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PubMed2005

Injecting shared drugs: an observational study of the process of drug acquisition, preparation, and injection by Puerto Rican drug users.

The practice of injecting shared drugs, in which drug users prepare, divide and inject portions of a drug solution, is a means of transmitting HIV, HCV, and other blood-borne pathogens. This study examined the process of injecting shared drugs among drug users in San Juan, Puerto Rico, through detailed observations of 25 episodes of the injection of shared drugs, and by informal interviewing of episode participants. The ways in which price and packaging of drugs, access to drug preparation materials, and social and economic relations between drug-sharing "partners" influence the process of injecting shared drugs are explored. Because differential power relations, and in turn, injection drug users' exposure to HIV and HCV, are apparent in some drug-sharing partnerships, a key objective of this study was to extend our understanding of contributions or "investments" made by different drug-sharing partners, the benefits and costs that different partners experience, and the extent to which IDUs assume different partner roles. The findings of this small, in-depth qualitative study provide insight into drug users' motivations for injecting shared drugs, and suggest reasons why certain standardized, countrywide HIV/HCV intervention efforts have not been entirely successful in preventing the devastating illnesses that disproportionately affect injection drug users.

Adult↗

PubMed2002

Sexual behavior of drug-users: is it different?

BACKGROUND: Across the world, drug-users (DU) have been shown to be at greater risk of contracting and transmitting sexually transmitted diseases and HIV infection. However, in the metropolitan cities of India, where drug-use patterns may uniquely vary between injection and noninjection, depending on drug availability, little is known about the risk behavior of drug-users. OBJECTIVE: The objective of the study was to find out whether drug-users are more likely to practice high-risk sexual behavior compared to non-drug users. METHODS: The sexual behavior of 70 drug-users, selected by snowball sampling, was compared with 128 age- and economic status-matched controls (non-drug-users), randomly selected from the same community. RESULTS: Seventy-eight percent sexually active drug-users and 43% sexually active non-drug-users had multiple sex partners (P < 0.02). The average number of sex partners was significantly higher among the drug-users (P = 0.05). Anal intercourse was practiced by 25.7% drug-users and 8.6% non-drug-users (OR = 3.7; P < 0.01). The drug-users were 6.7 times more likely to visit commercial sex workers (P < 0.0001). Sexually transmitted disease prevalence was higher among the drug-users (P < 0.003). CONCLUSIONS: Notwithstanding the small sample size, this study shows that drug-users practice high-risk sexual behavior more frequently. Interventions, in the form of awareness generation and prevention education programs, are required in order to reduce risk of sexually transmitted diseases and HIV transmission among drug-users.

Adult↗

PubMed1993

Sexual issues and condom use among injecting drug users.

Recent surveys of injecting drug users reveal that their injecting behaviours have changed in the light of HIV, but their sexual behaviours have not and, in particular, they remain reluctant to use condoms to reduce the risks of sexual transmission. In an attempt to explore this issue further the present study assessed the behaviours and attitudes of injecting drug users to sexual issues, including condom use. Condom use was low. Obstacles to their use included for some a desire to conceive, for many a belief in their infertility, a perceived invulnerability to HIV infection through their sexual behaviour patterns, a dislike of condoms and difficulty in negotiating condom use with partners. The lifestyle of drug users may also have an influence on condom use. Many drug users funded their habit through illegal activities including prostitution, theft and fraud. The association between these and other factors and condom use are explored.

Adult↗

PubMed1996

Determinants of HIV seroprevalence rates among sites participating in a community-based study of drug users.

The National Institute on Drug Abuse's National Cooperative Agreement Project is a nationwide study of the injection and sexual behaviors of three populations of out-of-treatment drug users: injecting drug users (IDUs) who did not smoke crack cocaine, non-injecting crack smokers, and those engaging in both types of use. The goal of the analyses we present was identification of subsets of behavioral variables that would, within each type of drug use, distinguish sites by HIV seroprevalence level. Among non-crack-smoking IDUs high seroprevalence rates were associated with race and sex, the overall frequency of injection, the frequency of cocaine injection, and geographic location. Among noninjecting crack smokers, cities were distinguished by the frequency of exchanging sex for money, the number of sex partners, the local seroprevalence rate among IDUs, and location. Among subjects engaging in both types of use, seroprevalence rates among sites was distinguished by the frequency of exchanging sex for drugs and location.

