Arud Centre for Addiction Medicine

Introduction: The number of backcountry skiers and snowboarder surged in the last years, especially during the COVID-19 pandemic, as ski resorts shut down. Inevitably, this led to an increase in avalanche-related injuries and death. As avalanche rescue device, avalanche airbags are increasingly becoming part of the standard winter mountaineering equipment. Method: This study provides a review of available data and an updated perspective on avalanche airbags, discussing their function and efficacy to reduce mortality and their limitations. Results: Causes of death in individuals caught by avalanches are multiple. Airbags seem to reduce mortality by decreasing chances of critical burial, the most determining risk factor. However, there is scarcity of reliable scientific research on the topic, and the way in which airbags reduce mortality and to what extent is still debated. Several elements seem to influence airbags efficacy, and their use still yields several limitations linked to manufacturing, proper use, users education, and risk compensation. Conclusion: Avalanche airbags seem to be an important tool in reducing mortality in backcountry expeditions. However, more research and standardized data collection is needed to fill the knowledge gap, mountain communities should promote adequate education of winter-recreationists on how to prevent and react to an avalanche, and on the correct use of airbags in combination with already available tools such as transceivers, probes and shovels, and manufacturing companies should ensure higher efficacy of the survival avalanche equipment for better prevention of burial, asphyxia, and trauma.

The World Health Organization (WHO) aims to reduce HCV mortality, but estimates are difficult to obtain. We aimed to identify electronic health records of individuals with HCV infection, and assess mortality and morbidity. We applied electronic phenotyping strategies on routinely collected data from patients hospitalized at a tertiary referral hospital in Switzerland between 2009 and 2017. Individuals with HCV infection were identified using International Classification of Disease (ICD)-10 codes, prescribed medications and laboratory results (antibody, PCR, antigen or genotype test). Controls were selected using propensity score methods (matching by age, sex, intravenous drug use, alcohol abuse and HIV co-infection). Main outcomes were in-hospital mortality and attributable mortality (in HCV cases and study population). The non-matched dataset included records from 165,972 individuals (287,255 hospital stays). Electronic phenotyping identified 2285 stays with evidence of HCV infection (1677 individuals). Propensity score matching yielded 6855 stays (2285 with HCV, 4570 controls). In-hospital mortality was higher in HCV cases (RR 2.10, 95%CI 1.64 to 2.70). Among those infected, 52.5% of the deaths were attributable to HCV (95%CI 38.9 to 63.1). When cases were matched, the fraction of deaths attributable to HCV was 26.9% (HCV prevalence: 33%), whilst in the non-matched dataset, it was 0.92% (HCV prevalence: 0.8%). In this study, HCV infection was strongly associated with increased mortality. Our methodology may be used to monitor the efforts towards meeting the WHO elimination targets and underline the importance of electronic cohorts as a basis for national longitudinal surveillance.

BACKGROUND AND AIMS: The prevalence of chronic hepatitis C in Switzerland is currently estimated at approximately 32,000 affected individuals (0.37% of the permanent resident population). An estimated 40% of affected individuals in Switzerland is undiagnosed. The Swiss Federal Office of Public Health requires laboratories to report all positive hepatitis C virus (HCV) test results. Approximately 900 newly diagnosed cases are reported annually. The number of HCV tests performed, however, is not collected by the Federal Office of Public Health and positive rates are therefore unknown. The aim of this study was to describe the longitudinal course of the numbers of hepatitis C antibody tests and of positive rates in Switzerland for the years 2007 to 2017. METHODS: Twenty laboratories were asked to provide the number of HCV antibody tests performed and the number of positive antibody tests per year. Using data from the Federal Office of Public Health reporting system for the years 2012 to 2017, we calculated a factor to correct our values for multiple tests of the same person. RESULTS: The annual number of HCV antibody tests performed tripled linearly from 2007 to 2017 (from 42,105 to 121,266) while the number of positive HCV antibody test results increased by only 75% over the same period (from 1,360 to 2,379). The HCV antibody test positive rate steadily decreased from 3.2% in 2007 to 2.0% in 2017. After correction for multiple tests per person, the person-level HCV antibody tested positive rate decreased from 2.2% to 1.7% from 2012 to 2017. CONCLUSION: In the Swiss laboratories considered, more HCV antibody tests were performed each year in the period (2007–2017) before and during the approval of the new hepatitis C drugs. At the same time, the HCV antibody positive rates decreased, both on the per-test as well as the per-person level. This study is the first to describe the evolution of tests performed and of positive rates for HCV antibody in Switzerland at the national level over several years. In order to more accurately guide future measures to achieve the goal of eliminating hepatitis C by 2030, we recommend annual collection and publication of positive rates by health authorities, along with mandatory reporting of numbers of tests and people treated.

