Estimated Drug Overdose Deaths Averted by North America's First Medically-Supervised Safer Injection Facility

Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6–78.1); 12.6 (95% CI: 9.6–15.7); 8.4 (95% CI: 6.5–10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

Background People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity. Findings We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40–2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28–2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94–1·65) and a 21% increase in HCV (1·21, 1·02–1·43) acquisition risk. Interpretation Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID

Impact of unstable housing on all-cause mortality among persons who inject drugs

BACKGROUND: Illicit drug injecting is a well-established risk factor for morbidity and mortality. However, a limited number of prospective studies have examined the independent effect of unstable housing on mortality among persons who inject drugs (PWIDs). In this study we sought to identify if a relationship exists between unstable housing and all-cause mortality among PWIDs living in Vancouver, Canada. METHODS: PWIDs participating in two prospective cohort studies in Vancouver, Canada were followed between May 1996 and December 2012. Cohort data were linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariate Cox proportional hazards regression to determine factors associated with all-cause mortality and to investigate the independent relationship between unstable housing and time to all-cause mortality. RESULTS: During the study period, 2453 individuals were followed for a median of 69 months (Inter-quartile range [IQR]: 34 – 113). In total, there were 515 (21.0%) deaths for an incidence density of 3.1 (95% Confidence Interval [CI]: 2.8 – 3.4) deaths per 100 person years. In multivariate analyses, after adjusting for potential confounders including HIV infection and drug use patterns, unstable housing remained independently associated with all-cause mortality (adjusted hazard ratio [AHR] = 1.30, 95% CI: 1.08 – 1.56). CONCLUSIONS: These findings demonstrate that unstable housing is an important risk factor for mortality independent of known risk factors including HIV infection and patterns of drug use. This study highlights the urgent need to provide supportive housing interventions to address elevated levels of preventable mortality among this population

Factors associated with optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA non-detectability among HIV-positive crack cocaine users: a prospective cohort study

BACKGROUND: Crack cocaine use is known to contribute to poor adherence to antiretroviral medications; however, little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. We sought to identify correlates of optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA viral load (pVL) suppression among this population. METHODS: Data from a prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, were linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. We used multivariable generalized linear mixed-effects modelling to longitudinally identify factors associated with ≥95 % adherence to pharmacy refills for antiretroviral medications and pVL <50 copies/mL among crack cocaine users exposed to highly-active antiretroviral therapy (HAART). RESULTS: Among 438 HAART-exposed crack cocaine users between 2005 and 2013, 240 (54.8 %) had ≥95 % pharmacy refill adherence in the previous 6 months at baseline. In multivariable analyses, homelessness (adjusted odds ratio [AOR]: 0.58), ≥daily crack cocaine smoking (AOR: 0.64), and ≥ daily heroin use (AOR: 0.43) were independently associated with optimal pharmacy refill adherence (all p < 0.05). The results for pVL non-detectability were consistent with those of medication adherence, except that longer history of HAART (AOR: 1.06), receiving a single tablet-per-day regimen (AOR: 3.02) and participation in opioid substitution therapies was independently associated with pVL non-detectability (AOR: 1.55) (all p < 0.05). CONCLUSIONS: Homelessness, and daily crack cocaine and/or heroin use were independently and negatively associated with optimal HAART-related outcomes. With the exception of opioid substitution therapies, no addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression. Evidence-based treatment options for crack cocaine use that also confer benefits to HAART need to be developed

Perceived Devaluation and STI Testing Uptake among a Cohort of Street-involved Youth in a Canadian Setting