Crack Cocaine↗

PubMed1989

Recommendations for control and prevention of human immunodeficiency virus (HIV) infection in intravenous drug users.

Considerable evidence indicates that intravenous drug users are emerging as the group at greatest risk for both acquiring and spreading human immunodeficiency virus (HIV) infection. Thus, all possible methods to control the spread of HIV infection in intravenous drug users should be explored. Key recommendations are that HIV antibody testing of intravenous drug users should be voluntary, because mandatory testing is counterproductive; free distribution of needles and syringes to intravenous drug users should occur only in carefully controlled circumstances to determine its effectiveness in decreasing infection rates; and drug-free and methadone maintenance treatment programs should be available on demand to all intravenous drug users as a means of reducing the spread of HIV infection. At present, the primary strategy for prevention must be education resulting in behavioral change. Education is currently the only definitive means for controlling the spread of HIV infection among intravenous drug users, their sex contacts, and to fetuses.

AIDS Serodiagnosis↗

PubMed1992

Seroepidemiology of viral infections among intravenous drug users in northern California.

Intravenous drug users are frequently exposed to parenterally transmitted viral infections, and these infections can spread to the general population through sexual activity. We investigated the prevalence of serologic markers for human immunodeficiency virus type 1 (HIV-1), human T-cell lymphotropic virus type I/II (HTLV-I/II), hepatitis B virus (HBV), and hepatitis C virus (HCV) in intravenous drug users and their sexual contacts. Of 585 drug users from northern California tested for these serologic markers, 72% were reactive for the antibody to HCV, 71% for the antibody to hepatitis B core antigen, 12% for HTLV-I/II antibodies, and 1% for the HIV-1 antibody. The prevalence of serologic markers for these four viruses correlated with the duration of intravenous drug use, the ethnic group, and the drug of choice. More than 85% of subjects infected with either HCV or HBV were coinfected with the other virus. All persons reactive to HTLV-I/II antibodies had antibodies for either HBV or HCV. Of 81 sexual contacts tested, 17% had evidence of HBV infection while only 6% were reactive for HTLV-I/II antibodies and 4% for the antibody to HCV. None of this group was infected with HIV-1. We conclude that HTLV-I/II and HCV are inefficiently transmitted to sexual contacts while HBV is spread more readily. Programs designed to discourage the sharing of drug paraphernalia, such as needle and syringe exchanges, should decrease the risk of parenterally spread viral infections in intravenous drug users and thus slow the spread of these infections to the general population.

Adult↗

PubMed1997

Pharmacokinetic and pharmacodynamic principles of illicit drug use and treatment of illicit drug users.

Many clinicians are confronted by the use of illicit drugs on a daily basis. The unsanctioned use of opioids, psychostimulants, benzodiazepines, alcohol and nicotine is a major cause of morbidity and mortality. Multiple factors have inhibited the scientific study of these agents including prohibition, public denial and lack of commercial interests. In dealing with problems related to these drugs, clinicians need a scientific understanding of their pharmacology, quantifiable effects and potential adverse effects. Illicit drug users select drugs with particular pharmacokinetic parameters and pharmacodynamic properties. Generally, rapid absorption, rapid entry into the central nervous system, high bioavailability, short half-life, small volume of distribution and high free drug clearance are pharmacokinetic characteristics which predict a high potential for harmful use because these factors increase positive reinforcement. Drug users adapt the method and route of drug administration to optimise the delivery of the drug to the brain while attempting to maximise the bioavailability of the drug. Inhalation and smoking are the routes of administration which allow the most rapid delivery of drug to the brain, while intravenous injection maximises the bioavailability of an administered drug. Each route of administration results in attendant complications related to mucosal damage, carcinogenesis and risk of infection. Negative reinforcement or withdrawal is a major drive to recurrent use. Many illicit drugs have pharmacological features that promote dependence, including long half-life, low free drug clearance and sufficient drug exposure to allow development of tolerance. The preventive or reductive pharmacotherapeutics of illicit drug use makes use of several subsets of agents: those which act on the same receptor or system as the illicit drug (such as methadone), those which produce an adverse reaction on consumption of the illicit drug (such as disulfiram) and those which symptomatically attenuate illicit drug withdrawal symptoms (such as clonidine). Many new agents are being trialled as potential preventive or reductive agents. It is important to consider pharmacotherapy as only one potential part of the treatment of illicit drug users. The complications of illicit drug use present many therapeutic challenges. As with all patients consuming multiple drugs, illicit drug users are prone to developing drug interactions. The most common interactions seen in practice are pharmacodynamic in nature, most often due to the additive effects of different drugs on the central nervous system. However, alcohol, cocaine, disulfiram, methadone and tricyclic antidepressants may be involved in important pharmacokinetic interactions. Of these the effect of long term alcohol consumption in increasing the hepatotoxicity of paracetamol and of cytochrome P450 3A microsomal enzyme stimulating drugs in diminishing the efficacy of methadone are the most commonly encountered.

