The Effectiveness of Universal Educational Interventions for Prevention of Illicit Drug Use among University Students: A Systematic Review.

Background: The extent of illicit drug use among university students necessitates effective preventive programs. To identify and assess the effectiveness of university-based interventions in preventing or reducing illicit drug use. Methods: The MEDLINE (PubMed), SCOPUS, ISI (Web of Science), and other sources were searched according to the Cochrane Collaboration method. RCTs, CRTs and non- RCTs evaluating university-based interventions designed to prevent illicit drug use were reviewed. Data were extracted independently by two reviewers. The quality of the publications was assessed. Interventions were classified by type, provider, duration, and theoretical background. Results: Of 6652 papers, 11 studies met the eligibility criteria that were conducted between 1987 and 2020. The effectiveness of interventions was different. Substantial heterogeneity among the studies prevented the integration of results for estimating summaries. Conclusion: Despite the importance of the subject, there is a paucity of studies about specific educational programs for illicit drug use, indicating the necessity of further research in other countries.

96-week retention in treatment with extended-release subcutaneous buprenorphine depot injections among people with opioid dependence: Extended follow-up after a single-arm trial.

BACKGROUND: The most recent formulation of buprenorphine treatment is extended-release depot injections (BUP-XR) that are administered subcutaneously by health care professionals. This study aimed to observe treatment outcomes of BUP-XR delivered in standard practice during a 96-week follow-up period in a community setting. METHODS: This study is an extension of the CoLAB study, a prospective single-arm, multicentre, open label trial (N=100, 7 sites in Australia) among people with opioid dependence who received monthly injections of BUP-XR to evaluate the retention in treatment. Participants were followed for 96 weeks, comprising 48 weeks of the CoLAB study followed by a 48-week extension. RESULTS: Of 100 participants at baseline, 47 were retained on BUP-XR at 96 weeks. The median time retained on monthly depot was 90 weeks. Heroin use (adjusted OR=0.19, P=0.012) in the month prior to baseline was associated with lower odds of retention on BUP-XR. Older age at first opioid use (adjusted OR= 1.08, P=0.009) and longer duration in OAT at baseline (adjusted OR= 1.12, P=0.001) were associated with increased retention. Prevalence of past four-weeks opioid use was estimated at 4% at 96 weeks of treatment (prevalence 0.04, 95%CI: 0.00-0.11) compared to 15% at baseline. Quality of life and medication treatment satisfaction improved over time for those retained in treatment. CONCLUSION: This is one of the few studies to describe long term (96 week) retention in treatment with BUP-XR in a community setting. It displayed retention rates with 47% of participants completing 96 weeks of treatment with BUP-XR. Patient reported outcomes suggest improvements in client wellbeing. FUNDING: Indivior.

Alcohol use, alcohol use disorder and heavy episodic drinking in the Eastern Mediterranean region: A systematic review.

BACKGROUND AND AMS: Despite the evident public health impact, the extent and patterns of alcohol use in the Eastern Mediterranean countries remain understudied. The latest estimation for the last 12-month use of alcohol in the region was 2.9% in 2016 by the World Health Organization. We reviewed the main indicators for alcohol consumption in the region since 2010. METHODS: We systematically searched on-line databases until September 2023, together with other global and regional sources for studies on the adult general population (aged ≥ 15 years) and young general populations (aged < 18 years) and studies on the treatment-seeking individuals with substance use in Eastern Mediterranean countries. Studies were included from 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen. RESULTS: A total of 148 were included (n = 95 on the prevalence of alcohol use, n = 46 on the prevalence of alcohol use disorder, regular use and heavy episodic drinking, n = 35 on alcohol use pattern among people who use substances and one report on alcohol per capita consumption, n = 29 had data for more than one category). The pooled prevalence of the last 12-month alcohol use in the adult general population was 9.5% [95% confidence interval (CI) = 6.4-13.7] among males, 2.8% (95% CI = 1.3-5.5\) among females and 6.2% (95% CI = 3.9-9.6) in both sexes in the region, with notable subregional variations. Data on the prevalence of alcohol use disorder and heavy drinking were limited to several countries, with heterogeneous indicators. The pooled estimate of alcohol as the primary substance of use among treatment-seeking people who used substances was 16.9% (95% CI = 8.8-26.9). CONCLUSIONS: More than 30 million adults in the Eastern Mediterranean region used alcohol in the last 12 months, with a prevalence of 6.2%. This is far fewer than the global estimate of 43% of the population aged 15 years and above, but is approximately two times more than the previous estimate (2.9%), reported by the World Health Organization in 2016, which might show an increasing trend.

