Main problems experienced by the neighbors of open drug scenes, Tehran, Iran: a mixed-method study.

BACKGROUND: Despite law enforcement and health interventions, open drug scenes have led to problems in many countries. The problems are, however, insufficiently explored. There are different types of drug scenes in Iran. This study aimed to explore the issues related to neighbors of one of the drug scenes in Tehran known as Farahzad. METHODS: Data were generated via semi-structured interviews in the first step of the current mixed-method study (2020-2021). Interviewees were people who use drugs (PWUDs), residents and business owners (N = 25). In the next step, a quantitative observation was conducted for eight days. The results were analyzed using conventional content analysis and descriptive statistics. RESULTS: The perceived problems were ambivalent attitudes about drug scene-related activities, violate of the territory of the self of the effected residents, and everyday concerns. The observation results indicated that men who use drugs are involved in drug scene-related activities more than women are. PWUDs try to hide their activities from the public view. Their efforts were considered "self-regulatory strategies" in the drug scene. CONCLUSIONS: Despite efforts of PWUDs to keep their activities invisible, drug scene-related issues are intolerable for neighbors. Neighbors and PWUDs have ambivalent attitudes. While they are concerned about the human rights of each other, drug scene-related activities have disturbed the neighbor's daily life and economic activities. Although law enforcement and harm reduction interventions reduce some of the problems, one of the approaches should be improving the coexistence between the neighbors and the residents of the drug scene to achieve broader and more sustainable compromises.

Mortality, Causes of Death, and Predictors of Death among Patients On and Off Opioid Agonist Treatment: Results from a 19-Year Cohort Study.

BACKGROUND: Mortality is increased among people with opioid use disorder but reduced while on opioid agonist treatment (OAT). However, the impact of patient and treatment characteristics on mortality and causes of death is insufficiently studied. OBJECTIVES: The objective of this study was to explore mortality and causes of death and examine the impact of patient and treatment characteristics on mortality in an OAT cohort with high retention in treatment. METHODS: Design: longitudinal cohort study. SETTING: Norway. Observation period: time from OAT start as of 1998 until death or end of 2016, 2,508 person-years (PY) in total. SAMPLE: 200 persons starting OAT 1998-2007. DATA SOURCES: hospital records, interviews, the Norwegian Cause of Death Registry, Statistics Norway. RESULTS: Retention: 86.4% of the observation period was on OAT, 9.0% off, 4.6% unknown OAT status. All-cause crude mortality rate per 100 PY during the whole observation period was 1.64 (95% CI: 1.19-2.20), for deaths of somatic cause 0.88 (0.56-1.31), for drug-induced deaths 0.44 (0.23-0.76), and traumatic deaths 0.24 (0.10-0.50). Off-versus-on-OAT all-cause mortality ratio was 2.31 (1.00-4.85). On OAT, 58% of the deaths were of somatic cause and 21% drug-induced; off OAT, 38% of somatic cause and 50% drug-induced. Increasing baseline age and rate of somatic hospital treatment episodes were independently associated with increased all-cause mortality risk, while increasing rate of in-patient psychiatric treatment episodes was associated with reduced risk. Increasing duration of nicotine and cannabis use and alcohol dependence as well as increasing severity of polydrug use were associated with increased all-cause and somatic mortality adjusted for age and sex. CONCLUSION: The long observation period made it possible to demonstrate the importance of long-term retention in OAT to reduce mortality. Further, the preponderance of somatic and reduction of drug-induced causes of death during OAT underlines the need for follow-up of chronic diseases and health-promoting lifestyle changes. These findings add to the knowledge about long-term OAT effects, not least in ageing OAT populations.

Organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder: a nation-wide 2-year cross-sectional study.

