Factors that influence smokers' and ex-smokers' use of IQOS: a qualitative study of IQOS users and ex-users in the UK.

BACKGROUND: One of the most widely available heated tobacco products is IQOS by Philip Morris International. However, there is a lack of independent research exploring IQOS initiation and subsequent use among smokers and ex-smokers. AIMS: To (1) explore the reasons why smokers and ex-smokers use and continue/discontinue IQOS and (2) consider implications for future research and policy. PARTICIPANTS: Adult (18+) current (n=22) and ex-users (n=8) of IQOS who either currently smoked or quit smoking in the last 2 years. METHODS: Qualitative interview study in London, UK. RESULTS: Six main factors influenced initiation and use of IQOS: (1) Health-wanting to reduce/quit smoking and perceptions of reduced harm (while understanding IQOS was not risk-free). Branded packaging, absence of pictorial warnings and physical health improvements conveyed reduced harm. (2) Financial-including high start-up costs, but cheaper ongoing costs than smoking. (3) Physical-mixed views on enjoyment and satisfaction. Sensory experiences influenced use including discreetness, cleanliness, reduced smell and tactile similarities relative to combustible cigarettes. (4) Practical-issues of accessibility, shortcomings with maintenance/operation limited ongoing use, whereas use in smoke-free places increased use. (5) Psychological-similarities in rituals and routines, although new practices developed to charge and clean; some liked trailblazing new technology. (6) Social-improved social interactions from using IQOS instead of smoking, but with more limited shared social experiences for some. CONCLUSION: For some, IQOS facilitated smoking substitution. Factors such as packaging, labelling, risk communication, price and smoke-free policies appear to influence initiation and use.

'I perceive it to be less harmful, I have no idea if it is or not:' a qualitative exploration of the harm perceptions of IQOS among adult users.

BACKGROUND: Harm perceptions of tobacco and nicotine products can influence their use and could be targeted by policies to change behaviour. IQOS was introduced to the UK in 2016, and there is little independent qualitative research on IQOS harm perceptions. This study explored the perceived health harms of IQOS to users and those exposed to the emissions, what shapes these perceptions, and what participants wanted to know about the harms of IQOS. METHODS: Qualitative interviews in London, UK, with 30 adult current and former IQOS users who currently smoked or quit smoking in the last 2 years. RESULTS: IQOS was perceived as less harmful than smoking but not risk-free, although there was great uncertainty. Influences on harm perceptions were consolidated into six themes: (1) dominance of manufacturer claims influenced perceptions that IQOS is less harmful than smoking to users and those around them, although mistrust of the tobacco industry heightened scepticism about harms; (2) limited independent and long-term research led to uncertainty about harms, although some participants trusted IQOS would not be marketed if it were very harmful. Participants wanted more independent and long-term studies into harm; (3) appearance of HEETS (tobacco sticks) packaging conveyed reduced harm because packets were 'pretty', without graphic/specific warnings, although written warnings conveyed some harm. Participants wanted more information on HEETS packets about harms; (4) process of heating and HEETS contents-heating, compared with burning, tobacco was perceived to produce fewer harmful chemicals, while tobacco, nicotine, and chemicals in HEETS were perceived to cause some harm. Participants wanted clarification about the harms of heating tobacco and HEETS ingredients; (5) improvements in physical health and personal appearance reduced perceptions of harm; (6) differences in sensory experiences (taste, sight, smell) when using IQOS over smoking reduced perceptions of harm, while 'black' deposits inside IQOS led to perceptions of some harm. Reduced volume and smell of IQOS emissions also reduced perceptions of harm to non-users exposed to the emissions. CONCLUSIONS: IQOS was perceived as less harmful than smoking but not risk-free, although there was great uncertainty. Participants wanted clarification about IQOS harms from independent sources in accessible forms, specifically related to HEETS ingredients, heating tobacco, and emissions to others.

Prolonged-release opioid agonist therapy: qualitative study exploring patients' views of 1-week, 1-month, and 6-month buprenorphine formulations.