Prevalence of Tuberculosis among People Who Use Drugs in Iran: A Systematic Review and Meta-analysis.

Background: Drug use, especially injecting drug use, is associated with a higher risk of tuberculosis (TB). This study aimed to systematically review the prevalence of TB among people who use drugs (PWUD) in Iran. Methods: A systematic search was conducted in international and national databases. All studies that provided data on the prevalence of TB among PWUD based on screening tests and diagnosis from 1990 up to August 2019 were assessed. Meta-analysis was performed on the prevalence of active TB among people who inject drugs (PWID). Findings: Overall, nine studies were included. The studies were carried out from 1994 to 2012 in seven out of the 31 provinces of Iran. Seven studies provided data on the prevalence of TB diagnosis among 1087 PWID. The pooled prevalence of TB diagnosis was 10.1% (95% CI: 4.5, 15.8) in studies carried out in hospitals and 0.54% (95% CI: 0.04, 1.04) in other settings. Conclusion: The present review suggests an approximately 40 times higher prevalence of TB among PWID compared to the general population. However, most of the included studies were conducted on a subpopulation of drug users, and caution should be exercised when generalizing the findings.

A Six-Year Follow-up of People Who Use Cannabis in Iran - A Case Series.

Background: Frequent cannabis use is associated with adverse health-related outcomes. This study followed up individuals who used cannabis to assess their use and adverse event status. Methods: The eligible individuals, recruited in the Iranian Mental Health Survey (IranMHS), were contacted via telephone calls six years after the index interview. The frequency of cannabis use and the occurrence of selected adverse events were recorded. The baseline status was extracted from the index survey. If any individual was inaccessible, his/her vital status was assessed. Findings: Of the 50 eligible individuals (all male), two had died. Moreover, from among 25 reached participants, 19 reported abstinence from cannabis in the past year, and 18 reported at least one adverse event in the past six years. Violence and imprisonment were the most common events reported. Conclusion: Six years after the index interview, most of the participants abstained from cannabis. Besides, adverse events were common, emphasizing the need for further investigations on larger samples of cannabis users.

Prevalence of injecting drug use and HIV, hepatitis B, and hepatitis C in people who inject drugs in the Eastern Mediterranean region: a systematic review and meta-analysis.

BACKGROUND: Considerable disease burden is attributed to injecting drug use (IDU). This regional systematic review and meta-analysis aimed to assess the prevalence of IDU and the characteristics of people who inject drugs in the 22 countries of the WHO Eastern Mediterranean region. METHODS: We conducted a systematic review and meta-analysis on the prevalence of IDU, estimation of the population size of people who inject drugs, the characteristics of people who inject drugs, commonly injected drugs, the prevalence of HIV, hepatitis C virus, and hepatitis B virus in people who inject drugs, and opioid agonist treatment and needle and syringe programme services. We searched PubMed, Web of Science, Scopus, Embase, and the Index Medicus for the Eastern Mediterranean Region for documents published between Jan 1, 2010, and April 17, 2022, with no language restrictions. We also searched government reports, civil society information, and UN websites and databases for grey literature published between Jan 1, 2010, and April 17, 2022. Documents were eligible if they reported or estimated an indicator of interest, or reported enough data to permit calculation of the indicator. We extracted data from the eligible documents and calculated national and regional estimates. FINDINGS: We identified 38 283 documents and included 201 documents in the systematic review. A total of 115 documents were included for the four outcomes for which meta-analyses were performed. The number of people who inject drugs was estimated as 864 597 (95% CI 641 909-1 205 255), amounting to a prevalence of 20·0 per 10 000 adults (95% CI 14·9-27·9) in the region. Among people who inject drugs, the prevalence of HIV was estimated as 19·22% (95% CI 12·86-26·36), hepatitis C virus as 44·82% (29·32-61·16), and hepatitis B virus as 2·66% (0·84-7·26). Countries varied greatly regarding the variables of interest and the availability of relevant data. Nine countries provided needle and syringe programme services and seven countries provided opioid agonist treatment services, mostly with very low, low, or unclear coverage. INTERPRETATION: The prevalence of IDU in the Eastern Mediterranean region is lower than the global mean, particularly among women. The HIV infection rate is higher than the global mean, and the hepatitis C virus infection rate is lower than the global mean. Harm-reduction services are underdeveloped. Data collection on IDU and provision of services need improvement in the region. FUNDING: World Health Organization. TRANSLATIONS: For the Arabic, Farsi and French translations of the abstract see Supplementary Materials section.

