Cannabis and Driving in Older Adults.

Importance: Epidemiological studies have found that cannabis increases the risk of a motor vehicle collision. Cannabis use is increasing in older adults, but laboratory studies of the association between cannabis and driving in people aged older than 65 years are lacking. Objective: To investigate the association between cannabis, simulated driving, and concurrent blood tetrahydrocannabinol (THC) levels in older adults. Design, Setting, and Participants: Using an ecologically valid counterbalanced design, in this cohort study, regular cannabis users operated a driving simulator before, 30 minutes after, and 180 minutes after smoking their preferred legal cannabis or after resting. This study was conducted in Toronto, Canada, between March and November 2022 with no follow-up period. Data were analyzed from December 2022 to February 2023. Exposures: Most participants chose THC-dominant cannabis with a mean (SD) content of 18.74% (6.12%) THC and 1.46% (3.37%) cannabidiol (CBD). Main outcomes and measures: The primary end point was SD of lateral position (SDLP, or weaving). Secondary outcomes were mean speed (MS), maximum speed, SD of speed, and reaction time. Driving was assessed under both single-task and dual-task (distracted) conditions. Blood THC and metabolites of THC and CBD were also measured at the time of the drives. Results: A total of 31 participants (21 male [68%]; 29 White [94%], 1 Latin American [3%], and 1 mixed race [3%]; mean [SD] age, 68.7 [3.5] years), completed all study procedures. SDLP was increased and MS was decreased at 30 but not 180 minutes after smoking cannabis compared with the control condition in both the single-task (SDLP effect size [ES], 0.30; b = 1.65; 95% CI, 0.37 to 2.93; MS ES, -0.58; b = -2.46; 95% CI, -3.56 to -1.36) and dual-task (SDLP ES, 0.27; b = 1.75; 95% CI, 0.21 to 3.28; MS ES, -0.47; b = -3.15; 95% CI, -5.05 to -1.24) conditions. Blood THC levels were significantly increased at 30 minutes but not 180 minutes. Blood THC was not correlated with SDLP or MS at 30 minutes, and SDLP was not correlated with MS. Subjective ratings remained elevated for 5 hours and participants reported that they were less willing to drive at 3 hours after smoking. Conclusions and relevance: In this cohort study, the findings suggested that older drivers should exercise caution after smoking cannabis.

Twelve-month Treatment Retention and Associated Factors: A Comparison of 2 Medically Assisted Therapy Clinics in Dar es Salaam, Tanzania.

OBJECTIVES: Retention in methadone maintenance treatment is instrumental in achieving better treatment outcomes. In this study, we compared 2 medication-assisted treatment (MAT) clinics in Dar es Salaam, Tanzania with respect to patient characteristics, outcomes, and factors that predict 12-month treatment retention. METHODS: This retrospective registry-based cohort study utilized data collected for routine clinical and program monitoring at 2 sites, Mwananyamala and Muhimbili MAT clinics. Cumulative retention in treatment was calculated using life tables. The analysis of treatment retention predictor variables used both Kaplan-Meier and Cox proportional hazard analyses. RESULTS: We examined the socio-demographic and program-related characteristics of 362 (181 from each clinic) patients. Twelve-month treatment retention was higher at Mwananyamala (73%) than Muhimbili (64%) MAT clinic, but the difference was not significant. In both clinics, a higher methadone dose (>60mg) significantly predicted treatment retention ( P < 0.05). Being employed and traveling an average short distance (<5 km) from home to clinic significantly increased the likelihood of remaining in treatment in Muhimbili MAT clinic (P< 0.05) only. CONCLUSIONS: A methadone dose of 60 mg and above was associated with longer retention in treatment. At 1 clinic in a denser and more central location, employment and a short travel distance from home to clinic were associated with longer tenure in treatment. These findings have potential implications for clinical practice, research, and scaling up MAT services in Tanzania.

Prevalence and factors associated with alcohol drinking among HIV and tuberculosis co-infected patients in Dar es Salaam, Tanzania.