BACKGROUND: Options for opioid agonist therapy (OAT) are expanding with the development of prolonged-release (also known as extended-release) 1-week, 1-month, and 6-month formulations of buprenorphine. There is an assumption that patients will welcome these new treatments and medication adherence will correspondingly increase. However, there has been little research exploring patients' views of prolonged-release buprenorphine. This paper aims to understand which durations patients prefer and why, and to consider the findings with reference to the development of future OAT products. METHODS: Data were generated as part of a qualitative interview study. Fieldwork was conducted in London, UK, during 2018 (before any prolonged-release OAT formulations were licensed in Europe). Participants (n = 36) were taking daily oral OAT (methadone or buprenorphine) or using heroin daily without OAT. They included 26 men and 10 women, aged 24-63 years. All were asked for their views on weekly, monthly, and six-monthly duration buprenorphine. Responses were audio-recorded, transcribed, and analyzed by Iterative Categorization. RESULTS: Participants generally stated that having buprenorphine of different prolonged durations was positive. They tended to believe that 'longer' prolonged-release formulations would be beneficial for patients who wanted to avoid thinking about drugs and drug-using associates, wished to evade the stigma of substance use, and desired 'normality' and 'recovery.' In contrast, participants favored 'shorter' prolonged-release formulations for patients who are new to OAT, worried about the safety and reliability/effectiveness of OAT, want a 'break' from street opioids, and need contact with services to monitor/support them. Participants indicated that transitioning between OAT medications of different duration would be a very individual process. Some also linked prolonged-release OAT duration to political, philosophical, and ethical issues, such as patient coercion and mental capability. CONCLUSIONS: Medication duration is an important but complex feature of prolonged-release buprenorphine, with patients' views and preferences likely to be influenced by a wide range of factors. We need further qualitative research to explore the experiences of people who have actually used prolonged-release OAT. Meanwhile, drug developers should continue to build flexibility and choice into OAT products to ensure that future treatment is acceptable to patients and able to accommodate their diverse individual needs.

'It's not what you'd term normal smoking': a qualitative exploration of language used to describe heated tobacco product use and associated user identity.

BACKGROUND AND AIMS: Tobacco and nicotine marketplaces have diversified over the past decade, including with the introduction of heated tobacco products (HTPs), such as the brand IQOS. HTPs typically heat tobacco to generate an aerosol that is inhaled. HTP nomenclature is lacking, and how HTP users define and identify themselves remains understudied. Research in this area is important because language can construct identity, and identity can shape behaviour. This study aimed to explore users' language choice when describing IQOS use, and how language relates to user identity. METHODS: Qualitative interviews in London, United Kingdom, with 30 adult current and former IQOS users. Analyses were guided by Iterative Categorization. RESULTS: Overall, participants expressed confusion and a lack of suitable terminology for how to describe IQOS use. Verbs such as heating and IQOSing were rarely endorsed. Most often, participants reverted to smoking when describing IQOS use and commonly referred to HEETS (tobacco sticks) as cigarettes. Yet the lack of combustion, electronic device, cleaner experience and perceived reductions in health risks led some to frame IQOS as distinct from smoking. Vaping was generally considered inappropriate for describing IQOS use. Participants also manipulated language to suit their circumstances and manage their identity, whereas some IQOS users embraced the terms smoking and smoker, most were eager to distinguish between using IQOS and being labelled a smoker because of the associated negative connotations and to align with perceptions of IQOS use as a better, less harmful behaviour. Instead, when describing their identity, IQOS users more willingly identified as vapers, or ex-smokers, or created new identities (e.g. HEET user). CONCLUSIONS: People who use or have used IQOS (a brand of heated tobacco product) are ambiguous about IQOS terminology. Participants in this study commonly referred to IQOS use as smoking for lack of a more suitable term, but also resisted being labelled as smokers, a choice that may influence smoking cessation. Clear terminology must be used in surveys and by healthcare professionals when asking about cigarette smoking and e-cigarette and heated tobacco product use.

Depot buprenorphine injections for opioid use disorder: Patient information needs and preferences.

