The International journal on drug policy

Published by Elsevier
Online ISSN: 0955-3959
Publications
Article
Buprenorphine/naloxone (BUP/NX) is not licenced for use in China or Thailand and there was little clinical experience with this drug combination in these countries at the inception of HIV Prevention Trial Network (HPTN) 058, a randomized trial comparing risk reduction counselling combined with either short-term or long-term medication assisted treatment with BUP/NX to prevent HIV infection and death amongst opioid-dependent injectors. We conducted a safety phase that included the first 50 subjects enrolled at each of the three initial study sites (N=150). Clinical and laboratory assessments were conducted at baseline and weekly for the first 4 weeks. Changes in laboratory parameters were estimated with random effects models. BUP/NX was well tolerated by study subjects and opioid withdrawal scores decreased substantially during the 3-day induction. Two participants experienced grade 3 clinical adverse events, which were categorized as probably not related to the study drug. Grade 2 or 3 increases in alanine aminotransferase (ALT) occurred in 25 (17%) subjects. The magnitude of ALT increase over 4-week follow-up was strongly associated with baseline ALT elevation. In Chinese and Thai opioid-dependent injectors, we found BUP/NX to be effective in reducing opioid withdrawal symptoms and safe during short-term use. ALT increases were observed over 4-week-follow-up, which are consistent with reports from Western populations. Long-term safety and efficacy evaluations are indicated.
 
Article
BACKGROUND: Doping is a very serious issue bedevilling the sporting arena. It has consequences for athletes' careers, perception of sports in the society and funding of sports events and sporting organisations. There is a widespread perception that doping unfairly improves results of athletes. METHODS: A statistical study of information on best lifetime results of top 100 m sprinters (males better than 9.98 s, females 11.00 s), over the period of 1980-2011 was conducted. Athletes were divided into categories of 'doped' (N = 17 males and 14 females), based on self admission, the confirmed detection of known doping agents in their bodies or doping conviction, and 'non-doped' (N = 46 males and 55 females). RESULTS: No significant differences (unpaired t-test) between dopers and non-dopers were found in their average results: male 'dopers' 9.89 s identical with 'non-dopers' 9.89 s, females 10.84 s and 10.88 s respectively. Slopes of regressions of best results on dates for both 'dopers' and 'non dopers' were not significantly different from zero. This indicates that no general improvement as a group in 100 m sprint results over a quarter of a century occurred irrespective of doping being or not being used. CONCLUSION: Since there are no statistical differences between athletes found "doping" and the others, one of the following must be true: (1) "doping" as used by athletes so detected does not improve results, or (2) "doping" is widespread and only sometimes detected. Since there was no improvement in overall results during the last quarter of the century, the first conclusion is more likely. Objectively, various "doping" agents have obvious physiological or anatomical effects. These may not translate into better results due to the clandestine use of doping that prevents its scientific structuring. Perception of the effectiveness of doping should be reconsidered. Policy changes may be required to ensure the continued fairness and equity in testing, legislation and sports in general.
 
Article
This paper exposes contemporary drug policy challenges in Central Asia by focusing on a single point in the history of drug control, in a single region of the global war against drugs and terrorism, and on one agency whose mission is to help make the world safer from crime, drugs and terrorism. By looking closely at the post 9/11 security-oriented donor priorities, I conclude that, in Central Asia, the rhetoric of the taking a more 'balanced approach' to drug policy is bankrupt. When enacted by the national law enforcement agencies in the Central Asian republics, the 'Drug Free' aspirational goal is driving the HIV epidemic among IDUs. The face-saving 'containment' thesis does not reflect the drug situation in this region but rather the failure to adopt an evidence-based approach. The harm reduction agenda continues to face many challenges including resistance to substitution treatment, the harm from drug treatment, from poorly designed drug prevention programmes and from repressive counter-narcotics policies and practices.
 
Lifetime alcohol use, use in the last 12-months and 30-days. 
Drinking five or more drinks on the same occasion. 
World Health Organisation ecological model of risk factors for alcohol-related youth violence (2006). 
Article
The UK is a high prevalence country for underage alcohol use. We conducted an evidence synthesis to examine (1) the changing trends in underage drinking in the UK compared to Europe and the USA, (2) the impact of underage drinking in terms of hospital admissions, (3) the association between underage drinking and violent youth offending, and (4) the evidence base for the effectiveness of alcohol harm reduction interventions aimed at children and adolescents under the age of 18 years. The following databases were searched from November 2002 until November 2012: Cochrane Database of Systematic Reviews, National Institute for Health and Clinical Excellence, The Evidence for Policy and Practice Information, DARE, Medline, The Campbell Collaboration, CINAHL, Criminal Justice Abstracts, Psych INFO and Social Care Online. Our findings revealed changes in the way children drink in the UK and how much they drink. Alcohol related harms are increasing in the UK despite overall population levels of consumption reducing in this age group. Girls aged 15-16 years report binge drinking and drunkenness more than boys. Girls are also more likely than boys to be admitted to hospital for alcohol related harm. The evidence suggests a strong association between heavy episodic binge drinking and violent youth offending. Only 7 out of 45 randomised controlled trials (RCTs) identified for this review included children and adolescents under the age of 18 years. Most were delivered in the emergency department (ED) and involved a brief intervention. All were characterised by a wide age range of participants, heterogeneous samples and high rates of refusal and attrition. The authors conclude that whilst the ED might be the best place to identify children and adolescents at risk of harm related to alcohol use it might not be the best place to deliver an intervention. Issues related to a lack of engagement with alcohol harm reduction interventions have been previously overlooked and warrant further investigation.
 
