"No-one just does drugs during business hours!": evaluation of a 24/7 primary needle and syringe program in St Kilda, Australia.

BACKGROUND: Primary needle and syringe programs (NSPs) have been integral for the prevention of blood-borne virus (BBV) transmission among people who inject drugs. Despite this, many people who inject drugs face barriers accessing these services, particularly after-hours when most services are closed. To our knowledge, the St Kilda NSP, in Melbourne, Victoria, is the only primary NSP providing 24/7 dedicated stand-alone face-to-face services for people who inject drugs in Australia. We conducted an evaluation of the St Kilda NSP to assess its role and effectiveness in meeting client needs. METHODS: Mixed research methods were used to conduct the evaluation. We analysed four quantitative data sets including the Victorian Needle and Syringe Program Information System data; NSP 'snapshot' survey data; and St Kilda NSP records of after-hours contacts and naloxone training events. Qualitative interviews were conducted with 20 purposively selected NSP clients, which were focused on individual needs, expectations and experiences accessing the service. Interviews were audio recorded and transcribed, and data were analysed thematically. A convergent research design was used to merge the five data sets. RESULTS: St Kilda NSP had 39,898 service contacts in 2018; 72% of contacts occurred outside business hours. Similarly, of 1,185,000 sterile needles and syringes dispatched, 71% were distributed outside business hours. Participants described valuing the after-hours service because drug use patterns did not always align with standard NSP opening hours and after-hours access afforded anonymity when collecting injecting equipment. Narratives highlighted several additional benefits of the 24/7 service, including: access to safer sex equipment; material support; naloxone training; referrals to specialist services; face-to-face emotional and social support from a non-judging worker; and for women involved in sex work in particular, being able to seek refuge when feeling unsafe on the streets. CONCLUSIONS: Our study provides evidence of the social and health benefits (beyond that of preventing BBV transmission) that can be gained through the provision of 24/7 primary NSP services. Findings support the need for the establishment of after-hours primary NSPs in other areas of Australia where active street-based drug markets operate outside business hours and concentrated numbers of people who inject drugs live and spend time.

The National Naloxone Reference Group: A collective voice on take-home naloxone policy and practice in Australia.

The National Naloxone Reference Group has played a key role in the development of take-home naloxone programs, policy and practice in Australia. In this commentary we detail the origins of the group, some of its main achievements since its inception and its future directions in light of the major policy changes around naloxone that have recently occurred in Australia.

Discontinuation of opioid agonist treatment following release from prison in a cohort of men who injected drugs prior to imprisonment in Victoria, Australia: A discrete-time survival analysis.

BACKGROUND: Retention in opioid agonist treatment (OAT) following release from prison is associated with improved outcomes, however factors associated with post-release OAT discontinuation in Australia are poorly understood. We examined post-release OAT discontinuation in a cohort of men who engaged in approximately monthly injecting drug use (IDU) prior to imprisonment in Victoria, Australia. METHODS: Longitudinal data were used to calculate incidence of first-event post-release OAT discontinuation among men released from prison receiving OAT, and single-event discrete-time survival methods were used to estimate associations with post-release OAT discontinuation. RESULTS: Among 110 participants, 55 OAT discontinuations were observed in the two years post-release, an overall crude incidence rate (IR) of 46 per 100 person-years (PY) (95 % confidence interval [95 %CI]: 36-60 per 100PY). Incidence was greatest between release from prison and first follow-up (IR: 84 per 100PY, 95 %CI: 62-116 per 100PY). Initiating OAT during index imprisonment (versus transitioning from community OAT; adjusted hazard rate [AHR]: 2.17, 95 %CI: 1.14-4.13) and identifying as Aboriginal and/or Torres Strait Islander (AHR: 4.95, 95 %CI: 2.00-12.25) were associated with an increased hazard of OAT discontinuation. CONCLUSION: In a cohort of men with recent histories of IDU released from prison receiving OAT, half reported OAT discontinuation within two years of release from prison, with incidence of discontinuation greatest soon after prison-release. Targeted support for men who initiate OAT during episodes of imprisonment and Aboriginal and/or Torres Strait Islander peoples is necessary to reduce incidence of OAT discontinuation among people at greatest risk of discontinuation.

High rates of resumption of injecting drug use following release from prison among men who injected drugs before imprisonment.

