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

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

Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes.

BACKGROUND: Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran. METHODS: We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication. RESULTS: Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits. CONCLUSION: The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.

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

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

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

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

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

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

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

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

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

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

Assessing risk behaviours in the Iranian general population: results from the Iranian Mental Health Survey.

BACKGROUND: The Islamic Republic of Iran is a majority Muslim country, with a culturally low acceptance of high-risk behaviours. AIMS: To investigate co-occurrence of risk behaviours in the Iranian general population. METHODS: This was a cross-sectional study. Data were obtained from a random subsample of 3508 participants in the Iranian Mental Health Survey conducted in 2011 who completed a self-administered questionnaire about risk behaviours. The latent class analysis was performed on 7 behaviours consisting of cigarette smoking, alcohol consumption, opium use, use of other illicit drugs, having multiple sexual partners, imprisonment, and running away from home. Unordered multinomial logistic regression was performed to examine characteristics of participants in the latent classes. RESULTS: In the past 12 months, the rates of cigarette smoking, alcohol consumption, opium use, and use of other illicit drugs were 19.4%, 6.3%, 4.4%, and 4.2%, respectively. Three classes were identified: 1, a large class with low prevalence of risk behaviours [89.2%; 95% confidence interval (CI): 88.2-90.2%]; 2, high prevalence of all risk behaviours except drug use (6.1%; 95% CI: 5.3-6.9%); and 3, high prevalence of all risk behaviours (4.7%; 95% CI: 4.1-5.5%). Men and individuals with psychiatric disorders were over-represented in both classes 2 and 3. CONCLUSION: Alcohol consumers and opium users were at risk of other risky behaviours.

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

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

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

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