations in a number of marine species, particularly in crustaceans such as lobsters. Previous research has considered the significance of factors such as sex and body weight on radionuclide concentrations. The current project set out to investigate whether seasonal variations in radionuclide concentrations in crabs and lobsters occur, with particular emphasis on the dynamics of (99)Tc and (137)Cs. Organisms were obtained from a site off the Isle of Man, where radionuclide concentrations were measurable but the site was sufficiently distant from Sellafield that the radionuclides were well mixed in the water column and not likely to be influenced by the pulsed nature of discharges of (99)Tc. Crab and lobster samples were collected monthly, between February 2000 and February 2001. Fifteen or 16 individuals (evenly split as male and female) of each species were collected on each occasion. Seawater samples were also collected over the 12-month period. Activity concentrations of (99)Tc in the edible meat fraction (both brown and white meat) ranged from 0.23 to 2.46 Bq kg(-1) (fresh weight (fw)) in crabs and 124 to 216 Bq kg(-1) (fw) in lobsters, with no observed seasonal variations. Activity concentrations of (137)Cs in both crab and lobster were lower, ranging from <0.16 to 0.85 Bq kg(-1) for crab meat (fw) and <0.3 to 3.3 Bq kg(-1) for lobster meat (fw). A statistically significant increase in activity concentrations of (137)Cs in the meat was observed in the summer months for both crab and lobster. The cause has not been investigated but may be related to the laying down of energy reserves during the active feeding period over the summer. At all times, uptake of (99)Tc is higher in the brown meat fraction of both crabs and lobsters, whilst (137)Cs is more uniformly distributed. These results are used to discuss the implications for sampling and monitoring programmes.

[Information on opiate and cocaine consumption in the emergency room clinical records: validity and reliability]. / Información sobre el consumo de opioides y cocaína en la anamnesis de urgencias: validez y fiabilidad.

BACKGROUND: Data on drug consumption obtained from emergency room clinical records have been used for various epidemiological purposes. However the validity and reliability of these data remain unknown. This paper assesses the reliability and validity of an Emergency Room Toxicological Register (HMR) which has collected information on drug misuse from emergency room clinical records since 1979, and examines the implications for epidemiological applications. SUBJECTS AND METHODS: An Emergency Room Survey (ERS) was carried out in a Barcelona Hospital including opiate or cocaine users identified by the physician and a systematic sample of other patients age 15 to 49 years old. Data on clinical records of interviewed patients were also reviewed. Episodes from identified drug users (686) and HMR (676) for the same study period were linked and validity and reliability were analyzed. RESULTS: Sensitivity ranged between 63 and 86%, and specificity was 98%, Kappa index higher than 0.72 and intraclass correlation coefficient was 0.99. CONCLUSIONS: Information about drug users included in emergency room clinical records proved to be valid as an information system for drug use surveillance. However data about patterns of less heavy users, as cocaine use, are underreported.

A framework for evaluating activities to reduce the demand for drugs in Europe.

This paper describes a provisional framework that could be used to help compare and evaluate activities concerned with reducing the demand for illicit drugs in the European Community. It provides a background to European concern in this field, and comments on some methodological problems that arise regarding evaluation. The overall goal of demand reduction may be attempted through a diverse range of activities--treatment and rehabilitation, reduction of secondary harm arising from drug use, primary prevention, and suppression of drug availability and use--each of which may involve different interventions at different levels of generality and with different subsidiary objectives. Thus it is essential that data for evaluation are collected in terms of a framework where demand reduction activities and their objectives are clearly specified, together with criteria for success or failure, appropriate measures for those criteria and suitable methods to obtain those measures. The paper provides some examples of how this framework could be applied to evaluating attempts to reduce demand for drug through treating addicts, and comments on the use of global measures (indicators) of trends in the demand for drugs. A possible administrative structure for comparing drug demand activities in different countries through a European network on health data is suggested.

[Prevalence of human immunodeficiency virus and risk behaviours among opioid users seen in an emergency room]. / Prevalencia de la infección por el virus de la inmunodeficiencia humana y conductas de riesgo en consumidores de opioides visitados en un servicio de urgencias.

