Baseline characteristics of people experiencing homelessness with a recent drug overdose in the PHOENIx pilot randomised controlled trial.

BACKGROUND: Drug-related deaths in Scotland are the highest in Europe. Half of all deaths in people experiencing homelessness are drug related, yet we know little about the unmet health needs of people experiencing homelessness with recent non-fatal overdose, limiting a tailored practice and policy response to a public health crisis. METHODS: People experiencing homelessness with at least one non-fatal street drug overdose in the previous 6 months were recruited from 20 venues in Glasgow, Scotland, and randomised into PHOENIx plus usual care, or usual care. PHOENIx is a collaborative assertive outreach intervention by independent prescriber NHS Pharmacists and third sector homelessness workers, offering repeated integrated, holistic physical, mental and addictions health and social care support including prescribing. We describe comprehensive baseline characteristics of randomised participants. RESULTS: One hundred and twenty-eight participants had a mean age of 42 years (SD 8.4); 71% male, homelessness for a median of 24 years (IQR 12-30). One hundred and eighteen (92%) lived in large, congregate city centre temporary accommodation. A quarter (25%) were not registered with a General Practitioner. Participants had overdosed a mean of 3.2 (SD 3.2) times in the preceding 6 months, using a median of 3 (IQR 2-4) non-prescription drugs concurrently: 112 (87.5%) street valium (benzodiazepine-type new psychoactive substances); 77 (60%) heroin; and 76 (59%) cocaine. Half (50%) were injecting, 50% into their groins. 90% were receiving care from Alcohol and Drug Recovery Services (ADRS), and in addition to using street drugs, 90% received opioid substitution therapy (OST), 10% diazepam for street valium use and one participant received heroin-assisted treatment. Participants had a mean of 2.2 (SD 1.3) mental health problems and 5.4 (SD 2.5) physical health problems; 50% received treatment for physical or mental health problems. Ninety-one per cent had at least one mental health problem; 66% had no specialist mental health support. Participants were frail (70%) or pre-frail (28%), with maximal levels of psychological distress, 44% received one or no daily meal, and 58% had previously attempted suicide. CONCLUSIONS: People at high risk of drug-related death continue to overdose repeatedly despite receiving OST. High levels of frailty, multimorbidity, unsuitable accommodation and unmet mental and physical health care needs require a reorientation of services informed by evidence of effectiveness and cost-effectiveness. Trial registration UK Clinical Trials Registry identifier: ISRCTN 10585019.

An avoidable crisis.

In Scotland drug policy and consequently the progress of evidence-based treatment options has been struggling for many years. Political inaction is brought about by a complex chain of legal and operational obstructions with local authorities deferring to national Government which in turn is paralysed by international convention. Scotland represents a case study demonstrating the adverse consequences of management by non medical requirements rather than implementation of a clinically proven progressive policy. The difficulty of translating theory and evidence into practice is acknowledged but suggestions are made for pragmatic and humanitarian initiatives.

Milestone house: The story of a hospice for people with HIV/AIDS.

The HIV/AIDS epidemic of the early 1980s has been extensively documented, with all its epidemiological, scientific and medical impacts. Cultural implications for many sectors of society have been profound and long-lasting. Some areas merit reflection for their ingenuity in the face of a crisis and the effect they have had on clinical practice. This report gives an account of a venture into the unknown territory of palliative care. Described here is a group of young people and their families propelled into a nightmarish condition. Those involved were outlawed and stigmatised, suffering from a disease leading to their inevitable death. By association with this group, carers and medical staff were left to interpret unhelpful guidelines and to venture into unknown therapeutic territory, sometimes beyond the margins of conventional practice.

Predisposition to accelerated Alzheimer-related changes in the brains of human immunodeficiency virus negative opiate abusers.

Cognitive impairment is a recognized effect of drug misuse, including the use of opiates. The pathological basis for this is unknown but the temporal and frontal cortices have been implicated. We have shown previously that deposits of hyperphosphorylated tau in drug user brains exceed those seen in age-matched controls. The present quantitative study of hyperphosphorylated tau and beta amyloid in drug user brains allows comparison with the related pathology in Alzheimer's disease. Brains were obtained from the Edinburgh Medical Research Council Brain Banks, comprising 39 human immunodeficiency virus negative drug users, five subjects with Alzheimer's disease and 37 age-matched, cognitively normal controls, all legally and ethically approved for research. Hyperphosphorylated tau positive (AT8, AT100) neuropil threads were significantly increased in the frontal and temporal cortex, and in the locus coeruleus, of drug users aged > 30 years (all P = 0.04). Under the age of 30 years, drug users showed a similar increase in neuropil threads compared with controls, but this reached significance only in the frontal cortex (P = 0.03). Immunopositivity for both three- and four-repeat tau was present in drug user brains. There was a direct relationship between the numbers of neuropil threads and of neurofibrillary tangles: neurofibrillary tangles were sparse in brains that had neuropil thread counts below 200 cm(2). Hyperphosphorylated tau positive neuropil threads increased at a faster rate in drug users than in controls and the levels of the phosphorylating enzyme, GSK-3, was raised in drug user brains. Beta amyloid (AB4, AB42 and 4G8) was raised in drug user brains (mainly as shadow plaques) but not significantly different from controls and there was no correlation between high beta amyloid and hyperphosphorylated tau in individual cases. Hyperphosphorylated tau levels correlated significantly (P = 0.038) with microglial activation in drug users but not in controls. The levels of hyperphosphorylated tau in drug users fell far short of those seen in Alzheimer's disease but overlapped with those in elderly controls. We conclude that drug users show early Alzheimer's disease-related brain pathology that may be the basis for cognitive impairment and that neuroinflammation is an early accompanying feature. This provides an opportunity to study the pathogenesis of tau pathology in the human brain.

