Incidence and treatment costs of severe bacterial infections among people who inject heroin: A cohort study in South London, England.

BACKGROUND: People who inject drugs often get bacterial infections. Few longitudinal studies have reported the incidence and treatment costs of these infections. METHODS: For a cohort of 2335 people who inject heroin entering treatment for drug dependence between 2006 and 2017 in London, England, we reported the rates of hospitalisation or death with primary causes of cutaneous abscess, cellulitis, phlebitis, septicaemia, osteomyelitis, septic arthritis, endocarditis, or necrotising fasciitis. We compared these rates to the general population. We also used NHS reference costs to calculate the cost of admissions. RESULTS: During a median of 8.0 years of follow-up, 24 % of patients (570/2335) had a severe bacterial infection, most commonly presenting with cutaneous abscesses or cellulitis. Bacterial infections accounted for 13 % of all hospital admissions. The rate was 73 per 1000 person-years (95 % CI 69-77); 50 times the general population, and the rate remained high throughout follow-up. The rate of severe bacterial infections for women was 1.50 (95 % CI 1.32-1.69) times the rate for men. The mean cost per admission was £4980, and we estimate that the annual cost of hospital treatment for people who inject heroin in London is £4.5 million. CONCLUSIONS: People who inject heroin have extreme and long-term risk of severe bacterial infections.

Mortality Risk among Cocaine Users before and after the Economic Recession: Results of a Longitudinal Study.

BACKGROUND: Studies have highlighted 2 different groups of cocaine users (CUs): "socially integrated" (stable living conditions, regular employment, use cocaine alone or in combination with other psychoactive substances) and "socially marginalized" (socioeconomic and health problems, former or current heroin users, many injecting cocaine). These differences are also found in the elevated mortality risk for CUs, higher among subjects with cocaine and heroin use. This study targeted residents in Northern Italy who turned to a public treatment center for drug addiction following problems caused by primary cocaine use between 1982 and 2016. OBJECTIVES: To estimate mortality risk for subjects who have never used heroin (CUs) compared to that of subjects who have used heroin (HCUs). METHOD: Retrospective cohort study. We selected 1,993 subjects; 18,015 Person Years (PY). RESULTS: Over time, the quota of subjects injecting cocaine and using heroin decreased, while patients not using heroin increased. Both new patients and crude mortality rates (CMR) decreased during the years 2009-2012 and increased in the following period. CMRs were 5.55 per 1,000 PY, higher for HCUs, men and subjects aged over 44 years. Standardized mortality rates were 3.49, higher for women, injecting cocaine and HCUS. Among CUs, most of the deaths were from injury excluding drug related and tumors; among HCUs, from drug-related causes and diseases of the cardiovascular system. CONCLUSION: The study results show a change in the characteristics of SERD clients being treated for primary cocaine use, which are reflected both in mortality risk and causes of death. After a long period of a decrease, mortality risk increased in the period after the economic recession. Aspects concerning the effects of the economic recession on the problematic consumption of cocaine and on the risk of death are discussed.

Facing the Growing Heroin Problem in Colombia: The New Methadone-assisted Treatment Programs. / Enfrentando el problema emergente de consumo de heroína en Colombia: los nuevos programas de tratamiento asistido con metadona.

OBJECTIVE: Colombia is facing a rising epidemic of intravenous heroin use. Knowledge of the methadone-assisted treatment programs in the country is crucial in order to propose improvement strategies. METHODS: 13 programmes from priority regions were surveyed. The demographic and clinical characteristics of the patients attending the programs, a description of the services offered, their methadone treatment protocols, the various barriers to treatment and the causes of treatment abandonment were reviewed. RESULTS: 12/13 questionnaires were analysed with a total of 538 active patients. Most of the patients attending these programs were men (85.5%) between 18 and 34 years-old (70%). Forty percent (40%) were intravenous drug users and 25% admitted sharing needles. The comorbidities associated with heroin use were mental illness (48%), hepatitis C (8.7%) and HIV (2%). Psychiatric comorbidity was more likely in patients attending the private sector (69.8% vs 29.7%; p<0.03). The initial average dose of methadone administered was 25.3±8.9mg/day, with a maintenance dose ranging from 41 to 80mg/day. Lack of alignment with primary care was perceived to be the most serious barrier to access, ahead of problems with insurance and prejudice towards treatment with methadone (p<0.05). Health Administration and insurance problems (p<0.003), together with the lack of availability of methadone (p<0.018) and relapse (p<0.014) were the most important reasons for abandonment of treatment. CONCLUSIONS: The treatment protocols of these programmes offer different levels of development and implementation. Some of the barriers to access and reasons for abandonment of treatment with methadone can be mitigated with better health administration.