Article
Between 1906 and 1917 China (under the Imperial and then Republican regimes) enacted a highly effective intervention to suppress the production of opium. Evidence from British Foreign Office records suggest that the intervention was centred, in many areas, upon a highly repressive incarnation of law enforcement in which rural populations had their property destroyed, their land confiscated and/or were publically tortured, humiliated and executed. Crops were forcefully eradicated and resistance was often brutally suppressed by the military. As few farmers received compensation or support for alternative livelihood creation the intervention pushed many deeper into poverty. Importantly, the repressive nature of the opium ban appears to have been a contributing factor to the fragmentation of China, highlighting the counter-productivity of repressive interventions to reduce drug crop production.
 
Article
Background: This qualitative historical policy analysis explores Japan's early postwar market for hiropon (methamphetamine/meth) and the impact of its anti-hiropon campaigns. The paper traces the origins of medical methamphetamine production in prewar Japan; known at that time by its former brand-name, 'Philopon' (pronounced hiropon), and argues that the anti-meth 'shock-horror' campaigns of the 1950s were exacerbated by long-simmering animosity toward non-Japanese residents - especially Koreans and Taiwanese. Methods: Through an analysis of both English- and Japanese-language source materials, the paper explores the gritty, frightening themes of Japan's 1950s-era anti-meth propaganda campaigns and the parallel effort by police to arrest, prosecute, and deport members of the resident Korean and Taiwanese communities. Results: The author demonstrates that by incorporating a wider variety of contemporary Japanese-language sources such as news reports and anti-drug propaganda materials about the postwar hiropon trade, we may more fully appreciate the historic, underlying social tensions behind the swift and targeted public response. Conclusion: The author concludes that Japan's postwar federal and municipal governments, together with police and media agencies, cultivated a sensational 'drug panic' designed both to dissuade citizens from using hiropon and to fuel a concerted police campaign against non-Japanese involved in the meth trade.
 
Article
Background: The drug problem has been a highly ideologized topic in the political debate in Sweden ever since the mid-1960s. The aim of the article is to investigate dominant conceptions of drugs, drug use, society and the individual in the political discussions on drug use in Sweden during the years 1965-1981. Methods: The empirical basis for the textual analysis consists of 146 parliamentary bills and 135 parliamentary protocols. Results: The unwanted drug appear as a sensitive litmus paper, an indication that something had gone wrong in society and as a suggestion of how the good society could be accomplished. The drug problem was connected to ideological core values such as class struggle, Christianity or criticism of urbanism and modernity. Conclusion: The analysis suggests that the drug problem was used as political ammunition, to pick holes in political opponents and to highlight one's own ideological stance. The hegemonic conversational order, the consensual spirit and the agreement that this was the most serious problem, did not hamper these political moves. Rather, the cross-party conception of the problem's severity and accelerating deterioration contributed to a common ground for political arguments and ideological visions. It also meant that the political discussions moved away from the more obvious drug policy issues.
 
Article
This article examines the political formulation and ideological solution of the Swedish drug problem in 1982-2000. How was the drug problem described in the Swedish parliament at the time? How serious was the problem and what solutions were proposed? What were the ideological implications of the problem description, and how was the general political and ideological solution formulated? The empirical basis for the textual analysis consists of parliamentary bills, government bills and parliamentary records discussing the drug issue during the years 1982-2000. In the prevailing spirit of consensus in the Swedish parliament at the time, both left-wing and right-wing parties portrayed drugs as a threat to the nation, people and the welfare state. Still, as the ideological dimension kept growing stronger, the drug question functioned even better as an arena for political discussions and ideological positions than in the 1970s. Compared to previous decades, the problem description broadened during the 1980s and 1990s, and the drug problem could be used to support arguments on almost any topic. The drug problem became a highly politicized issue about whom or what to change when the individual and the society clashed, but also about what the individual and/or society should be changed into.
 
Article
By the end of 2005, there were 10,158 reported cases of HIV infections in Taiwan, of them, 2,403 had developed full blown AIDS, and 1,333 had died. It represented an average annual increase of 15% in HIV diagnoses before 2003. The most common route of transmission is through men having sex with men followed by heterosexual contact, while infections through injecting drug use (IDUs) remained low. However, the number of newly reported HIV infections has been rising sharply since 2003, mainly among IDUs. The consequences of this HIV/IDU epidemic include a rapid increase in female HIV/AIDS patients and a decreased mean age of HIV/AIDS cases. Only 2% of patients in the IDU group have been diagnosed with AIDS, suggesting that most IDU cases are in the early stage of HIV infections. HIV/AIDS patients are provided with free medical care by the government in Taiwan, including anti-retroviral treatment. The case fatality rate of AIDS cases declined gradually from 64% in 1996 to 8.9% in 2005. Patients in the IDU group seek medical care less frequently than patients in the sexual contact group. Statistics show that 61.4% of patients in the IDU group did not seek HIV-related medical care, significantly higher compared to the sexual contact group. The Taiwanese government implemented a trial "Harm Reduction Programme," which involved a needle-syringe programme (NSP) and substitution treatment, in August 2005. After 1 year's pilot study, the HIV incidence in cities with NSP decreased from 13.9 to 13.3 per 100,000 persons compared to an incidence increase from 11.5 to 15.3 per 100,000 persons in cities without NSP. We scaled up the programme to cover the whole of Taiwan in July 2006 and are expecting to see the efficacy in the near future.
 
Article
National drug policies are often regarded as inconsequential, rhetorical documents, however this belies the subtlety with which such documents generate discourse and produce (and re-produce) policy issues over time. Critically analysing the ways in which policy language constructs and represents policy problems is important as these discursive constructions have implications for how we are invoked to think about (and justify) possible policy responses. Taking the case of Australia's National Drug Strategies, this paper used an approach informed by critical discourse analysis theory and aspects of Bacchi's (2009) 'What's the Problem Represented to be' framework to critically explore how drug policy problems are constructed and represented through the language of drug policy documents over time. Our analysis demonstrated shifts in the ways that drugs have been 'problematised' in Australia's National Drug Strategies. Central to these evolving constructions was the increasing reliance on evidence as a way of 'knowing the problem'. Furthermore, by analysing the stated aims of the policies, this case demonstrates how constructing drug problems in terms of 'drug-related harms' or alternately 'drug use' can affect what is perceived to be an appropriate set of policy responses. The gradual shift to constructing drug use as the policy problem altered the concept of harm minimisation and influenced the development of the concepts of demand- and harm-reduction over time. These findings have implications for how we understand policy development, and challenge us to critically consider how the construction and representation of drug problems serve to justify what are perceived to be acceptable responses to policy problems. These constructions are produced subtly, and become embedded slowly over decades of policy development. National drug policies should not merely be taken at face value; appreciation of the construction and representation of drug problems, and of how these 'problematisations' are produced, is essential.
 
