Injecting, sexual risk behaviors and HIV infection in young cocaine and heroin users in Spain.

AIM: To evaluate differences between young cocaine users and heroin users (HUs) regarding the prevalence of sexual and injection risk behavior, and HIV, HCV and HBV infection. METHODS: Two community cohorts were recruited in Madrid, Barcelona and Seville; 720 cocaine users, of whom 586 had never used heroin (CUs), and 991 HUs were interviewed. Dried blood spot samples were tested. RESULTS: CUs were less marginalized socially than HUs. Only 0.9% had ever injected versus 64.3%; none had ever injected with borrowed syringes versus 25%; 2.2% had an injecting steady partner in the last 12 months versus 24.9%; 4.8% had ever traded sex versus 16.0%. However, 31.0 versus 12.7% had unprotected sex with more than two occasional partners in the last 12 months; 45.0 versus 21.9% had sniffed through tubes used by more than 10 persons. Only 32.3% knew their HIV status versus 80.3%; 0.4 versus 18.1% were HIV positive; 0.9 versus 51.9% were HCV positive, and 1.5 versus 17.0% were HBV positive. CONCLUSIONS: The intense cocaine epidemic has hitherto had little impact on either HIV, HBV or HCV in Spain. However, surveillance should be intensified given the high percentage of CUs having unprotected sex with occasional partners.

[Recruitment methodology and characteristics of a cohort of young regular cocaine users in three Spanish cities (the Itinere-cocaine Project)]. / Metodología de reclutamiento y características de una cohorte de jóvenes consumidores habituales de cocaína de tres ciudades españolas (Proyecto Itínere-cocaína).

BACKGROUND: Health information systems that monitor drug use do not perform in-depth analyses of sociodemographic characteristics and patterns of use, or of the factors that influence health problems. We describe the recruitment methodology and characteristics of a cohort of young cocaine users. METHODS: A prospective cohort of 720 cocaine users who were not regular heroin users, recruited in the community independently of the health services by chain referral methods in the metropolitan areas of Madrid, Barcelona and Seville was studied. A computer-administered and partially self-administered questionnaire was used. A stratified analysis by city and by frequency of base cocaine use was performed. RESULTS: In the previous 12 months, 58.8% had used cocaine 1-2 days/week; 91.9% sniffed it regularly, 5.3 smoked it, and only 2.8% injected it; 6.1% had used it at least half the time in the form of base cocaine. Polydrug use was observed with cannabis (93.6%), ecstasy (73.2%) and amphetamines (60.6%). Approximately 4.0% had injected at least one drug. Crack users (22.1%) had a lower educational level, more intensive cocaine use, a higher prevalence of other drug use, especially opioids, and a much higher prevalence of injection. CONCLUSIONS: This study confirms and completes the sociodemographic and drug profile provided by the information systems based on health services or population surveys. The results show that a large proportion of young cocaine users consume the drug sporadically and that two very different subpopulations exist, according to whether or not they use base cocaine.

From illegal poison to legal medicine: a qualitative research in a heroin-prescription trial in Spain.

INTRODUCTION AND AIMS: In recent decades, studies have been made of the possible benefits of treatments using heroin, although qualitative methodologies have not usually been employed. In 2004, in Granada (Spain), a clinical experiment was launched: the Experimental Narcotics Prescription Programme in Andalusia (PEPSA). This project attempted to evaluate the effectiveness of intravenous heroin and orally-administered methadone prescription for long-term socially-excluded opiate addicts for whom other treatments have failed. The research described herein is qualitative and has been carried out within the framework of the aforementioned experiment. The objective was to discover the attitudes, opinions and experiences of patients (and relatives) once they had been included in the program and are receiving heroin in a therapeutic environment. DESIGN AND METHODS: Focused ethnographic procedures were used to establish the study population. During the field work, we carried out in-depth interviews and observations using 21 patients and relatives. Analysis was carried out by a team according to grounded theory. RESULTS: Our results show how the treatment process and the administering of heroin in a therapeutic context manages to break the habit of consuming heroin obtained illegally, thus changing the significance given to the substance and bringing about improvements in aspects such as the workplace, family relations and physical and mental health. DISCUSSION AND CONCLUSIONS: The move from 'substance addiction' to chronic 'illness' upon beginning the treatment provides a chance for a population with a long history of rejection and exclusion to become part of society once again.

Prevalence of and risk factors for hepatitis B virus infection among street-recruited young injection and non-injection heroin users in Barcelona, Madrid and Seville.

