Harm Reduction Journal

Objectives: Recent reports have suggested that Aboriginal and American Indian people are at elevated risk of HIV infection. We undertook the present study to compare socio-demographic and risk variables between Aboriginal and non-Aboriginal young (aged 13 - 24 years) injection drug users (IDUs) and characterize the burden of HIV infection among young Aboriginal IDUs.
Methods:
We compared socio-demographic and risk variables between Aboriginal and non-Aboriginal young IDUs. Data were collected through the Vancouver Injection Drug Users Study (VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and Hepatitis C (HCV).
Results:
To date over 1500 Vancouver IDU have been enrolled and followed, among whom 291 were aged 24 years and younger. Of the 291 young injectors, 80 (27%) were Aboriginal. In comparison to non-Aboriginal youth, Aboriginal youth were more likely to test seropositive for either HIV (20% vs 7%, p=>0.001) or Hepatitis C virus (HCV) (66% vs 38%, p=>0.001), be involved in sex work and live in the city's IDU epi-centre at baseline. After 48 months of follow-up, Aboriginal youth experienced significantly higher HIV seroconversion rates than non-Aboriginal youth, 27.8 per ppy (95% CI: 13.4-42.2) vs. 7.0 per ppy (95% CI: 2.3-11.8) respectively (log-rank p=0.005) and the incidence density over the entire follow-up period was 12.6 per 100 pyrs (CI: 6.49-21.96) and 3.9 per 100 pyrs (CI: 1.8-7.3) respectively.
Interpretation: These findings demonstrate that culturally relevant, evidence based prevention programs are urgently required to prevent HIV infection among Aboriginal youth.

Background:
We sought to assess injection practices, means of acquiring and disposing of syringes, and utilization and knowledge of harm reduction resources among injection drug users (IDUs) entering methadone maintenance treatment (MMT).
Methods:
Interviews with 100 consecutive patients, including 35 IDUs, entering a MMT program in the Bronx, NY.
Results:
Utilization of unsafe syringe sources was reported by 69% of IDUs in our sample. Most (80%) IDUs reused syringes, and syringe sharing was also common. Fewer than half knew that non-prescription pharmacy purchase of syringes was possible. The most common means of disposing of injecting equipment were the trash (63%) and syringe exchange programs (49%).
Conclusions:
These findings indicate that drug users entering treatment under-utilize sanctioned venues to obtain sterile syringes or safely dispose of used injection equipment. Programs providing services to drug users should adopt a proactive stance to address the safety and health issues faced by injectors.

Second Generation sub-population HIV Surveillance was undertaken in Kashgar City and Shache County, Xinjiang, Peoples Republic of China between December 2003 and January 2004, targeting injecting and mixed method drug users and pregnant and postnatal women. The study aimed to determine the extent to which the epidemic is shifting from a concentrated stage to a more generalised epidemic. One hundred and forty two (142) exclusively injecting drug users (66) and mixed method drug users (injecting and non-injecting - 76) participated in this survey. Eight hundred and two (802) pregnant and postnatal women participated in the survey. In Kashgar City and Shache County the serum prevalence of HIV amongst injecting drug users was 56.06%, for mixed method drug users 48.68% and 0.38% in pregnant women. In Shache County HIV infection rates were significantly lower in drug user groups and amongst pregnant and post-natal women, at 2.22% and 0% respectively. The behavioral survey indicated that 15% of injecting drug users have shared needles (however sero prevalence and knowledge in relation to access to clean needles and syringes suggests that this may not reflect the actual situation). Knowledge of prevention of transmission strategies (not sharing needles and condom utilisation) is similar between both groups at 60-70%. However it appears that this knowledge has not significantly impacted on behavior such as needle sharing and condom utilisation. In Kashgar City and Shache County there have been very few interventions to support HIV/AIDS prevention, care and control. The results from this survey will inform future directions and the development and implementation of targeted interventions including targeted information dissemination and harm reduction strategies.
This survey was funded by the Xinjiang HIV/AIDS Prevention and Care Project, a bilateral project jointly implemented by the Government of the People's Republic of China and the Government of Australia.