Drug use, drug use disorders, and treatment services in the Eastern Mediterranean region: a systematic review.

Drug use is an increasing global public health concern. We reviewed the prevalence and patterns of drug use, drug use disorders, and the extent of treatment services in 21 countries and one territory in the Eastern Mediterranean region from 2010 to 2022. Online databases were systematically searched on April 17, 2022, along with other sources for grey literature. The extracted data were analysed and used for synthesis at the country, subregional, and regional levels. The prevalence of drug use is higher in the Eastern Mediterranean region than global estimates, with cannabis, opium, khat, and tramadol among the main drugs used in the region. Data on the prevalence of drug use disorders were scarce and heterogeneous. Treatment facilities for drug use disorders are available in most countries, but opioid agonist treatment exists in only seven countries. There is a need to expand evidence-based and cost-effective care. Limited data exist, especially regarding drug use disorders, treatment coverage, and drug use among women and young people.

Mortality and negative outcomes of opioid use and opioid use disorder: a 6-year follow-up study.

BACKGROUND AND AIMS: There is a paucity of data on outcomes of opioid use disorder (OUD) from low- and middle-income countries. We aimed to investigate the mortality as well as negative social and health outcomes in a 6-year follow-up study of a cohort of individuals with opioid use, including those with OUD, in Iran. DESIGN AND SETTING: Participants with opioid use initially interviewed in late 2011 in the Iranian National Mental Health Survey (IranMHS)-a household survey of 15-64-year-old population-were followed-up in early 2018. PARTICIPANTS: All respondents (n = 236) who had reported use of any opioids at least five times during the 12-month period prior to the index interview were included in the study. MEASUREMENTS: Composite International Diagnostic Interview (CIDI) version 2.1 was used for assessment of opioid use and OUD at baseline. Vital status in the follow-up was ascertained through contact with participants/informants, primarily via telephone calls and also through the death registration systems. Weighted incidence rates of negative consequences of opioid use (e.g. incarceration, suicide attempts, violent behavior) were estimated for those who were interviewed. FINDINGS: Seven (3.3%) of the 236 participants with opioid use including four (3.1%) of the 136 with OUD had died by the time of the follow-up interview, resulting in death rates of 0.49 [95% confidence interval (CI) = 0.21-1.38] and 0.53 (95% CI = 0.16-2.62) per 100 person-years, respectively. Overall, 35.0% of participants with opioid use and 44.0% of those with OUD among the 145 individuals interviewed at follow-up experienced non-fatal serious adverse outcomes. CONCLUSIONS: In Iran, opioid use and opioid use disorder are associated with increased mortality and other adverse outcomes.

Spouse and Child Abuse Associated With Illicit Drug Use in Iran: A Systematic Review and Meta-Analysis.

BACKGROUND: There is a high prevalence of substance use disorders, especially among men, in Iran and is associated with a high burden on families. We aimed to systematically review the association between illicit drug use and spouse and child abuse in Iran. METHOD: Comprehensive terms were used to search three international databases (ISI, Medline, and Scopus) and a national database of Scientific Information Database up to September 2019. The retrieved citations were screened based on the eligibility criteria and then data were extracted, and the risk of bias was assessed by two independent investigators. Data were analyzed using random-effects model to estimate pooled odds ratios (ORs) and the heterogeneity of studies. RESULTS: The search yielded 18 articles that met the inclusion criteria. Illicit substance use in husbands was associated with increased odds of current violence (OR = 3.50; 95% CI [2.09, 5.86]), current physical violence (OR = 5.41; 95% CI [3.50, 8.35]), current psychological violence (OR = 6.20; 95% CI [3.74, 10.30]), and current sexual violence (OR = 7.23; 95% CI [4.06, 12.87]) against spouse. In studies on child abuse, the odds of current physical child abuse by parents who used an illicit substance was 3.88 times (95% CI [1.50, 10.01]) higher than parents who did not use any illicit substance. CONCLUSION: The results of the current study showed that illicit substance use is associated with an increased risk of spouse and child abuse. This is an important social and health consequence of drug use and should be addressed in all drug control plans.

