Frequency, factors and costs associated with injection site infections: findings from a national multi-site survey of injecting drug users in England.

BACKGROUND: Injection site infections among injecting drug users (IDUs) have been associated with serious morbidity and health service costs in North America. This study explores the frequency, factors and costs associated with injection site infections among IDUs in England. METHODS: Unlinked-anonymous survey during 2003/05 recruiting IDUs from community settings at seven locations across England. Self-reported injecting practice, symptoms of injection site infections (abscess or open wound) and health service utilisation data were collected using a questionnaire, participants also provided dried blood spot samples (tested for markers blood borne virus infections). Cost estimates were obtained by combining questionnaire data with information from national databases and the scientific literature. RESULTS: 36% of the 1,058 participants reported an injection site infection in the last year. Those reporting an injection site infection were more likely to be female and aged over 24, and to have: injected into legs, groin, and hands in last year; injected on 14 or more days during the last four weeks; cleaned needles/syringes for reuse; injected crack-cocaine; antibodies to hepatitis C; and previously received prescribed substitute drug. Two-thirds of those with an injection site infection reported seeking medical advice; half attended an emergency department and three-quarters of these reported hospital admission. Simple conservative estimates of associated healthcare costs range from pound 15.5 million per year to as high as pound 30 million; though if less conservative unit costs assumptions are made the total may be much higher (pound 47 million). The vast majority of these costs are due to hospital admissions and the uncertainty is due to little data on length of hospital stays. CONCLUSION: Symptoms of injection site infections are common among IDUs in England. The potential costs to the health service are substantial, but these costs need more accurate determination. Better-targeted interventions to support safer injection need to be developed and evaluated. The validity of self-reported symptoms, and the relationship between symptoms, infection severity, and health seeking behaviour require further research

Harm reduction among injecting drug users - evidence of effectiveness

This chapter synthesises and evaluates the available direct evidence relating to the impact of needle and syringe programmes (NSPs), opioid substitution treatment (OST), drug consumption rooms (DCRs), and peer naloxone distribution (PND) on HIV/hepatitis C (HCV) incidence/prevalence, injecting risk behaviour and overdose-related mortality. To achieve this, we conducted a review of reviews; a systematic and explicit method used to identify, select and critically appraise relevant findings from secondary level research (systematic reviews and/or meta-analyses) into an evidence briefing. In the absence of high-quality reviews, appraisal of the evidence was supplemented with a targeted review of the primary literature. We find that there is sufficient review-level evidence that OST reduces HIV transmission, while the evidence in support of NSPs reducing HIV transmission is more tentative, and for DCRs currently insufficient. There is tentative evidence that OST has limited effectiveness in reducing HCV transmission, and insufficient evidence to support or discount NSPs or DCRs' ability to reduce HCV transmission. There is sufficient review-level evidence that NSPs, OST and DCRs reduce self-reported injecting risk behaviour. There is sufficient review evidence that OST reduces risk of overdose mortality, but insufficient evidence to support or discount the effect of DCRs or PND on overdose deaths at the community level. Our review shows evidence in support of a variety of harm reduction interventions but highlights an uneven presence of high-quality review evidence. Future evaluation of harm reduction programmes should prioritise methodologically robust study designs

In Search of the Modern Skidmore Standard

This Article offers a comprehensive examination of the Skidmore standard for judicial review of agency legal interpretations as applied by the courts in the period since the Supreme Court revitalized Skidmore in United States v. Mead Corp. First, the Article documents an empirical study of five years worth of Skidmore applications in the federal courts of appeals. In the study, we evaluate two competing conceptions of Skidmore review - the independent judgment model and the theoretically more deferential sliding-scale model - and conclude that the appellate courts overwhelmingly follow the sliding scale approach. Also, contrary to two other, significantly more limited studies, we document that Skidmore review is highly deferential to agency interpretations of law, with agency interpretations prevailing in more than 60% of Skidmore applications. Drawing from the Skidmore applications studied, we then analyze more qualitatively how the appellate courts apply the Skidmore review standard as a sliding scale and identify where those courts are struggling to make sense of Skidmore\u27s dictates within that model. To resolve the lower courts\u27 difficulties, we propose re-conceptualizing Skidmore\u27s sliding scale as balancing comparative agency expertise against the potential for agency arbitrariness. Finally, we note several burgeoning issues concerning the scope of Skidmore\u27s applicability and offer preliminary thoughts for addressing those questions

Optimal control of hepatitis C antiviral treatment programme delivery for prevention amongst a population of injecting drug users.