HIV risk and the association with accessibility coverage to medical facilities and socioeconomic status among heroin users in Kaohsiung, Taiwan (2011-2015): A GIS approach.

Illegal drug use has caused considerable health and social costs. Access to medical treatment has been one of the most cost-effective interventions to reduce problematic drug use. Accessibility to treatment, which can be analyzed by the spatial approach such as geographic information system (GIS), has thus been utilized as a measure of the proportion of population that reaches appropriate health services. In this study, the association of accessibility coverage to medical facilities and socioeconomic status with human immunodeficiency virus (HIV) risk for heroin users was evaluated by GIS analysis in Kaohsiung, Taiwan. Data of 7890 heroin users were collected from 2011 to 2015 and categorized into five risk groups according to their income and distance to treatment settings. The results of this GIS-based analysis show that the areas with over 50% accessibility coverage rate had less amounts of HIV cases with statistical significance. Inconvenient access to medical facilities could result in poor treatment outcomes such as higher HIV incidences. Therefore, in order to effectively reduce HIV incidences among the heroin users, the accessibility coverage and locations of medical treatment facilities should meet the needs of drug users. It is also advised that the formulation of policies associated with illegal drug use problems should be evidence-based and geographical indicators could serve for this purpose from either prevention or intervention perspective.

Prescribing diamorphine in the United States: Insights from a nationally representative survey.

BACKGROUND: Some countries allow physicians to prescribe pharmaceutical-grade diamorphine to dependent users who have previously undergone treatment but are still using street-sourced heroin; this is not allowed in the US. This study provides the first nationally representative US data concerning public support for prescribing diamorphine to dependent users. We also test the hypothesis that calling it "diamorphine" instead of "heroin" increases support for this approach. METHODS: The RAND American Life Panel is a nationally representative, probability-based survey of US adults. Of the 3345 panel members invited to take the survey, 2530 (75.6%) provided a valid response to our question module. Respondents were randomly assigned to have the question refer to the prescribed drug as either "heroin" or "diamorphine." The groups did not significantly differ on sex, age, race/ethnicity, or education. We compare the distribution of responses for the two groups and conduct Pearson's chi-squared test with the Rao-Scott correction. RESULTS: For those asked whether the US should try prescribing pharmaceutical-grade "heroin," the share answering "Yes" (20.8%) was 15 percentage points lower than those responding "No" (35.8%). When the question asked about "diamorphine," the results were nearly reversed: the share answering "Yes" (30.6%) was almost 12 percentage points higher than those responding "No" (18.9%). The distributions of responses were significantly different (p < 0.001). CONCLUSIONS: Support for prescribing diamorphine to dependent users is low in the US. While the results are consistent with the hypothesis that referring to heroin as diamorphine may reduce stigma associated with the substance and increase support for prescribing it, opinions may change as individuals learn they are different names for the same substance.

Prescription Drug Monitoring Programs and Opioid Overdoses: Exploring Sources of Heterogeneity.

BACKGROUND: Prescription drug monitoring program are designed to reduce harms from prescription opioids; however, little is known about what populations benefit the most from these programs. We investigated how the relation between implementation of online prescription drug monitoring programs and rates of hospitalizations related to prescription opioids and heroin overdose changed over time, and varied across county levels of poverty and unemployment, and levels of medical access to opioids. METHODS: Ecologic county-level, spatiotemporal study, including 990 counties within 16 states, in 2001-2014. We modeled overdose counts using Bayesian hierarchical Poisson models. We defined medical access to opioids as the county-level rate of hospital discharges for noncancer pain conditions. RESULTS: In 2010-2014, online prescription drug monitoring programs were associated with lower rates of prescription opioid-related hospitalizations (rate ratio 2014 = 0.74; 95% credible interval = 0.69, 0.80). The association between online prescription drug monitoring programs and heroin-related hospitalization was also negative but tended to increase in later years. Counties with lower rates of noncancer pain conditions experienced a lower decrease in prescription opioid overdose and a faster increase in heroin overdoses. No differences were observed across different county levels of poverty and unemployment. CONCLUSIONS: Areas with lower levels of noncancer pain conditions experienced the smallest decrease in prescription opioid overdose and the faster increase in heroin overdose following implementation of online prescription drug monitoring programs. Our results are consistent with the hypothesis that prescription drug monitoring programs are most effective in areas where people are likely to access opioids through medical providers.