Public health risks associated with methadone in Iran: A systematic review and meta-analysis.

BACKGROUND: There has been a marked growth in methadone maintenance treatment (MMT) in Iran in the past two decades with positive health outcomes. We conducted a systematic review of studies on the prevalence of non-prescribed methadone use, methadone use disorder, and methadone-related poisoning and mortality in Iran. METHODS: We searched International and Iranian databases up to May 2020 and contacted relevant experts. The pooled proportions were estimated through random-effects model. Methadone-related adverse outcomes were evaluated over time. RESULTS: Sixty-five studies were included. The pooled estimates of non-prescribed methadone use in the last 12-month were 2.7% (95%CI: 0.9-5.4) and 0.1% (95%CI: 0.03-0.2) in the male and female general population, respectively. Among people who use drugs, 8.4% reported daily non-prescribed use in 2018. Four heterogeneous studies in drug treatment centers reported the existence of treatment-seeking for methadone use disorder. Methadone was responsible for 10.4% (95%CI: 4.5-18.3) of cases of acute poisoning in adults and 16.0% (95%CI: 9.3-24.1) in children. Methadone was reported as a cause of death in 53.5% of substance-related deaths referred to the Legal Medicine Organization while being the only cause in 35.8% of all cases. CONCLUSION: Non-prescribed use of methadone in the general population is much less than opiates and some other available prescription opioids, like tramadol. However, notwithstanding the large and successful MMT program in Iran, increasing trends in methadone-related poisoning and deaths pose serious public health concerns. There is an urgent need to explore these fatal and non-fatal poisoning cases and implement policies to curb the harms associated with methadone use.

HIV prevalence among non-injecting people who use drugs and related factors in Iran: A systematic review and meta-analysis.

ISSUES: This systematic review aimed to provide an updated estimate on the prevalence of human immunodeficiency virus (HIV) infection among non-injecting people who use drugs (PWUD) and the various subgroups and the odds of HIV infection in the injecting compared to non-injecting PWUD. APPROACH: A comprehensive search of international, regional and national databases was performed from January 2005 to May 2020. We conducted backward citation tracking of the included studies and contacted experts for unpublished studies. Studies providing HIV prevalence among non-injecting PWUD were included. Data were also drawn from a previous systematic review, covering 10 years from 1998 to 2007, and was added to the new database. The HIV prevalence was pooled for non-injecting PWUD and other subgroups using the random-effects model. KEY FINDINGS: Seventeen studies with a total sample of 9912 non-injecting PWUD were found. The prevalence of HIV infection was 1.9% (95% confidence interval 0.9, 3.1) for 2007 and afterward (nine studies). It was not significantly different from the estimate for the years before 2007 (0.5%; 95% confidence interval 0.0, 2.0; eight studies). No significant difference was found among gender subgroups. The overall estimate of odds of HIV infection among injecting PWUD was 5.7 (95% confidence interval 3.2, 10.0) times higher than non-injecting PWUD. IMPLICATIONS AND CONCLUSIONS: The HIV prevalence among the non-injecting PWUD was higher than the general population in Iran. Targeting non-injection PWUD by preventive measures such as harm reduction, drug and psychoeducation, and surveillance seem to be crucial in reducing HIV prevalence in this group.

Comparison of self-reported substance use with biological testing among treatment-seeking patients with opioid use disorder.