AIMS: To estimate incidence of post-release injecting drug use (IDU) among men who injected drugs before imprisonment and determine factors associated with post-release IDU frequency. DESIGN, SETTING, PARTICIPANTS: Prospective cohort study of men reporting monthly IDU before a period of sentenced imprisonment in Victoria, Australia, recruited between September 2014 and May 2016 (n = 195). MEASUREMENTS: Any post-release IDU and IDU frequency was measured via self-report at 3-month follow-up interview. IDU frequency, measured over the preceding month, was categorised as no IDU, irregular IDU (1-4 days IDU) and regular IDU (≥5 days IDU). Incidence of any IDU was calculated at 3 months post-release. Factors associated with IDU frequency were estimated using ordinal logistic regression. FINDINGS: Most (83%) participants reported post-release IDU (265 per 100 person-years, 95% CI, 227-309); with half (48%) reporting regular IDU, 23% irregular IDU and 29% no IDU in the month preceding follow-up. Poorer psychological well-being at follow-up (General Health Questionnaire [GHQ-12] score; adjusted odds ratio [AOR], 1.18; 95% CI, 1.07-1.29) and post-release unemployment (AOR, 4.57; 95% CI, 1.67-12.49) were associated with increased IDU frequency. Retention in opioid agonist treatment (AOR, 0.49; 95% CI, 0.24-0.98) was associated with reduced IDU frequency. Non-linear (inverted-u) associations between IDU frequency and age (age: AOR, 1.51; 95% CI, 1.17-1.96; age-squared: AOR, 0.99; 95% CI, 0.99-0.99) and pre-imprisonment IDU frequency (pre-imprisonment IDU frequency: AOR, 1.36; 95% CI, 1.15-1.61; pre-imprisonment IDU frequency-squared: AOR, 0.99; 95% CI, 0.99-0.99) were found, with odds peaking at age 39 and 19 days IDU, respectively. Longer baseline sentence length was associated with reduced odds of irregular and regular IDU (AOR, 0.99; 95% CI, 0.99-0.99). CONCLUSION: Among Australian men who inject drugs before imprisonment, resumption of injecting drug use after release from prison appears to be common, with imprisonment seeming to have little impact on reducing injecting drug use behaviour.

Emergency department presentations in the first weeks following release from prison among men with a history of injecting drug use in Victoria, Australia: A prospective cohort study.

OBJECTIVE: Rates of emergency department (ED) use are higher among people released from prison than in the general population. However, little is known about ED presentations specifically among people with a history of injecting drug use (IDU) leaving prison. We measured the incidence of ED presentation in the three months following release from prison, among a cohort of men with histories of IDU, and determined pre-release characteristics associated with presenting to an ED during this period. METHODS: We analysed linked survey and administrative data from the Prison and Transition Health (PATH) study (N = 400) using multiple-failure survival analysis. RESULTS: Twenty-one percent (n = 81/393) of the cohort presented to an ED at least once within the three months after release from prison. The incidence of ED presentation was highest in the first six days after release. Cox proportional hazards modelling showed that a history of in-patient psychiatric admission and housing instability were associated with increased hazard of an ED presentation, and identifying as Aboriginal and Torres Strait Islander was associated with decreased hazard. CONCLUSIONS: In our study, ED presentations following release from prison among people with a history of IDU was linked to acute health risks related to known mental health and social vulnerabilities in this population. Greater collaboration and systems integration between prison and community health and support services is needed to reduce presentations to ED and associated morbidities among people with a history of IDU after release from prison.

The Prison and Transition Health (PATH) cohort study: Prevalence of health, social, and crime characteristics after release from prison for men reporting a history of injecting drug use in Victoria, Australia.

BACKGROUND: People who inject drugs are overrepresented in prison and have diverse and complex health needs. However, outcomes after release from prison are poorly understood, limiting effective interventions supporting community reintegration. We describe the prevalence of socio-demographics, physical and mental health, alcohol and other drug use, and crime characteristics of men with histories of injecting drug use after their release from prison in Victoria, Australia. METHODS: Data come from the Prison and Transition Health (PATH) prospective cohort study. Interviews were undertaken approximately three, 12, and 24 months after release from their index prison episode and were completed in the community, or in prison for those reimprisoned during the study. We present cross-sectional descriptive statistics for each follow-up wave of the PATH study. RESULTS: Among 400 men recruited into PATH, 85 % (n = 336) completed at least one follow-up interview; 162 (42 %) completed all three interviews. Participants reported social disadvantage and health inequity, including high rates of unemployment, homelessness, and physical and mental health morbidities at each follow-up time point. Rapid return to illicit substance use was common, as was overdose (ranging 9 %-13 %), receptive syringe sharing (ranging 20 %-29 %), involvement in crime-related activities (ranging 49 %-58 %), and reimprisonment (ranging 22 %-50 %) over the duration of follow-up. CONCLUSION: Men in this study experienced substantial health and social challenges across a 24-month prospective follow-up period. Improved understanding of characteristics and experiences of this group after release from prison can inform more coordinated and continued care between prison and the community.