Adults who misuse opioids: Substance abuse treatment use and perceived treatment need.

Background: Opioid use disorder (OUD) and overdose deaths among the US population continue to increase. This study examined associations of OUD and other substance use disorders with substance abuse treatment use and perceived treatment need among US adults aged 18+ who misused opioids. Methods: The 2015-2016 National Survey on Drug Use and Health provided data (n = 5100 respondents who misused opioids in the past year). We used multivariable logistic regression models to examine associations of opioid and other substance use disorders with treatment use and perceived treatment need, adjusting for sociodemographic and health statuses. Results: The data showed that 4.7% of adults misused opioids and 19.1% of those who misused had an OUD. Of those with an OUD, only 31.5% had received substance abuse treatment in the past year and 13.6% perceived the need for such treatment. Of those with an OUD, heroin use disorder (adjusted odds ratio [AOR] = 2.59, 95% confidence interval [CI] = 1.59-4.23) and having been arrested/booked (AOR = 1.98, 95% CI = 1.18-3.33) were associated with higher odds of receiving treatment, whereas lack of health insurance (AOR = 0.49, 95% CI = 0.25-0.94) was associated with lower odds. Heroin use disorder (AOR = 2.16, 95% CI = 1.23-3.83) and higher mental health impairment scores (AOR = 1.05, 95% CI = 1.01-1.09) were associated with higher odds of perceived treatment need. Conclusions: The overall low socioeconomic status and high rates of polysubstance use disorders among those with OUD indicate that they need financial and other help to access treatment and relapse prevention services. The very low rates of perceived treatment need also point to the need for strategies to increase individuals' recognition of their need for treatment.

Estimates of the national trend of drugs use during 2000-2030 in China: A population-based mathematical model.

BACKGROUND: The use of synthetic drugs has exceeded heroin to become a major public health concern in China. We aimed to estimate the trend of heroin-only, synthetic drug-only and poly-drug (heroin and synthetic drug) use during 2000-2030 period in China using existing data. METHODS: We used data from the Annual Report on Drug Control in China and peer-reviewed publications. We constructed a mathematical model to estimate the drug use trend based on Monte Carlo simulations. RESULTS: The best calibrated model estimated that the number of drug users would increase from 0.86 million to 3,120,059 (95% CI 2,669,214-3,570,904) during 2000-2030 period. The proportion of heroin-only users among the total drug users will decrease from 96.8% (95% CI, 96.6-97.1%) in 2000 to 36.9% (30.1-40.8%) in 2030, while the proportion of synthetic drug-only users will increase from 1.1% (0.9-1.3%) in 2000 to 57.7% (51.7-65.6%) in 2030. In contrast, the proportion of poly-drug users shared an increasing trend during 2000-2016 (from 2.1% (1.5-2.8%) to 15.1 (13.8-17.1%)) but declined to 5.5% (3.4-7.2%) in 2030. Estimated 46,370 (41,634-51,106) heroin-only users and 3767 (3481-4053) synthetic drug only users initiated poly-drug use in 2000. We observed a cross-over in 2012 where more synthetic drug-only users were initiating heroin use than heroin-only users initiating synthetic drug use. There will be estimated 2,094,052 (1,819,830-2,368,274) synthetic drug-only users and poly-drug users 211,407 (177,150-245,664) in 2030. CONCLUSIONS: Synthetic drug use will become dominant in drug users in China, but poly-drug use of both heroin and synthetic drugs will remain substantial.

U.S. adults with opioid use disorder living with children: Treatment use and barriers to care.