AIMS: To document organ pathologies detected post-mortem in patients receiving opioid agonist treatment for opioid use disorder and estimate the extent to which individual characteristics are associated with pulmonary, cardiovascular, hepatic or renal pathologies. DESIGN: Two-year cross-sectional nation-wide study. SETTING: Norway. PARTICIPANTS: Among all 200 patients who died during opioid agonist treatment between 1 January 2014 and 31 December 2015, 125 patients (63%) were autopsied. Among these, 122 patients (75% men) had available autopsy reports and were included. The mean age at the time of death was 48 years. MEASUREMENTS: Information on pulmonary, cardiovascular, hepatic and renal pathologies were retrieved from forensic or medical autopsy reports, with no (0) and yes (1) as outcome variables and age, sex and body mass index as covariates in logistic regression analyses. FINDINGS: Pathologies in several organs were common. Two-thirds (65%) of the decedents had more than two organ system diseases. The most common organ pathologies were chronic liver disease (84%), cardiovascular disease (68%) and pulmonary emphysema (41%). In bivariate analyses, only older age was associated with any pulmonary pathology [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.01-1.10], cardiovascular pathology (OR = 1.11; 95% CI = 1.05-1.17) and renal pathology (OR = 1.05; 95% CI = 1.00-1.11). Older age remained independently associated with cardiovascular pathology (OR = 1.10; 95% CI = 1.04-1.16) and renal pathology (OR = 1.06; 95% CI = 1.01-1.12) adjusted for body mass index and sex. CONCLUSIONS: Among autopsied Norwegians who died during opioid agonist treatment in 2014 and 2015, two-thirds had more than two organ system diseases, despite their mean age of 48 years at the time of death. Older age was independently associated with at least one cardiovascular or renal pathology after adjusting for sex and body mass index.

Indicators of Drug-Related Community Impacts of Open Drug Scenes: A Scoping Review.

INTRODUCTION: Places where people deal and/or use drugs publicly are known as open drug scenes (ODSs). Drug-related community impacts (DRCIs) refer to drug-related issues that negatively influence public and individual health, communities, businesses, and recreational and public space enjoyment. There are no well-established criteria for identification of DRCIs. We therefore performed a scoping review of literature to determine DRCIs indicators associated with ODSs. METHODS: The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScP). We searched English articles in PubMed, Scopus, Web of Science, and EMBASE databases from 1990 to 2021. The keywords were drug-related crime, drug-related offense, misconduct, social marginalization, homeless drug users, open drug scene, drug-related street disorder, public nuisance, and community impact. RESULTS: Sixty-four studies were identified. Twenty-five studies were included. Two studies (8%) were about drug-related public nuisance, 1 (4%) considered drug-related social problems, 2 (8%) focused on drug-related social disorder, and 18 studies (72%) discussed indicators of community impacts such as crime, drug-related litter, safety, noise, and drug use in public. Two studies (8%) included the frequency of drug use in ODSs. DISCUSSION: DRCI indicators are heterogenic, and various factors affect the indicators. The factors include social mores, political discourse, and historical approaches to dealing with and using drugs. Some societies do not tolerate the existence of ODSs. In contrast, many countries have adopted harm reduction programs to manage DRCIs. Identified DRCI indicators were drug using and dealing in public, drug-related litter, crime, drug-related loitering, street-based income generation activities, noise, and unsafety feelings in inhabitants. To solve the problems associated with DRCIs and to make a major change in ODSs, it is necessary to pay attention to the improvement of the economic conditions (e.g., employment opportunities), amendment (e.g., determine the limits of criminalization in drug use), and adoption of social policies (e.g., providing low-threshold and supportive services for homeless drug users).

Quetiapine abuse - myth or reality? / Kvetiapinmisbruk ­ myte eller realitet?

Quetiapine is increasingly being used as a sedative and hypnotic drug, especially in the treatment of addiction disorders. Some have warned against this practice. However, a review of the research literature lends little support to these warnings.

Post-mortem toxicological analyses of blood samples from 107 patients receiving opioid agonist treatment: substances detected and pooled opioid and benzodiazepine concentrations.

