Article

The impact of methadone maintenance therapy on hepatitis C incidence among illicit drug users

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Abstract

AimsTo determine the relationship between methadone maintenance therapy (MMT) and hepatitis C (HCV) seroconversion among illicit drug users.DesignGeneralized Estimating Equation model assuming a binomial distribution and a logit link function was used to examine for a possible protective effect of MMT use on HCV incidence.SettingData from three prospective cohort studies of illicit drug users in Vancouver, Canada between 1996 and 2012.Participants1004 HCV antibody negative illicit drug users stratified by exposure to MMT.MeasurementsBaseline and semi-annual HCV antibody testing and standardised interviewer administered questionnaire soliciting self-reported data relating to drug use patterns, risk behaviours, detailed sociodemographic data and status of active participation in an MMT program.Findings184 HCV seroconversions were observed for an HCV incidence density of 6.32 [95% confidence interval [CI]: 5.44 – 7.31] per 100 person-years. After adjusting for potential confounders, MMT exposure was protective against HCV seroconversion (Adjusted Odds Ratio [AOR] = 0.47; 95% CI: 0.29 - 0.76). In sub-analyses, a dose-response protective effect of increasing MMT exposure on HCV incidence (AOR = 0.87; 95% CI: 0.78 – 0.97) per increasing 6-month period exposed to MMT was observed.Conclusion Participation in methadone maintenance treatment appears to be highly protective against hepatitis C incidence among illicit drug users. There appears to be a dose-response protective effect of increasing methadone exposure on hepatitis C incidence.

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... OMTs improve overall physical and mental health and social functioning abilities and decrease involvement in criminal activities associated with drug seeking behaviors. [51][52][53][54] NSPs are effective at decreasing HIV and hepatitis C transmission that results from needle sharing. 8,55 In Scott County, Indiana a public health emergency was declared on March 26, 2015 when 153 new cases of HIV developed over a 2-month period. ...
... Enrollment in a methadone maintenance program has been reported to be independently protective against hepatitis C seroconversion. 52 Methadone maintenance has also been demonstrated to decrease the incidence of HIV. 83 Methadone maintenance therapy has also been shown to improve access to HIV-related services by promoting testing and counseling for drug users and their partners. ...
Article
The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.
... Moreover, a controlled methadone or buprenorphine therapy also normalized the Th1/Th2 balance that was significantly unbalanced during chronic heroin use (41). The beneficial effect of methadone maintenance on immune system responses of heroin abusers has been consistently reported also more recently (42)(43)(44). Participation in methadone maintenance treatment was protective against hepatitis C incidence among illicit drug users and methadone exerted a dose-response protective effect on hepatitis C incidence (42). Naïve HIV-infected individuals using heroin and receiving methadone opioid substitution or controls (who never used opioids) were studied in the paper by Meijerink (44). ...
... The beneficial effect of methadone maintenance on immune system responses of heroin abusers has been consistently reported also more recently (42)(43)(44). Participation in methadone maintenance treatment was protective against hepatitis C incidence among illicit drug users and methadone exerted a dose-response protective effect on hepatitis C incidence (42). Naïve HIV-infected individuals using heroin and receiving methadone opioid substitution or controls (who never used opioids) were studied in the paper by Meijerink (44). ...
Article
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Suppression of the immune system has been constantly reported in the last years as a classical side effect of opioid drugs. Most of the studies on the immunological properties of opioids refer to morphine. Although morphine remains the “reference molecule,” other semisynthetic and synthetic opioids are frequently used in the clinical practice. The primary objective of this review is to analyze the available literature on the immunomodulating properties of opioid drugs different from morphine in preclinical models and in the human. A search strategy was conducted in PubMed, Embase, and the Cochrane databases using the terms “immunosuppression,” “immune system,” “opioids,” “Natural killer cells,” “cytokines,” and “lymphocytes.” The results achieved concerning the effects of fentanyl, methadone, oxycodone, buprenorphine, remifentanil, tramadol, and tapentadol on immune responses in animal studies, in healthy volunteers and in patients are reported. With some limitations due to the different methods used to measure immune system parameters, the large range of opioid doses and the relatively scarce number of participants in the available studies, we conclude that it is not correct to generalize immunosuppression as a common side effect of all opioid molecules.