BACKGROUND: U.S. Adults with an opioid use disorder who live with a child have unique treatment needs, but little is known about the treatment use of these adults. METHODS: Data come from the 2010-2014 versions of the National Survey on Drug Use and Health, an annual, nationally representative survey assessing substance use in the United States. Adults (>18) with a heroin or pain-reliever use disorder living in a household with a child (<18) were compared to adults not living with children on their use of substance use treatment, treatment settings, payment sources, perceived unmet need for treatment, and barriers to care using logistic regression to adjust for demographic differences between groups. RESULTS: Of the 820,000 adults with an opioid use disorder living with at least one child, 28% reported receiving any past-year substance use treatment, a rate comparable to adults not living with a child (30%). Among adults reporting unmet treatment need, those who lived with a child were more likely to report that access barriers like not being able to find the right kind of program (aOR 2.9, 95% CI 1.2-7.1), as well as stigma (aOR 4.1, 95% CI 1.5 to 11.2), kept them from receiving care. CONCLUSION: Most adults with opioid use disorder who live with a child are not receiving any substance use treatment. Efforts to expand opioid use disorder treatment programs must include investment in programs that meet the specialized needs of families.

A pragmatic harm reduction approach to manage a large outbreak of wound botulism in people who inject drugs, Scotland 2015.

BACKGROUND: People who inject drugs (PWID) are at an increased risk of wound botulism, a potentially fatal acute paralytic illness. During the first 6 months of 2015, a large outbreak of wound botulism was confirmed among PWID in Scotland, which resulted in the largest outbreak in Europe to date. METHODS: A multidisciplinary Incident Management Team (IMT) was convened to conduct an outbreak investigation, which consisted of enhanced surveillance of cases in order to characterise risk factors and identify potential sources of infection. RESULTS: Between the 24th of December 2014 and the 30th of May 2015, a total of 40 cases were reported across six regions in Scotland. The majority of the cases were male, over 30 and residents in Glasgow. All epidemiological evidence suggested a contaminated batch of heroin or cutting agent as the source of the outbreak. There are significant challenges associated with managing an outbreak among PWID, given their vulnerability and complex addiction needs. Thus, a pragmatic harm reduction approach was adopted which focused on reducing the risk of infection for those who continued to inject and limited consequences for those who got infected. CONCLUSIONS: The management of this outbreak highlighted the importance and need for pragmatic harm reduction interventions which support the addiction needs of PWID during an outbreak of spore-forming bacteria. Given the scale of this outbreak, the experimental learning gained during this and similar outbreaks involving spore-forming bacteria in the UK was collated into national guidance to improve the management and investigation of future outbreaks among PWID.

Mapping Drug Overdose Demographic and Socioeconomic Characteristics in the Community.

INTRODUCTION: Drug use and drug overdose have increased at an alarming rate. OBJECTIVE: To identify demographic and neighborhood social and economic factors associated with higher risk of overdose. These findings can be used to inform development of community programs and appropriately devote resources to prevent and treat drug abuse. METHODS: The electronic health records of all patients seen in the emergency department or admitted to the hospital for a drug overdose in 2016 at Gundersen Health System in La Crosse, Wisconsin, were reviewed retrospectively. Patient data collected included age, sex, race/ethnicity, insurance type, overdose intention (intentional, unintentional), drug involved, and total charge for the episode of care. Patient residence was geocode mapped to census tract to analyze the relationship of drug overdose to neighborhood characteristics. Overdose rates were calculated by census tract and compared by several sociodemographic characteristics. RESULTS: Four hundred nineteen patients were included in this study. Forty percent of overdoses were unintentional. Patients who were older, male, nonwhite, and who had no insurance were more likely to have unintentional overdoses. Opiates and heroin were most commonly present in unintentional overdoses, whereas benzodiazepines and sedatives were more common in intentional overdoses. Patients living in census tracts with a higher percentage of residents with some college also had a higher rate of unintentional overdose. Rates of overdose at the census tract level varied and were higher in tracts with lower median income, low income inequality ratio, high percentage of college attendance, and higher percentage of nonwhite residents. The average charge per overdose was $14,771 (median = $9,497) and totaled $6,188,923 for the year. CONCLUSIONS: This study provides demographic, geographic, and socioeconomic detail about drug overdose in the community that can be used to focus future treatment and prevention interventions.

Anodyne by Design; Measuring the Prevalence of Esoteric Designer Opioids in Pain Management Patients.