INTRODUCTION AND AIMS: There has been significant recent investment in new medications for opioid use disorder, including buprenorphine depot injections. Patients and professionals need good quality, independent information on medications to help them make informed treatment decisions. This paper aims to understand patients' information needs and preferences in relation to buprenorphine depot injections. DESIGN AND METHODS: Semi-structured qualitative interviews were conducted with 36 people using opioids (26 men, 10 women; 24-63 years). Twelve participants were currently prescribed daily oral methadone; 12 were currently prescribed daily oral buprenorphine; and 12 were using heroin and not in treatment. Interviews were transcribed, coded and analysed via Iterative Categorisation. RESULTS: Participants asked many questions about depot buprenorphine injections. These related to: (i) medication purpose and availability; (ii) pharmacology; (iii) evidence base and effectiveness; (iv) safety and side effects; (v) administration and dosing; and (vi) reducing and ending treatment. Additionally, participants expressed their information preferences in terms of (i) 'format' and (ii) 'source'. Specifically, they wanted printed, verbal and electronic materials provided by people in authority, particularly patients who had already had the medication. DISCUSSION AND CONCLUSIONS: All potential patients should be offered accessible information on depot buprenorphine to enable them to consider their options and participate meaningfully in treatment decision making. We recommend that further qualitative research is undertaken to produce informative video material that describes patient experiences of receiving depot buprenorphine. This should help to balance biomedical knowledge with lay knowledge, so facilitating more informed discussions when decisions about depot buprenorphine treatment are made.

Factors influencing recruitment to a randomised placebo-controlled trial of oral naltrexone and extended release implant naltrexone: Qualitative study.

AIMS: To understand the influences on recruitment to the Naltrexone Enhanced Addiction Treatment (NEAT) study, a randomised placebo-controlled trial of extended-release naltrexone (XR-NTX) implants for opioid use disorder (OUD), to learn lessons for the design and conduct of similar future research. METHODS: 29 face-to-face, semi-structured qualitative interviews were conducted with patients recruited to NEAT (n = 6), patients not recruited (n = 11), researchers who designed the trial (n = 5), and staff who delivered the trial (n = 7). The social marketing mix was used as a framework to guide the data analyses. RESULTS: Dimensions of the 7Ps of the social marketing mix - product, price, place, promotion, physical environment, people, and processes all influenced recruitment to the NEAT trial. Among other things, the potential to receive a naltrexone implant (product); the provision of transport passes and shopping vouchers (price); clear verbal explanations (promotion); familiarity of the trial setting (physical environment); and approachable, friendly and informative trial delivery staff (people) positively influenced recruitment. Whereas, wanting a less medical approach to recovery (product); the perceived time, physical, and psychological costs of taking part (price); service ideological opposition to naltrexone in recovery (place); inaccessible written information (promotion); the location and nature of the trial setting (physical environment); a lack of knowledge about implants (people); and the blind allocation and potential of placebo (processes) deterred people from joining the trial. CONCLUSIONS: Qualitative research informed by the social marketing mix as an analytical framework yielded detailed insights into understanding the factors and circumstances that influenced recruitment to the NEAT trial. Our findings have implications for the planning and implementation of future addiction trials, especially trials of extended-release formulations.

Opioid users' willingness to receive prolonged-release buprenorphine depot injections for opioid use disorder.