INTRODUCTION: As prevalence of HIV-1 among drug users in Spain is high and it is difficult to contact them because of their hidden behaviors, emergency rooms are one of the health facilities where they can be located. A cross-sectional interview study was planned. The aims of the study were to estimate prevalence of HIV-1 and to describe risk behaviors. METHODS: The sample included all patients that in spring 1992 were detected and referred by the doctor as being current opiate users, defined as any use in the 30 days prior the interview. Drug users who did not know their HIV status or were negative for more than six months were asked to provide a urine sample to test HIV serology. A descriptive analysis with simple stratification was carried out. Row and adjusted odds ratio were used to analyse association between different variables and HIV status. Logistic regression was used to examine variables associated with HIV infection and risk behaviors (injecting drug use, sharing needles, and no use of condom). RESULTS: Three hundred and eighty three opiate users were interviewed. It was possible to know HIV status of 94% of the subjects. Of them, 61% were positive (219). The best adjusted logistic model to predict associated variables with HIV included being female, primary school level, sickness absence, to attend because of organic pathology, and more years of parenteral use. Seventy five percent of the sample injected drugs during the past 30 days, and among them 30% shared syringes. The variables associated with a higher probability of having injected heroin or cocaine in the last 30 days were to have completed at least primary education, to be unemployed or reliant on illegal activities, not to be in drug treatment, and a larger number of drugs used in the last 30 days. A higher probability of sharing syringes was associated with a lower educational level, not to be in drug treatment, to live alone and a higher number of drugs used during last 30 days. Twenty one percent of the subjects who were sexually active always or nearly always used condom with regular partners and 56% with casual partners. Women were more likely to use condom than men with casual partners. Subjects who shared syringes during last 30 days were nearly three times more likely not to use condom with casual partners. CONCLUSIONS: Although a high prevalence of HIV-1 was estimated among opioid users seen in an emergency room, it is not higher than estimates for intravenous drug users recruited from treatment centres, prison or needles exchange programs. A high frequency of risk behavior was also observed indicating a need to develop specific prevention programs for drug users.

[The characteristics of opiate users seen in an emergency service]. / Características de los consumidores de opioides visitados en un servicio de urgencias.

INTRODUCTION: Despite of the fact that it was reported for years that emergency rooms are the first health services where drug users attend, there are very few direct studies of this population. In most emergency room studies, the information was obtained from data available in the clinical records, and in very few drug users were interviewed. With the aim of having a deeper knowledge of opiate users who attend the emergency room it was planned to carry out a cross-sectional study interviewing them. The aims of this paper are to describe demographic characteristics, patterns of drug use and to know whether they contact first to an emergency room or to a treatment centre. METHODS: The sample included all patients detected and referred by the doctor as being current opiate users, defined as any use in the 30 days prior the interview. A descriptive bivariate analysis with simple stratification was carried out. RESULTS: Of the subjects referred by the doctor 383 opiate users were interviewed and 76 were not interviewed. The male/female ratio for the 383 interviewed opiates users was 2. Women were younger than men (25.8 vs 28.3, p (3/4) 0.001). Heroin or cocaine ever injected was reported by 93% and 76% reported injecting in the last 30 days. The mean age at the first use of heroin was higher for those who started use during 1989 or after (21.6) than those who started before 1989 (17.9) (p (3/4) 0.0001). Patients attending the emergency room for organic pathology were older (28.5) than those who attended for withdrawal (26.2) and those who attended for overdose (27.3) (p (3/4) 0.05). Thirty eight percent reported to attend first an emergency room for a drug related problem since they started drug use, and 47% to contact first with a treatment centre for drug dependence. CONCLUSION: Drug users interviewed seem to be more heavy users than those who started drug treatment in the public centres of Barcelona in 1992. Also, the hypothesis that emergency rooms are for this population the first contact point with health services is not supported by this study.

Research and the help-seeking process.