BACKGROUND AND AIMS: Chronic hepatitis B infection (defined as sustained detection of hepatitis B virus [HBV] surface antigen [HBsAg] protein in serum) is a leading cause of cirrhosis, hepatocellular carcinoma and liver-related deaths. A situation analysis carried out by the Swiss Federal Office of Public Health estimated the HBsAg prevalence in Switzerland to be 0.53% (95% CI: 0.32–0.89%) in 2015 (~44,000 cases). A lower prevalence of chronic HBV in the younger generation and the adoption of universal coverage in the first year of life are expected to decrease the burden of HBV; however, a number of people in key populations (including migrants) remain undiagnosed and untreated, and infected individuals remain at risk of progressing to cirrhosis, hepatocellular carcinoma and death. Our primary objective was to examine the current and estimate the future disease burden of HBV in Switzerland and the impact of migration. The secondary objective was to estimate the impact of changing future treatment numbers. METHODS: A modelling study was performed using an existing, validated model (PRoGReSs Model) applied to the Swiss context. Model inputs were selected through a literature search and expert consensus. Population data from the Federal Statistical Office were used alongside prevalence data from the Polaris Observatory to estimate the number of HBV infections among people born abroad. The PRoGReSs Model was populated with and calibrated to the available data and what-if scenarios were developed to explore the impact of intervention on the future burden of disease. A Monte Carlo simulation was used to estimate 95% uncertainty intervals (95% UIs). RESULTS: In 2020, there were an estimated 50,100 (95% UI: 47,500–55,000) HBsAg+ cases among people born abroad. Among people born in Switzerland, there were approximately 62,700 (UI: 58,900–68,400) total HBV infections (0.72% [UI: 0.68–0.79%] prevalence). Prevalence among infants and children under the age of 5 were both

Background ‘Image- and performance-enhancing drugs’ (IPEDs) in sports are widely used to improve body image and performance goals worldwide. Regarding the growing research interest and use of these substances, which often does not include Switzerland, we conducted a scoping literature review on evidence of the use of these substances and substance users in Switzerland. Methods A scoping review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement. We searched PubMed/Medline, Embase and Google Scholar for articles published before August 2022. Primary outcomes were evidence of IPED use and users in Switzerland. We used a narrative synthesis approach for data analysis. Results Overall, 18 studies were reviewed, which in total comprised 11,401 survey participants, 140 interviews and 1,368 toxicologically analyzed substances. Articles were mostly peer-reviewed (83%) and mostly included evidence from professional athletes (43%). Mean publication year was 2011. In most articles both outcomes (78%) were evaluated simultaneously. We demonstrate that IPEDs appear to be prevalent among athletes and non-athletes in Switzerland. A wide variety of different substances exist, and the type of substances used could vary by age, motivation, gender, and sports discipline. The main motivation to use these substances was for image- and performance-enhancement purposes among others. The main route of acquisition of these substances appears to be the Internet. Furthermore, we demonstrate that substantial proportions of these substances, as well as supplements, may be counterfeit. Information on IPED use was acquired from different sources. Conclusions Although evidence of IPED use and its users in Switzerland is scarce and major gaps were established, we demonstrate that these substances are also prevalent among athletes and non-athletes in Switzerland. Furthermore, major proportions of substances acquired from unregulated drug markets are counterfeit, which puts users in a situation of unpredictable risk when consuming them. Overall, the use of these substances may pose a substantial risk to individual and public health among this possibly growing, and often insufficiently informed and medically neglected user community in Switzerland. There is a great need for future research, as well as prevention, harm reduction, and treatment programs for this hard-to-reach user community. Doping policies in Switzerland should be critically reviewed as simple medical care, as well as the evidence-based treatment for non-athlete IPED users is excessively criminalized under the current legislature, leaving possibly over 200,000 IPED users in Switzerland with inadequate medical care.

