Effectiveness of psychosocial interventions for reducing parental substance misuse.

BACKGROUND: Parental substance use is a substantial public health and safeguarding concern. There have been a number of trials of interventions relating to substance-using parents that have sought to address this risk factor, with potential outcomes for parent and child. OBJECTIVES: To assess the effectiveness of psychosocial interventions in reducing parental substance use (alcohol and/or illicit drugs, excluding tobacco). SEARCH METHODS: We searched the following databases from their inception to July 2020: the Cochrane Drugs and Alcohol Group Specialised Register; CENTRAL; MEDLINE; Embase; PsycINFO; CINAHL; Applied Social Science (ASSIA); Sociological Abstracts; Social Science Citation Index (SSCI), Scopus, ClinicalTrials.gov, WHO ICTRP, and TRoPHI. We also searched key journals and the reference lists of included papers and contacted authors publishing in the field. SELECTION CRITERIA: We included data from trials of complex psychosocial interventions targeting substance use in parents of children under the age of 21 years. Studies were only included if they had a minimum follow-up period of six months from the start of the intervention and compared psychosocial interventions to comparison conditions. The primary outcome of this review was a reduction in the frequency of parental substance use. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 22 unique studies with a total of 2274 participants (mean age of parents ranged from 26.3 to 40.9 years), examining 24 experimental interventions. The majority of studies intervened with mothers only (n = 16; 73%). Heroin, cocaine, and alcohol were the most commonly reported substances used by participants. The interventions targeted either parenting only (n = 13; 59%); drug and alcohol use only (n = 5; 23%); or integrated interventions which addressed both (n = 6; 27%). Half of the studies (n = 11; 50%) compared the experimental intervention to usual treatment. Other comparison groups were minimal intervention, attention controls, and alternative intervention. Eight of the included studies reported data relating to our primary outcome at 6- and/or 12-month follow-up and were included in a meta-analysis. We investigated intervention effectiveness separately for alcohol and drugs. Studies were found to be mostly at low or unclear risk for all 'Risk of bias' domains except blinding of participants and personnel and outcome assessment.  We found moderate-quality evidence that psychosocial interventions are probably more effective at reducing the frequency of parental alcohol misuse than comparison conditions at 6-month (mean difference (MD) -0.32, 95% confidence interval (CI) -0.51 to -0.13; 6 studies, 475 participants) and 12-month follow-up (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.03; 4 studies, 366 participants). We found a significant reduction in frequency of use at 12 months only (SMD -0.21, 95% CI -0.41 to -0.01; 6 studies, 514 participants, moderate-quality evidence). We examined the effect of the intervention type. We found low-quality evidence that psychosocial interventions targeting substance use only may not reduce the frequency of alcohol (6 months: SMD -0.35, 95% CI -0.86 to 0.16; 2 studies, 89 participants and 12 months: SMD -0.09, 95% CI -0.86 to 0.61; 1 study, 34 participants) or drug use (6 months: SMD 0.01, 95% CI -0.42 to 0.44; 2 studies; 87 participants and 12 months: SMD -0.08, 95% CI -0.81 to 0.65; 1 study, 32 participants). A parenting intervention only, without an adjunctive substance use component, may not reduce frequency of alcohol misuse (6 months: SMD -0.21, 95% CI -0.46 to 0.04, 3 studies; 273 participants, low-quality evidence and 12 months: SMD -0.11, 95% CI -0.64 to 0.41; 2 studies; 219 participants, very low-quality evidence) or frequency of drug use  (6 months: SMD 0.10, 95% CI -0.11 to 0.30; 4 studies; 407 participants, moderate-quality evidence and 12 months: SMD -0.13, 95% CI -0.52 to 0.26; 3 studies; 351 participants, very low-quality evidence). Parents receiving integrated interventions which combined both parenting- and substance use-targeted components may reduce alcohol misuse with a small effect size (6 months: SMD -0.56, 95% CI -0.96 to -0.16 and 12 months: SMD -0.42, 95% CI -0.82 to -0.03; 2 studies, 113 participants) and drug use (6 months: SMD -0.39, 95% CI -0.75 to -0.03 and 12 months: SMD -0.43, 95% CI -0.80 to -0.07; 2 studies, 131 participants). However, this evidence was of low quality. Psychosocial interventions in which the child was present in the sessions were not effective in reducing the frequency of parental alcohol or drug use, whilst interventions that did not involve children in any of the sessions were found to reduce frequency of alcohol misuse (6 months: SMD -0.47, 95% CI -0.76 to -0.18; 3 studies, 202 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use at 12-month follow-up (SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). The quality of this evidence was low. Interventions appeared to be more often beneficial for fathers than for mothers. We found low- to very low-quality evidence of a reduction in frequency of alcohol misuse for mothers at six months only (SMD -0.27, 95% CI -0.50 to -0.04; 4 studies, 328 participants), whilst in fathers there was a reduction in frequency of alcohol misuse (6 months: SMD -0.43, 95% CI -0.78 to -0.09; 2 studies, 147 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use (6 months: SMD -0.31, 95% CI -0.66 to 0.04; 2 studies, 141 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). AUTHORS' CONCLUSIONS: We found moderate-quality evidence that psychosocial interventions probably reduce the frequency at which parents use alcohol and drugs. Integrated psychosocial interventions which combine parenting skills interventions with a substance use component may show the most promise. Whilst it appears that mothers may benefit less than fathers from intervention, caution is advised in the interpretation of this evidence, as the interventions provided to mothers alone typically did not address their substance use and other related needs. We found low-quality evidence from few studies that interventions involving children are not beneficial.