In most developed countries, HCV is primarily transmitted by injecting drug users (IDUs). HCV antiviral treatment is effective, and deemed cost-effective for those with no re-infection risk. However, few active IDUs are currently treated. Previous modelling studies have shown antiviral treatment for active IDUs could reduce HCV prevalence, and there is emerging interest in developing targeted IDU treatment programmes. However, the optimal timing and scale-up of treatment is unknown, given the real-world constraints commonly existing for health programmes. We explore how the optimal programme is affected by a variety of policy objectives, budget constraints, and prevalence settings. We develop a model of HCV transmission and treatment amongst active IDUs, determine the optimal treatment programme strategy over 10 years for two baseline chronic HCV prevalence scenarios (30% and 45%), a range of maximum annual budgets (£50,000-300,000 per 1,000 IDUs), and a variety of objectives: minimising health service costs and health utility losses; minimising prevalence at 10 years; minimising health service costs and health utility losses with a final time prevalence target; minimising health service costs with a final time prevalence target but neglecting health utility losses. The largest programme allowed for a given budget is the programme which minimises both prevalence at 10 years, and HCV health utility loss and heath service costs, with higher budgets resulting in greater cost-effectiveness (measured by cost per QALY gained compared to no treatment). However, if the objective is to achieve a 20% relative prevalence reduction at 10 years, while minimising both health service costs and losses in health utility, the optimal treatment strategy is an immediate expansion of coverage over 5-8 years, and is less cost-effective. By contrast, if the objective is only to minimise costs to the health service while attaining the 20% prevalence reduction, the programme is deferred until the final years of the decade, and is the least cost-effective of the scenarios

In Search of the Modern Skidmore Standard

This Article offers a comprehensive examination of the Skidmore standard for judicial review of agency legal interpretations as applied by the courts in the period since the Supreme Court revitalized Skidmore in United States v. Mead Corp. First, the Article documents an empirical study of five years worth of Skidmore applications in the federal courts of appeals. In the study, we evaluate two competing conceptions of Skidmore review - the independent judgment model and the theoretically more deferential sliding-scale model - and conclude that the appellate courts overwhelmingly follow the sliding scale approach. Also, contrary to two other, significantly more limited studies, we document that Skidmore review is highly deferential to agency interpretations of law, with agency interpretations prevailing in more than 60% of Skidmore applications. Drawing from the Skidmore applications studied, we then analyze more qualitatively how the appellate courts apply the Skidmore review standard as a sliding scale and identify where those courts are struggling to make sense of Skidmore\u27s dictates within that model. To resolve the lower courts\u27 difficulties, we propose re-conceptualizing Skidmore\u27s sliding scale as balancing comparative agency expertise against the potential for agency arbitrariness. Finally, we note several burgeoning issues concerning the scope of Skidmore\u27s applicability and offer preliminary thoughts for addressing those questions

Cost-effectiveness of HCV case-finding for people who inject drugs via dried blood spot testing in specialist addiction services and prisons

ObjectivesPeople who inject drugs (PWID) are at high risk for acquiring hepatitis C virus (HCV), but many are unaware of their infection. HCV dried blood spot (DBS) testing increases case-finding in addiction services and prisons. We determine the cost-effectiveness of increasing HCV case-finding among PWID by offering DBS testing in specialist addiction services or prisons as compared to using venepuncture.DesignCost-utility analysis using a dynamic HCV transmission model among PWID, including: disease progression, diagnosis, treatment, injecting status, incarceration and addition services contact.Setting uk interventionDBS testing in specialist addiction services or prisons. Intervention impact was determined by a meta-analysis of primary data.Primary and secondary outcome measuresCosts (in UK £, £1=US$1.60) and utilities (quality-adjusted life years, QALYs) were attached to each state and the incremental cost effectiveness ratio (ICER) determined. Multivariate uncertainty and one-way sensitivity analyses were performed.ResultsFor a £20 000 per QALY gained willingness-to-pay threshold, DBS testing in addiction services is cost-effective (ICER of £14 600 per QALY gained). Under the base-case assumption of no continuity of treatment/care when exiting/entering prison, DBS testing in prisons is not cost-effective (ICER of £59 400 per QALY gained). Results are robust to changes in HCV prevalence; increasing PWID treatment rates to those for ex-PWID considerably reduces ICER (£4500 and £30 000 per QALY gained for addiction services and prison, respectively). If continuity of care is >40%, the prison DBS ICER falls below £20 000 per QALY gained.ConclusionsDespite low PWID treatment rates, increasing case-finding can be cost-effective in specialist addiction services, and in prisons if continuity of treatment/care is ensured

The effect of person, treatment and prescriber characteristics on retention in opioid agonist treatment:a 15-year retrospective cohort study