Background: Heroin-assisted treatment (HAT) is a proven effective treatment option for individuals with severe opioid use disorder (OUD). In Switzerland, pharmaceutical heroin (diacetylmorphine, DAM) is available in tablet form or as injectable liquid. This creates a large barrier for individuals who require the rapid onset of effect but are either unable or do not want to inject, or who primarily snort opioids. Early experimental data has demonstrated that intranasal DAM administration can be a viable alternative to the intravenous or intramuscular route of administration. The purpose of this study is to assess the feasibility, safety, and acceptability of intranasal HAT. Methods: This study will assess intranasal DAM using a prospective multicentre observational cohort study design in HAT clinics across Switzerland. Patients will be offered to switch from oral or injectable DAM to intranasal DAM. Participants will be followed-up over 3 years, with assessments at baseline, and after 4, 52, 104 and 156 weeks. The primary outcome measure (POM) is retention in treatment. Secondary outcomes (SOM) include prescriptions and routes of administration of other opioid agonists, illicit substance use, risk behaviour, delinquency, health and social functioning, treatment adherence, opioid craving, satisfaction, subjective effects, quality of life, physical health, and mental health. Conclusions: The results derived from this study will generate the first major body of clinical evidence on the safety, acceptability, and feasibility of intranasal HAT. If proven to be safe, feasible and acceptable, this study would increase the accessibility of intranasal OAT for individuals with OUD globally as a critical improvement in risk reduction.

Objectives: People who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) infection. HCV cure is associated with improved patient reported outcomes (PROs), but there are little data among PWID. The aim of this study was to assess the change in PROs during and after HCV direct-acting antiviral (DAA) treatment. Methods: This analysis utilised data from two clinical trials of DAA treatment in PWID. PROs assessed included health-related quality life (HRQoL), social functioning, psychological distress, housing and employment. Generalised estimating equations (GEE) and group-based trajectory modelling (GBTM) were used to assess changes in PROs over time. Results: No significant changes in EQ-5D-3L scores, EQ-VAS scores, social functioning, psychological distress, and housing were observed over the 108-week study period. There was a significant increase in the proportion of participants employed (18% [95% CI, 12 - 23%] at baseline to 28% [95% CI, 19 - 36%] at the end of the study). Participants were more likely to be employed at 24 weeks and 108 weeks following commencing treatment. Having stable housing increased the odds of being employed (OR= 1.70, [95% CI, 1.00 - 2.90]. The GBTM demonstrated that most outcomes remained stable during and after DAA treatment. Conclusions: Although no significant improvement in HRQoL following HCV DAA treatment was identified, there was a modest, but significant increase in employment during study follow-up. The study findings support the need for multifaceted models of HCV care for PWID addressing a range of issues beyond HCV treatment to improve quality of life.

Background Heroin-assisted treatment (HAT) is effective for individuals with severe opioid use disorder (OUD) who do not respond sufficiently to other opioid agonist treatments. It is mostly offered with injectable diacetylmorphine (DAM) or DAM tablets creating a barrier for individuals who need the rapid onset of action but are either unable or unwilling to inject, or primarily snort opioids. To explore another route of administration, we evaluated the safety and feasibility of intranasal (IN) DAM. Methods This is a multicentre observational cohort study among patients in Swiss HAT. All patients planning to receive IN DAM within the treatment centres were eligible to participate. Participants were either completely switched to IN DAM or received IN DAM in addition to other DAM formulations or opioid agonists. Patients were followed up for four weeks. Sociodemographic characteristics, current HAT regimen, reasons for starting IN DAM, IN DAM doses, number of injection events in the sample, IN DAM continuation rate, and appearance of adverse events and nose-related problems were evaluated. Results Participants ( n = 52) reported vein damage, preference for nasal route of administration, and desire of a stronger effect or for a less harmful route of administration as primary reasons for switching to IN DAM. After four weeks, 90.4% of participants ( n = 47) still received IN DAM. Weekly average realised injection events decreased by 44.4% from the month before IN DAM initiation to the month following. No severe adverse events were reported. Conclusions After four weeks, IN DAM was a feasible and safe alternative to other routes of administration for patients with severe OUD in HAT. It addressed the needs of individuals with OUD and reduced injection behaviour. More long-term research efforts are needed to systematically assess efficacy of and patient satisfaction with IN DAM.

In 2016, the Hepatitis B and C Public Policy Association (HepBCPPA), gathered all the main stakeholders in the field of hepatitis C virus (HCV) to launch the now landmark HCV Elimination Manifesto, calling for the elimination of HCV in the EU by 2030. Since then, many European countries have made progress towards HCV elimination. Multiple programs – from the municipality level to the EU level – were launched, resulting in an overall decrease of viremic HCV infections and liver‐related mortality. However, as of 2021, most countries are not on track to reach the 2030 HCV elimination targets set by the WHO. Moreover, the COVID‐19 pandemic has resulted in a decrease in HCV diagnoses and fewer direct acting antiviral treatment initiations in 2020. Diagnostic and therapeutic tools to easily diagnose and treat chronic HCV infection are now well established. Treating all patients with chronic HCV infection is more cost‐saving than treating and caring for patients with liver‐related complications, decompensated cirrhosis or hepatocellular carcinoma. It is more important than ever to reinforce and scale‐up action towards HCV elimination. Yet, efforts urgently need the dedicated commitment of policymakers at all governmental and policy levels. Therefore, the 3rd EU Policy Summit, held in March 2021, featured EU parliamentarians and other key decision makers to promote dialogue and take strides towards securing wider EU commitment to advance and achieve HCV elimination by 2030. We have summarized the key action points and report the ‘Call‐to‐Action’ statement supported by all the major relevant European associations in the field.