AIMS: Prolonged-release implantable and depot injection formulations of buprenorphine are very recent developments in the treatment of opioid use disorder. Such formulations remove the need for daily dosing and provide patients with sustained concentrations of buprenorphine over a period of weeks or months. We explored opioid users' personal willingness to receive prolonged-release buprenorphine depot injections and factors influencing their interest. METHODS: The study took place in London during 2018, before depot buprenorphine was licensed for use in Europe. Thirty-six face-to-face, semi-structured qualitative interviews were conducted with people who were: i) using heroin daily and not receiving any treatment for opioid use (n = 12); or ii) prescribed daily oral buprenorphine (n = 12); or iii) prescribed daily oral methadone (n = 12). Participants were asked about their willingness to receive depot buprenorphine and were encouraged to discuss factors that might alter their opinions. Interview data were analysed following the stages of Iterative Categorization. FINDINGS: Participants expressed a high level of willingness to receive depot buprenorphine. Their views were influenced both positively and negatively by six key features of depot buprenorphine: i) reduced contact with pharmacies and drug treatment services; ii) impact on illicit drug use and recovery; iii) the perceived effectiveness of depot buprenorphine; iv) the duration and dosage of depot buprenorphine injections; v) clinical administration of the depot buprenorphine injection; and vi) potential for side effects associated with the depot buprenorphine injection. CONCLUSIONS: Willingness to receive a given medication is complex, individual and changeable. Opioid users seem likely to welcome greater choice and flexibility in respect of opioid agonist medications and appear more likely to accept and adhere to depot buprenorphine if it enables them to reduce their illicit drug use and facilitates their recovery. Research is now needed to assess whether patients' reported willingness to receive depot buprenorphine translates into actual uptake and adherence.

Implementing and delivering personalised budgets for drug and alcohol users: A narrative systematic review.

Personalised budgets have historically been provided to groups of people with varying long-term health and social care needs. Since 2010, there has been increasing interest in providing personal budgets (PBs) to individuals with a history of drug and alcohol use in the UK, reflecting the policy and practice shift towards whole person recovery from substance use. However, information on implementing, delivering, and receiving such initiatives with this group is limited. This systematic review was conducted to identify and collate the existing experiences of providing personalised budgets to drug and alcohol users. Between March and April 2017, we searched six electronic and 11 grey literature databases for English language studies published between 1990 and April 2017 which described the implementation and delivery of personalised budget initiatives with drug and alcohol users. Search results (n = 6,749) were screened against inclusion and exclusion criteria; six records met the inclusion criteria. Across the studies, staff reported specific moral, ethical, and practical issues which affected the implementation and delivery of personalised budgets to drug and alcohol users. Staff working with drug and alcohol users with PBs reported greater job satisfaction due to having greater flexibility and autonomy but they had increased workloads and additional responsibilities beyond their remit and training. Drug and alcohol users' experiences of receiving personalised budgets included varying levels of awareness, knowledge, and control of their budgets, and difficulties in understanding what the budgets could be used for. Nevertheless, personalised budgets had been used to purchase various services and items beyond traditional drug and alcohol treatment. Outcomes for drug and alcohol users included reduced drug use, improved relationships, improved mental and physical well-being, and better daily structure. Although the review suggests that providing personalised budgets to drug and alcohol users presents unique implementation and delivery challenges, these were not insurmountable.

Qualitative exploration of relationships between peers in residential addiction treatment.

Relationships between peers are often considered central to the therapeutic process, yet there is relatively little empirical research either on the nature of peer-to-peer relationships within residential treatment or on how those relationships generate positive behaviour change or facilitate recovery. In this paper, we explore relationships between peers in residential addiction treatment, drawing upon the concept of social capital to frame our analyses. Our study was undertaken during 2015 and 2016 in two English residential treatment services using the same therapeutic community-informed model of treatment. We conducted 22 in-depth interviews with 13 current and 9 former service residents. All interviews were audio-recorded, transcribed verbatim, coded in MAXQDA, and analysed using Iterative Categorisation. Residents reported difficult relationship histories and limited social networks on entry into treatment. Once in treatment, few residents described bonding with their peers on the basis of shared experiences and lifestyles. Instead, interpersonal differences polarised residents in ways that undermined their social capital further. Some senior peers who had been in residential treatment longer acted as positive role models, but many modelled negative behaviours that undermined others' commitment to treatment. Relationships between peers could generate feelings of comfort and connectedness, and friendships developed when residents found things in common with each other. However, residents more often reported isolation, loneliness, wariness, bullying, manipulation, intimidation, social distancing, tensions and conflict. Overall, relationships between peers within residential treatment seemed to generate some positive but more negative social capital; undermining the notion of the community as a method of positive behaviour change. With the caveat that our data have limitations and further research is needed, we suggest that residential treatment providers should more routinely open the "black box" of "community as method" to consider the complex and dynamic nature of the relationships and social capital inside.

