Assessment of an Innovative Voluntary Substance Abuse Treatment Program Designed to Replace Compulsory Drug Detention Centers in Malaysia.

BACKGROUND: As part of an ongoing initiative by the Malaysian government to implement alternative approaches to involuntary detention of people who use drugs, the National Anti-Drug Agency has created new voluntary drug treatment programs known as Cure and Care (C&C) Centers that provide free access to addiction treatment services, including methadone maintenance therapy, integrated with social and health services. OBJECTIVES: We evaluated early treatment outcomes and client satisfaction among patients accessing C&C treatment and ancillary services at Malaysia's second C&C Center located in Kota Bharu, Kelantan. METHODS: In June-July 2012, a cross-sectional convenience survey of 96 C&C inpatients and outpatients who entered treatment >30 days previously was conducted to assess drug use, criminal justice experience, medical co-morbidities, motivation for seeking treatment, and attitudes towards the C&C. Drug use was compared for the 30-day-period before C&C entry and the 30-day-period before the interview. RESULTS: Self-reported drug use levels decreased significantly among both inpatient and outpatient clients after enrolling in C&C treatment. Higher levels of past drug use, lower levels of social support, and more severe mental health issues were reported by participants who were previously imprisoned. Self-reported satisfaction with C&C treatment services was high. Conclusions/Importance: Preliminary evidence of reduced drug use and high levels of client satisfaction among C&C clients provide support for Malaysia's ongoing transition from compulsory drug detention centers (CDDCs) to these voluntary drug treatment centers. If C&C centers are successful, Malaysia plans to gradually transition away from CDDCs entirely.

Understanding the revolving door: individual and structural-level predictors of recidivism among individuals with HIV leaving jail.

Incarceration, particularly when recurrent, can significantly compromise the health of individuals living with HIV. Despite this, the occurrence of recidivism among individuals with HIV has been little examined, particularly among those leaving jail, who may be at especially high risk for return to the criminal justice system. We evaluated individual- and structural-level predictors of recidivism and time to re-incarceration in a cohort of 798 individuals with HIV leaving jail. Nearly a third of the sample experienced at least one re-incarceration event in the 6 months following jail release. Having ever been diagnosed with a major psychiatric disorder, prior homelessness, having longer lifetime incarceration history, having been charged with a violent offense for the index incarceration and not having health insurance in the 30 days following jail release were predictive of recidivism and associated with shorter time to re-incarceration. Health interventions for individuals with HIV who are involved in the criminal justice system should also target recidivism as a predisposing factor for poor health outcomes. The factors found to be associated with recidivism in this study may be potential targets for intervention and need to be further explored. Reducing criminal justice involvement should be a key component of efforts to promote more sustainable improvements in health and well-being among individuals living with HIV.

Syringe acquisition experiences and attitudes among injection drug users undergoing short-term opioid detoxification in Massachusetts and Rhode Island.

Access to sterile syringes for injection drug users (IDUs) is a critical part of a comprehensive strategy to combat the transmission of HIV, hepatitis C virus, and other bloodborne pathogens. Understanding IDUs' experiences and attitudes about syringe acquisition is crucial to ensuring adequate syringe supply and access for this population. This study sought to assess and compare IDUs' syringe acquisition experiences and attitudes and HIV risk behavior in two neighboring states, Massachusetts (MA) and Rhode Island (RI). From March 2008 to May 2009, we surveyed 150 opioid IDUs at detoxification facilities in MA and RI, stratified the sample based on where respondents spent most of their time, and generated descriptive statistics to compare responses among the two groups. A large proportion of our participants (83%) reported pharmacies as a source of syringe in the last 6 months, while only 13% reported syringe exchange programs (SEPs) as a syringe source. Although 91% of our sample reported being able to obtain all of the syringes they needed in the past 6 months, 49% had used syringes or injection equipment previously used by someone else in that same time period. In comparison to syringe acquisition behaviors reported by patients of the same detoxification centers in 2001-2003 (data reported in previous publication), we found notable changes among MA participants. Our results reveal that some IDUs in our sample are still practicing high-risk injection behaviors, indicating a need for expanded and renewed efforts to promote safer injection behavior among IDUs. Our findings also indicate that pharmacies have become an important syringe source for IDUs and may represent a new and important setting in which IDUs can be engaged in a wide array of health services. Efforts should be made to involve pharmacists in providing harm reduction and HIV prevention services to IDUs. Finally, despite limited SEP access (especially in MA), SEPs are still used by approximately one of the three IDUs in our overall sample.

