Exclusive Therapeutic Use of Cannabis in a Large Sample of Daily Cannabis Users in France: A Cross-Sectional Survey.

Many cannabis users report therapeutic benefits from cannabis consumption, even when not recommended by a physician. To date, few data on therapeutic users of cannabis in France are available. Using a cross-sectional survey held in 2020, we collected sociodemographic, health and substance use data from 4150 daily cannabis users in France. We used multivariable logistic regression to assess factors associated with exclusive therapeutic use of cannabis. Approximately 10% (n = 453) of the participants reported using cannabis exclusively for therapeutic purposes. Exclusive therapeutic users of cannabis differed from non-exclusive (i.e. recreational and mixed) users, especially regarding age (aOR [95%CI] = 1.01 [1.00-1.02]), employment (aOR = 0.61 [0.47-0.79]), urban area of residence (aOR = 0.75 [0.60-0.94]), physical (aOR = 2.95 [2.34-3.70]) and mental health condition (aOR = 2.63 [1.99-3.49]), mode of cannabis administration (non-smoked, aOR = 1.89 [1.22-2.95); smoked with little tobacco, aOR = 1.39 [1.09-1.76]), frequency of cannabis use (aOR = 1.04 [1.01-1.06]), home cultivation (aOR = 1.56 [1.13-2.15]), at-ridsk alcohol use (aOR = 0.68 [0.54-0.84]), and previous-month opiate use (aOR = 1.67 [1.22-2.30]). A greater understanding of the distinct profiles of regular cannabis users could inform harm reduction strategies and care access for this population. Further studies are needed to better understand the boundaries between therapeutic and recreational use.

[Opioid overdose prevention and naloxone diffusion (POP program): Results of an overview conducted among addiction specialized centres]. / Prévention des surdoses opioïdes et diffusion de naloxone (programme POP) : résultats d'un état des lieux réalisé auprès des structures d'addictologie.

INTRODUCTION: In France, opioids are responsible for the majority of overdose deaths in France. The antidote naloxone is available in France in take home formulations since 2016. Addiction specialized centres are in front-line for naloxone diffusion. The objective was to provide an overview of professional practices, difficulties and needs regarding overdose prevention and naloxone diffusion in these centres of the Provence-Alpes-Côte d'Azur (PACA) region. METHODS: The POP programme "Prevention and harm reduction of opioid overdoses in PACA region" aims to improve the care of patients at risk of overdose and facilitate naloxone diffusion. The 75 addiction specialized centres of the PACA region were invited to respond to a semi-structured interview or a telephone questionnaire. Data collected included 2020 centres' activity and professionals' perceptions of overdose risk in their active file, their practices, difficulties and needs. RESULTS: Overall, 33 centres answered. Among them, 22 were dispensing naloxone with a mean of 20 kits dispensed in 2020 (min-max: 1-100). Two strategies were pointed out: systematically offering of naloxone to all opioids users or targeting people considered at risk. Several difficulties limiting naloxone diffusion were expressed: a lack of knowledge from opioids users, refusal from people not feeling concerned or refusing the injectable formulation, a lack of training of some professionals to be comfortable with the tool or reglementary or time constraints. CONCLUSION: Naloxone diffusion is incrementally getting into common practices. However barriers are persisting. On the basis of expressed difficulties and needs, information and training materials were co-designed and diffused.

Changes in cannabis use and associated correlates during France's first COVID-19 lockdown in daily cannabis users: results from a large community-based online survey.