Drug Interactions↗

PubMed1999

Predictors of increased condom use following HIV intervention with heterosexually active drug users.

Research with injection drug users (IDUs), at risk for acquiring and transmitting HIV, has focused primarily on their risky drug practices, with far less attention paid to their risky sex behaviors. The purpose of this study was to determine what variables were associated with an increase in condom use following an HIV intervention with 3357 IDUs in nine cities. Participants reported using condoms during 15% of their sexual encounters prior to the HIV intervention, and during 22% of their sexual encounters six months later. A logistic regression analysis indicated that individuals who increased their condom use were likely to be HIV seropositive (odds ratio OR = 2.49), to have received AIDS information prior to the intervention (OR = 1.28), to have multiple sex partners (OR = 2.14), to be single with multiple sex partners (OR = 1.34), or to have exchanged drugs or money for sex (OR = 1.33). Discussion focuses on the generally low incidence of condom use and the need for increased intervention, particularly among drug users in monogamous relationships and sex workers.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Hepatitis C infection among drug users in northern Thailand.

Illicit drug users are commonly infected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV). We evaluated the prevalence, incidence, and risk behaviors associated with HCV infection in 1,859 drug users in northern Thailand. The HCV prevalence was 27.3%: 86.0% among drug injectors (IDUs) and 5.3% among those who did not inject. Sexual behavior was not significantly associated with HCV among IDUs or drug users who used but didn't inject illicit drugs; only injection behaviors were independently associated with HCV in multivariate analysis. Among men, a history and increasing frequency of injecting drugs, older age, and a history of incarceration were associated with HCV infection. Among 514 opiate users who were HCV and HIV seronegative at baseline, 41 incident HCV infections and 6 HIV infections occurred on follow-up; the HCV incidence was 5.43/100 person-years; it was 44.3/100 person-years in IDUs and 1.9/100 person-years in non-injectors. HCV and HIV among drug users in Thailand are common and primarily associated with injection behavior.

Adolescent↗

PubMed1992

Mortality of intravenous drug users: attenders of the Wellington Drug Clinic, 1972-89.

A mortality study of 997 patients registered for treatment at the Wellington Drug Clinic since 1971 was undertaken by examining the New Zealand death records. Sixty-seven known deaths were reported. The mortality rates were increased 11.5 times under the age of 25 years, and 5.8 times for age 25-34 years, but not significantly thereafter. There were 7 deaths from trauma, 8 from suicide, and 28 accidental deaths. Myocarditis was the cause of death in four cases. In the 28 drug-related deaths the principle drugs incriminated were dextropropoxyphene, barbiturates, chloral hydrate, methadone and other opiates. Twenty-one deaths were due to unrelated diseases. It was considered important to document mortality in intravenous drug users in the 'pre-HIV' era. This study demonstrates quite low death rates from opioid drugs themselves.

Journal Article↗

PubMed1996

Predictors of mortality in the Amsterdam cohort of human immunodeficiency virus (HIV)-positive and HIV-negative drug users.