Objective Supraphysiologic doses of anabolic androgenic steroids (AAS) are widely used to improve body image and sport performance goals. These substances can easily be acquired over the internet, leading to a substantial black market. We reviewed literature that assessed the quality and quantity of AAS found on the black market. Methods We searched PubMed/Medline, Embase and Google Scholar for articles published before March 2022. Additional hand searches were conducted to obtain studies not found in the primary literature search. Studies were included if they report on qualitative and/or quantitative analytical findings of AAS from the black market. Primary outcomes were proportions of counterfeit or substandard AAS. Eligible articles were extracted; quality appraisal was done using the ToxRTool for in-vitro studies. We used random-effects models to calculate the overall mean estimates for outcomes. The review protocol has been published and registered in INPLASY. Results Overall, 19 studies, which in total comprised 5,413 anabolic samples, met the inclusion criteria, and passed the quality appraisal from two WHO world regions that reported findings, the Americas and Europe. Most studies were nonclinical laboratory studies (95%) and provided samples seized by authorities (74%). In 18 articles, proportions of counterfeit substances and in eight articles, proportions of substandard substances were presented. The overall mean estimate for counterfeit anabolic steroids found on the black market was 36% (95% CI = 29, 43). An additional 37% (95% CI = 17, 63) were of substandard quality. We also demonstrate that these drugs could contain no active ingredient, or in another amount than that labeled, a wrong active ingredient, as well as not all or more active ingredients than were labeled. High heterogeneity among all analyses and significant differences between geographical subgroups were found. Conclusion With this systematic review and meta-analysis, we demonstrate that substantial mean proportions of black-market AAS are counterfeit and of substandard quality. These products pose a considerable individual and public health threat, and the very wide range in proportions of fake black-market AAS puts the user in a situation of unpredictable uncertainty. There is a great need for future prevention and harm-reduction programs to protect users from these substances.

Background: Changes in mental and sexual health among men having sex with men (MSM) due to the SARS-CoV-2 pandemic remain unclear. Methods: Design: Longitudinal analysis of an ongoing, multicentre, pre-exposure prophylaxis (PrEP) cohort (NCT03893188) in Switzerland. Participants: HIV-negative MSM aged ≥18 who completed at least one questionnaire before and one after the start of the SARS-CoV-2 pandemic. Outcomes: Primary: mental health, defined as anxiety and depression scores assessed by the Patient Health Questionnaire-4. Secondary: sexual behaviour, well-being, PrEP use and disruption of care. Outcomes were assessed over seven periods corresponding to different SARS-CoV-2 prevention measures in Switzerland. We performed pairwise comparisons between periods (Wilcoxon signed rank test). Results: Data from 1,043 participants were included. Whilst anxiety scores remained stable over time, depression scores worsened in the second wave and the second lockdown period compared to pre-pandemic scores. This was confirmed by pairwise comparisons (pre-SARS-CoV-2/second wave and pre-SARS-CoV-2/second lockdown: p <0.001). Downward trends in sexual activity,sexualized substance use, and a switch from daily to "event-driven" PrEP were found. Disruption of care affected 42.6% (790/1856) of daily PrEP users' follow-up visits. Conclusion: In this longitudinal analysis of a PrEP cohort enrolling MSM, depression scores worsened in the second wave and the second lockdown compared to the pre-pandemic period.