The recent increase in illicit opioids sold on the black market, cut into heroin and masqueraded as prescription pills prompts a significant public health concern. Most designer opioids possess unknown potencies and unknown pharmacokinetics and their unregulated, variable dosages lead to rashes of overdoses. Additionally, many of the designer opioids, especially the fentanyl analogs are significantly more potent than heroin. High-profile cases involving overdoses of U-47700 and carfentanil have been reported in the media; however, the true prevalence of these and other designer opioids is unknown. Independent LC-MS-MS screen and confirmation methods have been developed and validated to identify and quantify fentanyl, and 18 designer opioids and their metabolites; methods were then exercised on urine specimens from contract pain management clients. Assuming patients in a pain management program may have a higher probability to seek out self-medication, samples from pain management patients were investigated for designer opioids. Similarly, pain management patients identified as using heroin may be more likely to experiment with or be accidentally exposed to designer opioids, specimens screening positive for the heroin metabolite 6-acetylmorphine were specifically chosen for designer opioid screening. Within this small group of pain management and heroin-positive samples, nine designer opioids were detected at a total prevalence of 25%. When screening random pain management samples not positive for heroin, a considerably lower percentage of samples (<1%) were identified as positive for designer opioids. Furanyl fentanyl, fluorobutyryl fentanyl and acetylfentanyl were the most prevalent designer opioids detected in both test groups.

The societal cost of heroin use disorder in the United States.

OBJECTIVE: Heroin use in the United States has reached epidemic proportions. The objective of this paper is to estimate the annual societal cost of heroin use disorder in the United States in 2015 US dollars. METHODS: An analytic model was created that included incarceration and crime; treatment for heroin use disorder; chronic infectious diseases (HIV, Hepatitis B, Hepatitis C, and Tuberculosis) and their treatments; treatment of neonatal abstinence syndrome; lost productivity; and death by heroin overdose. RESULTS: Using literature-based estimates to populate the model, the cost of heroin use disorder was estimated to be $51.2 billion in 2015 US dollars ($50,799 per heroin user). One-way sensitivity analyses showed that overall cost estimates were sensitive to the number of heroin users, cost of HCV treatment, and cost of incarcerating heroin users. CONCLUSION: The annual cost of heroin use disorder to society in the United States emphasizes the need for sustained investment in healthcare and non-healthcare related strategies that reduce the likelihood of abuse and provide care and support for users to overcome the disorder.

Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health.

In the United States, nonmedical prescription opioid use is a major public health concern. Various policy initiatives have been undertaken to tackle this crisis, including state prescription drug monitoring programs (PDMPs). This study uses the 2004-2014 National Survey of Drug Use and Health (NSDUH) and exploits state-level variation in the timing of PDMP implementation and PDMP characteristics to investigate whether PDMPs are associated with a reduction in prescription opioid misuse or whether they have the unintended consequence of increasing heroin use. In addition, the study examines the impact of PDMPs on the availability of opioids from various sources. The study finds no effect of PDMP status on various measures of nonmedical prescription opioid use (abuse, dependence, and initiation), but finds evidence of a reduction in the number of days of opioid misuse in the past year. The study also finds that implementation of PDMP was not associated with an increase in heroin use or initiation, but was associated with an increase in number of days of heroin use in the past year. Findings also suggest that PDMPs were associated with a significant decline in doctor shopping among individuals without increasing reliance on illegal sources (e.g., drug dealers, stealing, etc.) or social sources (friends or relatives) as a means of obtaining opioids. The President's FY2017 budget proposed the allocation of $1.1 billion in an effort to reduce prescription drug misuse, and highlighted the use of PDMPs as a policy tool. This study documents evidence that PDMPs might be having measurable impact.

Implementing take-home naloxone in an urban community pharmacy.