Article
Background: There have been no changes to the statutory penalties for cannabis use in New Zealand for over 35 years and this has attracted some criticism. However, statutory penalties often provide a poor picture of the actual criminal justice outcomes for minor drug offending. Aim: To examine criminal justice outcomes for cannabis use offences in New Zealand over the past two decades. Method: Rates of apprehension, prosecution, conviction and related criminal justice outcomes for the use of cannabis in New Zealand (per 100,000 population) were calculated for 1991-2008. The same measures were calculated (per 1000 last year cannabis users) for 1998, 2001, 2003 and 2006. Trends were tested for using logistic regression with year predicting each measure outcome and with chi-square tests. Results: The number of police apprehensions for cannabis use per year (per 100,000 population) declined from 468 in 1994 to 247 in 2008. The number of apprehensions for cannabis use per year (per 1000 cannabis users) also declined from 36 in 1998 to 21 in 2006. There were similar declines in prosecutions and convictions for cannabis use from 1991 to 2008. Those prosecuted for cannabis use in 2000-2008 were less likely than those prosecuted in 1991-1999 to be convicted and were more likely to be diverted away from the courts, 'discharged without conviction' and 'convicted and discharged'. Conclusion: There has been a substantial decline in arrests for cannabis use in New Zealand over the past decade and this lead to similar declines in prosecutions and convictions for cannabis use. The decline in convictions for cannabis use was further assisted by the expansion of police diversion to include cannabis use offences. Our findings underline the importance of examining the implementation of law, as well as statutory penalties, when characterising a country's criminal justice approach to minor drug offending.
 
Article
The past two decades have seen an increase in heroin-related morbidity and mortality in the United States. We report on trends in US heroin retail price and purity, including the effect of entry of Colombian-sourced heroin on the US heroin market. The average standardized price ($/mg-pure) and purity (% by weight) of heroin from 1993 to 2004 was from obtained from US Drug Enforcement Agency retail purchase data for 20 metropolitan statistical areas. Univariate statistics, robust Ordinary Least Squares regression and mixed fixed and random effect growth curve models were used to predict the price and purity data in each metropolitan statistical area over time. Over the 12 study years, heroin price decreased 62%. The median percentage of all heroin samples that are of South American origin increased an absolute 7% per year. Multivariate models suggest percent South American heroin is a significant predictor of lower heroin price and higher purity adjusting for time and demographics. These analyses reveal trends to historically low-cost heroin in many US cities. These changes correspond to the entrance into and rapid domination of the US heroin market by Colombian-sourced heroin. The implications of these changes are discussed.
 
Article
Drug policy is one of the most polarised subjects of public debate and media coverage, which frequently tend to be dramatic and event-centred. Although the role of the media in directing the drug discourse is widely acknowledged, limited research has been conducted in examining the particular role of the media in the science-policy nexus. We sought to determine how the (mis)representation of scientific knowledge in the media may, or may not, have an impact on the contribution of scientific knowledge to the drug-policy making process. Using a case study of the Belgian drug-policy debates between 1996 and 2003, we conducted a discourse analysis of specially selected 1067 newspaper articles and 164 policy documents. Our analysis focused on: textual elements that feature intra-discourse differences, how players and scientific knowledge are represented in the text, the arguments used and claims made, and the various types of research utilisation. Media discourse strongly influenced the public's and policy makers' understanding as well as the content of the Belgian drug policy debate between 1996 and 2003. As a major source of scientific knowledge, media coverage supported the 'enlightenment' role of scientific knowledge in the policy-making process by broadening and even determining frames of reference. However, as the presentation of scientific knowledge in the media was often inaccurate or distorted due to the lack of contextual information or statistical misinformation, the media may also support the selective utilisation of scientific knowledge. Many challenges as well as opportunities lie ahead for researchers who want to influence the policy-making process since most research fails to go beyond academic publications. Although media is a valuable linking mechanism between science and policy, by no means does it provide scientists with a guarantee of a more 'evidence-based' drug policy.
 
Article
We examine major causes of death amongst persons in contact with drug-treatment services across Scotland during April 1996-March 2006, hereafter Scottish Drug Misuse Database (SDMD) cohort. Drug-treatment records were linked to national registers of deaths and hepatitis C virus (HCV) diagnoses. For eras 1996/97-2000/01 and 2001/02-2005/06, we calculated cause-specific death-rates and standardised mortality ratios (SMRs) using age-, sex- and calendar-rates of the general Scottish population. Major causes of death were identified by high SMRs (>5 across eras) or rates (>50 per 100,000 person-years in either era), and their time-specific influences characterised by proportional hazards analyses. The SDMD cohort comprised 69,456 individuals, 350,315 person-years and 2590 deaths. The overall SMR reduced from 6.4 (95% CI: 6.0-6.9) to 4.8 (95% CI: 4.6-5.0) between eras. We identified five major causes of death: drug-related (1383 deaths), homicide (118) and infectious diseases (90) with high SMRs; suicide (269) and digestive system disease (168) with high rates. HCV diagnosis marked individuals with at least double the risk of cause-specific mortality, including adjusted hazard ratio (HR) for no HCV diagnosis of 0.46 (95% CI: 0.41-0.53) for drug-related deaths (DRDs) and 0.15 (95% CI: 0.10-0.22) for death from digestive system disease. Increased DRD risk at older age (>34 years) appeared specific to HCV-diagnosed individuals (interaction: χ₁²=7.7, p=0.01). Alcohol misuse increased HRs: for DRD (1.76, 95% CI: 1.50-2.06), suicide (1.88, 95% CI: 1.35-2.60), deaths from digestive system disease (3.19, 95% CI: 2.21-4.60) and non-major causes (1.87, 95% CI: 1.49-2.35). Stimulant misuse increased suicide risk: adjusted HR 1.91 (95% CI: 1.43-2.54). Drug-users in Scotland are exposed to variously increased mortality risks. HCV-diagnosed individuals are particularly vulnerable, and may need additional support.
 