BACKGROUND: Several factors may influence the validity of self-report. In this study, we aimed to assess the validity of self-reported drug use compared to urine testing among treatment-seeking patients with opioid use disorder (OUD). METHODS: This cross-sectional study recruited 293 patients with OUD, referred to the Iranian National Center for Addiction Studies (INCAS) clinic, from November 2015 to June 2017. The study compared self-reported opioid use in the past 72 h with the results of urinalysis, using immunoassay technique. We estimated sensitivity, negative predictive value, percent agreement, positive percent agreement, and Cohen's kappa statistics for those with OUD. RESULTS: The sensitivity of self-reported opioid use was 85.9%. Percent agreement, positive percent agreement, and Cohen's Kappa statistics between self-reported opioid use and urine testing for morphine in the first month were 88.5%, 78.1%, and 77.0, respectively. Multilevel logistic regression showed that longer treatment duration (OR = 1.21, 95%CI: 1.07-1.37, p-value = 0.002) was significantly associated with the agreement of self-reported opioid use with urine testing. CONCLUSION: Self-report can be used as a reliable method for monitoring treatment adherence combined with random urine tests.

Evidence for an increase in cannabis use in Iran - A systematic review and trend analysis.

BACKGROUND AND AIMS: Cannabis is the most widely used illicit substance globally. In this systematic review, we examined the prevalence and trends of cannabis use and cannabis use disorder in Iran. METHODS: We searched International and Iranian databases up to March 2021. Pooled prevalence of use among sex subgroups of the general population, university and high school students, combined youth groups, and high-risk groups was estimated through random-effects model. Trends of various use indicators and national seizures were examined. RESULTS: Ninety studies were included. The prevalence estimates of last 12-month cannabis use were 1.3% (95%CI: 0.1-3.6) and 0.2% (95%CI: 0.1-0.3) among the male and female Iranian general population, respectively. The prevalence of cannabis use disorder among general population in national studies rose from 0% in 2001 to 0.5% in 2011. In the 2016-2020 period, the pooled prevalence estimates of last 12-month cannabis use were 4.9% (95% CI: 3.4-6.7) and 0.3% (95% CI: 0.0-1.3) among males and females of "combined youth groups", respectively. The linear trend of last 12-month cannabis use among males of "combined youth groups" and among female university students increased significantly from 2000 to 2020. CONCLUSIONS: Prevalence of cannabis use in Iran is low compared to many countries. However, there is strong evidence of an increase in cannabis use among the youth and some evidence for an increase in cannabis use disorder.

Opium dependence and the potential impact of changes in treatment coverage level: A dynamic modeling study.

Background : The most common drug, illegally used in Iran is opium. The treatment of people with substance use disorder is one of the most important strategies in reducing its burden. The aim of this study was to investigate the effect of different increasing and decreasing opium treatment coverage on the patterns of abstinence, transition to heroin dependence and mortality, over 30 years. Methods: This study was a dynamic compartmental modeling conducted in three stages: 1) presenting a conceptual model of opium dependence treatment in Iran, 2) estimating model's parameters value, and 3) modeling of opium dependence treatment and examining the outcomes for different treatment coverage scenarios. The input parameters of the model were extracted from the literature, and secondary data analysis, which were finalized in expert panels. Results: The number of opium dependence will increase from 1180550 to 1522063 [28.93% (95% CI: 28.6 to 29.2)] over 30 years. With a 25% decrease in coverage compared to the status quo, the number of deaths will increase by 459 cases [3.28% (95% CI: 0.91 to 5.7)] in the first year, and this trend will continue to be 2989 cases [15.63% (95% CI: 13.4 to 17.9)] in the 30th year. A 25% increase in treatment coverage causes a cumulative decrease of heroin dependence by 14451 cases [10.1% (95% CI: 9.5 to 10.8)] in the first decade. Conclusion: The modeling showed that the treatment coverage level reduction has a greater impact than the coverage level increase in the country and any amount of reduction in the coverage level, even to a small extent, may have a large negative impact in the long run.

Buprenorphine abuse and health risks in Iran: A systematic review.