... Mean estimates for Europe range between 53% and 66%, with higher HCV prevalence rates in Eastern Europe, in PWID who are >35 years of age and in low-threshold settings, such as drug consumption rooms [4,5,7]. Rates of chronic infection (HCV RNA positivity) among anti-HCV-positive PWID range between 53% and 97% in Europe with a median of 72%, and HCV incidence rates among PWID in Europe are ranging from 2.7 to 66 per 100 person-years (PY), with a median around 13 per 100 PY [8], and higher rates among current injectors or persons not in opioid substitution treatment (OST) [8][9][10]. ...
... As we have no estimates for the infection risk of dropouts, we consider the higher rate of 2.5 more appropriate. In both cases, the anti-HCV incidence is low and supports previous findings that OST has a strong protective effect [9,36], for example, through reducing drug-related risk behavior [31]. ...
Article
Background: Hepatitis C virus (HCV) infection is highly prevalent among people who inject drugs (PWID). Accurate data on HCV prevalence and incidence rates among patients receiving opioid substitution treatment (OST) are needed to estimate the current and future burden of HCV infections in this high-risk population. Methods: Baseline data from routine care were collected between October 2014 and June 2016 from randomly selected OST facilities in Germany. The primary outcome measure was the HCV status (antibody and RNA prevalence). Patients who were HCV antibody-negative at baseline were followed up after 12 months to calculate the HCV incidence rate. Results: Sixty-three facilities from 14 German Federal States provided clinical data for a total of 2466 OST patients. HCV antibody and HCV RNA prevalence were 58.8% (95% confidence interval [CI], 56.8%-60.8%) and 27.3% (95% CI, 25.5%-29.2%), respectively. At baseline, a total of 528 patients (21.4%) had previously undergone antiviral treatment. Moreover, lower HCV RNA prevalence was associated with female gender, employment, younger age, and shorter duration of OST and opioid dependence. The HCV incidence rate was 2.5 cases per 100 person-years. Conclusions: The low HCV RNA prevalence and HCV incidence rates confirm that OST in Germany is an effective setting both for treating chronic HCV infections and for preventing new infections among PWID. Scaling up the provision of OST, HCV testing, and HCV treatment among OST patients are important public health strategies for reducing HCV infections in this high-risk population.This nationwide prospective cohort study supports the protective effects of opioid substitution treatment by confirming a low hepatitis C virus (HCV) RNA prevalence rate (27.3%) and low HCV incidence rate (2.5 cases per 100 person-years) among 2467 opioid-substituted patients in Germany.
... Increases in opioid use in the United States (U.S.) have been associated with increased rates of drug related deaths and health conditions such as HIV, hepatitis C, and bacterial infections (Brady et al., 2016;Compton et al., 2016;Jones et al., 2017;Jones et al., 2015;Mars et al., 2019;Peters et al., 2016;Rudd et al., 2016;Winkelman et al., 2018;Wurcel et al., 2016;Zibbell et al., 2018). Medications for Opioid Use Disorder (MOUD), particularly methadone and buprenorphine, are associated with important public health benefits, including reduced rates of overdose (Degenhardt et al., 2009;Gerra et al., 2011;Sordo et al., 2017), reduced transmission of HIV and hepatitis C (HCV) (Nolan et al., 2014;Palepu et al., 2006;Uhlmann et al., 2010), and reduced criminal recidivism (Bellin et al., 1999;Macswain et al., 2014). However, individual life events, social processes, structural conditions, and large public health emergencies can diminish or impede access to, and use of, MOUD (Frank, 2020;Frank & Walters, 2021a). ...
Article
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Background Medications for Opioid Use Disorder (MOUD) are associated with important public health benefits. Program changes implemented in response to COVID-19 hold promise as ongoing strategies to improve MOUD treatment. Methods: MOUD patients on buprenorphine or methadone, providers, government regulators, and persons who use drugs not in MOUD were recruited in the Northeast region of the United States between June and October of 2020 via advertisements, fliers, and word of mouth. Semi-structured qualitative interviews were conducted. Interviews were professionally transcribed and thematically coded by two independent coders. Results: We conducted interviews with 13 people currently on buprenorphine, 11 currently on methadone, 3 previously on buprenorphine, 4 previously on methadone, and 6 who used drugs but had never been on MOUD. In addition, we interviewed MOUD providers, clinic staff, and government officials at agencies that regulate MOUD. Most participants found increased take-home doses, home medication delivery, and telehealth implemented during COVID-19 to be favorable, reporting that these program changes reduced travel time to clinics, facilitated retention in care, and reduced stigma associated with clinic attendance. However, some participants reported negative consequences of COVID-19, most notably, decreased access to basic resources, such as food, clothing, and harm reduction materials that had previously been distributed at some MOUD clinics. Conclusion: Access to and retention in MOUD can be lifesaving for persons using drugs. COVID-19-impelled program changes, including increased take-home doses, home medication delivery, and telehealth generally improved participants' experiences with MOUD. Making these permanent could improve retention in care.