Article
Measuring syringe availability and coverage is essential in the assessment of HIV/AIDS risk reduction policies. Estimates of syringe availability and coverage were produced for the years 1996 and 2006, based on all relevant available national-level aggregated data from published sources. We defined availability as the total monthly number of syringes provided by harm reduction system divided by the estimated number of injecting drug users (IDU), and defined coverage as the proportion of injections performed with a new syringe, at national level (total supply over total demand). Estimates of supply of syringes were derived from the national monitoring system, including needle and syringe programmes (NSP), pharmacies, and medically prescribed heroin programmes. Estimates of syringe demand were based on the number of injections performed by IDU derived from surveys of low threshold facilities for drug users (LTF) with NSP combined with the number of IDU. This number was estimated by two methods combining estimates of heroin users (multiple estimation method) and (a) the number of IDU in methadone treatment (MT) (non-injectors) or (b) the proportion of injectors amongst LTF attendees. Central estimates and ranges were obtained for availability and coverage. The estimated number of IDU decreased markedly according to both methods. The MT-based method (from 14,818 to 4809) showed a much greater decrease and smaller size of the IDU population compared to the LTF-based method (from 24,510 to 12,320). Availability and coverage estimates are higher with the MT-based method. For 1996, central estimates of syringe availability were 30.5 and 18.4 per IDU per month; for 2006, they were 76.5 and 29.9. There were 4 central estimates of coverage. For 1996 they ranged from 24.3% to 43.3%, and for 2006, from 50.5% to 134.3%. Although 2006 estimates overlap 1996 estimates, the results suggest a shift to improved syringe availability and coverage over time.
 
Article
Global prevalence of hepatitis C virus (HCV) is estimated to be around 3% with approximately 170 million people affected. In Australia, and in many other resource rich countries, injecting drug use is the single most important risk factor for acquiring HCV, with around a third of diagnoses occurring in women. This study aims to assess gender differences in hepatitis C antibody prevalence and associated risk behaviours amongst a large sample of PWID in Australia. During a one to two week period in October, PWID attending selected NSP sites are invited to participate in the Australian NSP Survey. Between 1998 and 2008, approximately 16,000 individuals completed a self-administered questionnaire and provided a capillary blood sample for HIV and HCV antibody testing. We stratified our sample by time since onset of injecting and analysed the demographic characteristics, injecting behaviours and antibody test results to determine gender differences. Women were found to be at increased risk of exposure to hepatitis C in all duration of injection categories except those injecting for 17 or more years. In the early years of injecting, women also reported higher rates of receptive sharing of needles and syringe and ancillary equipment when compared to men. Last injecting heroin, methadone or buprenorphine was significantly associated with HCV antibody prevalence amongst both males and females injecting for less than 5 years. Findings indicate that women are at greater risk than men of HCV infection during the early years of injection through higher rates of receptive sharing of needles and syringes and/or ancillary equipment. Our results suggest that women who are new to injecting, and Indigenous women in particular, should be identified as priority populations when developing and implementing harm reduction strategies that target people who inject illicit drugs.
 
Article
HIV spread rapidly amongst injecting drug users (IDUs) in Bangkok in the late 1980s. In recent years, changes in the drugs injected by IDUs have been observed. We examined data from an HIV vaccine trial conducted amongst IDUs in Bangkok during 1999-2003 to describe drug injection practices, drugs injected, and determine if drug use choices altered the risk of incident HIV infection. The AIDSVAX B/E HIV vaccine trial was a randomized, double-blind, placebo-controlled trial. At enrolment and every 6 months thereafter, HIV status and risk behaviour were assessed. A proportional hazards model was used to evaluate demographic characteristics, incarceration, drug injection practices, sexual activity, and drugs injected during follow-up as independent predictors of HIV infection. The proportion of participants injecting drugs, sharing needles, and injecting daily declined from baseline to month 36. Amongst participants who injected, the proportion injecting heroin declined (98.6-91.9%), whilst the proportions injecting methamphetamine (16.2-19.6%) and midazolam (9.9-31.9%) increased. HIV incidence was highest amongst participants injecting methamphetamine, 7.1 (95% CI, 5.4-9.2) per 100 person years. Injecting heroin and injecting methamphetamine were independently associated with incident HIV infection. Amongst AIDSVAX B/E vaccine trial participants who injected drugs during follow-up, the proportion injecting heroin declined whilst the proportion injecting methamphetamine, midazolam, or combinations of these drugs increased. Controlling for heroin use and other risk factors, participants injecting methamphetamine were more likely to become HIV-infected than participants not injecting methamphetamine. Additional HIV prevention tools are urgently needed including tools that address methamphetamine use.
 
Article
This paper documents the operation of Australia's Ecstasy and Related Drugs Reporting System (EDRS), using multiple data sources to document trends in gamma-hydroxybutyrate (GHB) use in Sydney, Australia between the years 2000-2006. The EDRS monitors trends in ecstasy and related drug markets by means of a triangulation of data from interviews with regular ecstasy users (REU), surveys with key experts (KE), and analysis of secondary indicator data sources. The proportion of REU reporting lifetime GHB use increased from 5% in 2000 to 40% in 2006 and the proportion reporting recent use increased from 1% in 2000 to 21% in 2006. KE reports suggest GHB use may be a concern amongst specific drug user subcultures. REU and KE data suggest a change in the locations in which GHB is used, with a shift from dance venues and events to private homes and parties. There is a lack of indicator data from both health and law enforcement data collection systems concerning GHB. The EDRS has effectively monitored the increase in GHB amongst REU over the past seven years in Sydney, Australia. This increase is unlikely to have been as readily identified by other surveillance systems.
 