The impact of human immunodeficiency virus (HIV) infection and other risk factors on mortality was studied in a cohort of Dutch injection drug users and drug users who did not inject. Participants were recruited between 1985 and 1992 and followed up through 1993. Vital status was ascertained through repeat visit information, supplemented by population register data. A total of 77 deaths were recorded among 632 drug users, for a mortality rate per 1,000 person-years of 7 for HIV-negative noninjection drug users, 18 for HIV-negative injection drug users, and 64 for HIV-positive injection drug users. In multivariate analyses, limited to injection drug users, a positive HIV serostatus, age above 40 years, and using benzodiazepines several times daily were significantly associated with an elevated risk of death, both for death from all causes and for death preceding acquired immunodeficiency syndrome (AIDS) diagnosis (pre-AIDS). For pre-AIDS death, the adjusted relative risk associated with HIV infection was 2.2 (95% confidence interval 1.3-3.7). Only 38% of HIV-infected injection drug users who died were diagnosed with AIDS. However, 76% of HIV-infected injection drug users who died without AIDS diagnosis had evidence of immunosuppression (CD4 count < 500/microliters). Daily use of methadone and participation in needle and syringe exchange schemes were not associated with lower mortality rates. This study illustrates in a group of injection drug users with a 30% HIV seroprevalence and a high background mortality the profound influence on mortality that HIV infection has gained.

Adolescent↗

PubMed2002

[Qualitative study of drug-using and sexual behaviors of drug users in Guangxi].

OBJECTIVE: To understand where and how drug-using and sexual behaviors occurred among drug users. METHODS: Twenty-five drug users were recruited from detoxification centers and communities. In-depth interview was used to collect information about drug-using and sexual behaviors. Each subject was interviewed separately and privately for about 2 - 3 hours. RESULTS: Most drug users shifted from oral taking drugs to injecting drugs in order to reduce economic burden and look for "high feeling". Reasons for not injecting among few drug users included 'perceiving information on harm of injection', 'over-dose death' or 'infection with HIV'. Most drug users knew that HIV transmit through sharing needles or having sexual intercourse without using a condom. However, needles were shared at night when drug or needles were scarce. Promiscuous sexual relationship was common among drug users. Most female drug users had engaged in prostitution but few used condoms. CONCLUSION: High-risk drug injecting behaviors and high-risk sexual behaviors were prevalent among drug users despite knowledge on HIV transmission and prevention. Thus, education alone would not work unless specific intervention programs are taken.

Adolescent↗

PubMed1999

Access to antiretroviral treatment among French HIV infected injection drug users: the influence of continued drug use. MANIF 2000 Study Group.

STUDY OBJECTIVE: To determine the influence of continued drug use and its perception by prescribing physicians on access to antiretroviral treatment among French HIV infected injection drug users (IDUs). DESIGN: Cross sectional including enrollment data (October 1995-1996) of the cohort study MANIF 2000. Access to treatment is compared in three groups: former IDUs (n = 68) and active IDUs whether or not this behaviour remains undetected (n = 38) or detected (n = 17) by physicians. SETTING: Hospital departments for specialist AIDS care in south eastern France and inner suburbs of Paris. PATIENTS: All enrolled patients with CD4+ cell counts < 400 with detailed clinical history, access to treatment, risk behaviours, and past drug use as reported by both physicians and patients (n = 123). MAIN RESULTS: A minority (43.9%) already received an antiretroviral treatment. Active IDUs had worst socioeconomic and psychological conditions but only those detected by physicians were considered as poorly compliant. Logistic regression showed that, with respect to ex-IDUs and independently of clinical stage, active IDUs, whether or not they were perceived as such by physicians, were threefold more likely not to receive antiretroviral treatment. CONCLUSIONS: Even among French HIV infected IDUs who have regular access to AIDS specialised hospital care, continued drug use reduced the likelihood of being prescribed antiretroviral treatment. To reduce delays in access to new treatments, specific efforts must be devoted towards both AIDS specialists and IDU patients to overcome current stereotypes of non-compliance associated with continued injection.

Adolescent↗

PubMed2006

Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior?

BACKGROUND: Relapse rates among treated drug users in China are high. We examined the associations between frequency of drug detoxification treatment and HIV-related risky drug practices and sexual behavior. METHODS: A cross-sectional study was conducted among drug users in two Anhui province detoxification centers in 2003. RESULTS: A total of 312 drug users were recruited. Seventy-seven percent of the subjects had ever received two or more detoxification treatments. The median number of detoxification treatments received was three, with an interquartile range of two to five treatments. More than 7 in 10 (72%) ever injected drugs; 19% shared needles and syringes in the past 30 days; 40% of drug users reported having both regular and commercial sex partners in the past year and 48% reported having only regular sex partners. Multiple Poisson regression analysis documented that the frequency of detoxification treatment was not associated with a decrease in drug practice (injection or sharing needles) and in unprotected sex. CONCLUSION: Drug users who frequently received detoxification treatment did not change their risky drug use practices and sexual behavior. Effective behavioral interventions and substitution maintenance treatment should become an integral part of detoxification programs in China.