... A systematic review of 38 observational studies (sample sizes: 18-726 people) found that receipt of either methadone or buprenorphine was associated with less injection drug use, less sharing of injection equipment, less exchange of sex for drugs, and lower likelihood of having multiple sex partners among people with OUD (Gowing et al., 2011). Two cohort studies found that receipt of methadone or buprenorphine was associated with lower risk of hepatitis C among persons with OUD (Nolan et al., 2014;Tsui et al., 2014). ...
Technical Report
Full-text available
Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for California Senate Bill 11 Mental Health Parity and Substance Use Medications
... As such, many jurisdictions are scaling up the provision of medications for the treatment of opioid use disorder, including methadone. Methadone has been shown to be more effective reducing drug-related harms than non-pharmacological outpatient treatment approaches [2], including reductions in overdose mortality [3] and the transmission of hepatitis C and HIV infection [4,5]. Enrolment in methadone has also been shown to reduce engagement in criminalised activities and promote HIV treatment initiation and adherence [6][7][8]. ...
Article
Introduction and Aims Opioid‐related overdoses are an epidemic in North America, prompting a greater use of medications for opioid use disorder, such as methadone. Although many people work toward overall drug abstinence while on methadone, a sub‐population of people with and without histories of polysubstance use engage in stimulant use while on methadone treatment. This study explores motivations for concurrent stimulant and methadone use in a street‐involved drug‐using population. Design and Methods Semi‐structured qualitative interviews were conducted with 39 people on methadone in Vancouver, Canada. Participants were recruited from among the participants in two community‐based prospective cohort studies consisting of HIV‐positive and HIV‐negative people who use drugs. Interview transcripts were analysed using an inductive and iterative approach. Results Our analysis identified three primary themes. First, participants articulated how stimulants were used to counter the sedating effects of methadone and enable them to engage in daily and survival activities (e.g. income generation). Second, participants described increased stimulant use to compensate for reduced stimulant intoxication while taking methadone. Finally, participants described the desire to achieve intoxication on stimulants once stable on methadone, as their substance use treatment goals did not involve drug abstinence. Discussion and Conclusion Among a street‐involved drug‐using population in which people do not have abstinence‐based treatment goals, there are several functional reasons to use stimulants concurrently while on methadone. A deeper and more nuanced understanding of substance use motivators may contribute to further research and inform policy and guideline changes that support low threshold and harm reduction‐focused methadone treatment programs and other interventions to reduce drug‐related harms.
... Repeated contacts with the hospital surroundings by getting admitted more number of times also may help in prolonging the abstinence of substance abuse patients. [18][19][20] Our study did not find any statistically significant influence of factors such as age, duration of drug use, age at initiation, employment status, marital status, and other in the multivariate analysis. ...
Article
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Background: Long-term abstinence in substance abuse patients is a great clinical challenge. A novel behavior modification program (BMP) for ensuring abstinence in substance abuse patients was being run in a tertiary care hospital in Jeddah, Saudi Arabia. The aim of this study was to evaluate the factors associated with the length of abstinence in substance abuse patients who were enrolled in this BMP. Methods: This was a record-based study, where patients were identified from the records of Al-Amal hospital. The study group consisted of adult male patients suffering from drug addiction, exposed to an initial detoxification treatment program and subsequently enrolled into BMP during the year 1424 Hijri, the reason of period selection that it was before the modification of inpatient BMP in the facility toward more outpatient one. Multiple stepwise regression with backward elimination was done to identify factors independently associated with length of abstinence in the BMP program. Results: Mean (SD) age of the participants was 31.9 (8.4) years and a majority had 6-9 years of education (65%), were single (63%), and unemployed (72%). Presence of mood disorder (b = 111.3; 62.3-160.3), good program attendance score (b = 33.2; 21.0-45.4), and higher total number of previous hospital admissions (b = 6.4; 3.1-9.6) were associated with a longer length of abstinence in the BMP program. Conclusion: A number of factors as described above can be utilized to modify the BMP and target different groups of patients who are less likely to stay abstinent for a longer duration, ensuring greater effectiveness of the BMP.