Article
This paper uses Australian heroin seizure data, along with estimates of the size of the Australian heroin market to evaluate the impact of drug law enforcement on the 2001 Australian heroin shortage from the percentage of the market seized. It also critically examines international heroin production trends and published reports on the causes of the Australian heroin shortage. Its conclusion is that previous studies may have overstated the success of drug law enforcement and that the most likely explanation for Australia's 2001 heroin shortage was a significant decline in heroin production world-wide, due to a general move away from heroin production in the countries of Southeast Asia and the prohibition on opium growing by the Taliban regime in Afghanistan.
 
Article
Injecting drug use is a major driver of the HIV epidemic globally. Whilst robust evidence points to the effectiveness of harm reduction programmes to halt and reverse injecting drug use driven epidemics, uptake of these programmes in developing and transitional countries has been slow. In part, this slow uptake stems from inadequate financial resources for harm reduction; legal, socio-cultural and medical barriers leading to stigmatisation; and weak health systems unequipped to manage marginalized groups. The Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2002, has become the major multilateral source of external funding for harm reduction programmes in countries experiencing concentrated HIV epidemics driven by injecting drug use. Between 2004 to end of 2008, the Global Fund invested around US$180 million in harm reduction programmes in 42 countries. This funding has helped to initiate and scale up harm reduction programmes in settings where domestic funding was lacking. In addition to financing harm reduction programmes globally, the Global Fund has stimulated a strong dialogue between vulnerable groups and governments. Furthermore, the Global Fund has engaged in a dialogue with countries to encourage an evidence-based approach to policy-making that recognizes the immense value of harm reduction in HIV prevention and control.
 
Distribution of Global Fund investments for major interventions and cost categories. Note: Percentages are rounded.
Budgeted and projected Global Fund investments for people who inject drugs. Note: Round 9 grants include “single stream of funding” grants, where new proposals are consolidated with existing grants to the same recipient in order to simplify the Global Fund grant architecture (Global Fund, 2011d).
of Global Fund investments for major interventions and cost categories (US$ millions).
Article
Injecting drug use has been documented in 158 countries and is a major contributor to HIV epidemics. People who inject drugs have poor and inequitable access to HIV services. The Global Fund to Fight AIDS, Tuberculosis and Malaria is the leading multilateral donor for HIV programmes and encourages applicants to include harm reduction interventions in their proposals. This study is the first detailed analysis of Global Fund investments in harm reduction interventions. The full list of more than 1000 Global Fund grants was analysed to identify HIV grants that contain activities for people who inject drugs. Data were collected from the detailed budgets agreed between the Global Fund and grant recipients. Relevant budget lines were recorded and analysed in terms of the resources allocated to different interventions. 120 grants from 55 countries and territories contained activities for people who inject drugs worth a total of US$ 361 million, increasing to US$ 430 million after projections were made for grants that had yet to enter their final phase of funding. Two-thirds of the budgeted US$ 361 million was allocated to core harm reduction activities as defined by the United Nations. Thirty-nine of the 55 countries were in Eastern Europe and Asia. Only three countries with generalised HIV epidemics had grants that included harm reduction activities. This study represents the most comprehensive assessment of Global Fund investments in harm reduction. This funding, while substantial, falls short of the estimated needs. Investments in harm reduction must increase if HIV transmission among people who inject drugs is to be halved by 2015.
 
Article
Providing equitable access to highly active antiretroviral treatment (HAART) to injecting drug users (IDUs) is both feasible and desirable. Given the evidence that IDUs can adhere to HAART as well as non-IDUs and the imperative to provide universal and equitable access to HIV/AIDS treatment for all who need it, here we examine whether IDUs in the 52 countries in the WHO European Region have equitable access to HAART and whether that access has changed over time between 2002 and 2004. We consider regional and country differences in IDU HAART access; examine preliminary data regarding the injecting status of those initiating HAART and the use of opioid substitution therapy among HAART patients, and discuss how HAART might be better delivered to injecting drug users. Our data adds to the evidence that IDUs in Europe have poor and inequitable access to HAART, with only a relatively small improvement in access between 2002 and 2004. Regional and country comparisons reveal that inequities in IDU access to HAART are worst in eastern European countries.
 
Article
Media reporting on illicit issues has been frequently criticised for being sensationalised, biased and narrow. Yet, there have been few broad and systematic analyses of the nature of reporting. Using a large sample and methods commonly adopted in media communications analysis this paper sought to identify the dominant media portrayals used to denote illicit drugs in Australian newspapers and to compare and contrast portrayals across drug types. A retrospective content analysis of Australian print media was carried out over the period 2003-2008 from a sample comprised of 11 newspapers. Articles that contained one or more mention of five different drugs (or derivatives) were identified: cannabis, amphetamines, ecstasy, cocaine and heroin. A sub-sample of 4397 articles was selected for media content analysis (with 2045 selected for full content analysis) and a large number of text elements coded for each. Key elements included topic, explicit or implicit messages about the consequences of drugs/use and three value dimensions: overall tone, whether drugs were portrayed as a crisis issue and moral evaluations of drugs/use. The dominant media portrayals depicted law enforcement or criminal justice action (55%), but most articles were reported in a neutral manner, in the absence of crisis framings. Portrayals differed between drugs, with some containing more narrow frames and more explicit moral evaluations than others. For example, heroin was disproportionately framed as a drug that will lead to legal problems. In contrast, ecstasy and cocaine were much more likely to emphasise health and social problems. Media reporting on illicit drugs is heavily distorted towards crime and deviance framings, but may be less overtly sensationalised, biased and narrowly framed than previously suggested. This is not to suggest there is no sensationalism or imbalance, but this appears more associated with particular drug types and episodes of heightened public concern.
 