Linkage to care for HIV-infected heterosexual men in the United States.

In the United States, the human immunodeficiency virus (HIV) epidemic among heterosexual men disproportionately affects individuals involved with the criminal justice system, injection drug and other substance users, and racial and ethnic minorities. These overlapping populations confront similar social and structural disparities that contribute to HIV risk and limit access to HIV testing, treatment, and care. In this review, we discuss barriers to linkage to comprehensive HIV care for specific subpopulations of heterosexual men and examine approaches for enhancing linkage to care for this diverse population.

High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study.

BACKGROUND: Overdose is the leading cause of death among opioid users, but no data are available on overdose among people who inject drugs in Malaysia. We present the first estimates of the prevalence and correlates of recent non-fatal overdose among people who inject drugs in Malaysia. METHODS: In 2010, 460 people who inject drugs were recruited using respondent-driven sampling (RDS) in Klang Valley to assess health outcomes associated with injection drug use. Self-reported history of non-fatal overdose in the previous 6 months was the primary outcome. Sociodemographic, behavioral and structural correlates of non-fatal overdose were assessed using multivariable logistic regression. RESULTS: All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Most injected daily (91.3%) and were male (96.3%) and ethnically Malay (90.4%). Overall, 20% of participants had overdosed in the prior 6 months, and 43.3% had ever overdosed. The RDS-adjusted estimate of the 6-month period prevalence of overdose was 12.3% (95% confidence interval [CI] 7.9-16.6%). Having injected for more years was associated with lower odds of overdose (adjusted odds ratio [AOR] 0.6 per 5 years of injection, CI: 0.5-0.7). Rushing an injection from fear of the police nearly doubled the odds of overdose (AOR 1.9, CI: 1.9-3.6). Alcohol use was associated with recent non-fatal overdose (AOR 2.1, CI: 1.1-4.2), as was methamphetamine use (AOR 2.3, CI: 1.3-4.6). When adjusting for past-month drug use, intermittent but not daily methadone use was associated with overdose (AOR 2.8, CI: 1.5-5.9). CONCLUSION: This study reveals a large, previously undocumented burden of non-fatal overdose among people who inject drugs in Malaysia and highlights the need for interventions that might reduce the risk of overdose, such as continuous opioid substitution therapy, provision of naloxone to prevent fatal overdose, treatment of polysubstance use, and working with police to improve the risk environment.

The Impact of Healthcare Access on Knowledge and Willingness for HIV Testing in Chinese Female Entertainment Workers.

Chinese female entertainment workers are at high risk for HIV. We assessed the impact of healthcare access on HIV knowledge, condom use, and their willingness to receive HIV testing. We surveyed 257 entertainment workers in a cross-sectional study. Demographic, knowledge, and behavioral risk factors were examined. Of 257 women, 107 (42.1%) reported inconsistent condom use. Only 9% had prior HIV testing. Their HIV knowledge was generally poor. Having access to healthcare, being able to obtain condoms, and managers providing health information were associated with consistent condom use (all P < 0.01). Having access to healthcare was related to previous HIV testing (P < 0.01). Our study showed that having a doctor and access to healthcare had positive effects on HIV knowledge and likelihood of condom use and previous HIV testing. Chinese medical providers can play a significant role in encouraging HIV testing and outreach in migrant women employed at entertainment venues.

Forced withdrawal from methadone maintenance therapy in criminal justice settings: a critical treatment barrier in the United States.