Background:
As the "war on drugs" enters the latter half of its third decade since being forged into the American lexicon by President Ronald Reagan, the public has grown more skeptical of the current strategy and has proven to be receptive to a broader consideration of alternatives to incarceration. This has been the case most notably with marijuana offenses, where the policy discussion has shifted in some localities to one of decriminalization or de-prioritizing law enforcement resources dedicated to pursuing possession offenses. Despite the increased profile surrounding marijuana policy in recent years, there remains a significant degree of misunderstanding regarding the current strategy, both in terms of how resources are being allocated and to what eventual gain.
Methods:
Previous studies have analyzed drug offenses as a general category, but there has yet to be a single study that has focused specifically on marijuana offenders at all stages of the system. This report analyzes multiple sources of data for the period 1990-2002 from each of the critical points in the criminal justice system, from arrest through court processing and into the correctional system, to create an overall portrait of this country's strategy in dealing with marijuana use.
Results:
The study found that since 1990, the primary focus of the war on drugs has shifted to low-level marijuana offenses. During the study period, 82% of the increase in drug arrests nationally (450,000) was for marijuana offenses, and virtually all of that increase was in possession offenses. Of the nearly 700,000 arrests in 2002, 88% were for possession. Only 1 in 18 of these arrests results in a felony conviction, with the rest either being dismissed or adjudicated as a misdemeanor, meaning that a substantial amount of resources, roughly $4 billion per year for marijuana alone, is being dedicated to minor offenses.
Conclusions:
The results of this study suggest that law enforcement resources are not being effectively allocated to offenses which are most costly to society. The financial and personnel investment in marijuana offenses, at all points in the criminal justice system, diverts funds away from other crime types, thereby representing a questionable policy choice.

Background:
Assessment of the abuse liability of prescription opioid products and growing efforts by the pharmaceutical industry to develop 'abuse-resistant' formulations highlight a need to understand the features that make one product more 'attractive' than another to potential abusers. We developed a scale to measure the 'attractiveness' of prescription opioids to potential abusers, and used the scale to measure the relative attractiveness of 14 opioid analgesic products.
Methods:
First, the concept of attractiveness was empirically defined with a group of prescription opioid abusers and experts in opioid abuse using a process called Concept Mapping. Abuse liability consisted of two components: factors intrinsic to the drug formulation (e.g., speed of onset, duration) and factors extrinsic to drug formulation (e.g., availability, availability of alternatives, cost). A 17-item Opioid Attractiveness Scale (OAS) was constructed, focusing on factors intrinsic to the drug product.
Results:
A total of 144 individuals participated in tests of validity and reliability. Internal consistency was excellent (Cronbach's a=0.85-0.94). Drug rankings based on OAS scores achieved good inter-rater agreement (Kendall's W 0.37, p<0.001). Agreement on drug OAS scores between the developmental sample and a confirmation sample was good (IntraClass Correlations [ICC] of 0.65-0.69). Global ratings of overall attractiveness of the 14 selected opioid products by substance abuse counselors corresponded with the rankings based on OAS ratings of the abuser group. Finally, substance abuse counselors completed the OAS, yielding a high level of correspondence with ratings by the abuser group (ICC=0.83, p=0.002). The OAS differentiated attractiveness among 14 selected pharmaceutical opioid products. OxyContin, Dilaudid, and Percocet were ranked highest (most attractive); Talwin NX and Duragesic were ranked lowest (least attractive).
Conclusions:
The OAS appears to be a valid and reliable scale capable of providing important guidance on product features that may be attractive to potential abusers.