BACKGROUND: Lockdown measures during the first wave of the COVID-19 pandemic in France led to serious public health concerns over people who use illicit drugs, especially in terms of mental health. We assessed changes in cannabis use during the first lockdown in France among daily cannabis users and associated correlates. METHODS: CANNAVID is a French, national, cross-sectional web-based survey, conducted from 17 April to 11 May 2020. Daily cannabis users aged ≥ 18 years and living in France were invited to participate through advertisements. Respondents completed an ad hoc questionnaire on a dedicated online platform. We analyzed changes in cannabis use during the first lockdown (i.e., stopped, decreased, unchanged, or increased) and performed a multinomial logistic regression analysis to evaluate correlates of these changes. RESULTS: Of the 4019 participants, 74.0% were men. Median age was 27 years (interquartile range: 22-37). With regard to cannabis use, 293 (7.3%) persons stopped, 1153 (28.7%) decreased, 1146 (28.5%) did not change, and 1427 (35.5%) increased their use during the lockdown. A multinomial logistic regression model revealed several sociodemographic, behavioral and health-related factors associated with changes in cannabis use. Compared with participants with an unchanged level of cannabis use during the lockdown, those who increased and those who stopped cannabis use were more likely to have increased tobacco and alcohol use and to have experienced depression and sleep disorders intensification. Those who stopped cannabis use were also more likely to have increased benzodiazepine use and to have experienced pain increase during lockdown. CONCLUSIONS: France's first COVID-19-related lockdown had a differential impact on daily cannabis users' consumption patterns. Most study respondents reported changes to their cannabis consumption pattern. Those who reported a stable cannabis use were more likely to report fewer negative changes. Specific interventions are needed for this population, as well as research to assess the long-term impacts of these changes.

Safety concerns on the abuse potential of esketamine: Multidimensional analysis of a new anti-depressive drug on the market.

Prominent features of esketamine (e.g., similar mechanism of action as ketamine and target population) require to be vigilant regarding its benefits/risks balance and its risks of abuse in real-life settings. The aim of this study was to review all available pharmacological and clinical data to assess the abuse potential of esketamine shortly after its marketing. This multidimensional study is a quantitative and qualitative analysis of complementary data sources, ranging from preauthorization data (i.e., fundamental pharmacology and clinical trials) to real-life settings data (i.e., pharmacovigilance databases and web forums). According to esketamine pharmacology, its psychoactive effects play a role both in its therapeutic effect and its abuse potential. Only one out of the three short-term efficacy trials found a significant difference between esketamine and placebo in treatment-resistant depression. Beside adverse events that may be sought for abuse purpose (e.g., dissociation, sedation, euphoric mood, hallucination, feeling drunk, and derealization), clinical signs related to substance use disorder (e.g., tolerance, withdrawal syndrome, and drug dependence) and misuse (e.g., off-label use) were also identified in pharmacovigilance databases. Analysis of pharmacovigilance narratives and web forums showed that esketamine psychoactive effects are appreciated by some patients, while they are badly experienced by others. Strict compliance with the market authorization, close monitoring of patients by psychiatrists, and surveillance of any signs of misuse, abuse, or dependence must be part of any treatment course.

Antidepressants abuse in subjects with opioid use disorders: A 10-year study in the French OPPIDUM program.

Accumulating evidence shows that some antidepressants are abused for their psychostimulant effects, but the extent of antidepressants abuse is unknown in subjects with opioid use disorders (OUD). The objective of this work is to assess the prevalence of antidepressant abuse and its correlates in subjects with OUD. Subjects ≥18 year-old in an opiate maintenance treatment (OMT) program who reported using an antidepressant were selected from the OPPIDUM program from 2011 to 2020. The outcome was antidepressant abuse. Antidepressant abusers were identified as subjects reporting at least one of the following behaviors: "drug abuse," "concomitant use of alcohol," "illegal obtaining," and "dose higher than recommended in the Summary of Product Characteristics." Among the 83 040 observations of subjects ≥18 year-old in an OMT program included in the OPPIDUM program from 2011 to 2020, 2708 (3.3%) subjects reported using an antidepressant in monotherapy. Among them, there were 385 (14.2%) abusers. The proportion of abusers was the highest for amitriptyline (n = 31, 25.0%). In multivariate analysis, antidepressant abuse was positively associated with amitriptyline (OR 2.07, 95% CI [1.16, 3.73]; p = 0.015), unemployment (OR 1.52, 95% CI [1.16, 2.01]; p = 0.003), the use of intravenous route of administration (OR 1.77, 95% CI [1.12, 2.80]; p = 0.014), and the use of benzodiazepines (OR 1.53, 95% CI [1.21, 1.94]; p < 0.001). Clinicians should be aware of the risk of antidepressant abuse when prescribing in subjects with OUD, accounting for their heterogeneous pharmacological properties that may account for their abuse potential.