The World Health Organization classifies methadone as an essential medicine, yet methadone maintenance therapy remains widely unavailable in criminal justice settings throughout the United States. Methadone maintenance therapy is often terminated at the time of incarceration, with inmates forced to withdraw from this evidence-based therapy. We assessed whether these forced withdrawal policies deter opioid-dependent individuals in the community from engaging methadone maintenance therapy in two states that routinely force inmates to withdraw from methadone (N = 205). Nearly half of all participants reported that concern regarding forced methadone withdrawal during incarceration deterred them engaging methadone maintenance therapy in the community. Participants in the state where more severe methadone withdrawal procedures are used during incarceration were more likely to report concern regarding forced withdrawal as a treatment deterrent. Methadone withdrawal policies in the criminal justice system may be a broader treatment deterrent for opioid-dependent individuals than previously realized. Redressing this treatment barrier is both a health and human rights imperative.

Partner violence and health among HIV-infected jail detainees.

PURPOSE: Little is known about the association of intimate partner violence (IPV) with specific HIV-treatment outcomes, especially among criminal justice (CJ) populations who are disproportionately affected by IPV, HIV, mental, and substance use disorders (SUDs) and are at high risk of poor post-release continuity of care. DESIGN/METHODOLOGY/APPROACH: Mixed methods were used to describe the prevalence, severity, and correlates of lifetime IPV exposure among HIV-infected jail detainees enrolled in a novel jail-release demonstration project in Connecticut. Additionally, the effect of IPV on HIV treatment outcomes and longitudinal healthcare utilization was examined. FINDINGS: Structured baseline surveys defined 49 percent of 84 participants as having significant IPV exposure, which was associated with female gender, longer duration since HIV diagnosis, suicidal ideation, having higher alcohol use severity, having experienced other forms of childhood and adulthood abuse, and homo/bisexual orientation. IPV was not directly correlated with HIV healthcare utilization or treatment outcomes. In-depth qualitative interviews with 20 surveyed participants, however, confirmed that IPV was associated with disengagement from HIV care especially in the context of overlapping vulnerabilities, including transitioning from CJ to community settings, having untreated mental disorders, and actively using drugs or alcohol at the time of incarceration. ORIGINALITY/VALUE: Post-release interventions for HIV-infected CJ populations should minimally integrate HIV secondary prevention with violence reduction and treatment for SUDs.

Absence of antiretroviral therapy and other risk factors for morbidity and mortality in Malaysian compulsory drug detention and rehabilitation centers.

BACKGROUND: Throughout Asia, people who use drugs are confined in facilities referred to as compulsory drug detention and rehabilitation centers. The limited transparency and accessibility of these centers has posed a significant challenge to evaluating detainees and detention conditions directly. Despite HIV being highly prevalent in this type of confined setting, direct evaluation of detainees with HIV and their access to medical care has yet to be reported in the literature. METHODS: We evaluated the health status of 100 adult male detainees with HIV and their access to medical care in the two largest Malaysian compulsory drug detention and rehabilitation centers holding HIV-infected individuals. RESULTS: Approximately 80% of all detainees with HIV were surveyed in each detention center. Most participants reported multiple untreated medical conditions. None reported being able to access antiretroviral therapy during detention and only 9% reported receiving any HIV-related clinical assessment or care. Nearly a quarter screened positive for symptoms indicative of active tuberculosis, yet none reported having been evaluated for tuberculosis. Although 95% of participants met criteria for opioid dependence prior to detention, none reported being able to access opioid substitution therapy during detention, with 86% reporting current cravings for opioids and 87% anticipating relapsing to drug use after release. Fourteen percent of participants reported suicidal ideation over the previous two weeks. CONCLUSION: We identified a lack of access to antiretroviral therapy in two of the six compulsory drug detention and rehabilitation centers in Malaysia designated to hold HIV-infected individuals and found significant, unmet health needs among detainees with HIV. Individuals confined under such conditions are placed at considerably high risk for morbidity and mortality. Our findings underscore the urgent need for evidence-based drug policies that respect the rights of people who use drugs and seek to improve, rather than undermine, their health.

Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users.