... The potential health benefits of MAT extend beyond a reduction in mortality. Patients in MAT programs are at less risk for hepatitis C and HIV seroconversion [12,13]. For those already HIV positive, MAT is associated with a decrease in the rate of antiretroviral treatment discontinuation and an increase in plasma HIV RNA suppression [14]. ...
... Comprehensive STI, HIV, and HCV care for incarcerated women includes: 1) universal screening with a clear choice to opt out; 2) rapid testing with systems to ensure women who have returned to the community receive results; 3) a treatment-as-prevention approach to continuation and initiation of medications for HIV and HCV with linkage to care in the community following incarceration; and 4) funding, implementation, and evaluation of prevention interventions. These interventions include bio-behavioral strategies such as pre-exposure prophylaxis (PrEP) for HIV and medication-assisted treatment (MAT) for opioid use disorder to reduce risk for HCV as well as education, skills training, housing, and employment assistance [21]. ...
Article
Women who are involved in the criminal justice system experience poorer reproductive health outcomes. Resolving this inequality will require addressing reproductive health disparities facing incarcerated women, improving the health of criminal justice-involved women in the community, and preventing engagement of women with the criminal justice system altogether.
... 7,8 Opioid use disorder can be readily treated with agonist medications for opioid use disorder (MOUD), methadone and buprenorphine, reducing illegal activity and recidivism, improving functioning, decreasing mortality and transmission of infectious diseases like HIV and HCV, and substantially reducing costs. [9][10][11][12][13][14][15][16] Long-acting naltrexone, an opioid antagonist, is a newer medication for OUD and data demonstrate effectiveness for reducing opioid use, but challenges with initiation and retention. [17][18][19][20] A major challenge in breaking the cycle of OUD and illegal behaviors, and related morbidity and mortality, is seamlessly getting individuals on MOUD as they leave jail or prison. ...
Article
Full-text available
Purpose: Opioid use disorder (OUD) is a medical condition that is effectively treated with medications. A major challenge in breaking the cycle of OUD and related illegal activity is seamlessly introducing medications for opioid use disorder (MOUD) as individuals leave jail or prison. We examined the feasibility of a pilot intervention to link participants to ongoing MOUD and psychosocial supports following release from custody. Methods: The study enrolled adults with a history of OUD released from Washington State prisons to Department of Corrections (DOC) community supervision. Participants were randomized to the study intervention or comparison group. The intervention consisted of education on OUD and available treatments, support with individualized treatment decision making, and continued care navigation for 6 months to facilitate linkage to chosen treatments. Participants randomized to the control condition received referral to services in the community from their community corrections officers. A care navigation activity log documented intervention participants' intervention engagement, service utilization, and needs. Follow-up interviews were conducted at 1 and 6 months to assess satisfaction with the intervention. Results: Fifteen participants were enrolled. All were male, most were white (86.6%) and the average age was 36.9 years. The majority (14 of 15 participants) were near-daily heroin users with severe OUD prior to incarceration. Of the seven intervention participants, two wished to start medications immediately. Three participants reported starting buprenorphine or methadone in the subsequent follow-up period, with or without social support and/or outpatient counseling, and three reported enrolling in social support and/or outpatient counseling without medications. Participants who received the intervention reported high satisfaction. We discuss barriers and facilitators to study implementation. Conclusion: An intervention to link participants to ongoing MOUD and psychosocial supports following release from prison had broad acceptability among participants and was feasible to implement among those recruited; however, enrollment was much lower than anticipated and the study intervention did not demonstrate the intended effect to facilitate use of MOUD immediately post-release in this small sample of participants. Given recent research showing benefits of pre-release medication initiation, the potential added benefits of this two-part intervention should be studied in systems that initiate MOUD prior to release.
... A systematic review of 38 observational studies (sample sizes: 18-726 subjects) found that receipt of either methadone or buprenorphine was associated with less injection drug use, less sharing of injection equipment, less exchange of sex for drugs, and lower likelihood of having multiple sex partners among people with OUD (Gowing et al., 2011). Two cohort studies found that receipt of methadone or buprenorphine was associated with lower risk of hepatitis C among persons with OUD (Nolan et al., 2014;Tsui et al., 2014). ...
Technical Report
Full-text available
Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for Medication-Assisted Treatment
... A systematic review by Mattick et al. [2] found that patients were 34% more likely to be retained in programmes which offered methadone maintenance therapy compared to programmes which did not, such as detoxification or drug-free rehabilitation [2]. OAT has been associated with reductions in injection risk behaviour [3], human immunodeficiency virus (HIV) and incidence of hepatitis C virus (HCV) infection [4][5][6][7], mortality, both all-cause and mortality due to overdose [8], crime [2] and mental health problems [9]. Additionally, OAT has been associated with increased HIV and HCV testing and linkage to care [10]. ...