Illicit drug abuse and HIV/AIDS have increased rapidly in the past 10 to 20 years in China. This paper reviews drug abuse in China, the HIV/AIDS epidemic and its association with injection drug use (IDU), and Chinese policies on illicit drug abuse and prevention of HIV/AIDS based on published literature and unpublished official data. As a major drug trans-shipment country with source drugs from the "Golden Triangle" and "Gold Crescent" areas in Asia, China has also become an increasingly important drug consuming market. About half of China's 1.14 million documented drug users inject, and many share needles. IDU has contributed to 42% of cumulatively reported HIV/AIDS cases thus far. Drug trafficking is illegal in China and can lead to the death penalty. The public security departments adopt "zero tolerance" approach to drug use, which conflicts with harm reduction policies of the public health departments. Past experience in China suggests that cracking down on drug smuggling and prohibiting drug use alone can not prevent or solve all illicit drug related problems in the era of globalization. In recent years, the central government has outlined a series of pragmatic policies to encourage harm reduction programs; meanwhile, some local governments have not fully mobilized to deal with drug abuse and HIV/AIDS problems seriously. Strengthening government leadership at both central and local levels, scaling up methadone substitution and needle exchange programs, making HIV voluntary counseling and testing available and affordable to both urban and rural drug users, and increasing utilization of outreach and nongovernmental organizations are offered as additional strategies to help cope with China's HIV and drug abuse problem.

Readiness to change is a crucial issue in the treatment of substance use disorders. Experiences with methadone maintenance treatment [MMT] has shown that continuous drug and alcohol use with all its consequences characterize most MMT programs. In a prospective study of drug abusers seeking opiate agonist maintenance treatment in the City of Copenhagen, subjects were administered the Addiction Severity Index, and the Readiness Ruler for each of 11 different licit and illicit drugs by research technicians. Data was collected upon admission to the program and at a 18 month follow-up. Subjects who indicated they wanted to quit or cut down upon admission, reported less drug use at 18 month follow-up, after controlling for severity of drug problems at intake. Subjects who expressed readiness to change their drug use upon admission decreased their drug use. It is concluded that the Readiness Ruler measures a construct related to actual readiness, supporting its use in the clinical context.

Aim: This study aimed to examine drug use, drug treatment history and risk behaviour among a sample of Iranian drug users seeking treatment through a general practice clinic in Iran.
Methods:
Review of medical records and an intake questionnaire at a large general practice in Marvdasht, Iran, with a special interest in drug dependence treatment. Records from a random sample of injecting drug users (IDU), non-injecting drug users (DU) and non-drug using patients were examined.
Results:
292 records were reviewed (34% IDU, 31% DU and 35% non-drug users). Eighty-three percent were males; all females were non-drug users. The mean age of the sample was 30 years. Of the IDU sample, 67% reported sharing a needle or syringe, 19% of these had done so in prison. Of those who had ever used drugs, being 'tired' of drug use was the most common reason for seeking help (34%). Mean age of first drug use was 20 years. The first drugs most commonly used were opium (72%), heroin (13%) and hashish/ other cannabinoids (13%). Three quarters reported having previously attempted to cease their drug use. IDU were more likely than DU to report having ever been imprisoned (41% vs 7%) and 41% to have used drugs in prison.
Conclusion:
This study has shown that there is a need for general practice clinics in Iran to treat drug users including those who inject and that a substantial proportion of those who inject have shared needles and syringes, placing them at risk of BBVI such as HIV and hepatitis C. The expansion of services for drug users in Iran such as needle and syringe programs and pharmacotherapies are likely to be effective in reducing the harms associated with opium use and heroin injection.

There is growing evidence of the public health and community harms associated with crack cocaine smoking, particularly the risk of blood-borne transmission through non-parenteral routes. In response, community advocates and policy makers in Vancouver, Canada are calling for an exemption from Health Canada to pilot a medically supervised safer smoking facility (SSF) for non-injection drug users (NIDU). Current reluctance on the part of health authorities is likely due to the lack of existing evidence surrounding the extent of related harm and potential uptake of such a facility among NIDUs in this setting. In November 2004, a feasibility study was conducted among 437 crack cocaine smokers. Univariate analyses were conducted to determine associations with willingness to use a SSF and logistic regression was used to adjust for potentially confounding variables (p<0.05). Variables found to be independently associated with willingness to use a SSF included recent injection drug use (OR=1.72, 95% CI: 1.09-2.70), having equipment confiscated or broken by police (OR=1.96, 95% CI: 1.24-2.85), crack bingeing (OR=2.16, 95% CI: 1.39-3.12), smoking crack in public places (OR=2.48, 95% CI: 1.65-3.27), borrowing crack pipes (OR=2.50, 95% CI: 1.86-3.40), and burns/ inhaled brillo due to rushing smoke in public places (OR=4.37, 95% CI: 2.71-8.64). The results suggest a strong potential for a SSF to reduce the health related harms and address concerns of public order and open drug use among crack cocaine smokers should a facility be implemented in this setting.