Article
In January 2004 the British government announced that cannabis would be reclassified from Classes B to C, taking into account its level of harmfulness for human health and considering the penalties for possession and supplying. It was argued by the Government, that cannabis reclassification would save some resources and stop the criminalisation of otherwise law-abiding citizens. One year later, in 2005 the discussion about cannabis reclassification shifted from the argument about efficiency in the use of resources toward a debate about the effects of cannabis on mental health. The purpose of this article is to determine what happened between these two moments, and how the discussion originally formulated in terms of public management and efficiency became a matter of both mental health and criminality. Using a post-Structuralist approach, based on selected ideas from the French philosopher Michel Foucault, and supported by extensive research, this article proposes that the political decision regarding cannabis reclassification can be understood as part of the re-definition of the 'cannabis problem' and hence, the creation of a new type of 'cannabis user'. Although the debate took place in the United Kingdom, the main arguments can be extended to other reforms on cannabis legislation in other European countries.
 
Article
Despite Thailand's war on drugs, methamphetamine ("yaba" in Thai) use and the drug economy both thrive. This analysis identifies predictors of incident and recurrent involvement in the sale or delivery of drugs for profit amongst young Thai yaba users. Between April 2005 and June 2006, 983 yaba users, ages 18-25, were enrolled in a randomized behavioural intervention in Chiang Mai Province (415 index and 568 of their drug network members). Questionnaires administered at baseline, 3-, 6-, 9-, and 12-month follow-up visits assessed socio-demographic factors, current and prior drug use, social network characteristics, sexual risk behaviours and drug use norms. Exposures were lagged by three months (prior visit). Outcomes included incident and recurrent drug economy involvement. Generalized linear mixed models were fit using GLIMMIX (SASv9.1). Incident drug economy involvement was predicted by yaba use frequency (adjusted odds ratio [AOR]: 1.05; 95% confidence interval [CI]: 1.01, 1.10), recent incarceration (AOR: 2.37; 95% CI: 1.07, 5.25) and the proportion of yaba-using networks who quit recently (AOR: .34; 95% CI: .15, .78). Recurrent drug economy involvement was predicted by age (AOR: 0.81; 95% CI: 0.68, 0.96), frequency of yaba use (AOR: 1.06; 95% CI: 1.02, 1.09), drug economy involvement at the previous visit (AOR: 2.61; CI: 1.59, 4.28), incarceration in the prior three months (AOR: 2.29; 95% CI: 1.07, 4.86), and the proportion of yaba-users in his/her network who quit recently (AOR: .38; 95% CI: .20, .71). Individual drug use, drug use in social networks and recent incarceration were predictors of incident and recurrent involvement in the drug economy. These results suggest that interrupting drug use and/or minimizing the influence of drug-using networks may help prevent further involvement in the drug economy. The emergence of recent incarceration as a predictor for both models highlights the need for more appropriate drug rehabilitation programmes and demonstrates that continued criminalization of drug users may fuel Thailand's yaba epidemic.
 
Article
The purpose of this paper was to examine the context of injection drug use in Kabul, Afghanistan among injection drug users (IDUs) utilising and not utilising needle and syringe programmes (NSPs). Following identification of themes from eight focus group discussions, free-lists were used for further exploration with both NSP using (n=30) and non-NSP using (n=31) IDUs. All participants were male, had been injecting for 5 years (mean), and most (95%) had been refugees in the past decade. Main reasons for sharing syringes were convenience and lack of availability and did not vary based on NSP use. Drug users perceived alienation from the community, evidenced by names used for drug users by the community which convey social stigma and moral judgment. Health risks were the principal stated risk associated with drug use, which was mentioned more frequently by NSP users. Harm reduction services available in Kabul are perceived to be insufficient for those in need of services, resulting in under utilisation. The limited scope and distribution of services was frequently cited both as an area for improvement among NSP using IDU or as a reason not to use existing programmes. While some positive differences emerged among NSP-using IDU, the current context indicates that both rapid scale-up and increased variety of services, particularly in the realm of addiction treatment, are urgently needed in this setting.
 
Article
There are many models that study aspects of smoking habits: the influence of price, tax, relapse time, and the effects of prohibition. There are also studies examining the effects of the Spanish smoke-free law. We wanted to build a model able to separate the effect of the law from the pre-law evolution of smoking habits. Using data from the Spanish Ministry of Health and Social Policy, we developed a dynamic model of tobacco use. The model projects the evolution over time of the number of non-smokers, smokers and ex-smokers before 2006. Then, we compared the predictions of the model with data for the years after the law came into force, 2006 and 2009. We show that smoke-free law has had a significant impact on different sub-populations. The number of ex-smokers increased significantly in 2006 and this increase was maintained in 2009. The number of smokers also decreased significantly in 2006, but in 2009 this returned to its value before the law. Simultaneously, the number of non-smokers decreased in 2009. When the law came into force (2006), its restriction on smoking in public and work places made many smokers decide to give up smoking, decreasing the number of smokers and increasing the number of ex-smokers. In 2009, the majority of those who succeeded in giving up smoking did not return to the habit. However, the smoke-free law had no effect on new smokers and the number of smokers returned to previous levels, whereas the number of non-smokers decreased. Therefore, we can conclude that the law had a very positive effect in the first few years but this has dissipated over time, with the exception of ex-smokers, whose number is still higher than before the law.
 