OBJECTIVES: We examined the use, procurement, and motivations for the use of diverted buprenorphine/naloxone among injecting and noninjecting opioid users in an urban area. METHODS: A survey was self-administered among 51 injecting opioid users and 49 noninjecting opioid users in Providence, RI. Participants were recruited from a fixed-site syringe exchange program and a community outreach site between August and November 2009. RESULTS: A majority (76%) of participants reported having obtained buprenorphine/naloxone illicitly, with 41% having done so in the previous month. More injection drug users (IDUs) than non-IDUs reported the use of diverted buprenorphine/naloxone (86% vs 65%, P = 0.01). The majority of participants who had used buprenorphine/naloxone reported doing so to treat opioid withdrawal symptoms (74%) or to stop using other opioids (66%) or because they could not afford drug treatment (64%). More IDUs than non-IDUs reported using diverted buprenorphine/naloxone for these reasons. Significantly more non-IDUs than IDUs reported ever using buprenorphine/naloxone to "get high" (69% vs 32%, P < 0.01). The majority of respondents, both IDUs and non-IDUs, were interested in receiving treatment for opioid dependence, with greater reported interest in buprenorphine/naloxone than in methadone. Common reasons given for not being currently enrolled in a buprenorphine/naloxone program included cost and unavailability of prescribing physicians. CONCLUSIONS: The use of diverted buprenorphine/naloxone was common in our sample. However, many opioid users, particularly IDUs, were using diverted buprenorphine/naloxone for reasons consistent with its therapeutic purpose, such as alleviating opioid withdrawal symptoms and reducing the use of other opioids. These findings highlight the need to explore the full impact of buprenorphine/naloxone diversion and improve the accessibility of buprenorphine/naloxone through licensed treatment providers.

Preventing opiate overdose deaths: examining objections to take-home naloxone.

Opiate overdose persists as a major public health problem, contributing to significant morbidity and mortality among opiate users globally. Opiate overdose can be reversed by the timely administration of naloxone. Programs that distribute naloxone to opiate users and their acquaintances have been successfully implemented in a number of cities around the world and have shown that non-medical personnel are able to administer naloxone to reverse opiate overdoses and save lives. Objections to distributing naloxone to non-medical personnel persist despite a lack of scientific evidence. Here we respond to some common objections to naloxone distribution and their implications.

The impact of financial discharge from methadone maintenance therapy on incarceration.

OBJECTIVES: the authors sought to analyze the relationship between financial discharge from methadone maintenance therapy (MMT) and subsequent involvement in the criminal justice system among individuals receiving state-subsidized MMT slots and individuals who were financially discharged from MMT. METHODS: the authors examined state-level client treatment records from all individuals who were on a subsidized MMT slot and all individuals who were discharged due to their inability to pay (financial discharge) from one of the three MMT programs during an 18-month period. The authors cross-referenced these records, through a state-managed database, with records of the Department of Corrections. RESULTS: individuals in the control group had longer durations of stay in MMT and fewer other kinds of treatment admissions during the study period. An 81 percent of individuals in the financially discharged group received other treatment episodes versus 0.3 percent in the control group (p < 0.001). More than twice the number of individuals financially discharged from MMT were incarcerated during the study period when compared with the control group (67 percent vs 33 percent, p < 0.001). In logistic regression analysis, individuals in the control group had 0.26 times the odds of incarceration when compared with individuals financially discharged from MMT (95% CI: O. 09-0.73). CONCLUSIONS: MMT has been shown to reduce involvement in the criminal justice system, yet cost of MMT continues to inhibit its accessibility. Our data suggest that removal of cost as a barrier to access MMT may facilitate longer treatment duration and minimize involvement with the criminal justice system.

Opportunities to diagnose, treat, and prevent HIV in the criminal justice system.

Persons involved with the criminal justice system are at risk for HIV and other transmissible diseases due to substance use and related risk behaviors. Incarceration provides a public health opportunity to test for HIV, viral hepatitis, and other sexually transmitted infections, provide treatment such as highly active antiretroviral therapy, and link infected persons to longitudinal comprehensive HIV care upon their release for such comorbidities as addiction and mental illness. Delivering health interventions inside prisons and jails can be challenging, yet the challenges pale in comparison to the benefits of interventions for inmates and their communities. This article reviews the current state of delivering HIV testing, prevention, treatment, and transition services to incarcerated populations in the United States. It concludes with summary recommendations for research and practice to improve the health of inmates and their communities.