Towards a framework for implementing physician education in substance use disorders.

•Substance use education is inadequate despite the urgent need to equip health care professionals to effectively treat substance use disorders.•Ineffective timing of substance use education within the timeline of medical training contributes to a lack of knowledge and negative attitudes.•The imminent implementation or scaling up of the various training initiatives calls for an urgent examination of their methods from a contextual perspective.

Injecting drug use, the skin and vasculature.

Damage to the skin, subcutaneous tissues and blood vessels are among the most common health harms related to injecting drug use. From a limited range of early reports of injecting-related skin and soft tissue damage there is now an increasing literature relating to new drugs, new contaminants and problems associated with unsafe injection practices. Clinical issues range from ubiquitous problems associated with repeated minor localised injection trauma to skin and soft tissue and infections around injection sites, to systemic blood infections and chronic vascular disease. The interplay of limited availability and access to sterile injecting equipment, poor injecting technique, compromised drug purity, drug toxicity and difficult personal and environmental conditions give rise to injection-related health harms. This review of injecting-related skin, soft tissue and vascular damage focuses on epidemiology and causation, clinical examination and investigation, treatment and prevention.

Brexit threatens the UK's ability to tackle illicit drugs and organised crime: What needs to happen now?

BACKGROUND: The decision by the UK government to leave the European Union comes at a time when parts of the UK are experiencing a marked rise in reported gun and knife crimes. The health effects of Brexit will have serious consequences as to how the UK tackles this upsurge in drug-related crime. HEALTH POLICY PROCESSES: The UK's future participation with the EU's specialised agencies will depend on the detail of any agreement reached on future collaboration with the EU and its drug agency, the EMCDDA. CONTEXT: The EMCDDA provides the EU and its Member States with a factual overview of European drug problems and a solid evidence base to support debates on drugs policies. It also supports early warning initiatives and coordinates measures at national and supranational levels with Europol and supranational enforcement agencies. EXPECTED OUTCOMES: While these arrangements might continue throughout any transition period, those working within the sector require guidance and assurances from the British government about its long-term intentions after any transition. CONCLUSIONS: The scale of collaboration between the UK and European institutions is extensive. It is not clear how this might be replicated after Brexit. Yet an alternative framework of collaboration between the UK and the EU is clearly needed to facilitate shared and agreed approaches to data sharing and drug surveillance after Brexit.

Heavy Cannabis Use Is Associated With Low Bone Mineral Density and an Increased Risk of Fractures.

PURPOSE: To investigate possible associations between recreational cannabis use and bone health in humans. METHODS: Cross-sectional study of individuals recruited from primary care in the UK between 2011 and 2013. Cases were regular smokers of cannabis divided into moderate (n = 56) and heavy user (n = 144) subgroups depending on whether they reported fewer or more than 5000 cannabis smoking episodes during their lifetime. Controls comprised 114 cigarette smokers. RESULTS: Heavy cannabis users had lower total hip bone mineral density (mean ± SD Z-score: -0.20 ± 0.9 vs +0.2 ± 0.9, P < .0005), lower spine bone mineral density (-0.5 ± 1.2 vs 0.0 ± 1.2, P < .0005), and lower body mass index (BMI; 26.5 ± 6.0 vs 29.0 ± 7.0, P = .01) than controls. Fracture rate was also increased in heavy users (rate ratio = 2.17; 95% confidence interval, 1.59-2.95; P < .001). When compared with controls, serum cross-linked C-telopeptide of type 1 collagen (CTX) concentrations were raised in heavy cannabis users (0.3 ± 0.1 vs 0.2 ± 0.1 pg/mL, P = .045), as were serum N-terminal propeptide of type 1 procollagen (P1NP) concentrations (47.1 ± 19.2 vs 41.2 ± 17.8 pg/mL, P = .01). Serum total 25-hydroxyvitamin D concentrations were reduced in heavy users compared with controls (25.3 ± 16.8 vs 36.9 ± 26.7 nmol/L, P = .002). Multiple regression analysis revealed that heavy cannabis use was an independent predictor of spine bone mineral density, accounting for 5.4% of the variance (P = .035), and total hip bone mineral density, accounting for 5.8% of the variance (P = .001), but mediation analysis suggested that the effect on spine bone mineral density was indirect and mediated through low body mass index. CONCLUSIONS: Heavy cannabis use is associated with low bone mineral density, low BMI, high bone turnover, and an increased risk of fracture. Heavy cannabis use negatively impacts on bone health both directly and indirectly through an effect on BMI.