Add-on repetitive transcranial magnetic stimulation in patients with opioid use disorder undergoing methadone maintenance therapy.

Background: Repetitive transcranial magnetic stimulation (rTMS) shows potential therapeutic effects for individuals with addiction, but few studies have examined individuals with opioid use disorder (OUD).Objectives: We conducted an add-on double-blinded, sham-controlled rTMS feasibility pilot trial to examine OUD participants undergoing methadone maintenance therapy (MMT). The current report focused on the effects of rTMS on (1) craving and heroin use behavior and (2) depression, impulsivity, and attention.Methods: Active or sham rTMS treatment was applied to the left dorsolateral prefrontal cortex (DLPFC) over a total of 11 sessions in 4 weeks (15-Hz frequency, 4 seconds per train, intertrain interval of 26 seconds, 40 trains per session) in OUD participants (ClinicalTrials.gov registration number: NCT03229642). Craving, heroin use severity, urine morphine tests, the Hamilton Depression Rating Scale (HDRS), the Barratt Impulsiveness Scale-11 (BIS-11), and the Continuous Performance Tests (CPTs) were measured.Results: Twenty-two OUD participants were enrolled, of which eleven (8 males) were undergoing active rTMS and nine (8 males) were in the sham rTMS group. After 12 weeks of follow-up, the active rTMS group did not show significantly greater improvements than the sham group with respect to craving, heroin use, or urine morphine test results. However, HDRS scores, BIS-11 attentional subscales, and CPTs commission T-scores (C-TS) were significantly lower in the active rTMS group (P = .003, 0.04, and 0.02, respectively) than in the sham group.Conclusion: Add-on rTMS did not appear to improve heroin use behavior but may have benefitted depressive symptoms, impulse control and attention in OUD participants undergoing MMT.

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study.

BACKGROUND: In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved. AIMS: Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning. DESIGN: Retrospective cohort study SETTING: An open prison with 120 places SUBJECTS: Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group). MEASUREMENTS: Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned). FINDINGS: Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group. CONCLUSIONS: This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Temporal changes in non-fatal opioid overdose patterns among people who use drugs in a Canadian setting.

