"My first 48 hours out": drug users' perspectives on challenges and strategies upon release from prison.

BACKGROUND: Prisoners report much higher prevalence rates of drug use and more harmful consumption patterns than the general population. People who use drugs have above-average experiences with the criminal justice system in general, and the prison system and subsequent release situations in particular. Release from prison is associated with increased mortality rates among drug users due to the risk of overdose. The EU-funded project 'My first 48 hours out' aimed to address the gaps in continuity of care for long-term drug users in prison and upon release, with a special focus on drug user's perspectives on needs and challenges upon release. METHODS: A multi-country (Belgium, France, Germany and Portugal) qualitative study was set up to explore drug users' perceptions of drug use and risk behaviour upon prison release, experiences of incarceration and release, and strategies to avoid risks when being released. In total, 104 prisoners and recently released persons with a history of drug use participated in semi-structured interviews and focus groups discussions on these topics. RESULTS: Respondents pointed out that there are numerous challenges for people who use drugs when released from prison. Lack of stable housing and employment support were frequently mentioned, as well as complex administrative procedures regarding access to services, health insurance and welfare benefits. Besides structural challenges, individual issues may challenge social reintegration like 'old habits', mental health problems and disrupted social networks. As a result, (ex-)prisoners adopt individual strategies to cope with the risks and challenges at release. CONCLUSION: Measures to prepare prisoners for release often do not focus on the individual and specific challenges of persons who use drugs. Psychosocial and medical support need to be improved and adjusted to drug users' needs inside and outside prison. To improve the quality and continuity of care around release, the perspectives and coping strategies of people who use drugs should be used to better address their needs and barriers to treatment.

Assessment of a psychiatric intervention at community level for people who inject drugs in a low-middle income country: the DRIVE-Mind cohort study in Hai Phong, Viet Nam.

BACKGROUND: Access to psychiatric care for people who inject drugs (PWID) is limited/absent and stigmatized in most low-middle-income countries (LMICs). Innovative interventions are needed. We aimed to describe and assess the impact of a community-based psychiatric intervention among PWID in Hai Phong, Vietnam. METHODS: In a cohort study with one year psychiatric follow-up, PWID diagnosed with a psychotic disorder, a major depressive episode, or suicide risk, were recruited from the wider Drug-Related Infections in ViEtnam (DRIVE) project in the city of Hai Phong. The community-based psychiatric intervention included specialized follow-up (free consultations with psychiatrists, free medication, referral to mental health department for hospitalization when necessary) and support from community-based organisations (case management, harm reduction, administrative support, linkage to HIV care, methadone maintenance treatment and mental health support). The main outcome was reduction/remission of symptoms. Access to and retention in psychiatric care, quality-of-life and stigmatization were also measured pre and post-intervention. FINDINGS: Among the 1212 participants screened from March to May 2019, 271 met the inclusion criteria, 233 (86.3%) accepted the intervention and 170 completed the follow-up (72.9%). At inclusion, 80.6% were diagnosed with current depression, 44.7% with psychotic disorder and 42.4% with suicide risk. After a one-year follow-up, these proportions dropped to 15.9%, 21.8%, and 22.9% respectively. Quality-of-life and perceived stigma related to mental health were also significantly improved, while drug use decreased only marginally. INTERPRETATION: Community-based psychiatric interventions are both feasible and efficient in the Vietnamese context. Similar interventions should be implemented and evaluated in other, different LMICs. FUNDING: : This work was supported by grants from NIDA (US) (#DA041978) and ANRS (France) (#13353). The funding agencies had no role in designing the research, data analyses, or preparation of the report.

Development and assessment of a community-based screening tool for mental health disorders among people who inject drugs.

INTRODUCTION: The prevalence of mental health disorders among people who use drugs is high and well documented. This hard-to-reach population faces a very low awareness and access to mental health care, especially in developing countries. The objectives of this study were to design and assess a quick screening tool (QST) that community-based organisations (CBO) could routinely apply to a Vietnamese population of people who inject drugs (PWID), in order to refer them appropriately to mental health specialists. METHODS: We devised a tool that included nine questions covering anxiety, depression, suicide risk and psychotic symptomatology. Its use required no specific background and 2 h training. Specificity and sensitivity of the QST were assessed in a population of 418 PWID recruited via respondent driven sampling, using the Mini International Neuropsychiatric Interview questionnaire plus clinical evaluation as a reference standard. Acceptability was assessed using a self-administered anonymous questionnaire submitted to all CBO members who used the QST. RESULTS: CBO members considered the QST easy to use, relevant and helpful to deal with mental health issues. Area under the curve for detection of any symptom using the QST was 0.770. The maximum sensitivity and specificity were reached with a cut-off of 2 [sensitivity was 71.1% (95% confidence interval 62.4, 78.8), specificity was 75.9% (70.5, 80.7)]. DISCUSSION AND CONCLUSIONS: The QST appeared to be both efficient and well accepted. Given the burden of mental health problems among hard-to-reach PWID in developing countries, community-based screenings such as this one could be a particularly appropriate response.

Injecting drug use during sex (known as "slamming") among men who have sex with men: Results from a time-location sampling survey conducted in five cities, France.