Patient views of opioid pharmacotherapy biodelivery systems: Qualitative study to assist treatment decision making.

The technology for delivering opioid pharmacotherapy (OPT) is expanding. It is important to know what OPT patients think of these developments and to find ways of enabling patients and clinicians to make informed decisions about which biodelivery system to choose. We explored the views of current and former OPT patients with a history of heroin use to identify factors influencing their preferences regarding routes of OPT administration. Data were generated via seven focus groups conducted in London, United Kingdom. Participants (n = 44) considered standard biodelivery systems (liquid/linctus, tablet, injectables), emergent systems (implants, depot injections), and a hypothetical system (nasal sprays). Groups were audio-recorded, transcribed verbatim, coded using qualitative software, and analyzed inductively via iterative categorization. Participants were cautious of, but willing to consider, new ways of receiving OPT and they welcomed having more choice. Their preferences and decision-making processes were influenced by nine interconnected factors: (a) personal dislike of particular biodelivery systems, (b) desired feelings following OPT administration, (c) perceived effectiveness of OPT biodelivery systems, (d) concerns about side effects, (e) ability to control the OPT, (f) impact on daily lives, (g) concerns about OPT-related stigma, (h) need for psychosocial support, and (i) personal treatment goals. This complexity may make it difficult for patients and clinicians to evaluate the pros and cons of the expanding array of OPT biodelivery systems and to arrive at clear conclusions. We therefore use the findings to construct a checklist that may facilitate discussions with patients when decisions about OPT need to be made. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Improving recruitment to pharmacological trials for illicit opioid use: findings from a qualitative focus group study.

AIM: To explore potential study participants' views on willingness to join clinical trials of pharmacological interventions for illicit opioid use to inform and improve future recruitment strategies. DESIGN: Qualitative focus group study [six groups: oral methadone (two groups); buprenorphine tablets (two groups); injectable opioid agonist treatment (one group); and former opioid agonist treatment (one group)]. SETTINGS: Drug and alcohol services and a peer support recovery service (London, UK). PARTICIPANTS: Forty people with experience of opioid agonist treatment for heroin dependence (26 males, 14 females; aged 33-66 years). MEASUREMENTS: Data collection was facilitated by a topic guide that explored willingness to enrol in clinical pharmacological trials. Groups were audio-recorded and transcribed. Transcribed data were analysed inductively via Iterative Categorization. FINDINGS: Participants' willingness to join pharmacological trials of medications for opioid dependence was affected by factors relating to study burden, study drug, study design, study population and study relationships. Participants worried that the trial drug might be worse than, or interfere with, their current treatment. They also misunderstood aspects of trial design despite the researchers' explanations. CONCLUSIONS: Recruitment of participants for clinical trials of pharmacological interventions for illicit opioid use could be improved if researchers became better at explaining clinical trials to potential participants, dispelling misconceptions about trials and increasing trust in the research process and research establishment. A checklist of issues to consider when designing pharmacological trials for illicit opioid use is proposed.

Do women with complex alcohol and other drug use histories want women-only residential treatment?

BACKGROUND: Women-only addiction services tend to be provided on a poorly evidenced assumption that women want single-sex treatment. We draw upon women's expectations and experiences of women-only residential rehabilitation to stimulate debate on this issue. METHODS: Semi-structured interviews were undertaken with 19 women aged 25-44 years [currently in treatment (n = 9), successfully completed treatment (n = 5), left treatment prematurely (n = 5)]. All had histories of physical or sexual abuse, and relapses linked to relationships with men. Interviews were audio-recorded, transcribed verbatim, coded and analysed inductively following Iterative Categorization. FINDINGS: Women reported routinely that they had been concerned, anxious or scared about entering women-only treatment. They attributed these feelings to previous poor relationships with women, being more accustomed to male company and negative experiences of other women-only residential settings. Few women said that they had wanted women-only treatment, although many became more positive after entering the women-only service. Once in treatment, women often explained that they felt safe, supported, relaxed, understood and able to open up and develop relationships with other female residents. However, they also described tensions, conflicts, mistrust and social distancing that undermined their treatment experiences. CONCLUSIONS: Women who have complex histories of alcohol and other drug use do not necessarily want or perceive benefit in women-only residential treatment.

