Effectiveness of pharmacotherapies in increasing treatment retention and reducing opioid overdose death in individuals recently released from prison: A systematic review

Background: Opioid dependence is common amongst the prison population, with increased risk of fatal overdose in the immediate post-release period. Aim: The study aimed to review the effectiveness of pharmacotherapies (Methadone (METH), Buprenorphine (BUP), levo-alpha acetyl methadol (LAAM), Naltrexone (NLT) and Naloxone (NLX)) in reducing overdose deaths and increasing treatment retention in opioid dependent prisoners on release. Methods: A systematic review of studies on recently discharged opioid dependent prisoners receiving METH, BUP, LAAM, NLT and/or NLX was conducted. Factors of interest regarded post-release treatment retention, non-fatal overdoses (NFODs), overdose mortality, and continued heroin and/or other illicit drug use. Searches were conducted using MESH terms; opioid related disorder, prisoner, NLT, NLX, METH, BUP, LAAM, overdose. Exclusion criteria were applied as per PRISMA guidelines. Quality, outcome and risk of bias assessments were applied across studies. Results: Eight randomised control trials (RCT), one non-randomised trial and five observational studies formed the data set. Agonist Opioid Treatment (AOT) (METH, BUP, LAAM) initiated pre-release was associated with significant post-release treatment retention on discharge into the community, and post-release reduction in heroin use. Prisoners on BUP or METH on discharge had significantly reduced mortality risks in the immediate four weeks post-release. There was insufficient evidence supporting a reduction in NFODs and continued other illicit drug use. Conclusions: The review underscores the need for prisoners on AOT to be supported with continued treatment on release into the community. Further research is warranted to investigate potential utility of long-acting NLT formulations and take-home NLX (THN) in pre-release opioid dependant prisoners. © 2017, Pacini Editore S.p.A. All rights reserved

Exploring Irish Travellers’ experiences of Opioid Substitute Treatment: A Phenomenological Study

The Irish Travelling community are identified “as a people with shared history, culture and traditions including, historically, a nomadic way of life”. The core of Travelling culture is strong family bonds which support resilience, however changing social circumstances and dislocation have contributed to significant mental and physical health issues accompanied by a steep rise in substance abuse and addiction. Aim: To explore and describe Irish Travellers’ experiences of drug use and opioid agonist treatment (OAT), with a view to improving service delivery and expanding the limited research base. Methods: A phenomenological approach using semi-structured interviews was conducted with seven opioid dependent Irish Travellers (two females/five males) currently on OAT at an outpatient clinic in Dublin, Ireland. Results: All participants described the complexities arising from drug use, with significant life events often accompanied by depression and drug use (street, prescribed and over the counter) as a means of self-medication. Barriers to accessing treatment included shame and stigma, fears around being shunned by the community, and a negative attitude towards OAT. All participants and particularly women reported that stigma related physical violence came from community elders if suspected of drug use or association with drug users. Despite initial strong reservations about OAT, experiences were largely positive with acceptance by and support from staff viewed as instrumental. Conclusions: The development of culturally appropriate, gender sensitive and integrated OAT and mental health support services, designed with input from addiction and mental health specialists, alongside community members is warranted

Prevalence and risk factors for hepatitis C viral infection amongst a cohort of irish drug users attending a drug treatment centre for agonist opioid treatment (AOT)

Background: Injecting drug use (IDU) is a major driver of the European hepatitis C virus (HCV) epidemic. National data on prevalence of HCV amongst Irish drug users remains confined to certain treatment sites and prison settings. Aim: To examine the prevalence of HCV infection and risk factors associated with infection among the 228 patients attending agonist opioid treatment (AOT) in a clinic in Dublin. Methods: A retrospective cross-sectional study was conducted using data collected from Health Research Board (HRB) forms and standardised written and electronic assessment forms routinely completed on treatment initiation. Results: The prevalence of HCV infection was 63.6% (n= 145) with no significant gender difference (p=0.717). Patients who were infected with HCV were older than those uninfected (41.1 ± 7.5 years versus 37.5 ± 8.5 years; p = 0.001), with prevalence significantly lower in younger adults (p=0.002). Multivariate analysis identified age of first drug use (p=0.002) and first injection (p=0.001), type of first drug used; cannabis (p=0.015), heroin (p=0.014) and cocaine (p=0.018) and early age of AOT entry (p=0.001) as the most significant risk factors for HCV infection in this cohort. Those with no IDU had decreased odds of being HCV positive by 91.1%. Conclusion: Data for this Irish sample indicates high prevalence of HCV infection, and the need to consider age of first drug onset and injecting use, particular drug types and earlier commencement of AOT to inform targeted HCV treatment and prevention interventions in Ireland. © Icro Maremmani

Irish General Practitioner (GP) Perspectives Toward Decriminalisation, Legalisation and Cannabis for Therapeutic Purposes (CTP)

Cannabis is the most prevalent illicit drug used globally. Regulatory debate in Ireland on the decriminalisation of cannabis and legalisation for therapeutic purposes (CTP) is on-going. The study aimed to investigate Irish general practitioner (GP) attitudes toward decriminalisation of cannabis and assess levels of support for CTP. An online survey was administered to all GPs in the Irish College of General Practitioner (ICGP) database. A content analysis was conducted on open-ended survey questions, with five themes emerging. GPs were concerned around early onset of use and intergenerational impacts, vulnerabilities to drug induced psychosis, patient self-medication with cannabis and potential for misuse of prescribed cannabis. The study reflects concerns around the mental health consequences of cannabis use and potential for misuse in the event of legalisation, and the need for product regulation and an enhanced evidence base to support treatment decision making. Further research and medical education is warranted. © 2016, Springer Science+Business Media New York