Adolescent↗

PubMed1994

Explanations for sharing injection equipment in injecting drug users and barriers to safer drug use.

We examined the explanations given by a sample of 1245 injecting drug users in Sydney, Australia for accepting used injection equipment. Factor analysis of these reasons revealed three dimensions of sharing: not caring when withdrawing or intoxicated, unavailability of equipment, and not seeing it as high risk or ease of injecting. The most common reasons given were difficulty in obtaining sterile equipment (73% of cases), the dangers not seeming so important when in withdrawal (40%) and sharing being something done with friends or lovers (31%). Most common reasons for not sharing were related to health issues (91% citing AIDS and 67% hepatitis). These data suggest that interventions target provision of sterile equipment, and education which highlights risk situations such as intoxication and withdrawal.

Adult↗

PubMed1993

Risk factors for HIV infection among injection drug users: results of blinded surveys in drug treatment centers, King County, Washington 1988-1991.

Among injection drug users (IDUs) entering drug treatment in King County, Washington between 1988 and 1991, we investigated HIV seroprevalence in relationship to demographic, sexual, and drug-use characteristics. Eighty-two of 3,039 (2.7%) IDUs tested HIV positive. Gay or bisexual men had the highest HIV prevalence (37.1%), followed by lesbian or bisexual women (8.3%), heterosexual men (2.3%), and heterosexual women (1.5%). American Indians were more likely to be infected with HIV than were whites. Those with no permanent address were more likely to be infected than those with an address. Unexpectedly, the prevalence of HIV infection among amphetamine injectors (13.1% of 168) was higher than among those who did not report using amphetamines. After adjustment for sexual orientation, HIV prevalence was four times higher among primary amphetamine injectors and three times higher among secondary amphetamine injectors than among injectors of other drugs. The basis for the strong association observed between HIV infection and a history of injection of amphetamines is not known and should be clarified through further research that obtains more detailed information on IDUs.

Amphetamines↗

PubMed1994

Management of hospitalized intravenous drug users: role of the internist.

Intravenous drug users present significant clinical challenges to internists. In this paper, we review common clinical dilemmas faced by internists when managing intravenous drug users in the inpatient hospital setting. Articles were identified through a MEDLINE search and bibliographies of published articles. Studies and reviews were selected for information relevant to the management of hospitalized intravenous drug users. Seventy-three papers were selected for this review. We summarize data and information from the relevant literature concerning common presenting medical problems (fever, musculoskeletal pain, and dyspnea), the importance of knowing patients' HIV status, common behavioral issues, special concerns of women, and the diagnosis and management of drug withdrawal in intravenous drug users. We also offer recommendations for hospital discharge planning. With appropriate knowledge of the epidemiology and management of important medical and substance use problems among intravenous drug users, internists may more effectively care for them in the hospital setting.

Dyspnea↗

PubMed1972

Amphetamine and other non-opioid drug users attending a special drug dependence clinic.

This paper reports the findings in 104 users of nonopioid drugs (mainly amphetamines) attending a drug dependence clinic in London between March 1968 and February 1969 in relation to demographic characteristics, forensic, psychiatric, and medical histories, clinical groups, management policy, and the use of biochemical tests for the presence of drugs in the urine.Nearly one-third gave a history of starting amphetamine misuse while at school (13.5%) or within a year of leaving school (16.3%). Amphetamine psychosis had occurred in 35% of cases and was a more frequent complication of intravenous than of oral abuse. Except for a small proportion of older patients who have become dependent on drugs originally prescribed for therapeutic purposes, "maintenance therapy" is most unlikely to be effective in the treatment of amphetamine dependence. Nevertheless, about one-quarter of the younger patients in this series had obtained prescriptions from general practitioners after starting their drug abuse illicitly. There is a strong case for the compulsory notification under the Misuse of Drugs Act (1971) of persons dependent on amphetamines.

Adolescent↗