A syndemic examination of injecting drug use, incarceration and multiple drug-related harms in French opioid users.

PURPOSE: People who inject drugs (PWID) face multiple health problems, including infectious diseases and drug overdoses. Applying syndemic and risk environment frameworks, this paper aims to examine the co-occurrence and clustering of drug-related harms and their association with incarceration experience with or without in-prison drug injection. DESIGN/METHODOLOGY/APPROACH: The authors used data from a cross-sectional survey conducted in 2015 among 557 active opioid injectors. Self-reported data were collected through face-to-face or online questionnaires. They distinguished three harm categories, namely, viral infections, bacterial infections and overdoses, and built an index variable by summing the number of harm categories experienced, yielding a score from 0 to 3. Association between incarceration experience and co-occurrence of harms was modelled using a multinomial logistic regression. FINDINGS: Of the 557 participants, 30% reported lifetime experience of drug-related viral infection, 46% bacterial infection and 22% drug overdose. Multinomial logistic models showed that those who injected drugs during incarceration were more likely to report two (aOR = 2.35, 95% CI: 1.03-5.36) and three (aOR = 9.72, 95% CI: 3.23-29.22) harm categories than those who had never been incarcerated. They were also more likely to report three harm categories than formerly incarcerated respondents who did not inject drugs in prison (aOR = 5.14, 95% CI: 1.71-15.48). ORIGINALITY/VALUE: This study provides insights of the syndemic nature of drug-related harms and highlights that drug injection during incarceration is associated with co-occurring harms. Public health interventions and policy changes are needed to limit the deleterious impact of prison on PWID.

A two-component intervention to improve hand hygiene practices and promote alcohol-based hand rub use among people who inject drugs: a mixed-methods evaluation.

BACKGROUND: Inconsistent hand hygiene puts people who inject drugs (PWID) at high risk of infectious diseases, in particular skin and soft tissue infections. In healthcare settings, handwashing with alcohol-based hand rubs (ABRH) is recommended before aseptic procedures including intravenous injections. We aimed to evaluate the acceptability, safety and preliminary efficacy of an intervention combining ABHR provision and educational training for PWID. METHODS: A mixed-methods design was used including a pre-post quantitative study and a qualitative study. Participants were active PWID recruited in 4 harm reduction programmes of France and followed up for 6 weeks. After baseline assessment, participants received a face-to-face educational intervention. ABHR was then provided throughout the study period. Quantitative data were collected through questionnaires at baseline, and weeks 2 (W2) and 6 (W6) post-intervention. Qualitative data were collected through focus groups with participants who completed the 6-week study. RESULTS: Among the 59 participants included, 48 (81%) and 43 (73%) attended W2 and W6 visits, respectively. ABHR acceptability was high and adoption rates were 50% (W2) and 61% (W6). Only a minority of participants reported adverse skin reactions (ranging from 2 to 6%). Preliminary efficacy of the intervention was shown through increased hand hygiene frequency (multivariable linear mixed model: coef. W2 = 0.58, p = 0.002; coef. W6 = 0.61, p = 0.002) and fewer self-reported injecting-related infections (multivariable logistic mixed model: AOR W6 = 0.23, p = 0.021). Two focus groups were conducted with 10 participants and showed that young PWID and those living in unstable housing benefited most from the intervention. CONCLUSIONS: ABHR for hand hygiene prior to injection are acceptable to and safe for PWID, particularly those living in unstable housing. The intervention's educational component was crucial to ensure adoption of safe practices. We also provide preliminary evidence of the intervention's efficacy through increased hand hygiene frequency and a reduced risk of infection.