There is scarcity of information on the burden of alcohol use among people living with HIV in Tanzania despite the high burden of HIV. We examined the prevalence and factors associated with alcohol use among HIV and tuberculosis (TB) co-infected patients in fourteen clinics with highest notification of TB in Dar es Salaam, Tanzania, between October 2010 and December 2011. Proportions were used to describe the prevalence and pattern of alcohol use. Logistic regression was used to assess the association of various participant characteristics with alcohol use. Out of the 515 participants, 38 (7.4%) were current alcohol drinkers, 183 (35.5%) were ex-drinkers and the rest, 294 (57.1%) denied ever drinking alcohol. Approximately, 15% of past and current drinkers were classified as heavy drinkers. Patients with normal BMI, cigarette smokers, and those with higher income were more likely to be drinkers. Similarly, compared to civil servants, those in petty trade and other occupations were more likely to be drinkers. We concluded that, the level of current alcohol use among HIV positive people receiving pulmonary TB treatment in this population was low. Nevertheless, alcohol use screening and assessment should be added as an integral part of service provision in HIV clinics given the effect of alcohol on health outcomes among HIV positive patients.

Prevalence and patterns of cigarette smoking among patients co-infected with human immunodeficiency virus and tuberculosis in Tanzania.

INTRODUCTION: Cigarette smoking is one of the major risk factors for non-AIDS related morbidities and is highly prevalent among HIV infected people. However, no reports exist from Tanzania, one of the countries highly affected by the HIV pandemic and one of Africa's biggest tobacco producer. METHODS: We examined the patterns and prevalence of cigarette smoking among HIV and TB co-infected adult patients in Dar es Salaam using a cross sectional study design. Proportions were used to describe the pattern of cigarette smoking. Logistic regression was used to assess the association of various participant characteristics with smoking. RESULTS: Out of the 518 participants, 17 (3.3%) were current smokers, 96 (18.5%) were ex-smokers and the rest (78.2%) denied ever smoking. Male sex (p<0.001), alcohol (p<0.001), and illicit substance use (p<0.001) were significantly associated with cigarette smoking. CONCLUSIONS: The study indicates that, the level of current cigarette smoking among HIV/TB co-infected patients in Dar es Salaam is low. Nevertheless, the preponderance of cigarette smoking among men, alcohol drinkers, and those who use illicit substances provides a unique opportunity for targeting such population with smoking cessation interventions; HIV care and treatment clinics are uniquely positioned to provide such interventions.

Harm reduction as a complex adaptive system: A dynamic framework for analyzing Tanzanian policies concerning heroin use.

Contrary to popular belief, policies on drug use are not always based on scientific evidence or composed in a rational manner. Rather, decisions concerning drug policies reflect the negotiation of actors' ambitions, values, and facts as they organize in different ways around the perceived problems associated with illicit drug use. Drug policy is thus best represented as a complex adaptive system (CAS) that is dynamic, self-organizing, and coevolving. In this analysis, we use a CAS framework to examine how harm reduction emerged around heroin trafficking and use in Tanzania over the past thirty years (1985-present). This account is an organizational ethnography based on of the observant participation of the authors as actors within this system. We review the dynamic history and self-organizing nature of harm reduction, noting how interactions among system actors and components have coevolved with patterns of heroin us, policing, and treatment activities over time. Using a CAS framework, we describe harm reduction as a complex process where ambitions, values, facts, and technologies interact in the Tanzanian sociopolitical environment. We review the dynamic history and self-organizing nature of heroin policies, noting how the interactions within and between competing prohibitionist and harm reduction policies have changed with patterns of heroin use, policing, and treatment activities over time. Actors learn from their experiences to organize with other actors, align their values and facts, and implement new policies. Using a CAS approach provides researchers and policy actors a better understanding of patterns and intricacies in drug policy. This knowledge of how the system works can help improve the policy process through adaptive action to introduce new actors, different ideas, and avenues for communication into the system.

Real-world effectiveness of varenicline versus nicotine replacement therapy in patients with and without psychiatric disorders.