BACKGROUND: To evaluate the prevalence of hepatitis B virus (HBV) and associated factors in 949 heroin users (HU): injectors (IHUs) and non-injectors (NIHUs). METHODS: Cross-sectional study; structured questionnaire administered by computer-assisted personal interviewing and audio computer-assisted self-interviewing; dry blood samples analysed for the hepatitis B core antigen and hepatitis B surface antigen; bivariate analysis and logistic regression. RESULTS: The prevalence of infection was significantly higher in IHUs (22.5%) than in NIHUs (7.4%) in the three cities. In the logistic analysis of male IHUs, infection was found to be associated with living in Seville, age over 25, foreign nationality, having had a sexual partner who traded sex, hepatitis C virus infection, and having injected for more than 5 years. In female IHUs, HBV infection was associated with age over 25, having injected as the first main route of administration, and having begun to inject before 18 years of age. In NIHUs, the associated factors were female gender, foreign nationality and having been tattooed. In young IHUs, the prevalence of HBV infection remains four times higher than in the general population of the same age group. CONCLUSION: The vaccination strategy urgently needs to be reinforced and redesigned to achieve acceptable control of the HBV infection in the most vulnerable groups, with special attention to immigrants.

Validity of the Severity of Dependence Scale (SDS) construct applying the item response theory to a non-clinical sample of heroin users.

AIMS: The purpose of this work is to study the validity of the Severity of Dependence Scale (SDS) construct by applying Rasch models to a non-clinical sample of heroin abusers. SUBJECTS: 982 (73% men) young people 30 years old or under (mean age 25.9 years) participated. All of them were captured from the community in the metropolitan areas of Madrid, Barcelona and Seville, between April 2002 and December 2003. ANALYSIS: Dimensionality of the scale and calibration of items were studied using the Rating Scale model, which is a Rasch-type model. A factorial analysis was also performed to check the dimensionality of the scale. RESULTS: The analysis of fit shows that all the items have infit and outfit values between +/- 2 logits, indicating that the data fit the model and that it may be assumed to be unidimensional. The principal components analysis also showed the existence of a principal factor that explains 52.5% of the variance observed. Item calibration found that they are between +0.89 and -1.04 logits on the scale. CONCLUSION: The results show unidimensional structure of the SDS scale. Item calibration shows they are distributed along the continuum, which must be taken into account when calculating total scores. The study's limitations are noted.

[Validity evidence of the Health-Related Quality of Life for Drug Abusers Test based on the Biaxial Model of Addiction]. / Evidencias de validez del test para la evaluación de la calidad de vida en adictos a sustancias psicoactivas a partir del modelo biaxial de la adicción.

The aim of this work is to show evidence of the validity of the Health-Related Quality of Life for Drug Abusers Test (HRQoLDA Test). This test was developed to measure specific HRQoL for drugs abusers, within the theoretical addiction framework of the biaxial model. The sample comprised 138 patients diagnosed with opiate drug dependence. In this study, the following constructs and variables of the biaxial model were measured: severity of dependence, physical health status, psychological adjustment and substance consumption. Results indicate that the HRQoLDA Test scores are related to dependency and consumption-related problems. Multiple regression analysis reveals that HRQoL can be predicted from drug dependence, physical health status and psychological adjustment. These results contribute empirical evidence of the theoretical relationships established between HRQoL and the biaxial model, and they support the interpretation of the HRQoLDA Test to measure HRQoL in drug abusers, thus providing a test to measure this specific construct in this population.

Hepatitis B vaccination: an unmet challenge in the era of harm reduction programs.

The prevalence of vaccination against hepatitis B virus (HBV), factors associated with vaccination, and missed opportunities for vaccination were assessed among 949 street-recruited young injecting heroin users (IHUs) and noninjecting HUs (NIHUs). A cross-sectional study was carried out in Madrid, Barcelona, and Seville. Face-to-face interviews were held using a structured questionnaire with computer-assisted personal interviewing. Dried blood spot samples were tested for anti-HBV core antigen and HBV surface antigen. Bivariate and logistic regression analyses were performed. The prevalence of HBV vaccination was 21.7%, with significant differences among the cities (13.3% in Madrid, 18.4% in Seville, and 33.2% in Barcelona) and between IHUs (23.8%) and NIHUs (17.9%). In the logistic regression analysis, living in Barcelona and being aged 25 years or younger were associated with HBV vaccination in IHUs and NIHUs; in IHUs, vaccination was also associated with living in the street or in institutions for most of the last 12 months. Practically all those susceptible to HBV infection had missed at least one opportunity for vaccination, and most of them had missed such an opportunity in the last year. The proportion of vaccinated HUs remains very low despite efforts to set up harm reduction programs. New and more active strategies must be incorporated in these programs.