Strategies to maximise study retention and limit attrition bias in a prospective cohort study of men reporting a history of injecting drug use released from prison: the prison and transition health study.

BACKGROUND: There are significant challenges associated with studies of people released from custodial settings, including loss to follow-up in the community. Interpretation of findings with consideration of differences between those followed up and those not followed up is critical in the development of evidence-informed policies and practices. We describe attrition bias in the Prison and Transition Health (PATH) prospective cohort study, and strategies employed to minimise attrition. METHODS: PATH involves 400 men with a history of injecting drug use recruited from three prisons in Victoria, Australia. Four interviews were conducted: one pre-release ('baseline') and three interviews at approximately 3, 12, and 24 months post-release ('follow-up'). We assessed differences in baseline characteristics between those retained and not retained in the study, reporting mean differences and 95% confidence intervals (95% CIs).  RESULTS: Most participants (85%) completed at least one follow-up interview and 162 (42%) completed all three follow-up interviews. Retained participants were younger than those lost to follow-up (mean diff - 3.1 years, 95% CI -5.3, - 0.9). There were no other statistically significant differences observed in baseline characteristics. CONCLUSION: The high proportion of participants retained in the PATH cohort study via comprehensive follow-up procedures, coupled with extensive record linkage to a range of administrative datasets, is a considerable strength of the study. Our findings highlight how strategic and comprehensive follow-up procedures, frequent contact with participants and secondary contacts, and established working relationships with the relevant government departments can improve study retention and potentially minimise attrition bias.

The Prison and Transition Health (PATH) Cohort Study: Study Protocol and Baseline Characteristics of a Cohort of Men with a History of Injecting Drug Use Leaving Prison in Australia.

People who inject drugs (PWID) are disproportionately represented among individuals who experience imprisonment and often have more complex physical and mental health needs than people in prison without injecting histories. The trajectories of PWID after prison release are poorly understood, hampering the development of effective strategies to address their distinct health needs. The Prison and Transition Health (PATH) Cohort Study is characterising the post-release trajectories of incarcerated male PWID in Victoria, Australia. We outline study methodology and baseline characteristics of participants prior to their release. Four hundred participants were recruited from three prisons and completed researcher-administered baseline interviews covering socio-demographics, social supports, physical health, mental health, alcohol and other drug use, and pre-release and transitional service utilisation. The median age among participants was 36 years (IQR 30-42), and they reported a median of five (IQR 3-9) previous adult incarcerations. Almost half (49%) were reliant on government payments prior to incarceration. One quarter (25%) of participants reported removal from their parents' care as children and 64% reported being a parent or primary caregiver to children. Most participants (81%) reported a previous mental health diagnosis and 44% reported three or more diagnoses. The most common drugs injected prior to incarceration were crystal methamphetamine (80%) and heroin (62%), and most (85%) reported being under the influence of drugs at the time of committing offences for which they were currently incarcerated. Injecting drug use during their current sentence was reported by 40% of participants, and 48% reported engaging with some form of drug treatment during their current sentence. Study participants are characterised by significant mental health and substance use morbidities, social disadvantage and criminogenic histories that present challenges for the provision of post-release support services. Data from the PATH Cohort Study will help inform strategies to improve the health and social outcomes of this population.

Lifetime prevalence and correlates of self-harm and suicide attempts among male prisoners with histories of injecting drug use.

BACKGROUND: Histories of self-harm and suicide attempts are common among people in prison in Australia, and substance dependence is an established risk factor for these lifetime experiences. We describe the prevalence of self-reported history of non-suicidal self-injury (NSSI) and suicide attempts in a cohort of men with recent histories of injecting drug use (IDU) imprisoned in Victoria, Australia. Baseline interviews from the Prison and Transition Health (PATH) prospective cohort study were conducted in the weeks prior to release from prison among 400 incarcerated men who reported regular IDU in the six months prior to incarceration. RESULTS: Participants completed a researcher-administered structured questionnaire that collected information on sociodemographics, substance use patterns, and physical and mental health indicators. More than one third (37%) reported a history of NSSI and almost half of participants (47%) reported a history of suicide attempts. In multivariable Poisson regression models, a history of NSSI was associated with: being aged 30-39 years; moving accommodation three or more times in the year prior to current sentence; self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting three or more previous drug overdoses. History of suicide attempts was significantly associated with: self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting a history of 1-2 and > 3 drug overdoses. CONCLUSION: We observed a disconcertingly high lifetime prevalence of non-suicidal self-injury and suicide attempts among incarcerated males with a history of recent regular injecting drug use. Significant associations with indicators of mental illness and drug related harms support the need to prioritise in-prison screening and early intervention to reduce the risk of future harms for this population.