OBJECTIVE: To compare the effectiveness and safety of varenicline with nicotine replacement therapy (NRT) among smokers with or without psychiatric disorders attending a storefront smoking cessation clinic in an urban addiction and mental health academic health science center. METHODS: A retrospective chart review was conducted to compare treatment outcomes, demographics, and clinical characteristics for adult smokers prescribed varenicline (n = 98) or NRT (n = 98) between 2007 and 2010. Subjects were matched 1:1 on age, sex, and year of initial assessment. RESULTS: End-of-treatment quit rates were almost twice as high among those prescribed varenicline (33.7%) versus NRT (18.4%) (RR = 1.83, 95% CI = 1.11-3.03, P = 0.02). After adjusting for several baseline and treatment characteristics, varenicline was still significantly more effective than NRT (ARR = 1.71, 95% CI = 1.05-2.79, P = 0.03). History of psychiatric disorder (excluding substance use disorders) and treatment duration were also independent predictors of end-of-treatment quit rates. Nausea was more commonly reported among those using varenicline (13.3% vs 3.1%, P = 0.009). No single neuropsychiatric adverse effect significantly differed between groups; however, overall reporting of any neuropsychiatric effect was somewhat higher in the varenicline group (31.6% vs 20.4%, P = 0.07). There was one incident of suicidal ideation in each medication group. CONCLUSIONS: Varenicline seems to be more effective than NRT and as safe in real-world settings among patients with and without a history of psychiatric disorder.

Methadone treatment for HIV prevention-feasibility, retention, and predictors of attrition in Dar es Salaam, Tanzania: a retrospective cohort study.

BACKGROUND: People who inject drugs (PWID) in Dar es Salaam, Tanzania, have an estimated human immunodeficiency virus (HIV) prevalence of 42%-50% compared with 6.9% among the general population. Extensive evidence supports methadone maintenance to lower morbidity, mortality, and transmission of HIV and other infectious diseases among PWID. In 2011, the Tanzanian government launched the first publicly funded methadone clinic on the mainland of sub-Saharan Africa at Muhimbili National Hospital. METHODS: We conducted a retrospective cohort study of methadone-naive patients enrolling into methadone maintenance treatment. Kaplan-Meier survival curves were constructed to assess retention probability. Proportional hazards regression models were used to evaluate the association of characteristics with attrition from the methadone program. RESULTS: Overall, 629 PWID enrolled into methadone treatment during the study. At 12 months, the proportion of clients retained in care was 57% (95% confidence interval [CI], 53%-62%). Compared with those receiving a low dose (<40 mg), clients receiving a medium (40-85 mg) (adjusted hazard ratio [aHR], 0.50 [95% CI, .37-.68]) and high (>85 mg) (aHR, 0.41 [95% CI, .29-.59]) dose of methadone had a lower likelihood of attrition, adjusting for other characteristics. Older clients (aHR, 0.53 per 10 years [95% CI, .42-.69]) and female clients (aHR, 0.50 [95% CI, .28-.90]) had a significantly lower likelihood of attrition, whereas clients who reported a history of sexual abuse (aHR, 2.84 [95% CI, 1.24-6.51]) had a significantly higher likelihood of attrition. CONCLUSIONS: Patient retention in methadone maintenance is comparable to estimates from programs in North America, Europe, and Asia. Future implementation strategies should focus on higher doses and flexible dosing strategies to optimize program retention and strengthened efforts for clients at higher risk of attrition.

Drug trafficking, use, and HIV risk: the need for comprehensive interventions.

The rapid increase in communication and transportation between Africa and other continents as well as the erosion of social fabric attended by poverty, ethnic conflicts, and civil wars has led to increased trafficking and consumption of illicit drugs. Cannabis dominates illicit trade and accounts for as much as 40% of global interdiction. Due to escalating seizures in recent years, the illicit trade in heroin and cocaine has become a concern that has quickly spread from West Africa to include Eastern and Southern Africa in the past 10 years. All regions of Africa are characterized by the use of cannabis, reflecting its entrenched status all over Africa. Most alarming though is the use of heroin, which is now being injected frequently and threatens to reverse the gain made in the prevention of HIV/AIDS. The prevalence of HIV infection and other blood-borne diseases among injection drug users is five to six times that among the general population, calling for urgent intervention among this group. Programs that aim to reduce the drug trafficking in Africa and needle syringe programs as well as medication-assisted treatment (MAT) of heroin dependence while still in their infancy in Africa show promise and need to be scaled up.