Background and Aims: Little is known about how the expansion of opioid agonist therapy (OAT) and emergence of fentanyl in the illicit drug supply in North America has influenced non-fatal opioid overdose (NFOD) risk. Therefore, we sought to identify patterns of substance use and addiction treatment engagement (i.e., OAT, other inpatient or outpatient treatment) prior to NFOD, as well as the trends and correlates of each pattern among people who use drugs (PWUD) in Vancouver, Canada. Methods: Data were derived from participants in three prospective cohorts of PWUD in Vancouver in 2009-2016. Observations from participants reporting opioid-related NFOD in the previous six months were included. A latent class analysis was used to identify classes based on substances used at the time of last NFOD and addiction treatment engagement in the month prior to the last NFOD. Multivariable generalized estimating equations estimated the correlates of each class membership. Results: In total, 889 observations from 570 participants were included. Four distinct classes were identified: (1) polysubstance use (PSU) and addiction treatment engagement; (2) PSU without treatment engagement; (3) exposure to unknown substances, mostly without treatment engagement; and (4) primary heroin users without treatment engagement. The class of exposure to unknown substances appeared in 2015 and became the dominant group (76.9%) in 2016. In multivariable analyses, the odds of membership in the class of primary heroin users decreased over time (adjusted odds ratio [AOR]: 0.74, 95% confidence interval [CI]: 0.68-0.81). Conclusions: Changing profiles of PWUD reporting opioid-related NFOD were seen over time. Notably, there was a sudden increase in reports of overdose following exposure to unknown substances since 2015, the majority of whom reported no recent addiction treatment engagement. Further study into patterns of substance use and strategies to improve addiction treatment engagement is needed to improve and focus overdose prevention efforts.

A study of pathways to care among opioid dependent individuals seeking treatment at a community de-addiction clinic in India.

Drug use, including opioid use disorder, is one of the rapidly rising and serious problems affecting populations globally. There is a treatment gap and delay in presentation of drug users to treatment centers. The present study aimed at assessing the pathways to care among opioid-dependent individuals seeking treatment from a community-based treatment center in India. In a cross-sectional observational study conducted at a community clinic of the National Drug Dependence Treatment Centre (NDDTC), New Delhi, India, a total of 100 treatment-seeking drug users (age 18-60 years) fulfilling DSM IV TR criteria for opioid dependence were recruited. The data were collected using a semistructured pro forma based on patient self-report and the encounter form used in the World Health Organization (WHO) Pathway Study. All participants were male, were mostly married, were employed, and belonged to nuclear families. Ninety-eight percent of participants has ever used heroin in a dependent fashion and 20% were using it currently. Mean age of the participants was 40.83 years (SD 12.7). Median age of onset of heroin use was 22 years (IQR 12). Median duration of heroin use was 138 months (IQR 132). Only 21% of participants visited the community deaddiction clinic at the first contact with care. The median time for first treatment-seeking attempt was 9.5 years (IQR 7). The study findings suggest significant delay between onset of drug-related problems and first treatment contact. There is a need to increase the availability and accessibility of treatment services to reduce the delay in treatment seeking.

When is coercive methadone therapy justified?

Heroin use poses a significant health and economic burden to society, and individuals with heroin dependence are responsible for a significant amount of crime. Owing to its efficacy and cost-effectiveness, methadone maintenance therapy (MMT) is offered as an optional alternative to imprisonment for drug offenders in several jurisdictions. Some object to such 'MMT offers' on the basis that they involve coercion and thus invalidate the offender's consent to MMT. While we find these arguments unpersuasive, we do not attempt to build a case against them here. Instead, we explore whether administration of MMT following acceptance of an MMT offer might be permissible even on the assumption that MMT offers are coercive, and in such a way that the resulting MMT is non-consensual. We argue that non-consensual MMT following an MMT offer is typically permissible. We first offer empirical evidence to demonstrate the substantial benefits to the offender and society of implementing non-consensual MMT in the criminal justice system. We then explore and respond to potential objections to such uses of MMT. These appeal respectively to harm, autonomy, bodily and mental interference, and penal theoretic considerations. Finally, we introduce and dismiss a potential response to our argument that takes a revisionist position, rejecting prevailing incarceration practices.