INTRODUCTION: Buprenorphine maintenance treatment (BMT) is widely used in Iran, and its use is growing continuously. We reviewed studies on buprenorphine use, non-prescribed use, use disorder and treatment-seeking for it, buprenorphine-associated poisoning, and mortality in Iran in the current systematic review. METHODS: An Iranian database (Scientific Information Database; SID) and three International electronic databases (PubMed, Scopus, and Web of Science) were searched for publications up to August 2020 for the relevant data. Opportunistic methods (Contact with experts and backward citation tracking) were also used for this purpose. Identified records were screened for eligibility criteria, and data of included studies were extracted. For context, the trend of BMT in the country was also examined. RESULTS: Ten studies were found on the prevalence of non-prescribed buprenorphine use, seven were on the regular use and use disorder, and two studies on buprenorphine poisoning. The last 12-month prevalence of non-prescribed use was lower than 0.5 % in the general population, university, and high school students. The indicator was 2.5 % among persons who use drugs in a 2018 national study. The proportion of buprenorphine poisoning was 4.9 % among all illicit substance poisoning cases admitted to a hospital. The proportion of buprenorphine poisoning cases among all acute pediatric drug poisoning cases increased from 1.2 % to 2.5 % in a 3-year study. CONCLUSION: Despite the expansion of BMT in Iran in the last decade, the adverse health consequences associated with buprenorphine are infrequent, when compared to other opioids used in Iran, suggesting the safety of BMT for future expansion.

Hepatitis B virus infection among people who use drugs in Iran: a systematic review, meta-analysis, and trend analysis.

BACKGROUND: People who use drugs (PWUD) are considered as one of the main at-risk populations for Hepatitis B virus (HBV) infection. We conducted a systematic review on the prevalence of HBV infection among PWUD in Iran. METHODS: Consistent with PRISMA guideline, international (Medline, Web of Science, Scopus, and Embase) and national (Scientific Information Database) databases were searched using a comprehensive search strategy up to September 2019. The retrieved records were reviewed, and experts were contacted for unpublished studies. Studies on Iranian PWUD reporting HBV surface Antigen (HBsAg) prevalence among people who inject drugs (PWID) and non-injecting PWUD were included. HBsAg prevalence was pooled for PWID and non-injecting PWUD and for other subgroups using random-effects model meta-analysis. The trend of HBV prevalence over time was investigated using meta-regression analysis. RESULTS: Overall, 35 studies reported data on HBV infection among PWID (33 studies) and non-injecting PWUD (11 studies). The pooled prevalence of HBsAg among PWID was 4.8% (95% CI 3.7-6.2). The only risk factor significantly associated with the odds of positive HBsAg in PWID was the previous history of imprisonment (OR 1.72, 95% CI 1.29-2.30, p value = 0.000). The pooled estimate of HBsAg among non-injecting PWUD was 2.9% (95% CI 2.5-3.2). Time trend analyses showed significant decrease in HBV prevalence among PWID reaching from 8.2% (95% CI 3.9-16.5) in 2004-2006 to 3.1% (95% CI 2.3-4.1) in 2016 and later (b = -0.07; p value = 0.05). No significant trend was detected for non-injecting PWUD. CONCLUSION: The prevalence of HBV infection among non-injecting PWUD and even PWID was not considerably higher than the Iranian general population. This might be the result of extensive harm reduction interventions in Iran. However, it seems that there are subgroups of PWID, who do not adequately benefit from existing harm reduction interventions. Future programs should more specifically target these high-risk groups.

Tramadol use and public health consequences in Iran: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Misuse of tramadol, an opioid prescription analgesic, is known as a public health challenge globally. We aimed to systematically review studies on the prevalence of non-prescribed use, regular tramadol use and dependence, tramadol-induced poisoning and mortality in Iran. METHODS: Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, international (Medline, Scopus, Web of Science) and Persian (SID) databases were systematically searched up to June 2019. Other relevant data were collected through personal contacts and review of reference lists. Pooled estimates of prevalence of tramadol use in subgroups of males and females, percentage of tramadol poisoning among admitted poisoning cases, tramadol-associated seizures and mortality among tramadol poisonings and percentage of tramadol as a cause of death among fatal drug-poisoning records were estimated through a random-effects model. RESULTS: A total of 84 records were included. Pooled estimates of last 12-month use of tramadol in the Iranian general population were 4.9% [95% confidence interval (CI) = 4.1-5.9] and 0.8% (95% CI = 0.2-1.8) among males and females, respectively. The estimates for last 12-month use among Iranian male and female university students were 4.8% (95% CI = 1.9-8.9) and 0.7% (95% CI = 0.3-1.1), respectively. Six heterogeneous reports indicated the existence of regular use of tramadol and dependence in Iran. Sixty-two studies provided data on tramadol-induced poisoning, seizures and mortality. The pooled estimate of the percentage of tramadol poisoning among all drug-poisoning patients was 13.1% (95% CI = 5.7-22.9). The overall estimates of seizures and mortality among tramadol-poisoning patients were 34.6% (95% CI = 29.6-39.8) and 0.7% (95% CI = 0.0-1.9), respectively. The pooled percentage of tramadol-related fatalities among drug-poisoned cases was 5.7% (95% CI = 0.5-15.4). CONCLUSION: Despite control policies, tramadol use is as prevalent as the use of illicit opioids in Iran. Numerous cases of tramadol abuse, dependence, poisonings, seizures and hundreds of tramadol-related deaths have been reported in recent years.