Cannabis, tobacco smoking, and lung function: a cross-sectional observational study in a general practice population.

BACKGROUND: Health concerns around cannabis use have focused on the potential relationship with psychosis but the effect of cannabis smoking on respiratory health has received less attention. AIM: To investigate the association between tobacco-only smoking compared with tobacco plus cannabis smoking and adverse outcomes in respiratory health and lung function. DESIGN AND SETTING: The design was cross-sectional with two groups recruited: cigarette smokers with tobacco pack-years; cannabis smokers with cannabis joint-years. Recruitment occurred in a general practice in Scotland with 12 500 patients. METHOD: Exposures measured were tobacco smoking (pack-years) and cannabis smoking (joint-years). Cannabis type (resin, herbal, or both) was recorded by self-report. Respiratory symptoms were recorded using NHANES and MRC questionnaires. Lung function was measured by spirometry (FEV1/FVC ratio). RESULTS: Participants consisted of 500 individuals (242 males). Mean age of tobacco-only smokers was 45 years; median tobacco exposure was 25 pack-years. Mean age of cannabis and tobacco smokers was 37 years; median tobacco exposure was 19 pack-years, rising to 22.5 when tobacco smoked with cannabis. Although tobacco and cannabis use were associated with increased reporting of respiratory symptoms, this was higher among those who also smoked cannabis. Both tobacco and cannabis users had evidence of impaired lung function but, in fully adjusted analyses, each additional joint-year of cannabis use was associated with a 0.3% (95% confidence interval = 0.0 to 0.5) increase in prevalence of chronic obstructive pulmonary disease. CONCLUSION: In adults who predominantly smoked resin cannabis mixed with tobacco, additional adverse effects were observed on respiratory health relating to cannabis use.

Factors affecting repeated cessations of injecting drug use and relapses during the entire injecting career among the Edinburgh Addiction Cohort.

BACKGROUND AND AIMS: Injecting drug use is a chronic condition, with people who inject drugs (PWID) typically experiencing repeated cessations and relapses during their injection careers. We characterize patterns of ceasing and relapsing and the impact of opiate substitution treatment (OST) during the entire injecting careers of PWID in the Edinburgh Addiction Cohort (EAC). METHODS: During 2005-2007, 432 surviving participants of the EAC were interviewed about their injecting histories. Adjusted associations between covariates and hazards of cessation and relapse were estimated using random-effects models. RESULTS: OST was strongly associated with a higher hazard of cessation (HR = 1 .71, P < 0.001), but there was no significant evidence of association with hazard of relapse (HR = 0.81, P = 0.14). Women and older PWID were less likely to relapse (HR = 0.73, P = 0.02 and HR = 0.55, P < 0.001, respectively). Hazards of both cessation and relapse decreased monotonically with time since last relapse/cessation (both P < 0.001). An individual's hazard of cessation increased with his/her number of previous cessations (HR = 3.58 for 10+ previous cessations, P < 0.001), but there was no evidence that an individual's hazard of relapse changed with number of previous relapses (P = 0.37). There was heterogeneity in the individual hazards of both cessation and relapse. CONCLUSIONS: OST was associated with reduced time to cessation, and there was some suggestion of increased time to relapse too. The likelihood of prolonged cessation is greater for women, increases with age, and decreases with time since last relapse.

Hepatitis B vaccination and injecting drug users.

This study seeks to test the feasibility of vaccinating injecting drug users for hepatitis B in primary care and to identify predictors of poor immune response. Two hundred and seventy-five injecting drug users were identified from the case notes of a large general practice in an area of high multiple deprivation in northwest Edinburgh and, where appropriate, offered hepatitis B vaccination followed by a post-vaccination serological test. We concluded that hepatitis B vaccination of drug users in primary care is both feasible and effective. This study was unable to identify a group at risk of vaccine failure, however, it found post-vaccination serological testing to be problematic and potentially misleading. Therefore, we would not recommend its routine use in a primary care setting. Significantly, prolonged primary courses were not associated with reduced efficacy. The findings indicate that an appropriate vaccination schedule for primary care should be flexible to maximise compliance.