Recognition of changes in the nature and extent of problem drug taking in the early 1980s led to changes in service provision and to an increased interest in help-seeking. The advent of AIDS accelerated these changes. This paper introduces concepts from the wider field of help-seeking and compliance with preventive health measures. It reviews the major conclusions of studies of help-seeking by problem drug takers, and identifies areas for further research. These include the need to 'unpack' the concept of 'drug problems' and to differentiate dimensions of needs in different individuals and populations; to evaluate attempts to make services attractive and accessible and to contact out-of-treatment groups; to assess the role of 'significant others'; to understand the demands that changing service roles place on agency staff; and to give greater prominence to studies of the process of help-seeking in terms of drug users' perceptions of their drug use, of problems, of risks and of services within the wider context of their lifestyles.

Current situation relating to drug abuse assessment in European countries.

An increasing abuse of drugs among young people emerged in northwestern Europe during the late 1960s and early 1970s. Since the mid-1970s, the two most important trends have been the substantial increase in heroin abuse in most countries and increasing drug abuse in southern and eastern European countries that had relatively little previous experience with illicit drug use. Drug abuse is assessed using routine statistics, which are available but unreliable, or special epidemiological studies, which are more reliable but also more expensive. There is a need for more systematic and centralized monitoring of routine data from both treatment and enforcement sources; improved co-operation in such activities between European countries would enhance the value and utility of epidemiological work. Common criteria and definitions, as well as data-gathering instruments, need to be adopted so that data on drug abuse will be more comparable. The ways and means through which countries exchange knowledge and experience gained in drug abuse assessment need to be improved.

The role of significant life events in discriminating help-seeking among illicit drug users.

This paper examines the role of significant life events in distinguishing two samples of illicit drug users: 120 help-seekers (the "agency group") and 120 not seeking help (the "non-agency group"). We examined 10 life areas clustered around the general categories of "substance use," "social functioning," and "emotional and interpersonal functioning." A range of objective and self-reported information was collected regarding each life area covering the 12 months prior to interview. Analysis revealed that the agency group experienced a greater number of negatively perceived drug-related life events than the non-agency group. These life events were also more likely to have occurred in recent months, prompting reported "concern" and "need for help" among the agency group. Additionally, length of use of current primary drug was seen to be a contributory variable in distinguishing between the groups.

Help-seeking among illicit drug users: some differences between a treatment and nontreatment sample.

A number of both medical and nonmedical disciplines have expressed concern regarding the large numbers of individuals that fail to present to services, despite experiencing problems similar to those of active help-seekers. Such a concern is most pertinent in the field of substance misuse, particularly in terms of the role of injecting drug users in the spread of HIV and AIDS. This study looked at two samples of problem drug takers in London: 120 seeking help (the "agency group") and 120 not seeking help (the "non-agency group"). A number of factors were examined to distinguish the two groups, including sociodemographic profiles, drug histories, and self-reported "concern" and "need for help" in a wide variety of life areas. Data analysis highlighted the significance of "concern" and "need for help" in specified life areas.

Use of capture-recapture to estimate the prevalence of opiate addiction in Barcelona, Spain, 1989.

It is difficult to obtain accurate prevalence estimates of opiate addiction with direct methods. The capture-recapture method has been used to estimate the prevalence of hidden populations, including opiate addicts. In this study, we applied capture-recapture, including log-linear modeling, to estimate the prevalence of opiate addicts in Barcelona, Spain. Anonymous identification data from three 1989 sources (hospital emergency rooms, treatment admissions, and heroin overdose deaths) in Barcelona were used to obtain population samples. For prevalence estimation, two strategies were followed: 1) emergency room data only, divided into trimesters; and 2) all three sources used simultaneously. Estimates based only on emergency room data were lower than estimates obtained by the simultaneous analysis of all three data sources; the latter estimates gave narrower confidence intervals (6,324-7,414 addicts), giving a prevalence for Barcelona in 1989 of between 8.5 and 9.9 opiate addicts per 1,000 residents aged 15-44 years. The estimated prevalence varied by sex and age group and was highest in males aged 15-29 years (between 17.1 and 21.2). At least 42% had contacted one or more of the services studied, although only one in seven had been admitted for treatment during 1989. Capture-recapture is the election method for prevalence estimation when direct methods are not feasible.