AbstractBackground and Aims: There is limited evidence on the relationship between retention in opioid agonist treatment for opioid dependence and characteristics of treatment prescribers. This study estimated retention in buprenorphine and methadone treatment and its relationship with person, treatment, and prescriber characteristics. Design: Retrospective longitudinal study.Setting: New South Wales, Australia.Participants: People entering the opioid agonist treatment program for the first time between August 2001 and December 2015.Measurements: Time in opioid agonist treatment (primary outcome) was modelled using a generalised estimating equation model to estimate associations with person, treatment, and prescriber characteristics. Findings: The impact of medication type on opioid agonist treatment retention reduced over time; risk of leaving treatment when on buprenorphine compared with methadone was higher among those that entered treatment earlier (e.g. 2001-2003: OR 1.59, 95% CI 1.44-1.74) and lowest among those that entered most recently (2013-2015: OR 1.24, 95% CI 1.12-1.37). In adjusted analyses, risk of leaving was reduced among people whose prescriber had longer tenure of prescribing (e.g. 3 versus 8 years: OR 0.94, 95% CI 0.93-0.95) compared with prescribers with shorter tenure. Aboriginal and Torres Strait Islander people, being of younger age, past-year psychosis disorder, and having been convicted of more criminal charges in the year prior to treatment entry were associated with increased risk of leaving treatment. Conclusion: In New South Wales, Australia, retention in buprenorphine treatment for opioid dependence, compared with methadone, has improved over time since its introduction in 2001. Opioid agonist treatment (OAT) retention is affected not only by characteristics of the person and his or her treatment, but also of the prescriber, with those of longer prescribing tenure associated with increased retention of people in OAT. <br/

The Effect of Glass Shape on Alcohol Consumption in a Naturalistic Setting: A Feasibility Study

BACKGROUND: Alcohol-related harms are a major public health concern, and population-level interventions are needed to reduce excessive alcohol consumption. Glass shape is an easily modifiable target for public health intervention. Laboratory findings show beer is consumed slower from a straight glass compared to a curved glass, but these findings have not been replicated in a naturalistic setting. The purpose of this study is to investigate the feasibility of conducting a randomised controlled trial investigating the effect of glass shape on alcohol consumption in public houses. METHODS: Straight and curved half-pint and pint glasses were delivered to three public houses over two weekends. Glass type was counterbalanced over the two weekends and between the public houses. Monetary takings were recorded as an indirect measure of consumption. RESULTS: Replacing stocks of glassware in public houses was feasible and can be enacted in a short space of time. One landlord found the study too disruptive, possibly due to a laborious exchange of glassware and complaints about the new glassware from some customers. One public house’s dishwasher could not accommodate the supplied curved full-pint glasses. Obtaining monetary takings from public house staff was a feasible and efficient way of measuring consumption, although reporting absolute amounts may be commercially sensitive. Monetary takings were reduced by 24 % (95 % confidence interval 77 % reduction to 29 % increase) when straight glasses were used compared to curved glasses. CONCLUSIONS: This study shows that it is feasible to carry out a trial investigating glass shape in a naturalistic environment, although a number of challenges were encountered. Brewery owners and landlords are willing to engage with public health research in settings where alcohol is consumed, such as public houses. Good communication with stakeholders was vital to acquire good data, and highlighting the potential commercial benefits of participating was vital to the study’s success. A full scale evaluation of the effects of glass shape on alcohol consumption could inform local and national policy

Assessment of rates of recanting and hair testing as a biological measure of drug use in a general population sample of young people

AIMS: We investigate the extent of and factors associated with denial of previously reported cannabis and other illicit drug use, and assess the potential of hair testing for measuring substance use in general population samples. DESIGN: Birth cohort study. SETTING: United Kingdom, 1991–present. PARTICIPANTS: A total of 3643 participants who provided hair and self‐report measures of cannabis and other illicit drug use in the Avon Longitudinal Study of Parents and Children (ALSPAC) at age 18 years. MEASUREMENTS: Denial of ever use of cannabis and other illicit drugs at age 18 following previously reported use. Positive hair drug tests for cannabis and other illicit drugs, and expected numbers of false positives and false negatives based on expected sensitivity and specificity. FINDINGS: Cannabis and other illicit drug use was reported by 1223 and 393 individuals, respectively, before age 18 years. Of these 176 (14.4%) and 99 (25.2%), respectively, denied use at age 18. Denial of cannabis use decreased with the reporting of other substances and antisocial behaviour. Cannabis and other illicit drug use at age 18 was reported by 547 (22.5%) and 203 (8.4%) individuals, respectively. Of these, 111 (20.3%) and 13 (6.4%) were hair‐positive for cannabis and other illicit drugs, respectively. Based on hair testing for cannabis use we expect 0 [95% confidence interval (CI) = 0–169] false positives and 394 (95% CI = 323–449) false negatives compared to observed 362 potential false positives and 436 potential false negatives based on self‐report. In hair‐positive individuals, reporting the use of other substances and antisocial behaviour decreased the odds of a negative self‐report. CONCLUSIONS: Hair analysis provides an unreliable marker of substance use in general population samples. People who report more frequent substance use before age 18 are less likely to later deny previous substance use at age 18 than people who report occasional use