Implants and depot injections for treating opioid dependence: Qualitative study of people who use or have used heroin.

BACKGROUND: Long-acting opioid pharmacotherapy (OPT) is presumed to offer benefits over more conventional OPT formulations. This paper analyzes the views and experiences of people who use or have used heroin in order to explore two novel systems for delivering long-acting OPT: implants and depot injections. New materialism theorizing is used to interpret and frame the findings. METHODS: Qualitative data were generated via seven focus groups conducted during 2017 in London, UK. Participants (n = 44; 28 men and 16 women; ages 33-66 years) had all received OPT. Focus group discussions covered real and potential OPT delivery systems. All participant data relating to implants and depot injections were coded using MAXQDA software and analysed inductively via Iterative Categorisation. FINDINGS: Participants discussed implants and depot injections in terms of interacting physical, psychological and social factors: dose stability; OPT administration; stopping treatment; co-presence of an antagonist; breaking rituals and habits; reduced choice and control; feeling normal; information needs; getting on with everyday life; and social interaction. Participants identified both benefits and concerns, and variable needs and preferences, with respect to each delivery system. CONCLUSIONS: Implants and depot injections are not 'fixed' medications that can be administered to people to achieve pre-determined treatment aims. Rather, they are complex 'assemblages' with uncertain outcomes. Furthermore, they are themselves part of wider interactive 'assemblages'. Drug developers and treatment providers need to understand this complexity in order to target long-acting OPT at people most likely to benefit from it, and to reduce any unintended negative consequences.

Buprenorphine versus dihydrocodeine for opiate detoxification in primary care: a randomised controlled trial.

BACKGROUND: Many drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care. METHODS: Open label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded. RESULTS: Only 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescription. Risk of non-completion of detoxification was reduced if allocated buprenorphine (68% vs 88%, RR 0.58 CI 0.35-0.96, p = 0.065). A higher proportion of people allocated to buprenorphine provided a clean urine sample compared with those who received dihydrocodeine (21% vs 3%, RR 2.06 CI 1.33-3.21, p = 0.028). People allocated to buprenorphine had fewer visits to professional carers during detoxification and more were abstinent at three months (10 vs 4, RR 1.55 CI 0.96-2.52) and six months post detoxification (7 vs 3, RR 1.45 CI 0.84-2.49). CONCLUSION: Informative randomised trials evaluating routine care within the primary care setting are possible amongst drug using populations. This small study generates unique data on commonly used treatment regimens.

Is peer injecting a form of intimate partner abuse? A qualitative study of the experiences of women drug users.

Women are over-represented as the recipients of injections of illicit drugs and are often injected by their intimate partners. This study used qualitative research to explore women drug users' experiences of abuse from intimate partners when being injected with illicit drugs. In-depth interviews were conducted with 45 women drug users in the city of Leeds and the area of North Nottinghamshire, UK. The practice of peer injecting illicit drugs places women recipients at risk of physical, economic and emotional abuse from their male intimate partner injectors. However, this was not a universal feature. In trusting, supportive intimate partner relationships peer injecting took place through reciprocal arrangements. Moving away from peer injecting was technically and emotionally difficult for women and rarely straightforward. The implications of the work are discussed as clinicians and wider drug service staff should be aware of the possibility of abuse and enquire about peer injecting when consulting with women injecting drug users. However, clinicians should avoid working within a simplistic clinical framework that views all peer injecting as intrinsically abusive. More research is needed to provide evidence for best practice. Until then, generic principles of best practice management of intimate partner abuse could apply, including enhancing women's motivation to effect change in an abusive situation.

How can health services effectively meet the health needs of homeless people?