Systematic review and meta-analysis of safety and efficacy of high-intensity focused ultrasound (HIFU) for face and neck rejuvenation.

High-intensity focused ultrasound (HIFU) is widely used for skin rejuvenation and tightening. The aim of this study was to determine the safety and efficacy of HIFU for face and neck rejuvenation. A systematic search of peer reviewed articles published before December 2017 was performed using Medline, Web of Science, and Scopus databases. Retrieved studies were screened, and clinical trials or follow-up studies which were evaluated the effect of HIFU on rejuvenation treatments of face and neck area were included. Risk of bias for each study was assessed and was reported. Safety and efficacy variables, which were reported more often in papers, were included in meta-analysis. Seventeen studies involving 477 participants were included in the analysis. Meta-analysis showed moderate improvement as scores of 2.74 (95% CI 2.06-3.43) and 2.68 (95% CI 1.92-3.45), out of 5 maximum score, for objective improvement score and subjective satisfaction score, respectively. Meta-analysis of mean pain score, assessed by a 0-10 Likert score, was 4.2 (95% CI 4.27-5.19). Edema and erythema showed considerable heterogeneity, and no hyperpigmentation was reported by included studies. Included studies used multiple and different outcome variables with different scoring at various time points. Long follow-up was not reported by majority of studies. HIFU is safe procedure in short term and has a moderate effect on rejuvenation of face and neck areas.

HIV prevalence among people who inject drugs (PWID) and related factors in Iran: a systematic review, meta-analysis and trend analysis.

AIMS: In Iran, injecting drug use has been the major route of human immunodeficiency virus (HIV) transmission. In order to control the HIV epidemic, a harm reduction program was initiated and has been expanded in recent years. The aim of this study was to provide an updated estimate of HIV prevalence among people who inject drugs (PWID) in Iran, investigate prevalence differences over time and assess prevalence correlates. DESIGN: A comprehensive systematic review was undertaken in the international, regional and national bibliographic databases in November 2018 and extensive contacts with authors were made. For studies conducted before 2005, we used data from a previous published systematic review. SETTING: All studies conducted in Iran were included. Recruitment settings included anywhere except studies conducted in infectious diseases wards or HIV counseling centers. PARTICIPANTS: PWID with any definition utilized in the studies. Thirty-six studies were included, which were conducted in 24 of 31 provinces with a sample size of 22 160 PWID. MEASUREMENTS: We included studies that had performed HIV testing and had a confirmed diagnosis of HIV through repeating the enzyme-linked immunosorbent assay (ELISA) or Western immunoblot assay (WB). Pooled prevalence of HIV was calculated for the total sample and for different subgroups, by available socio-demographic and behavioral factors. For assessing the trend of HIV prevalence over time, a linear meta-regression model was fitted separately for before 2007 and during 2007 and afterwards. FINDINGS: The pooled prevalences of HIV before 2007 and in 2007 and afterwards were 14.3% [95% confidence interval (CI) = 9.8-18.9] and 9.7% (95% CI = 7.6-11.9), respectively. HIV prevalence increased until 2005-06 and then slowly declined until 2009-10, which was not significant. Prevalence of HIV was significantly higher in PWID above age 25 years, and in those with history of imprisonment and history of needle/syringe-sharing. HIV prevalence was higher in men than in women, but the difference was insignificant. CONCLUSION: The prevalence of HIV among people who inject drugs in Iran decreased after 2006 which could, at least in part, be attributed to the development of extensive harm reduction programs in the country.

Correction: The Knowledge Translation Status in Selected Eastern-Mediterranean Universities and Research Institutes.

[This corrects the article DOI: 10.1371/journal.pone.0103732.].