Individual and structural correlates of willingness for intravenous buprenorphine treatment among people who inject sublingual buprenorphine in France.

BACKGROUND: Some people do not benefit from oral administration of opioid agonist treatment, and an intravenous (IV) formulation may be more suitable. Our objective was to evaluate the willingness of people who regularly inject sublingual buprenorphine to receive IV buprenorphine as a prescribed treatment, and to examine related correlates. METHODS: We performed a secondary analysis of data from the cross-sectional study PrebupIV, conducted in France in 2015 among 557 people who inject opioids. The study comprised questionnaires completed either face to face or online and community-based workshops. We only included participants who reported buprenorphine as their main injected drug (n = 209). Willingness to receive IV buprenorphine treatment was measured on a scale from 0 to 10. Ordinal logistic regression identified correlates of willingness. Artworks and testimonies from participants in the workshops were also used to illustrate correlates of willingness. RESULTS: Among the 209 participants, the mean score (SD) for willingness to receive IV buprenorphine was 8.0 (2.8). Multivariate analysis showed that participants who reported using non-prescribed buprenorphine (AOR = 4.82, p = 0.019), a higher daily dosage of buprenorphine (AOR (for 1 mg) = 1.05, p = 0.043), and a higher number of complications due to injection (AOR = 2.28, p = 0.037), were more willing to receive IV buprenorphine treatment. CONCLUSIONS: Willingness to initiate IV buprenorphine treatment was high among people who regularly inject sublingual buprenorphine. A prescribed IV formulation could attract and retain more people into care and reduce harms associated with the injection of buprenorphine tablets.

Implementation and evaluation of an educational intervention for safer injection in people who inject drugs in Europe: a multi-country mixed-methods study.

BACKGROUND: Harm reduction (HR) interventions are essential to reduce human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission in people who inject drugs (PWID). Preliminary testing of the Individually Tailored Support and Education for Safer Injection (ITSESI) evidence-based educational intervention for PWID was performed in France in 2011. We created the Eurosider project to implement and evaluate ITSESI at a wider European level, with a view to its future pan-European diffusion. METHODS: We performed a mixed-methods study involving quantitative (a 6-month before-after study with PWID) and qualitative (focus groups with field workers) components. The study was conducted in 2018-2019 with 307 eligible PWID participating in four existing HR programmes in Bulgaria, Greece, Portugal, and Romania. ITSESI consists in trained field workers observing PWID injection practices and providing an educational exchange. For the present study, PWID participants were allocated to either the control group (i.e., they continued receiving only the current HR services) or the intervention group (i.e., current HR services plus ITSESI). We used the RE-AIM QuEST framework to assess the effectiveness of ITSESI and its acceptability by field workers. Effectiveness was defined as a reduction in both syringe sharing - the highest HIV/HCV transmission risk practice - and in cutaneous abscesses. We used a multivariable mixed logit model to analyse both effectiveness outcomes and to provide adjusted odds ratios (aOR) and 95% confidence intervals (CI). Field workers' acceptability of the intervention was described using a thematic analysis of the qualitative data. RESULTS: Of the 307 PWID, 55% received ITSESI. Syringe sharing and cutaneous abscesses decreased during follow-up in the intervention group (from 25 to 16% and from 27 to 14%, respectively). Reductions were smaller in the control group (from 29 to 24% and from 23 to 18%, respectively). The multivariable analyses confirmed the effect of the intervention on both of these outcomes (aOR [95% CI]: 0.38 [0.17, 0.85]) and (aOR [95% CI]: 0.38 [0.16, 0.90], respectively). Our qualitative data on acceptability showed the feasibility of involving field workers as proactive research partners in making ITSESI more accessible and acceptable across Europe. CONCLUSIONS: We demonstrated both the effectiveness of ITSESI in reducing syringe sharing and cutaneous abscesses in four European countries, and a high level of intervention acceptability by field workers. Our findings provide important insights into how ITSESI can be adapted for pan-European implementation.