BACKGROUND: In the last decade, European cities saw the development of "slamming," a practice related to chemsex that combines three elements: a sexual context, psychostimulant drug use, and injection practices. Epidemiological data on this practice is still sparse and media attention might have unintentionally distorted the size of this phenomenon. Therefore, we aimed to estimate the prevalence of men practicing slam and to identify factors associated with this practice. METHODS: We used data from the Prevagay 2015 bio-behavioral survey to estimate the prevalence of slamming practices. A time-location sampling was performed among gay-labeled venues in five French cites. Behavioral information was recorded using a self-administered questionnaire. The HIV and HCV serostatus were investigated using ELISA tests on dried blood spots. The factors associated with slamming were assessed using a multiple logistic regression. We applied a weighting mechanism to enhance the generalizability of the estimates. RESULTS: Among the 2646 men who have sex with men (MSM) included in our study, 3.1% reported slamming at least once during their lifetime (95% confidence interval (CI) = 2.2-4.3) and 1.6% (95% CI = 1-2.3) said they participated in a slamming session in the last 12 months. In the multivariate analysis, both HCV and HIV biological status were strongly associated with practicing "slam" in the last 12 months (OR = 13.37 (95% CI = 3.26-54.81) and 4.73 (95% CI = 1.58-14.44), respectively). Furthermore, a ten-point decrease in mental health scores was linked with the practice with an OR of 1.37 (95% CI = 1.08-1.73), indicating poorer mental health. CONCLUSION: Even though slamming seems to involve a relatively small proportion of MSM, the vulnerability of this sub-group is high enough to justify setting up harm reduction measures and specific care. Training health professionals and creating services combining sexual health and drug dependence could be an effective response.

Daily heroin injection and psychiatric disorders: A cross-sectional survey among People Who Inject Drugs (PWID) in Haiphong, Vietnam.

BACKGROUND: Psychiatric comorbidities are frequent among people who inject drugs, they are associated with a poorer prognosis and need to be addressed. Their interaction with daily heroin injection requires clarification. METHODS: A cross-sectional survey was conducted among PWID recruited in the city of Haiphong, Vietnam, by respondent-driven sampling. The inclusion criteria were age 18 or older and current injection drug use, verified by skin marks and positive urine tests for heroin or methamphetamine. Data on socio-demographic characteristics, drug use, sexual behaviour and access to treatment were collected using face-to-face questionnaires by trained interviewers. PWID were screened by trained psychiatrists for depression, psychotic disorder and suicidality, using the MINI questionnaire. RESULTS: 418 participants were included in the analyses. All were injected heroin users, 21 % were diagnosed with a current major depressive disorder, 15 % with a current psychotic disorder and 12 % presented a suicide risk. In the bivariate analyses, regular meth use, cannabis use and ketamine use were positively associated with presenting at least one psychiatric condition while daily heroin injection and being currently treated with methadone were negatively associated. In the multivariate model, poly-substance use was positively associated with depression (methamphetamine and drinking in addition to heroin) and psychotic disorder (methamphetamine and/or hazardous drinking in addition to heroin) while daily heroin injection and current methadone treatment were negatively and independently associated with depression and psychotic syndrome. CONCLUSIONS: Our survey confirms the burden of methamphetamine use and the protective effect of methadone but also a possible protective effect of daily heroin injection.

Self-reported injection practices among people who use drugs in French prisons: Public health implications (ANRS-Coquelicot survey 2011-2013).

INTRODUCTION AND AIMS: The aims of this study were to describe the prevalences of injection practices and needle/syringe sharing in people who use drugs in French prisons, and to investigate associated factors. DESIGN AND METHODS: Using the ANRS-Coquelicot survey (2011-2013), a random sample of 1718 people who used drugs in free society was included. Information regarding a history of incarceration, drug-injection practices inside prison and needle/syringe sharing was collected during interviews. RESULTS: In our sample, 65.5% reported a history of injection and 57.4% had been incarcerated at least once. Among those who reported both of these conditions, 14% reported injection practices inside prison, 40.5% of whom had shared needles/syringes. In the multivariable model, the following variables were associated with injection practices inside prison: being a Russian-speaking detainee, having spent more time in prison, and having started to inject before 1996 and especially before 1987. Being Russian speaking was also associated with needle/syringe sharing in prison. DISCUSSION AND CONCLUSIONS: The prevalences of injection practices and needle/syringe sharing in prisons are alarmingly high. Effective interventions to prevent the transmission of infectious diseases among people who use drugs in the prison setting are essential. The implementation of international recommendations on the principle of equivalence between prisons and the community is still very limited in most countries, and should be complemented with tailored interventions for the most vulnerable prison populations, especially Russian-speaking detainees.

Low-grade systemic inflammation: a partial mediator of the relationship between diabetes and lung function.

PURPOSE: An association has been consistently found between diabetes mellitus and decreased lung function. We evaluated to what extent low-grade inflammation (as measured by the level of high-sensitivity C-reactive protein [hs-CRP]) could explain this relationship. METHODS: A sample of 1878 middle-aged adults from the cross-sectional Enquête Littoral Souffle Air Biologie Environnement survey without self-reported pulmonary and atherosclerosis disease was included. A mediation analysis was performed to assess and quantify the hs-CRP level as a mediator of the relationship between diabetes and lung function. RESULTS: Diabetes was associated with higher hs-CRP level (+22.9%, 95% confidence interval = [5.1, 43.6]). The hs-CRP (>4 vs. ≤1 mg/L) was associated with lower percentage predicted values for the forced expiratory volume in the first second (FEV1) (-4% [-6.1, -1.9]) and forced vital capacity (FVC) (-4.4% [-6.5, -2.3]). Diabetes was associated with FEV1 (-3.5% [-5.8, -1.3]) and FVC (-3.6% [-5.9, -1.3]). The proportion of the effect that is mediated by hs-CRP was 12% [2.4, 37] and 13% [3.7, 39.4] for FEV1 and FVC, respectively. CONCLUSIONS: Our results suggest that low-grade systemic inflammation could only explain a small part of the relationship between diabetes and lung function.