Article
Aims To estimate incidence and predictors of opioid agonist therapy (OAT) discontinuation in a national cohort of people who inject drugs (PWID). Design and Setting Annually repeated cross‐sectional sero‐surveillance among PWID attending ~50 needle syringe programs across Australia. Participants Between 1995‐2018, 2,651 PWID who reported current OAT and had subsequent survey participation completed 6,739 surveys. Respondents were followed over 11,984 person‐years of observation (PYO). Respondents were predominantly male (60%), and the median age was 34 years. Heroin was the most commonly reported drug last injected (46%), and methadone was the most commonly prescribed OAT (77%). Measurements The primary outcome was discontinuation of OAT (methadone, buprenorphine or buprenorphine‐naloxone). Among respondents who reported current OAT, those who did not report current OAT in all subsequent records were defined as discontinued, and those with current OAT at all subsequent records were defined as retained. Predictors of discontinuation included self‐reported demographic (sex, location, Indigenous status) and drug use characteristics (drug last injected, frequency of injection). Findings Just under one third of respondents (29%) reported an OAT discontinuation event. The crude discontinuation rate was 6.3 (95% confidence intervals [CI]=5.9‐6.8) per 100 PYO. Discontinuation was significantly higher among respondents who reported last injecting pharmaceutical opioids (adjusted hazard ratio [aHR] 1.75, 95% CI=1.41‐2.17, p <0.001), being prescribed buprenorphine (aHR 1.44, 95% CI=1.18‐1.76, p =0.001) or buprenorphine‐naloxone (aHR 1.68, 95% CI=1.20‐2.34, p =0.002), daily or more frequent injection (aHR 1.51, 95% CI=1.23‐1.85, p <0.001), recent public injecting (aHR 1.37, 95% CI=1.17‐1.60, p <0.001), incarceration in the previous 12 months (aHR 1.31, 95% CI=1.05‐1.64, p =0.017), recent receptive syringe or injection equipment sharing (aHR 1.28, 95% CI=1.10‐1.48, p =0.001), and male sex (aHR 1.27, 95% CI=1.09‐1.47, p =0.002). Conclusion People who inject drugs attending needle syringe programs in Australia appear to be significantly more likely to discontinue opioid agonist treatment if they were prescribed buprenorphine or buprenorphine‐naloxone compared with methadone, are male, or report injection risk behaviours and recent incarceration.
... However, OAT does not curtail use of stimulants, benzodiazepines, or alcohol and its efficacy can be compromised by continued use of these substances. Nevertheless, OAT has been shown to reduce the incidence of primary HCV infection [5,6], and it holds promise to reduce the risk of HCV reinfection following HCV treatment [7]. Nationwide, over 375 000 patients receive OAT in the form of methadone or buprenorphine from approximately 1500 opioid treatment programs (OTPs) [8], and conservative estimates suggest that over 60% of PWID in OTPs are infected with HCV [9]. ...
Article
Full-text available
Background: Direct acting antiviral (DAA) therapy is highly effective in PWID; however, rates, specific injection behaviors, and social determinants of drug use associated with HCV reinfection following DAA therapy among PWID on opioid agonist therapy (OAT) are poorly understood. Methods: PREVAIL was a randomized control trial that assessed models of HCV care for 150 PWID on OAT. Those who achieved SVR (n=141; 94%) were eligible for this extension study. Interviews and assessments of recurrent HCV viremia occurred at 6-month intervals for up to 24 months following PREVAIL. We used survival analysis to analyze variables associated with time to reinfection. Results: Of 141 who achieved SVR, 114 had a least one visit in the extension study (62% male, mean age 52). Injection drug use (IDU) after SVR24 was reported in 19% (n=22). HCV reinfection was observed in three participants. Over 246 person-years of follow-up, the incidence of reinfection was 1.22/100 person-years (95% CI 0.25-3.57). All reinfections occurred among participants reporting ongoing IDU. The incidence of reinfection in participants reporting ongoing IDU (41 person-years of follow-up) was 7.4/100 person-years (95% CI 1.5-21.6). Reinfection was associated with reporting ongoing IDU in the follow-up period (p<.001), a lack confidence in the ability to avoid contracting HCV (p<.001), homelessness (p=.002), and living with a PWID (p=.007). Conclusion: HCV reinfection was low overall, but more common among people with ongoing IDU following DAA therapy on OAT, as well as those who were not confident in the ability to avoid contracting HCV, homeless, or living with a person who injects drugs. Interventions to mediate these risk factors following HCV therapy are warranted.