Context: There is considerable concern about the spread of HIV disease among Aboriginal peoples in British Columbia. ObjectiveTo estimate the number of Aboriginal British Columbians infected with HIV.
Design and Setting: A population-based analysis of Aboriginal men and women in British Columbia, Canada from 1980 to 2001.
Participants: Epidemic curves were fit for gay and bisexual men, injection drug users, men and women aged 15 to 49 years and persons over 50 years of age.
Main Outcome Measures -- HIV prevalence for the total Aboriginal population was modeled using the UNAIDS/WHO Estimation and Projection Package (EPP). Monte Carlo simulation was used to estimate potential number infected for select transmission group in 2001.
Results:
A total of 170,025 Aboriginals resided in British Columbia in 2001, of whom 69% were 15 years and older. Of these 1,691 (range 1,479 - 1,955) men and women aged 15 years and over were living with HIV/AIDS with overall prevalence ranging from 1.26% to 1.66%. The majority of the persons infected were men. Injection drug users (range 1,202 - 1,744) and gay and bisexual men (range 145, 232) contributed the greatest number of infections. Few persons infected were from low risk populations.
Conclusion:
More than 1 in every 100 Aboriginals aged 15 years and over was living with HIV/AIDS in 2001. Culturally appropriate approaches are needed to tailor effective HIV interventions to this community.

This article examines harm reduction from a novel perspective. Its central thesis is that harm reduction is not only a social concept, but also a biological one. More specifically, evolution does not make moral distinctions in the selection process, but utilizes a cannabis-based approach to harm reduction in order to promote survival of the fittest. Evidence will be provided from peer-reviewed scientific literature that supports the hypothesis that humans, and all animals, make and use internally produced cannabis-like products (endocannabinoids) as part of the evolutionary harm reduction program. More specifically, endocannabinoids homeostatically regulate all body systems (cardiovascular, digestive, endocrine, excretory, immune, nervous, musculo-skeletal, reproductive). Therefore, the health of each individual is dependant on this system working appropriately.

Background:
New and explosive HIV epidemics are being witnessed in certain countries of Eastern Europe, including Ukraine, as well as a rapid and dramatic increase in the supply, use, and negative public health consequences of illicit drugs. A majority of registered HIV cases in Ukraine occur among injection drug users (IDUs), large numbers of whom report HIV risk behaviors such as needle sharing. The purpose of this study was to apply the World Health Organization's Rapid Assessment and Response on Injection Drug Use (IDU-RAR) guide to create a situational picture in the Vinnitsya Oblast, Ukraine, a region with very scarce information about the HIV/AIDS and injection drug use (IDU) epidemics.
Methods:
The IDU-RAR uses a combination of qualitative data collection techniques commonly employed in social science and evaluation research to quickly depict the extent and nature of the given health problem and propose locally relevant recommendations for improvement. The investigators focused their assessment on the contextual factors, drug use, and intervention and policy components of the IDU-RAR. A combination of network and block sampling techniques was used. Data collection methods included direct observation, review of existing data, structured and unstructured interviews, and focus group discussions. Key informants and locations were visited until no new information was being generated.
Results:
The number of registered HIV cases in Vinnitsya has increased from 3 (1987&#8211;1995) to 860 (1999&#8211;10/2004), 57 of whom have already died. Ten percent of annual admissions to the area's Regional Narcological Dispensary were for opiate disorders, and the number of registered IDUs rose by 20% from 1999 to 2000. The level of HIV/AIDS awareness is generally poor among the general population but high among high-risk populations. Both HIV/AIDS and injection drug use carry a strong stigma in the community, even among medical professionals. There was very little evidence of primary HIV/AIDS prevention efforts, and IDU prevention efforts focused on promotion of anti-drug messages in the schools.
Conclusion:
Given that Ukraine has sparse resources to be devoted to this problem, action recommendations should be prioritized, realistic, and initially targeted to persons in greatest need. The following action recommendations are prioritized by the following categories: First priority: Voluntary Counseling and Testing; Second Priority: Prevention and Education; and Third Priority: Harm Reduction and Treatment. They are provided in this sequence based on what response can realistically be implemented first with limited additional resources and can make the greatest immediate impact. The persons at greatest risk, HIV positive persons and IDUs, should be attended to first.