Metabolic syndrome among individuals with heroin use disorders on methadone therapy: Prevalence, characteristics, and related factors.

BACKGROUND: Observational studies have reported a high prevalence of obesity and diabetes in subjects on methadone therapy; there are, however, limited data about metabolic syndrome. The aim of the study was to evaluate the prevalence of metabolic syndrome and related factors in individuals with heroin use disorder on methadone therapy. METHODS: A cross-sectional study in individuals with heroin use disorder on methadone therapy at a drug abuse outpatient center. Medical examinations and laboratory analyses after a 12-hour overnight fast were recorded. Metabolic syndrome was diagnosed according to the National Cholesterol Education Program Adult Treatment Panel III (ATP III) criteria. RESULTS: One hundred and twenty-two subjects were included, with a mean age of 46.1 ± 9 years, a median body mass index (BMI) of 25.3 kg/m2 (interquartile range [IQR]: 21.2-28), and 77.9% were men. Median exposure to methadone therapy was 13 years (IQR: 5-20). Overweight and obesity were present in 29.5% and 17.2% of the participants, respectively. Metabolic syndrome components were low high-density lipoprotein (HDL) cholesterol (51.6%), hypertriglyceridemia (36.8%), high blood pressure (36.8%), abdominal obesity (27.0%), and raised blood glucose levels (18.0%). Abdominal obesity was more prevalent in women (52% vs. 20%, P = >0.01) and high blood pressure more prevalent in men (41.1% vs. 22.2%, P = .07). Prevalence of metabolic syndrome was 29.5% (95% confidence interval [CI]: 16.6-31.8). In the multivariate logistic regression analysis, BMI (per 1 kg/m2 increase odds ratio [OR]: 1.49, 95% CI: 1.27-1.76) and exposure time to methadone therapy (per 5 years of treatment increase OR: 1.38, 95% CI: 1.28-1.48) were associated with metabolic syndrome. CONCLUSIONS: Overweight and metabolic syndrome are prevalent findings in individuals with heroin use disorder on methadone therapy. Of specific concern is the association of methadone exposure with metabolic syndrome. Preventive measures and clinical routine screening should be recommended to prevent metabolic syndrome in subjects on methadone therapy.

Addiction medicine ethics: relapse, no lapse and the struggle to treat addicts like everyone else.

Two case studies are presented as a focus for discussion of ethics in addiction medicine. The first is that of the alcohol-dependent patient who receives a liver transplant. The second is that of a heroin-dependent patient who continues to inject himself while in a general medical ward. I make some comments about the obligations of doctors to treat those who cause harm to themselves as they would treat those who are 'not responsible'.

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility.

BACKGROUND: In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. METHODS: We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. RESULTS: We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. CONCLUSIONS: We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Rates of HIV and Hepatitis Infections in Clients Entering Heroin-Assisted Treatment between 2003 and 2013 and Risk Factors for Hepatitis C Infection.

BACKGROUND/AIMS: We report on the rates of hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in 1,313 clients entering heroin-assisted treatment (HAT) in Switzerland from 2003 to 2013. We identify predictors of HCV infection. METHODS: Data were collected using questionnaires within 2 weeks of clients' first entry into HAT. Prevalence of HAV, HBV, HCV and HIV was calculated using laboratory test results collected at entry or using reports of older test results. Predictors of HCV status were identified through multiple logistic regression analysis. RESULTS: Results show stable rates of HIV-positive clients and decreasing proportions of HAV- and HBV-infected clients. In 2013, there were 12% (n = 8) HIV-, 20% (n = 12) HAV-, 20% (n = 12) HBV- and 52% HCV- (n = 34) positive clients. Vaccination against HAV and HBV had become more frequent. Predictors of positive HCV status included older age, female gender, earlier year of entry, having spent 1 month or more in detention or prison, use of injected heroin and more years of intravenous use. CONCLUSION: Our results highlight the fact that efforts to prevent and test for infections and to promote vaccination against HAV and HBV in heroin users need to be continued.