Perceived devaluation has been shown to have adverse effects on the mental and physical health outcomes of people who use drugs. However, the impact of perceived devaluation on sexually transmitted infections (STI) testing uptake among street-involved youth, who face multiple and intersecting stigmas due to their association with drug use and risky sexual practices, has not been fully characterized. Data were obtained between&nbsp;December 2013&nbsp;and November 2014 from a cohort of street-involved youth who use illicit drugs aged 14–26 in Vancouver, British Columbia. Multivariable generalized estimating equations were constructed to assess the independent relationship between perceived devaluation and STI testing uptake. Among 300 street-involved youth, 87.0% reported a high perceived devaluation score at baseline. In the multivariable analysis, high perceived devaluation was negatively associated with STI testing uptake after adjustment for potential confounders (Adjusted Odds Ratio = 0.38, 95% Confidence Interval 0.15–0.98). Perceived devaluation was high among street-involved youth in our sample and appears to have adverse effects on STI testing uptake. HIV prevention and care programs should be examined and improved to better meet the special needs of street-involved youth in non-stigmatizing ways

“Working the System”—British American Tobacco's Influence on the European Union Treaty and Its Implications for Policy: An Analysis of Internal Tobacco Industry Documents

Katherine Smith and colleagues investigate the ways in which British American Tobacco influenced the European Union Treaty so that new EU policies advance the interests of major corporations, including those that produce products damaging to health

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

Background: People who inject drugs (PWID) experience high rates of incarceration and may be at high risk of HIV and hepatitis C (HCV) virus infection during or after incarceration. We conducted a systematic review and meta-analysis to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.Methods: MEDLINE, Embase and PsycINFO databases were searched for studies in any language published since 2000 assessing HIV or HCV incidence among PWID. Studies were included if they reported the association between recent (in last 3, 6 or 12 months or since last follow-up) or past incarceration and HIV or HCV (primary or reinfection) incidence. Authors of incidence studies not reporting these outcomes were contacted for data. Data were extracted and pooled using random-effects meta-analyses. Findings: Twenty published and 21 unpublished studies were included, originating from Australasia, Western and Eastern Europe, North and Latin America and East and Southeast Asia. Recent incarceration was associated with an 81% (rate ratio (RR):1.81, 95%CI: 1.40-2.34) and 62% (RR:1.62, 95%CI:1.28-2.05) increase in HIV and HCV acquisition risk, respectively. Past incarceration was associated with a 25% and 21% increase in HIV (RR:1.25, 95%CI:0.94-1.66) and HCV (RR:1.21, 95%CI:1.02-1.43) and acquisition risk, respectively.Interpretation: Incarceration is associated with substantial short-term HIV and HCV acquisition risk among PWID and could be a significant driver for HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV acquisition – including addressing structural risks associated with drug laws and excessive incarceration of PWID

Patterns of Non-injection Drug Use Associated with Injection Cessation among Street-Involved Youth in Vancouver, Canada

Although abstinence from drug use is often a key goal of youth substance use treatment, transitioning to less harmful routes and types of drug use is desirable from both a clinical and public health perspective. Despite this, little is known about the trajectories of youth who inject drugs including changes in patterns of non-injection drug use. The At-Risk Youth Study (ARYS) is a longitudinal cohort of street-involved youth who use drugs in Vancouver, Canada. We used linear growth curve modeling to compare changes in non-injection drug use among participants who ceased injecting drugs for at least one 6-month period between September 2005 and May 2015 to matched controls who continued injecting over the same period. Of 387 eligible participants, 173 (44.7%) reported ceasing drug injection at least once. Non-injection drug use occurred during 160 (79.6%) periods of injection cessation. In adjusted linear growth curve analyses, the only non-injection drug use pattern observed to decrease significantly more than controls following injection cessation was daily crack/cocaine use (p&thinsp;=&thinsp;0.024). With the exception of frequent crack/cocaine use, transitions out of injection drug use did not appear to coincide with increased reductions in patterns of non-injection drug use. Our findings indicate that most (80%) of the observed injection cessation events occurred in the context of ongoing substance use. Given that transitioning out of drug injection represents a significant reduction in risk and harm, efforts supporting vulnerable youth to move away from injecting may benefit from approaches that allow for ongoing non-injection drug use. &nbsp