BACKGROUND: Homelessness affects many people in contemporary society with consequences for individuals and the wider community. Homeless people experience poorer levels of general physical and mental health than the general population and there is a substantial international evidence base which documents multiple morbidity. Despite this, they often have problems in obtaining suitable health care. AIM: To critically examine the international literature pertaining to the health care of homeless people and discuss the effectiveness of treatment interventions. DESIGN OF STUDY: Review and synthesis of current evidence. METHOD: Medline (1966-2003), EMBASE (1980-2003), PsycINFO (1985-2003), CINAHL (1982-2003), Web of Science (1981-2003) and the Cochrane Library (Evidence Based Health) databases were reviewed using key terms relating to homelessness, intervention studies, drug misuse, alcohol misuse and mental health. The review was not limited to publications in English. It included searching the internet using key terms, and grey literature was also accessed through discussion with experts. RESULTS: Internationally, there are differing models and services aimed at providing health care for homeless people. Effective interventions for drug dependence include adequate oral opiate maintenance therapy, hepatitis A, B and tetanus immunisation, safer injecting advice and access to needle exchange programmes. There is emerging evidence for the effectiveness of supervised injecting rooms for homeless injecting drug users and for the peer distribution of take home naloxone in reducing drug-related deaths. There is some evidence that assertive outreach programmes for those with mental ill health, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain. CONCLUSIONS: As multiple morbidity is common among homeless people, accessible and available primary health care is a pre-requisite for effective health interventions. This requires addressing barriers to provision and multi-agency working so that homeless people can access the full range of health and social care services. There are examples of best practice in the treatment and retention of homeless people in health and social care and such models can inform future provision.

A review of the evidence for the effectiveness of primary prevention interventions for hepatitis C among injecting drug users.

BACKGROUND: Hepatitis C (HCV) prevalence is most common amongst injecting drug users where up to 98% of the population can be infected despite a low prevalence of HIV. This review considers the evidence for the effectiveness of primary prevention interventions to reduce incidence or prevalence of hepatitis C. METHODS: Systematic review of the major electronic medical databases: Medline, EMBASE, PsycINFO, CINAHL and the Cochrane Library (Evidence Based Health). Either intervention or observational studies were included if they described an intervention targeting injecting drug using populations with the outcome to reduce either the prevalence or incidence of hepatitis C infection. RESULTS: 18 papers were included in the final review from 1007 abstracts. Needle exchange programmes reduce the prevalence of HCV though prevalence remains high. Similarly the effectiveness of methadone maintenance treatment is only marginally effective at reducing HCV incidence. There is limited evidence evaluating either the effectiveness of behavioural interventions, bleach disinfectants, or drug consumption rooms. CONCLUSION: Primary prevention interventions have led to a reduction in HIV incidence, have been less effective at reducing HCV incidence. Global prevalence of HCV remains disturbingly high in injecting drug users. A robust response to the global health problem of HCV will require provision of new interventions. Behavioural interventions; distribution of bleach disinfectant; other injecting paraphernalia alongside sterile needle distribution; and evaluation of drug consumption rooms merit further expansion internationally and research activity to contribute to the emerging evidence base. Whilst the prevalence of HCV remains high, nevertheless many current interventions aimed at primary HCV prevention have been shown to be cost-effective due to their significant positive impact upon prevalence of HIV.

Qualitative evaluation of a novel contingency management-related intervention for patients receiving supervised injectable opioid treatment.