AIMS: To present the substances and their concentrations detected post-mortem in patients receiving opioid agonist treatment (OAT) stratified by cause of death, estimate the pooled opioid and benzodiazepine concentrations using established conversion factors for blood concentrations from the Norwegian Road Traffic Act, and explore the association between drug-induced cause of death and the pooled opioid and benzodiazepine concentrations. DESIGN: Cross-sectional nationwide study. SETTING: Norway. PARTICIPANTS: One hundred and seven patients who died during OAT (i.e. within 5 days after the last intake of OAT medication) between 1 January 2014 and 31 December 2015, with post-mortem femoral blood available for toxicology. Data were collected from hospital records, the Norwegian Cause of Death Registry and autopsy reports. MEASUREMENTS: Presence of alcohol and non-alcohol substances in the bloodstream at time of death, determined through records of toxicology of post-mortem femoral blood. FINDINGS: A median of four substances was detected across the causes of death. At least one benzodiazepine was detected in 81 (76%) patients. The median pooled opioid concentration was significantly higher in drug-induced deaths compared with other causes of death (362 ng/mL versus 182 ng/mL, P < 0.001), in contrast to the pooled benzodiazepine concentration (5466 versus 5701 ng/mL, P = 0.353). The multivariate regression analysis showed that only increasing pooled opioid concentration (ng/ML) was associated with increased odds of a drug-induced cause of death (odds ratio, 1.003; 95% confidence interval: 1.001-1.006). CONCLUSIONS: In Norway, overall opioid concentration seems to play an important role in drug-induced deaths during opioid agonist treatment in patients prescribed methadone or buprenorphine. Patients prescribed buprenorphine tend to replace their agonist with full agonists, while patients prescribed methadone tend to have high opioid concentrations from methadone as the only opioid.

Drug-related community issues and the required interventions in open drug scenes in Tehran, Iran: a qualitative study protocol.

BACKGROUND AND OBJECTIVES: Many low-income and middle-income countries experience problems with open drug scenes and drug-related community issues (DRCIs). These experiences occur in settings with varying levels of health and law enforcement initiatives, and accordingly a range of approaches are implemented to curb the problem. Most of the published literature stems from Western and high-income societies. With this concern, the present study aims to describe a planned project to explore DRCIs in the open drug scenes of Tehran, including its typology, and predisposing and reinforcing factors. In addition, the study attempts to investigate the perceptions with respect to the required interventions and barriers to their accessibility. METHODS: To this end, the current study focuses on the Farahzad drug scene due to its structure and the difficult access to the scene by harm reduction providers. Data collection techniques encompass field observation, indepth interview and focus group discussion. Further, semistructured interviews are conducted with people who use drugs and other key informants who are engaged at this drug scene, including business, community, voluntary and statutory stakeholders, for an average of 90 min (average of 45 min for each part of the study). Furthermore, as a complementary method, field observation is performed regarding the themes of DRCIs at this scene. Then, focus group discussions are held to further describe the themes of DRCIs as well as to explore the required interventions, for an average of 90 min. Finally, the results are evaluated using qualitative content analysis. ETHICS AND DISSEMINATION: Ethical approval for the study was obtained from the Ethics Committee of Iran University of Medical Sciences, Iran. Additionally, participants are to provide written informed consent. The findings of the study are expected to play a role in promoting the current intervention.

Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: a national register study.

BACKGROUND: Mortality rates and causes of death among individuals in opioid agonist treatment (OAT) vary according to several factors such as geographical region, age, gender, subpopulations, drug culture and OAT status. Patients in OAT are ageing due to effective OAT as well as demographic changes, which has implications for morbidity and mortality. Norway has one of the oldest OAT populations in Europe. Because of the varying mortality rates and causes of death in different subgroups and countries, research gaps still exist. The aims of this study were to describe the causes of death among OAT patients in Norway, to estimate all-cause and cause-specific crude mortality rates (CMRs) during OAT and to explore characteristics associated with drug-induced cause of death compared with other causes of death during OAT. METHODS: This was a national, observational register study. Data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry were combined with data from medical records. We included all patients in the Norwegian OAT programme who died not more than 5 days after the last intake of OAT medication, between 1 January 2014 and 31 December 2015. RESULTS: In the 2-year observation period, 200 (1.4%) of the OAT patients died. A forensic or medical autopsy was performed in 63% of the cases. The mean age at the time of death was 48.9 years (standard deviation 8.4), and 74% were men. Somatic disease was the most common cause of death (45%), followed by drug-induced death (42%), and violent death (12%). In general, CMRs increased with age, and they were higher in men and in patients taking methadone compared with buprenorphine. Increasing somatic comorbidity, measured by the Charlson comorbidity index, reduced the odds of dying of a drug-induced cause of death compared with other causes of death. CONCLUSIONS: Both somatic and drug-induced causes of death were common during OAT. Improved treatment and follow-up of chronic diseases, especially in patients aged > 40 years, and continuous measures to reduce drug-induced deaths appear to be essential to reduce future morbidity and mortality burdens in this population.