Correlates of Self-Reported Cotton Fever Experience among People Who Inject Opioids.

Background: Cotton fever is a febrile syndrome occurring after intravenous drug injection. Although its clinical presentation is well described in the literature, data regarding prevention is lacking. We aimed to assess proportion and correlates of cotton fever experience among people who inject opioids. Methods: We performed a cross-sectional study using data from the community-based survey PrebupIV conducted in France in 2015 among 557 people who regularly injected opioids. Self-reported sociodemographic data, together with data on substance use, injecting practices and occurrence of cotton fever were all collected through face-to-face (n = 398) or online (n = 159) questionnaires. Factors associated with cotton fever experience were assessed using logistic regression model. Results: Over half of the participants (54%) reported cotton fever experience. In the multivariable logistic regression, crack cocaine injection (adjusted Odds Ratio (aOR) = 1.96, 95% Confidence Interval (CI) = 1.03-3.63), longer duration of opioid use (for 1 year of use: aOR = 1.05, 95%CI = 1.02-1.09), and filtering mainly with cotton filters (compared with membrane filters, aOR = 1.86, 95%CI = 1.24-2.78) were all associated with cotton fever experience. Conclusions: Our findings highlight that cotton fever is a frequent complication of injecting drug use. Avoiding the use and reuse of cotton balls to filter injected solutions, and promoting membrane filters use could reduce the risk of the condition occurring.

Changes in supervised drug-injecting practices following a community-based educational intervention: A longitudinal analysis.

BACKGROUND: People who inject drugs face several health issues because of unsafe injecting practices. We aimed to evaluate changes in supervised drug-injecting practices following the implementation of a face-to-face educational intervention. METHODS: The national study ANRS-AERLI was conducted in 17 harm reduction (HR) facilities in France between 2011 and 2013. Eight offered the intervention and nine did not. We conducted a pre-post analysis focusing on injecting practices data, collected in the 8 HR facilities providing the intervention. The intervention consisted of providing face-to-face educational sessions including direct observation of injecting practices, counseling about safer injecting, and shared discussion. Injecting practices were collected following a checklist and classified as safe or unsafe. To assess changes in injecting practices, practices were compared before (at baseline) and after at least one educational session. FINDINGS: Mixed logistic models showed that the 78 participants included were more likely to improve in the following drug-use steps: setting up a clean preparation area (Adjusted Odds Ratio (AOR) = 3.4, 95% Confidence Interval (95% CI) = 1.6-7.6), hand washing (AOR = 7.2, 95% CI = 3.1-16.4), skin cleaning (AOR = 5.6, 95% CI = 2.5-12.1), choice of safe injection site (AOR = 6.5, 95% CI = 1.5-28.8) and post-injection bleeding management (AOR = 12.8, 95% CI = 5.5-29.9). Furthermore, participants were less likely to lick their needles before injecting (AOR = 8.1, 95% CI = 1.5-43.4) and to perform booting/flushing (AOR = 2.5, 95% CI = 1.2-5.3). CONCLUSIONS: The AERLI intervention seems to be effective in increasing safe drug-injecting practices.

Factors associated with perceived loss of libido in people who inject opioids: Results from a community-based survey in France.