Gender Differences in Heroin Addiction and Treatment: Results from the VEdeTTE Cohort.

BACKGROUND: Gender differences strongly affect heroin addiction, from risk factors to patterns of consumption, access to treatments, and outcomes. OBJECTIVES: To investigate gender differences in the VEdeTTE cohort of heroin addicts. METHODS: VEdeTTE is a cohort of 10,454 heroin users enrolled between 1998 and 2001 in 115 public drug treatment centres in Italy. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Gender differences were explored with regard to characteristics at intake, treatments, and retention in methadone maintenance and therapeutic community. Cox Proportional models were carried out to identify risk factors for treatment abandon. RESULTS: Compared with men, at their first access to treatment women with drug addiction were younger, more frequently married, legally separated, divorced or widow, unemployed though better educated, HIV+; more frequently they lived with their partner and sons. They reported a higher use of sedatives, but a lower use of alcohol; more frequently they had psychiatric comorbidity, including depression, self-injuries, and suicide attempts. Psychotherapy was more frequently prescribed to women, pharmacological treatments to men. Methadone maintenance was less frequently abandoned by women. Drug abuse severity factors predicted abandon of methadone among women. High methadone doses and the combination with psychotherapy improved treatment retention in both genders. Low education level and severity factors among women and young age among men predicted abandon of therapeutic community. CONCLUSIONS: Gender differences in the VEdeTTE cohort suggest the need of a gender sensitive approach to improve treatment outcomes among heroin addicts.

Quality of life among former Soviet Union and Israeli origin methadone users.

A common treatment intervention for heroin addiction is methadone maintenance. In recent years a wider perspective has been adapted to understand and evaluate addiction through quality of life. This article examines quality of life conditions of 170 male former Soviet Union and Israeli origin drug users in methadone maintenance and provides an understanding of conditions linked to the World Health Organization Quality of Life project's best available techniques reference document. Having a partner or spouse and less chronic illness are positive factors affecting quality of life regardless of country of origin. Israeli born drug users reported better quality of life based on their psychological health and environment domain responses; no difference was found for the physical health and social relationship domains of the Israeli and former Soviet Union origin males. Because heroin addiction is a chronic and relapsing illness, one of the goals of methadone maintenance is to address patients' health status from a broad perspective. Based on clinical observations, the treatment of special populations may be enhanced if their particular needs are considered and met. Quality of life factors are relevant for assessing high risk groups, including those from different ethnic origins, in poor physical and psychological health, their treatment and personal adjustment, and their service personnel training needs.

Hypothesis: Is heroin a 'barrier' against cancer? A retrospective analysis of heroin-addicted individuals untreated for opioid dependence between 2001-2010.

PURPOSE: The findings of previous studies attracted our interest in searching and defining the percentage of deaths from cancer in 'heroin regular addicts' i.e. those who had never stopped taking the drug since they started. METHODS: The archives of the Greek Reitox Focal Point of the years 2001 to 2010 were retrospectively searched, focusing on the number of deaths from cancer of the regular heroin addicts. RESULTS: The records from 2,321 regular heroin addicts showed that none of them died from cancer. It seems that heroin might act as a "barrier" against cancer. CONCLUSION: Further studies are needed to confirm our results and to explore the potential cause for this surprising finding.

Transcutaneous electrical acupoint stimulation for the treatment of withdrawal syndrome in heroin addicts.