AIM: To evaluate a novel contingency management (CM)-related intervention for people experiencing complex drug problems, thereby increasing understanding of CM implementation in real-world settings. Objectives are to provide new insights into (i) how context influences intervention delivery; (ii) aspects of intervention delivery that influence outcomes; and (iii) intervention outcomes. DESIGN: Qualitative realist evaluation of a novel CM-related intervention: conditional budgets (CB). SETTING: Supervised injectable opioid treatment (IOT) clinic in England (May 2014-March 2015). PARTICIPANTS: Twenty IOT clinic patients (14 men; six women); 10 IOT clinic staff (seven men; three women). MEASUREMENTS: Semi-structured interviews systematically coded relating to knowledge and views of the intervention, experiences of delivering/receiving the intervention, and effectiveness of the intervention. INTERVENTION: Personal budgets provided to patients who reduced their supervised IOT while demonstrating ongoing stability. FINDINGS: (i) Contextual factors influencing intervention delivery included patient motivation; clarity of intervention information; prior trust in the treatment system; patient and staff involvement in intervention design; stability of the treatment setting. (ii) Aspects of delivery influencing outcomes included transparency of the eligibility criteria, rules and operating processes; rule enforcement; continued verbal information about the intervention; speed of incentive processing and receipt. (iii) Reduced drug use was difficult to attribute to CBs, as patients who did well were those most motivated to change before the intervention started. Unintended outcomes were positive (improved patient psychological wellbeing, staff job satisfaction, staff/patient relationships) and negative (patient relapse, increased staff work-load, tensions in clinic relationships). CONCLUSIONS: A 'qualitative realist' evaluation of a contingency management intervention to help address complex substance use disorder problems suggests that the programmes need to have stakeholder input, implement consistent eligibility criteria, rules and processes and be introduced into stable treatment settings where relationships are trusting and patients and staff feel secure.

Associations between injecting illicit drugs into the femoral vein and deep vein thrombosis: A case control study.

INTRODUCTION AND AIMS: Injecting drug use is a risk factor for deep vein thrombosis (DVT), and people who inject drugs commonly report injecting into the femoral vein. However, it is unclear whether the act of inserting a needle into the femoral vein or the pharmacodynamic properties of the injected drug increases DVT risk. We aimed to quantify the strength of association between injecting illicit drugs into the femoral vein and the odds of acquiring ileo-femoral DVT. DESIGN AND METHODS: We used case control methodology. The study took place in Leeds, UK. A total of 313 people who inject drugs (112 'cases' with a diagnosis of DVT from hospital accident and emergency departments and 201 'controls' with no DVT from needle exchanges) completed a questionnaire about their drug use and administration routes. RESULTS: The act of injecting into the femoral vein was strongly associated with DVT (χ(2) (1) = 53.453, P < 0.001), a finding that remained significant after adjusting for the type of illicit drug injected, age, gender, smoking status and history of clotting disorder. Independent of the act of femoral vein injecting, after adjusting for the effects of potential confounders, crack cocaine use was significantly associated with DVT, whereas amphetamine and heroin use were negatively independently associated with DVT. CONCLUSIONS: The practice of injecting into the femoral vein in the groin and the practice of injecting crack cocaine are associated with the odds of acquiring ileo-femoral DVT. [Wright NMJ, Allgar V, Tompkins CNE. Associations between injecting illicit drugs into the femoral vein and deep vein thrombosis: A case control study. Drug Alcohol Rev 2016;35:605-610].

Exploring risk perception and behaviour of homeless injecting drug users diagnosed with hepatitis C.

Injecting drug users (IDUs) are at the greatest risk of hepatitis C infection by using any item of injecting equipment that has come into contact with contaminated blood. Alongside this, homeless IDUs have been identified as being at increased risk of harm in their illicit drug taking behaviour. This study interviewed 17 hepatitis C positive homeless IDUs about their injecting practices. In-depth interviews explored the impact of a positive hepatitis C diagnosis on their injecting and identified their risk behaviours and perceptions. The interviews were tape-recorded, transcribed and analysed using the framework approach. Homeless IDUs engaged in both high risk and unhygienic injecting practices, such as using drugs outside and in public places, sharing injecting equipment and re-using cleaned needles. Excessive needle reuse whilst in prison was also identified. However, the findings were not universally bleak as a positive diagnosis of hepatitis C did lead to some behaviour change towards safer injecting and some adopted other lifestyle and behaviour changes. It was, however, common for homeless people to devolve responsibility for preventing hepatitis C transmission to their peers, especially when injecting with others. Knowledge regarding possible transmission through injecting paraphernalia appeared to make users more careful to reduce it through these routes. Placing a continuous emphasis on health promotion is therefore important in educating IDUs about the hepatitis C transmission risks associated with injecting drug use. Information regarding safer and hygienic use, including accurate information regarding the most effective methods to clean used equipment, must be re-enforced by people working with homeless injecting drug users.