BACKGROUND: Regular consumption of opioids exposes individuals to several side effects. One of these is a loss of libido, which has a negative impact on quality of life. We used a cross-sectional community-based survey of people who inject opioids to study factors associated with loss of libido, and more particularly the impact of the type of opioid injected. METHODS: This secondary study was conducted throughout France in 2015 and involved 514 people who inject opioids. Self-reported sociodemographic characteristics, drug consumption, injection-related data and loss of libido were collected using a brief questionnaire administered either through face-to-face interviews or online. Two different models were used to identify factors associated with loss of libido: simple logistic regression and a two-step Heckman model. RESULTS: Forty-three percent of the participants reported a loss of libido. The first model showed that filling in the questionnaire online (OR[95%CI] = 2.55[1.64;3.96]; p < 0.001), reporting that morphine sulfate (OR[95%CI] = 2.67[1.56;4.58]; p < 0.001) or methadone (OR[95%CI] = 2.50[1.13;5.56]; p = 0.030) was the opioid they injected most (versus buprenorphine), and reporting benzodiazepine use (OR[95%CI] = 1.62[1.07;2.44]; p = 0.033) were factors strongly associated with loss of libido. In the two-step, Heckman model which corrected for selection bias, along with these factors, reporting heroin as the opioid injected most was also strongly associated. CONCLUSION: Our findings showed that full-opioid agonists could have a negative impact on libido when injected regularly. Libido can improve quality of life and should be routinely discussed through counseling in prevention services with people who inject drugs.

Profile, risk practices and needs of people who inject morphine sulfate: Results from the ANRS-AERLI study.

AIMS: In France, a non-negligible proportion of opioid-dependent individuals inject morphine sulfate. Although it has not yet been officially approved as an opioid substitution treatment (OST), some physicians can prescribe its use for people in methadone or buprenorphine treatment failure. Longitudinal data from the ANRS-AERLI study, which evaluated an educational intervention for safer injection called AERLI, provided us the opportunity to better characterize the profile, risk practices and needs of people who inject morphine sulfate (MSI), through comparison with other injectors, and to identify correlates of HIV/HCV risk practices in this group. METHODS: The national multisite ANRS-AERLI study assessed the impact of AERLI offered in volunteer harm reduction (HR) centers ("with intervention") (n = 113) through comparison with standard HR centers ("without intervention") (n = 127). All participants were scheduled to be followed up for 12 months and have 3 telephone interviews: at baseline, 6 months and 12 months. We compared MSI (n = 79) with other opioid injectors (n = 161) and then used a mixed logistic model to identify factors associated with HIV/HCV risk practices among MSI. FINDINGS: Of the 240 eligible participants, 79 were regular MSI. They were less likely to use cocaine, crack or buprenorphine and to receive OST than other participants. Conversely, MSI were more likely to inject drugs more than three times a day and to report HIV/HCV risk practices. Among MSI, multivariate analysis showed that those receiving morphine sulfate as an OST were less likely to report such practices than other participants (aOR [95%CI] = 0.11 [0.02-0.61]). CONCLUSION: Our results show that while MSI use fewer stimulants, they have more HIV/HCV risk practices than other injectors. However, when MSI are prescribed morphine sulfate as a treatment, these practices tend to decrease. Our findings suggest the importance of increasing access to morphine sulfate as a new OST in France.

Validation of an algorithm identifying incident primary immune thrombocytopenia in the French national health insurance database.

OBJECTIVES: To evaluate the accuracy of an algorithm identifying newly diagnosed immune thrombocytopenia (ITP) patients in the French national health insurance database (SNIIRAM). METHODS: The source of data was the SNIIRAM of Midi-Pyrenees region (southwest of France, three million inhabitants). Data of patients with at least one ITP code (D69.3 code of the International Classification of Disease, version 10) were extracted between January 1, 2012, and December 31, 2014. We used an algorithm that identifies newly diagnosed primary ITPs. Medical charts of incident ITPs were reviewed. Positive predictive values (PPVs) of identification of true, incident, and primary ITP cases were estimated. RESULTS: Of the 168 patients selected, 161 were true ITP cases yielding a PPV of 95.8% (95% confidence interval-95% CI: 92.8-98.8). Among them, 128 were truly incident according to symptom onset date and 134 according to the diagnosis date yielding PPVs of 79.5% (95% CI: 73.2-85.7) and 83.2% (95% CI: 77.4-89.0), respectively. Median time between estimated diagnosis date by the algorithm and true diagnosis date was 0 days (interquartile range: 0 to 15). CONCLUSIONS: This study showed a very good PPV of this algorithm identifying incident primary ITP patients in the SNIIRAM.