Acceptability of prison-based take-home naloxone programmes among a cohort of incarcerated men with a history of regular injecting drug use.

BACKGROUND: Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia. METHODS: The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison. RESULTS: Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03-4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32-4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14-5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73-11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18-0.77) was associated with decreased odds of willingness to participate in a prison THN training. CONCLUSION: Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to participate in THN training prior to release. Factors associated with willingness to participate in prison THN programmes offer insights to help support the implementation and uptake of THN programmes to reduce opioid-overdose deaths in the post-release period.

The associations of poor psychiatric well-being among incarcerated men with injecting drug use histories in Victoria, Australia.

BACKGROUND: Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome. METHODS AND RESULTS: Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03-1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30-2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05-2.22) were statistically significantly associated with current poor psychiatric well-being. CONCLUSIONS: Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk.

Modelling the Impact of Condom Distribution on the Incidence and Prevalence of Sexually Transmitted Infections in an Adult Male Prison System.

AIMS: To determine the effects of 1) a condom distribution program and 2) a condom distribution program combined with opt-out sexually transmitted infection (STI) screening on the transmission and prevalence of STIs in a prison system. METHODS: Using data from an implementation evaluation of a state-wide prison condom program and parameter estimates from available literature, a deterministic model was developed to quantify the incidence and prevalence of sexually transmitted HIV, hepatitis B, chlamydia, syphilis and gonorrhoea across 14 Victorian prisons. The model included individual prison populations (by longer (>2 years) or shorter sentence lengths) and monthly prisoner transfers. For each STI, simulations were compared: without any intervention; with a condom distribution program; and with a combined condom and opt-out STI screening at prison reception intervention program. RESULTS: Condoms reduced the annual incidence of syphilis by 99% (N = 66 averted cases); gonorrhoea by 98% (N = 113 cases); hepatitis B by 71% (N = 5 cases); chlamydia by 27% (N = 196 cases); and HIV by 50% (N = 2 cases every 10 years). Condom availability changed the in-prison epidemiology of gonorrhoea and syphilis from self-sustaining to levels unlikely to result in infection outbreaks; however, condoms did not reduce chlamydia prevalence below a self-sustaining level due to its high infectiousness, high prevalence and low detection rate. When combined with a screening intervention program, condoms reduced chlamydia prevalence further, but not below a self-sustaining level. The low prevalence of HIV and hepatitis B in Australian prisons meant the effects of condoms were predicted to be small. CONCLUSION: Condoms are predicted to effectively reduce the incidence of STIs in prison and are predicted to control syphilis and gonorrhoea transmission, however even combined with a screening on arrival program may be insufficient to reduce chlamydia prevalence below self-sustaining levels. To control chlamydia transmission additional screening of the existing prison population would be required.

Correlates of property crime in a cohort of recently released prisoners with a history of injecting drug use.

BACKGROUND: Injecting drug use (IDU) is a strong predictor of recidivism and re-incarceration in ex-prisoners. Although the links between drug use and crime are well documented, studies examining post-release criminal activity and re-incarceration risk among ex-prisoners with a history of IDU are limited. We aimed to explore factors associated with property crime among people with a history of IDU recently released from prison. METHOD: Individuals with a history of IDU released from prison within the past month were recruited via targeted and snowball sampling methods from street drug markets and services for people who inject drugs (PWID) into a 6-month cohort study. A multivariate logistic regression analysis of baseline data identified adjusted associations with self-reported property crime soon after release. RESULTS: Interviews were conducted a median of 23 days post-release with 141 participants. Twenty-eight percent reported property crime in this period and 85% had injected drugs since release. Twenty-three percent reported injecting at least daily. Reporting daily injecting (adjusted odds ratio (aOR) 4.36; 95% confidence interval (CI) = 1.45-13.07), illicit benzodiazepine use (aOR = 2.59; 95% CI = 1.02-5.67), being arrested (aOR = 6.12; 95% CI = 1.83-20.45) and contact with mental health services (aOR = 4.27; 95% CI = 1.45-12.60) since release were associated with property crime. CONCLUSION: Criminal activity soon after release was common in this sample of PWID, underscoring the need for improved pre-release, transitional and post-release drug use dependence and prevention programmes. Addressing co-occurring mental disorder and poly-pharmaceutical misuse among those with a history of IDU in prison, and during the transition to the community, may reduce property crime in this group.