OBJECTIVE: Morbidity and mortality associated with opioid use have increased across the nation, growing into what can only be described as an epidemic. SETTING: In Washington State between 2002 and 2004, the statewide death rate attributed to any opioid was 6.6 per 100,000 people, but between 2011 and 2013 it increased to 8.6 per 100,000 people. Pharmacies provide a unique access point for harm reduction services to patients due to their ease of accessibility in the community. PRACTICE DESCRIPTION: In development of a take-home naloxone (THN) program, there were multiple areas that needed to be considered. These included product selection, collaborative practice agreements, training format and materials, managing patient and provider expectations, partnerships, and community perception of the service. PRACTICE INNOVATION: Initial demographics from our experience of people obtaining THN showed a significant difference in the median age from other available programs in the area (57 years vs. 34, 35, and 31). These people tended to be bystanders, instead of end users of opioids, which led to redirecting marketing of our program. We provided community and group trainings for various organizations around the greater Seattle area. We have trained approximately 1400 unique individuals on how to recognize and respond to an opioid overdose, and how to administer naloxone. EVALUATION: One organization reports 20 successful overdose rescues from 99 kits (100% intranasal route) dispensed by our pharmacy (20.2% rescue rate). RESULTS: Since 2012 when our THN program began, we have seen growth of these programs across the state. Based on data through 2015, deaths from heroin in King County have decreased for the first time in the last 7 years, and the number of people seeking treatment for heroin addiction has increased. CONCLUSION: Take-home naloxone programs can be successfully implemented into community pharmacies to increase access and awareness of opioid overdose recognition and response.

Real-time assessment of alcohol drinking and drug use in opioid-dependent polydrug users.

We investigated relationships between drinking, other drug use, and drug craving, using ecological momentary assessment (EMA), in a sample of polydrug users who were not heavy drinkers. In a prospective longitudinal cohort study, 114 heroin and cocaine users on methadone-maintenance treatment carried handheld electronic diaries during waking hours and were screened for drug and alcohol use for up to 25 weeks. Individuals who fulfilled the Diagnostic and Statistical Manual of Mental Disorders criteria for alcohol abuse or dependence were excluded. Participants responded to 2-5 random prompts per day to report on their moods, cravings, and activities and initiated entries when they used or acutely craved heroin or cocaine. Drinking alcohol was assessed in both types of entries. Breath alcohol was measured three times weekly. Participants reported drinking alcohol in 1.6% of random-prompt entries, 3.7% of event-contingent entries when craving cocaine and/or heroin, and 11.6% of event-contingent entries when using cocaine and/or heroin. Alcohol drinking was also associated with higher craving ratings and prestudy alcohol use. More drinking was detected by ambulatory self-report than by in-clinic breath testing. Even though we had screened out heavy drinkers from our sample of polydrug users, drinking was associated with heroin and cocaine craving and actual use.

Essential/precursor chemicals and drug consumption: impacts of US sodium permanganate and Mexico pseudoephedrine controls on the numbers of US cocaine and methamphetamine users.

BACKGROUND AND AIMS: In December 2006 the United States regulated sodium permanganate, a cocaine essential chemical. In March 2007 Mexico, the United States' primary source for methamphetamine, closed a chemical company accused of illicitly importing 60+ tons of pseudoephedrine, a methamphetamine precursor chemical. US cocaine availability and methamphetamine availability, respectively, decreased in association. This study tested whether the controls had impacts upon the numbers of US cocaine users and methamphetamine users. DESIGN: Auto-regressive integrated moving average (ARIMA) intervention time-series analysis. Comparison series-heroin and marijuana users-were used. SETTING: United States, 2002-14. PARTICIPANTS: The National Survey on Drug Use and Health (n = 723 283), a complex sample survey of the US civilian, non-institutionalized population. MEASUREMENTS: Estimates of the numbers of (1) past-year users and (2) past-month users were constructed for each calendar quarter from 2002 to 2014, providing each series with 52 time-periods. FINDINGS: Downward shifts in cocaine users started at the time of the cocaine regulation. Past-year and past-month cocaine users series levels decreased by approximately 1 946 271 (-32%) (P < 0.05) and 694 770 (-29%) (P < 0.01), respectively-no apparent recovery occurred through 2014. Downward shifts in methamphetamine users started at the time of the chemical company closure. Past-year and past-month methamphetamine series levels decreased by 494 440 (-35%) [P < 0.01; 95% confidence interval (CI) = -771 897, -216 982] and 277 380 (-45%) (P < 0.05; CI = -554 073, -686), respectively-partial recovery possibly occurred in 2013. The comparison series changed little at the intervention times. CONCLUSIONS: Essential/precursor chemical controls in the United States (2006) and Mexico (2007) were associated with large, extended (7+ years) reductions in cocaine users and methamphetamine users in the United States.