Poor validity of self-reported HBV vaccination among young heroin users in Spain supports the policy "don't ask, draw a blood sample, vaccinate and try to schedule another visit".

OBJECTIVES: To assess the validity of self-reported hepatitis B virus vaccination status in young heroin users. STUDY DESIGN: Cross-sectional study among 949 street-recruited young injection heroin users (IHUs) and non-injection heroin users (NIHUs) in Madrid, Barcelona and Seville. Face-to-face interviews and dried blood spot tested for anti-HBc and anti-HBs. The validity of self-reported vaccination status was assessed comparing with the serological status. The percentage of agreement with the kappa (kappa) statistic and the positive predictive value were calculated. RESULTS: The percentage of agreement between self-reported and serologic vaccination status was 51.9% overall, with little difference by city (53.1% in Barcelona, 49.0% in Madrid and 51.5% in Seville) or between IHUs (51.3%) and NIHUs (53.0%). All the kappa scores were lower than 0.1. The positive predictive value of self-reports was less than 25% in all categories analysed, except in the city of Barcelona (37%). Among those who indicated that they had been vaccinated, 31% were actually susceptible. CONCLUSIONS: In areas with a high prevalence of infection and rising coverage of vaccination the policy "don't ask, take a blood sample, give a dose of vaccine and try to schedule another visit" should be recommended in clinical practice.

Do young heroin users in Madrid, Barcelona and Seville have sufficient knowledge of the risk factors for unintentional opioid overdose?

To identify the self-perceived reasons for unintentional opioid overdose of young heroin users in three Spanish cities and their agreement with objective risk factors for overdose. Computer-Assisted Personal Interviews (CAPI) were held with 991 street-recruited current heroin users aged 18-30. The general reasons for overdose and the reasons for the last overdose suffered were explored with open-ended (OEQs) and pre-coded questions (PCQs). Limited knowledge of overdose risk factors was defined as mention of fewer than two objective risk factors for unintentional overdose in the OEQ. Univariate, bivariate, and logistic regression methods were used. 77.8% (Seville), 64.9% (Madrid) and 57.2% (Barcelona) of participants have limited knowledge of overdose risk factors. Residence in Seville and not having attended courses or meetings on overdoses were significantly associated with limited knowledge, after adjusting for other factors. The most frequently identified general reasons in OEQ or PCQ were using heroin in large amounts (66.8%), together with tranquilizers (62.0%), adulterated (60.7%), or purer than usual (57.6%). Most reasons were selected more frequently in PCQ than in OEQ, especially rapid injection of the entire dose and using heroin shortly after using tranquilizers or alcohol, by injection, or after a period of abstinence. The results were similar for overdoses suffered by participants. Most young heroin users do not have sufficient knowledge of overdose risk factors, especially the use of heroin by injection, after a period of abstinence, or together with alcohol or methadone. Specific informational or educational programs adapted to the local context are critically needed.

Injecting and HIV prevalence among young heroin users in three Spanish cities and their association with the delayed implementation of harm reduction programmes.

OBJECTIVES: To evaluate changes in the prevalence of HIV infection among young heroin users in three Spanish cities, and their association with harm reduction programmes (HRPs). METHODS: Two cross sectional studies. The 1995 study included 596 users; half were street recruited and half were recruited at drug treatment centres. The 2001-03 study included 981 street recruited users. Face to face interviews were conducted using a structured questionnaire. Samples for HIV testing (saliva in 1995 and dried blood spot in 2001-03) were collected. RESULTS: The proportion who had ever injected (IDUs) decreased in all three cities. HIV prevalence in IDUs decreased by half in Barcelona (44.1% to 20.8%) and Seville (44.2% to 22.2%), but remained constant in Madrid (36.8% and 34.9%). This difference was attributable to a decrease in HIV prevalence in long term IDUs in Barcelona and Seville, but not in Madrid. The crude odds ratio for HIV prevalence in Madrid compared with Barcelona in long term IDUs was 2.3 (95%CI 1.4 to 3.7), increasing to 3.1 (95%CI 1.5 to 6.2) after adjusting for sociodemographic and risk factors. HIV prevalence in short term IDUs was similar in all cities. In 1992 Barcelona already had 20 heroin users in methadone maintenance programmes (MMPs) per 10 000 population aged 15-49 years; Seville reached this rate in 1994, and Madrid, not until 1998. CONCLUSIONS: The prevalence of HIV infection did not decrease in long term injectors in Madrid. The delayed implementation of HRPs, especially MMPs, may be the most plausible hypothesis. This finding should shed light on decision making in countries in a similar epidemiological and sociological situation.