Background:
The New South Wales State Government recently proposed a trial of the medical use of cannabis. Australians who currently use cannabis medicinally do so illegally and without assurances of quality control. Given the dearth of local information on this issue, this study explored the experiences of medical cannabis users.
Methods:
Australian adults who had used cannabis for medical purposes were recruited using media stories. A total of 147 respondents were screened by phone and anonymous questionnaires were mailed, to be returned by postage paid envelope.
Results:
Data were available for 128 participants. Long term and regular medical cannabis use was frequently reported for multiple medical conditions including chronic pain (57%), depression (56%), arthritis (35%), persistent nausea (27%) and weight loss (26%). Cannabis was perceived to provide "great relief" overall (86%), and substantial relief of specific symptoms such as pain, nausea and insomnia. It was also typically perceived as superior to other medications in terms of undesirable effects, and the extent of relief provided. However, nearly one half (41%) experienced conditions or symptoms that were not helped by its use. The most prevalent concerns related to its illegality. Participants reported strong support for their use from clinicians and family. There was almost universal interest (89%) in participating in a clinical trial of medical cannabis, and strong support (79%) for investigating alternative delivery methods.
Conclusion:
Australian medical cannabis users are risking legal ramifications, but consistent with users elsewhere, claim moderate to substantial benefits from its use in the management of their medical condition. In addition to strong public support, medical cannabis users show strong interest in clinical cannabis research, including the investigation of alternative delivery methods.

HIV infection rates have reached epidemic proportions amongst injecting drug users (IDUs) in Iran. Although a number of community-based interventions have being implemented in the country, there is little information on the risk behaviors of IDU participants in these programs. This cross-sectional report aimed to compare the risk behaviors of injecting drug users with differential exposure rates to an HIV outreach program in Tehran, Iran. Results indicated that shared use of needle/syringe in the past month was significantly lower among IDUs who received estimated &#8805; 7 syringes per week than those who did not [adjusted odds ratio (OR) = 14.36, 95% confidence interval (CI) 2.30&#8211;89.56]. While the effectiveness of this outreach program needs further evaluation through a longitudinal investigation, our preliminary findings suggest that the outreach program in Tehran may have been beneficial in reducing direct sharing among those who received more than several needles/syringes from the program.

More people are using the cannabis plant as modern basic and clinical science reaffirms and extends its medicinal uses. Concomitantly, concern and opposition to smoked medicine has occurred, in part due to the known carcinogenic consequences of smoking tobacco. Are these reactions justified? While chemically very similar, there are fundamental differences in the pharmacological properties between cannabis and tobacco smoke. Cannabis smoke contains cannabinoids whereas tobacco smoke contains nicotine. Available scientific data, that examines the carcinogenic properties of inhaling smoke and its biological consequences, suggests reasons why tobacco smoke, but not cannabis smoke, may result in lung cancer.

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This paper provides a brief overview of the harm reduction programme for injecting drug users (IDU) of CARE, Bangladesh in Dhaka city and uses data from surveillance and a focussed research study on a cohort of IDU, to evaluate the programme. The harm reduction programme in Dhaka is run by CARE, Bangladesh and includes needle/syringe exchange, awareness raising on HIV/STI, abscess management, condom distribution and advocacy with different groups of people. The needle/syringe exchange programme (NEP) has been in place since 1998, the 2nd Generation Surveillance in Bangladesh is being conducted since 1998, and an in-depth cohort study, started in 2002, is being conducted in two areas of Dhaka city with approximately 500 IDU under CARE's NEP who are being followed bi-annually to assess risk behaviour, incidence of HIV, hepatitis C and syphilis. As the surveillance and the cohort study are both closely associated with the NEP of CARE, Bangladesh, these data can be used to monitor the NEP.