OBJECTIVE: To assess the therapeutic effect of transcutaneous electric acupoint stimulation (TEAS) for the treatment of withdrawal syndrome in heroin addicts. METHODS: A total of 63 male heroin addicts with withdrawal score higher than 20 were recruited in the Detoxification Center of Zhongshan city, Guangdong province, China. They were randomly distributed into two groups: TEAS group (n = 31) received TEAS by using a Han's acupoint nerve stimulator (HANS) model 200A with two output channels, 2-3 sessions per day, 30 minutes per session for 10 consecutive days. Electrical stimulation of alternating frequencies of 2- and 100-Hz with 3 second each, and with intensity of 10-15 mA was applied on Hegu (LI-4) and Laogong (PC-8) points on one hand, and Neiguan (PC-6) and Waiguan (SJ-5) points on the other forearm via electroconductive skin pads of 4 cm × 4 cm in size. The control group (n = 32) was treated with similar procedure except that the leads of the output of the stimulator was disconnected. Assessments of the severity of the withdrawal syndrome were conducted one day before and on each day during the whole treatment period of 10 days. Buprenorphin of 1 mg per day sublingually was provided to all subjects in the first two days, and then to those with withdrawal score over 20 in the following days. RESULTS: The TEAS treatment dramatically alleviated the withdrawal syndrome during heroin detoxification. No significant difference was found in withdrawal scores between the two groups at the beginning of the observation. Withdrawal scores showed a more marked drop in TEAS group than the control starting from the second day, and maintained at a lower level for the whole course of treatment. The area under the curve of withdrawal score in TEAS group was only 40% of that in the control (P < 0.001, two way repeated measures analysis of variance), and the requirement of buprenorphine was only 10% of that in the control. No adverse effects were observed in either group. CONCLUSION: TEAS of 2/100 Hz for 10 days in abrupt abstinence of the heroin addicts resulted in a marked reduction of the withdrawal syndrome as well as a reduced requirement for rescue opioids.

Effects of a recovery management intervention on Chinese heroin users' community recovery through the mediation effect of enhanced service utilization.

BACKGROUND: This study investigates whether a recovery management intervention (RMI) can improve the utilization of community drug treatment and wraparound services among heroin users in China and subsequently lead to positive recovery outcomes. METHODS: Secondary analysis was conducted drawing data from a randomized controlled trial; 100 heroin users with no severe mental health problems were recruited in two Shanghai districts (Hongkou and Yangpu) upon their release from compulsory rehabilitation facilities. A latent variable modeling approach was utilized to test whether the RMI influences heroin users' perceived motivation and readiness for treatment, enhances treatment and wraparound service participation, and, in turn, predicts better recovery outcomes. RESULTS: Enrollment in drug treatment and other social service utilization increased significantly as a result of RMI rather than an individual drug user's motivation and readiness for treatment. Increased service utilization thus led to more positive individual recovery outcomes. In addition to this mediation effect through service utilization, the RMI also improved participants' community recovery directly. CONCLUSIONS: Findings suggest that better drug treatment enrollment, community service utilization and recovery outcomes can be potentially achieved among heroin users in China with carefully designed case management interventions.

Evaluation of Femoral Ultrasonography as a Tool for Promoting Cessation of Groin-Injecting Behaviour.

AIM: To assess the impact of femoral ultrasonography accompanied by explanation of the findings (UFV) on groin-injecting behaviour. METHODS: 348 heroin-addicted groin injectors (GIs) on opioid substitution treatment (OST) were included in the study: 174 received UFV (cases), 174 did not (controls). Injecting behaviour among cases and matched controls were compared for both 'persistent GIs' (patients who had injected via the femoral vein in the 28-day period preceding the baseline) and 'former GIs' (patients with a history of previous groin injecting). FINDINGS: There were no significant between-group differences in gender, mean age, time in treatment, substitute medication and mean dose at baseline or injecting behaviour prior to baseline. After baseline, reduction by a third in the proportion still groin injecting was immediately evident among UFV cases versus controls (number needed to treat: 3, 95% CI: 2, 8; p < 0.001). Marked reduction in groin-injecting behaviour among UFV cases was maintained over 12 months, including fewer relapses among 'former GIs' (number needed to treat: 5, 95% CI: 4, 9; p < 0.001). CONCLUSION: Single-session UFV may promote cessation of groin-injecting behaviour among patients receiving OST. This benefit appears to be evident 12 months later. Further evaluation of this novel approach to the management of groin injecting, a particularly harmful behaviour, is now warranted.