Article
Canadian injection drug users (IDUs) are at high risk of hepatitis C virus infection (HCV). However, little is known about the costs associated with their HCV-related medical treatment. We estimated the medical costs of treating HCV-infected IDUs from 2006 to 2026. We employed a Markov model of entry through birth or immigration to exposure-related behaviours or experiences, HCV infection, progression to HCV sequelae and mortality for active and ex-IDUs in Canada. We estimated direct and indirect treatment costs using data from the Ontario Case Costing Initiative (OCCI). Approximately 137,000 IDUs will suffer from HCV-related disease each year until 2026. Applying the OCCI cost data to the prevalence of HCV-related disease from 2006 to 2026 yielded an estimated cost of $3.96 billion CND to treat HCV-infected IDUs. Substantial costs are associated with the treatment of HCV-related disease among Canadian IDUs. Given the lack of effective HCV prevention strategies in Canada, we must develop targeted evidence-based responses to prevent HCV transmission and ensure appropriate allocation of medical resources to meet the present and future treatment needs of HCV-infected IDUs.
 
Article
Background: The last decade has seen the emergence of a new phenomenon in recreational substance use with the availability of herbal and synthetic, unregulated, psychoactive drugs in the market place; alongside this, international concern has developed in relation to their use and associated harms. New Zealand (NZ) was one of the first countries to experience this new phenomenon, with products containing chemicals of the piperazine group - mainly benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP). In 2008, the NZ Government prohibited these substances, but allowed a 6-month amnesty period for possession. Our study aimed to obtain a measure of change in BZP use over time. Methods: This study used a longitudinal, web-based survey, with data collected at two time points from the same participants. The first survey was carried out 3 months after BZP prohibition, and included retrospective questions for the 6 months preceding the survey. The second survey was conducted 9 months after prohibition and also included retrospective questions for the 6 months preceding the survey. Results: 273 sets of paired data were identified. The use of BZP party pills (p<0.0001) and legally available smokeable products (p=0.002) reduced over time. A majority of users of party pills obtained them from friends or from their own stockpiled supplies. The misuse of prescription drugs (p=0.02) increased over time, whereas statistically significant increases in stimulant or alcohol use were not noted. Conclusion: Following prohibition of piperazine-based party pills, we noted a significant reduction in the proportions of participants using them. The observed increase in the misuse of prescription medicines may relate to their perceived 'quality', or as being less 'illegal' than illicit drugs.
 
Article
Police presence within street-based drug scenes has the potential to disrupt injection drug users' (IDUs) access to health services and prompt increased injection-related risk behaviour. We examined street-level policing in the Downtown Eastside (DTES) of Vancouver during the Olympic Winter games, to assess the potential impact on access to harm reduction services and injection-related risk behaviour. We analysed data from observational activities documenting police and drug user behaviour, unstructured interviews with drug users in street settings (n=15), expert interviews with legal and health professionals (n=6), as well as utilisation statistics from a local supervised injection facility (SIF). Although police presence was elevated within the DTES during the Olympics, there was little evidence to suggest that police activities influenced IDUs' access to health services or injection-related risk behaviour. SIF attendance during the Olympics was consistent with regular monthly patterns. Police presence during the Olympics did not reduce access to health services amongst local IDUs or prompt increased injection-related risk behaviour. Increased cooperation between local law enforcement and public health bodies likely offset the potential for negative health consequences resulting from police activity.
 
Article
Between late 2010 and mid 2011 there was a significant heroin shortage in the United Kingdom (UK), resulting in a rapid drop in street heroin purity and increase in price. The most well documented event of this kind is the 2000-2001 Australian heroin shortage, with little published research addressing the UK context. In this paper we draw on qualitative data to explore the impact of, and responses to, the 2010/2011 shortage among London-based heroin users. Data collection comprised longitudinal life history and narrative interviews with 37 PWID in 2010-2011. The average age of participants was 40, with a 20-year average duration of injecting. Heroin was the drug of choice for the majority of participants (25), with 12 preferring to inject a crack-cocaine and heroin mix. Recruitment took place through London drug and alcohol services and peer networks. The majority of participants continued to source and inject heroin despite reported decline in purity and increased adulteration. Transitions to poly-drug use during the heroin shortage were also common, increasing vulnerability to overdose and other drug related harms. Participants enacted indigenous harm reduction strategies in attempting to manage changes in drug purity and availability, with variable success. Epidemiological data gathered during periods of heroin shortage is often drawn on to emphasise the health benefits of reductions in supply. Our findings highlight the importance of understanding the ways in which heroin shortages may increase, as well as reduce, harm. There is a need for enhanced service provision during periods of drug shortage as well as caution in regard to the posited benefits of supply-side drug law enforcement. Copyright © 2014 Elsevier B.V. All rights reserved.
 
Article
In 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an "accountability matrix", focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress. We searched peer-reviewed literature, conducted online searches, and contacted experts for 'grey' literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews. Policy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs. Prevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.
 
Article
Background: Injecting drug use (IDU) is a growing concern in Tanzania compounded by reports of high-risk injecting and sexual risk behaviours among people who inject drugs (PWID). These behaviours have implications for transmission of blood-borne viruses, including HIV and hepatitis C (HCV). Methods: We recruited 267 PWID (87% male) from Temeke District, Dar-es-Salaam through snowball and targeted sampling. A behavioural survey was administered alongside repeated rapid HIV and HCV antibody testing. HIV and HCV prevalence estimates with 95% confidence intervals (CIs) were calculated. Results: Among PWID, 34.8% (95%CI 29.1-40.9) tested HIV positive (29.9% of males and 66.7% of females); 27.7% (95%CI 22.0-34.0) tested HCV antibody positive. Almost all (97%) participants were aware of HIV and 34% of HCV. 45% of male and 64% of female PWID reported a previous HIV test; only five (2%) PWID reported a previous HCV test. Of HIV and HCV positive tests, 73% and 99%, respectively, represented newly diagnosed infections. Conclusion: High prevalence of HIV and HCV were detected in this population of PWID. Rapid scale-up of targeted primary prevention and testing and treatment services for PWID in Tanzania is needed to prevent further transmission and consequent morbidities.
 