Muslim countries, previously considered protected from HIV/AIDS due to religious and cultural norms, are facing a rapidly rising threat. Despite the evidence of an advancing epidemic, the usual response from the policy makers in Muslim countries, for protection against HIV infection, is a major focus on propagating abstention from illicit drug and sexual practices. Sexuality, considered a private matter, is a taboo topic for discussion. Harm reduction, a pragmatic approach for HIV prevention, is underutilized. The social stigma attached to HIV/AIDS, that exists in all societies is much more pronounced in Muslim cultures. This stigma prevents those at risk from coming forward for appropriate counseling, testing, and treatment, as it involves disclosure of risky practices. The purpose of this paper is to define the extent of the HIV/AIDS problem in Muslim countries, outline the major challenges to HIV/AIDS prevention and treatment, and discuss the concept of harm reduction, with a cultural approach, as a strategy to prevent further spread of the disease. Recommendations include integrating HIV prevention and treatment strategies within existing social, cultural and religious frameworks, working with religious leaders as key collaborators, and provision of appropriate healthcare resources and infrastructure for successful HIV prevention and treatment programs in Muslim countries.

Recent studies have indicated that injection-related infections such as abscesses and cellulitis account for the majority of emergency room visits and acute hospitalizations accrued by local injection drug users. The objective of this analysis was to examine the prevalence and correlates of developing an abscess among a cohort of injection drug users in Vancouver and to identify socio-demographic and drug use variables associated with abscesses at baseline. We examined abscesses among participants enrolled in a prospective cohort of injection drug users. Categorical variables were analyzed using the Pearson's chi-square test and continuous variables were analyzed using the Wilcoxon signed rank test. Among 1 585 baseline participants, 341 (21.5%) reported having an abscess in the last six months. In a logistic regression model that adjusted for all variables that were associated with having an abscess at p < 0.1 in univariate analyses, female gender [odds ratio (OR) = 1.7, [95%CI: 1.2 &#8211; 2.4]; p = 0.002), recent incarceration (OR = 1.7, [95%CI: 1.3 &#8211; 2.2]; p < 0.001), sex trade involvement (OR = 1.4 [95% CI: 1.0 &#8211; 2.0]; p = 0.03), frequent cocaine use (OR = 1.5 [95%CI: 1.2 &#8211; 2.0]; p = 0.002) and HIV serostatus (OR = 1.5, [95%CI: 1.2 &#8211; 2.0]; p = 0.003) were positively associated with having an abscess. Explanations for these associations require further study, and interventions are needed to address this highly prevalent concern.

Background:
In general the health of methadone clients has been found to be poorer than that of the general population. In New Zealand specialist services are not funded to provide primary healthcare services. Many of the conditions could potentially be managed by community pharmacists who have frequent contact with this client group. This study sought to explore the health problems suffered by methadone clients, who they sought help from, and the potential for greater involvement of pharmacists.
Methods:
Self-completion questionnaire of methadone maintenance clients managed in specialist care in Auckland, New Zealand.
Results:
The most common health problem experienced by these clients in the past three months was sweating (70.0%). More than half of the respondents also reported experiencing headache, fatigue and depression. The least frequently experienced conditions were hay fever (12.9%) and abscesses (12.1%). Respondents indicated the top three choices from whom they would seek help were GP (56.7%), the client's partner (31.6%) and community pharmacists (27.9%). Barriers to seeking help from pharmacists included issues around cost, perceptions of pharmacist knowledge and skills, privacy and confidentiality.
Conclusions:
Methadone clients in this study indicated that they suffered a number of general health problems, and in many cases were likely to seek help from a GP or their own partner, before seeking help from pharmacists. However, for over one quarter of respondents the pharmacist was in the top three from whom they would seek advice. Any barriers towards consulting pharmacists in the main, seem to be resolvable.