The LASSO Program in Oslo: Harm Reduction Using Buprenorphine-Naloxone (Suboxone®) in a Low Threshold Setting.

BACKGROUND: This is a 6-year retrospective quality control study of the LASSO Program (Low Threshold Substitution Treatment in Oslo), using exclusively Suboxone® (buprenorphine-naloxone [BPNX]) in out-patient settings. Adequate abstinence prior to induction is necessary to avoid acute onset opioid withdrawal symptoms; thus, its use in low threshold settings is far less common than methadone. OBJECTIVES: The aim of this study was to determine if BPNX is a safe and feasible medication to use in a low threshold setting. METHODS: The analysis is based on daily supervised BPNX medication. The standardized induction regime started with 4-mg BPNX increasing by 4 mg daily until 16 mg, with individual adjustments based on clinical status. Treatment effect was evaluated by the number of medication induction attempts, treatment length and lag time between initial contact and medication start. Statistical computations were performed with SPSS®. RESULTS: There were 331 out of 394 registered patient inquires that started on BPNX. Two hundred fifty-three patients (76.4%) completed induction on first attempt with 95% Wilson score CIs of (0.716-0.807). The accumulated percentage increased to 85.2% during successive inductions. No significant association was found between lag time and (i) the number of days on medication during the first induction; or (ii) total treatment length. Patients had a median lag time of 5 days, remained in treatment a median of 52.0 days with an average of 3.9 inductions. There were no cases of severe precipitated withdrawal and only 2 cases of adverse reactions among the 1,293 inductions and 25,544 administered dosages. CONCLUSION: This study shows that BPNX is highly effective in treating marginalized heroin addicts in low threshold settings. Even during their first attempt, 76.4% completed induction. There were no cases of severe precipitated withdrawal. Prolonged lag time affected neither the length of first treatment nor the total treatment length. Individualized induction readiness approach and motivation were central to the above results.

Differences in combinations and concentrations of drugs of abuse in fatal intoxication and driving under the influence cases.

BACKGROUND: In toxicology, international classification systems focus on single intoxicants as the cause of death. It is, however, well known that very few drug related deaths are caused by a single substance and that information concerning the drug concentrations as well as the combinations of drugs are essential in order to ascertain the cause of death. The aim of the study was to assess whether those prone to fatal intoxications differ significantly from chronic drug users - in terms of demographics and drug exposure patterns. MATERIAL AND METHODS: Fatal psychoactive drug intoxications in Norway during 2012, where a forensic autopsy including toxicological analysis were performed, were included. Analytical findings in blood were compared with concentrations in blood from apprehended drivers under the influence of drugs and ethanol (DUID) during the same time period. The opioid and benzodiazepine concentrations were assessed as morphine and diazepam equivalents, respectively, in order to compare concentrations across the different groups. RESULTS: A total of 194 autopsy cases and 4811 DUID cases were included. Opioids were detected in around 90% of the drug intoxication cases, but in only 16% of the DUID cases. The number of substances detected in fatal intoxications was 4.9 compared to 2.6 in the DUID cases. The total opioid concentrations were significantly higher in the fatal intoxication cases compared to DUID cases (229ng/mL versus 56.9ng/mL morphine equivalents, respectively). Benzodiazepines were detected in 90% of the fatal cases. Only one fatal opioid mono-intoxication was found; a case with a very high methadone concentration (1238ng/mL). DISCUSSION: Mono-intoxication with heroin was not seen in any of the fatal intoxications in Norway, and single drug intoxications were rare (1.5%). Fatal intoxications were caused by a combination of drugs with significantly more substances as well as higher total drug concentrations among the fatal cases compared to the DUID cases. The combination of opioids and benzodiazepines seemed to represent an increased risk of death. CONCLUSION: The total load of drugs influence the degree of intoxication and the total concentration level must be considered, including the total number of substances. Our findings imply that international statistics regarding an opioid being the main intoxicant should have a shift in focus towards combinations of drugs (especially opioids and benzodiazepines) as a major risk factor for fatal drug overdoses.