Article
Background: A plant with dissociative and psychoactive properties began to attract the attention of the media and United States policymakers following a well-publicized suicide in 2006 and reports that the plant served as a 'legal high' and substitute for cannabis. As a result, Salvia divinorum and its active ingredient, salvinorin A, were classified as Schedule I substances by the Florida Legislature on July 1, 2008. As of yet, no research has explored the efficacy of this policy or similar policies in other jurisdictions. Methods: Three self-report studies collected from young adults both prior to and following the policy's implementation are employed to investigate the potential relationship between the policy and usage rates. In addition, law enforcement personnel from the state's most populated areas were interviewed to determine the extent to which they were encountering salvia in their work. Results: It was indicated that less than two-thirds of those surveyed were aware of the drug's legal status. Lifetime prevalence of salvia use was largely unchanged. However, the rates of self-reported past year and past month use in Florida were significantly lower following the scheduling. Though use of Salvia divinorum appears to have decreased, perceptions of peer use increased markedly. Law enforcement officers and laboratories reported rarely, if ever, dealing with cases of salvia possession. Conclusions: Data suggests the classification of Salvia divinorum as a Schedule I drug was followed by a substantial reduction in recreational use. We caution that other factors may have influenced use, that the efficacy of scheduling novel substances is likely to vary by drug type, that such a reduction in reported use may only exist transiently until a sophisticated illicit market develops to replace the legitimate one, and that a state's success in regulating salvia may be related to their regulation of and enforcement of other drug prohibitions.
 
Article
Background: Scientific consensus holds that if, at the outset of the HIV/AIDS epidemic, injection drug users (IDUs) had had better access to sterile syringes, much of the epidemic among IDUs in the U.S. could have been prevented. In the context of preventing infectious diseases, 100% syringe coverage - that is, one sterile syringe per injector for each injection - is a public health goal. Notably, we know little about variations in syringe coverage within the U.S. and elsewhere, or about the social and political factors that might determine this coverage. Methods: Using data from Holmberg (1996), the 1990 United States Census, the 2000 Beth Israel National Syringe Exchange Survey (n=72), and estimates of IDUs in metropolitan areas (MSAs); (Friedman et al., 2004), we explore the impact of (1) political factors (ACT UP, outreach, early syringe exchange programme (SEP) presence, men who have sex with men (MSM) per capita, drug arrests, and police per capita); (2) local resources for SEPs; and (3) indicators of socioeconomic inequality on SEP coverage. We define "syringe coverage" as the ratio of syringes distributed at SEPs to the number of syringes heroin injectors need in a year. We calculated the number of syringes heroin injectors need in a year by multiplying an estimate of the number of IDUs in each MSA by an estimate of the average number of times heroin injectors inject heroin per year (2.8 times per day times 365 days). In this analysis, the sample was limited to 35 MSAs in which the primary drug of choice among injectors was heroin. Results: SEP coverage varies greatly across MSAs, with an average of 3 syringes distributed per 100 injection events (S.D.=0.045; range: 2 syringes per 10 injection events, to 3 syringes per 10,000 injection events). In bivariate regression analyses, a 1 unit difference in the proportion of the population that was MSM per 1000 was associated with a difference of 0.002 in SEP coverage (p=0.052); early SEP presence was associated with a difference of 0.038 in coverage (p=0.012); and having government funding was associated with a 0.040 difference in SEP coverage (p=0.021). Conclusions: This analysis suggests that longer duration of SEP presence may increase syringe distribution and enhance successful programme utilization. Furthermore, MSAs with greater proportions of MSM tend to have better SEP coverage, perhaps providing further evidence that grassroots activism plays an important role in programme implementation and successful SEP coverage. This research provides evidence that government funding for SEPs contributes to better syringe coverage.
 
Article
A prior study concluded that drug treatment coverage, defined as the percentage of injection drug users in drug treatment, varied from 1 percent to 39 percent (median 9 percent) in 96 metropolitan statistical areas (MSAs) in the United States. Here, we determine which metropolitan area characteristics are associated with drug treatment coverage. We conducted secondary analysis of official data, including the number of injection drug users in treatment and other variables, for 94 large US MSAs. We estimated the number of injection drug users in these metropolitan areas using previously described methods. We used lagged cross-sectional analyses where the independent variables, chosen on the basis of a Theory of Community Action, preceded the dependent variable (drug treatment coverage) in time. Predictors were determined using ordinary least squares multiple regression and confirmed with robust regression. Independent predictors of higher drug treatment coverage for injectors were: presence of organisations that support treatment (unstandardized beta=1.64; 95 percent CI .59 to 2.69); education expenditures per capita in the MSA (unstandardized beta=.12; 95 percent CI -.34 to 2.69); lower percentage of drug users in treatment who are non-injection drug users (unstandardized beta=-0.18; 95 percent CI -0.24 to -0.12); higher percentage of the population who are non-Hispanic White (unstandardized beta=.14; 95 percent CI .08 to .20); lower per capita long-term debt of governments in the metropolitan area (unstandardized beta=-0.93; 95 percent CI -1.51 to -0.35). In conditions of scarce treatment coverage for drug injectors, an indicator of epidemiologic need (the per capita extent of AIDS among injection drug users) does not predict treatment coverage, and competition for treatment slots by non-injectors may reduce injectors' access to treatment. Metropolitan finances limit treatment coverage. Political variables (racial structures, the presence of organisations that support drug treatment, and budget priorities) may be important determinants of treatment coverage for injectors. Although confidence in these results would be higher if we had used a longitudinal design, these results suggest that further research and action that address structural, political, and other barriers to treatment expansion are sorely needed.
 
Top-cited authors
Tim Rhodes
  • London School of Hygiene and Tropical Medicine
Will Small
  • Simon Fraser University
Jason Grebely
  • UNSW Sydney
Lisa Maher
  • UNSW Sydney
Judith Aldridge
  • The University of Manchester