Background: Direct-acting antivirals present a treatment opportunity that provides high rates of sustained viral response even for people who have lived for years with hepatitis C virus (HCV) infection. While it is known that liver-related morbidity and mortality can be decreased and many symptoms reversed, this population's need for post-treatment professional support has not been extensively assessed. Therefore, our study aimed to describe the experiences of patients cured of chronic HCV infection and explore the meaning of these experiences regarding specific follow-up care needs within the context of the Swiss health system. Methods: For this qualitative study, we applied a reflexive thematic analysis approach with a social constructivist orientation. Twelve participants shared their experiences of being cured and their needs regarding follow-up care. Subsequently, the data were analysed in an iterative process based on Braun and Clarke's six phases of analysis. Results: In the overarching theme, participants summarised their new situation with the statement, "being cured feels like being released from a cage". They experienced striking health improvements with overwhelmingly positive influences on their everyday lives. This experience was characterised for all participants by important changes on three levels. We categorised these in three sub-themes: a) "the ball and chain have been lightened": this sub-theme illustrates the reduction of social limitations and emotional stress; b) "the gnawing at the liver has let up": this signifies relief from physical symptoms and strongly improved well-being. And under the third sub-theme, "shaping the new freedom", the participants described their new situation as a sometimes-stressful challenge because they had to reorient their self-management. They shared their concerns regarding the ongoing stigma of HCV infection, feeling insecure in their own health after being cured, and learning how to use their heightened sense of confidence and openness to enact behavioural changes that would improve their health-related lifestyles. Conclusion: The findings of this study provide insights into treatment experiences of patients cured of chronic HCV infection and the need for follow-up care even after successful virus eradication. The results can sensitise healthcare professionals to patients' post-cure challenges and guide their care interventions. Some of these challenges, such as dealing with stigma, can be addressed during treatment; other needs, like providing motivation to engage in healthy behaviour, may warrant targeted follow-up.

Background Hepatitis C virus (HCV) represents a significant public health burden. When new HCV drugs arrived in 2014, the disease became curable, but the administration remained reluctant to address this public health issue. However, the Swiss parliament recently decided to integrate HCV into the next national HIV programme. This study investigates how HCV came onto the political agenda in Switzerland and which actors and factors were influential in this process. Methods The data collection is based on document analysis and semi-structured interviews. The transcripts were coded by deriving the codes from the data in terms of content followed by the application of the multiple streams framework. Results Health authorities, unlike experts, did not see the HCV epidemic as a relevant public health threat. Due to cost-related restriction of access to treatment, the potential of the new HCV drugs could not be fully exploited. The administration’s position proved difficult to change, despite evidence to the contrary. For 30 years, authorities set the agenda in health policy regarding HCV, unheeded by politicians. But recently, a policy entrepreneur has for the first time successfully managed to put HCV on the political agenda. After years of education and lobbying, it used the window of opportunity in the form of the new edition of the national HIV programme. The parliamentary decision to include HCV in this programme broke the long-standing primacy of the administration in the field of HCV, which had long prevented a more active handling of the HCV field. Conclusions The case of HCV in Switzerland shows that evidence alone is not enough to bring about health policy changes. A policy entrepreneur is needed who overcomes resistance, brings together the three streams—problem, policy and political—and exploits the window of opportunity at the right time. To be successful, the policy entrepreneur must identify the indicators that map the problem, network and convince decision-makers, recognize policy windows and use them—as has been the case with HCV in Switzerland.

Background and aims: Among people on opioid agonist treatment (OAT), social-environmental and behavioural risk factors may promote the spread of SARS-CoV-2, and somatic comorbidities are highly prevalent. Thus, this population is considered at elevated risk for being infected as well as for developing a more severe course of COVID-19 disease. The aim was to assess the SARS-CoV-2 seroprevalence among people in ongoing OAT, to explore whether the antibody positive group differed from the antibody negative group, and to compare the SARS-CoV-2 seroprevalence among OAT patients with the prevalence in the regional general population. Methods: The nationwide Corona Immunitas study assessed the participants' Sars-CoV-2 antibody status, social characteristics and behavioural data after the first wave of the corona pandemic in Switzerland, between the end of June and beginning of September 2020. We analysed the subsample of OAT patients (n = 122) and the subsample from the general population of the canton of Zurich (n = 472). Results: SARS-CoV-2 seroprevalence in the general population (mean age ± standard deviation 44.7 ± 11.7 years; 50.9% female) was 3.5% (95% confidence interval [CI] 2.2-4.8%) vs 9.8% (5.1-17.2%) in the OAT population age 44.3 ± 9.4 years; 30.3% female), corresponding to a prevalence ratio of 2.9 (95% CI 1.37-5.94; p = 0.004). OAT patients had a significantly worse health status than the general population. In the OAT group, we found no significant difference between seropositive and seronegative individuals regarding socioeconomic status, risk behaviour, COVID-19-related symptoms or comorbidity. None of the OAT patients who tested positive had a severe course of COVID-19. Conclusion: The 3-fold higher seroprevalence suggests a higher than average viral exposure in the OAT group. Nevertheless, no severe COVID-19 course occurred, although the number of study participants was relatively small. One possible reason for this could be possible cross-immunity to SARS-CoV-2 due to frequent viral contacts in OAT patients.