Chasing the rainbow: pleasure, sex-based sociality and consumerism in navigating and exiting the Irish Chemsex scene

Club drug use among gay, bisexual and other men who have sex with men is increasingly normalised within sexual contexts and is associated with increased sexual risk behaviours. The term Chemsex is used to describe sexualised drug use lasting several hours or days with multiple sexual partners. A small pilot study, underpinned by interpretative phenomenological analysis (IPA), was conducted in Dublin, Ireland. Interviews were conducted with 10 men who were experiencing physical and emotional health problems as a consequence of their participation in sexualised drug use and wished to exit the Chemsex scene. Interviews explored experiences of sexualised drug use, motives to partake, the organisation of Chemsex parties and group connectivity, drugs used, harm reduction, pleasure and consequences of participation over time. Four basic themes emerged from the analysis: social and cyber arrangements within the Dublin Chemsex scene; poly drug use and experiences of drug dependence; drug and sexual harm reduction within the Chemsex circle of novices and experts; and sexualised drug use, escapism and compulsive participation. Two higher-order themes were also apparent: first, the reinforcing aspects of drug and sexual pleasure; and second, the interplay between excess drug consumption and sex, and drug dependence. © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group

Characteristics of methadone related overdose deaths and comparisons between those dying on and off methadone substitution treatment: a national cohort study.

Background: Opioid users, particularly those with a history of injecting and dependence, have a high risk of fatal polysubstance and methadone related overdose. Aim: To describe characteristics of methadone related overdose deaths and assess if differences exist between those dying on and off opioid agonist treatment (OAT). Methods: A descriptive study of all persons dying of drug overdose involving methadone on the Irish National Drug Related Deaths Index (NDRDI) in 2012 and 2013. Results: A total of 182 methadone implicated deaths were recorded . 78% (n=142) were male; with a mean age of 36 years. Of the cohort, 61% (n=111) were not in receipt of opiate agonist treatment (OAT) at the time of death, 15.9% (n=29) had a previous history of non-fatal overdose and 24.7% (n=45) a history of alcohol dependence. Analysis and interpretations are limited by incomplete data on other characteristics but where available show that 89% (n=73) were injecting drug users, with 57.8% (n=26) injecting drugs at the time of death. History of mental illness was recorded in 96.3% (n=77) of cases, with 94.7% (n=107) having history of substance dependency treatment. Polysubstances were implicated in 86.8% (n=158) of deaths. The majority died in a private dwelling (74.7% n= 127) and were not alone 67.4% (n=114). Conclusions: Methadone related fatal overdose is a significant cause of death in young Irish, who share many characteristics with other drug related deaths. Improved monitoring, risk assessment and OAT retention strategies is warranted to inform national drug overdose plans and overdose prevention

Exploring patient characteristics and barriers to Hepatitis C treatment in patients on opioid substitution treatment (OST) attending a community based fibro-scanning clinic.

Background and Objectives: Hepatitis C virus (HCV) infection is a major public health issue. There is substandard uptake in HCV assessment and treatment among people who inject drugs (PWID). Community fibroscanning is used to assess disease severity and target treatment. Methods: A survey was administered to a cohort of chronically HCV infected patients attending a community fibroscanning clinic. Questions targeted diagnosis of HCV, suitability, willingness and barriers to engagement in treatment. Descriptive and regression analysis, with thematic analysis of open-ended data was conducted. Results: There was high acceptance of community fibroscanning among this cohort with over 90% (68) attending. High levels of unemployment (90%) and homelessness (40%) were identified. Most patients were on methadone treatment and had been HCV infected for greater than 10 years with length of time since HCV diagnosis being significantly longer in patients with fibroscan scores > 8.5 kPa (P = 0.016). With each unit increase in methadone dose, the odds of the >8.5 fibroscan group increased by 5.2%. Patient identified barriers to engagement were alcohol and drug use, fear of HCV treatment and liver biopsy, imprisonment, distance to hospital and early morning appointments. Conclusion: The study highlights the usefulness of community fibroscanning. Identifying barriers to treatment in this cohort affords an opportunity to increase the treatment uptake. The availability of afternoon clinics and enhanced prison linkage are warranted

Competing priorities and second chances - A qualitative exploration of prisoners’ journeys through the Hepatitis C continuum of care.

High levels of undiagnosed and untreated HCV infection exist in prison populations globally. Prisons are a key location to identify, treat and prevent HCV infection among people who inject drugs (PWID). Understanding prisoners’ lived experiences of the HCV continuum of care informs how HCV care can be effectively delivered to this marginalised and high-risk population. This study aimed to explore Irish prisoners’ experience of prison and community-based HCV care. We conducted one-to-one interviews with 25 male prisoners with chronic HCV infection. Data collection and analysis was informed by grounded theory. The mean age of participants and first incarceration was 39.5 and 18.3 years respectively. The mean number of incarcerations was eight. The following themes were identified: medical and social factors influencing engagement (fear of treatment and lack of knowledge, HCV relevance and competing priorities), adverse impact of HCV on health and wellness, positive experience of prison life and health care and the transformative clinical and non-clinical changes associated with HCV treatment and cure. Findings suggest that prison release was associated with multiple stressors including homelessness and drug dependence which quickly eroded the health benefits gained during incarceration. The study generated a substantive theory of the need to increase the importance of HCV care among the routine competing priorities associated with the lives of PWID. HCV infected prisoners often lead complex lives and understanding their journeys through the HCV continuum can inform the development of meaningful HCV care pathways. Many challenges exist to optimising HCV treatment uptake in this group and incarceration is an opportunity to successfully engage HCV infected prisoners who underutilise and are underserved by community-based medical services. Support and linkage to care on release is essential to optimising HCV management