... This low rate of HCV reinfection is similar to that in other studies such as C-EDGE CO-STAR [4,10], which also included PWID receiving MOUD, and the SIMPLIFY trial [11], which included PWUD with ongoing drug use not receiving MOUD. Overall, MOUD has been shown to reduce an individual's risk of acquiring HCV by about half [12][13][14]. ...
... A systematic review of 38 observational studies (sample sizes: 18-726 people) found that receipt of either methadone or buprenorphine was associated with less injection drug use, less sharing of injection equipment, less exchange of sex for drugs, and lower likelihood of having multiple sex partners among people with OUD (Gowing et al., 2011). Two cohort studies found that receipt of methadone or buprenorphine was associated with lower risk of hepatitis C among persons with OUD (Nolan et al., 2014;Tsui et al., 2014). ...
Research
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Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for medications for substance use disorder.
... La revue systématique de Wiessing et al. (2008) souligne des avantages tant pour la collectivité (réduction du crime, meilleur « fonctionnement » sociétal, etc.) que pour les personnes en traitement (RdM liée aux drogues, baisse de la mortalité, amélioration de la santé et des conditions économiques, etc.). Dans plusieurs pays, les TDO ont favorisé la diminution de la consommation d'opioïdes illicites et des surdoses (Corsi et al., 2009 ;Darke et al., 2007), la diminution des taux d'incidence des infections par le VIH et le VHC (Nolan et al., 2014 ;White et al., 2014) et l'amélioration de la qualité de vie (Karow et al., 2010 ;Villeneuve et al., 2006). Les TDO contribuent à la réduction de la criminalisation et de la marginalisation sociale des PUDI, ce qui leur permet de s'investir dans d'autres projets que la consommation (Beck, Guigard, Gautier, Palle et Obradovic, 2013 ;Coppel, 2002 ;Oliver et al., 2010). ...
Article
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Opioid Dependence Treatment seen by People who Actively Inject Dugs in Montreal In a study conducted in Montreal, we analysed the experience of opioid dependence treatment (ODT) for people who actively inject drugs (PWID). How does this substitution treatment fit into PWID’s self-acceptance in it’s in their bodily, emotional, psychological and social dimensions? What difficulties are these people confronted with when interacting with healthcare services? The results suggest that PWID may opt for ODT mainly to avoid the distressing symptoms of withdrawal and to disengage from a consumption-centred lifestyle. Although participants consider ODT as a way to improve their quality of life, they deplore the side effects, the associated stigma, and the difficulties in accessing and remaining in treatment. These difficulties contribute to making the experience of ODT one that is more consistent with a drug-centred lifestyle than one who breaks away from it.
... onist therapy is an effective strategy to reduce HCV risk behavior and active drug use (22,23). Nationwide, more than 375 000 patients receive OAT in the form of methadone or buprenorphine from approximately 1500 opioid treatment programs (OTPs) (24), and conservative estimates suggest that more than 60% of PWID in OTPs have HCV infection (25). ...
Article
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Background: Many people who inject drugs (PWID) are denied treatment for hepatitis C virus (HCV) infection, even if they are receiving opioid agonist therapy (OAT). Research suggests that HCV in PWID may be treated effectively, but optimal models of care for promoting adherence and sustained virologic response (SVR) have not been evaluated in the direct-acting antiviral (DAA) era. Objective: To determine whether directly observed therapy (DOT) and group treatment (GT) are more effective than self-administered individual treatment (SIT) in promoting adherence and achieving SVR among PWID receiving OAT. Design: Three-group, randomized controlled trial conducted from October 2013 to April 2017. (ClinicalTrials.gov: NCT01857245). Setting: Three OAT programs in Bronx, New York. Participants: Persons aged 18 years and older with genotype 1 HCV infection who were willing to receive HCV therapy on site in the OAT program. Of 190 persons screened, 158 were randomly assigned to a study group and 150 initiated treatment: DOT (n = 51), GT (n = 48), and SIT (n = 51). Intervention: 2 intensive interventions (DOT and GT) and 1 control condition (SIT). Measurements: Primary: adherence, measured by using electronic blister packs. Secondary: HCV treatment completion and SVR 12 weeks after treatment completion. Results: Mean age was 51 years; 65% of participants had positive results on urine drug testing during the 6 months before treatment, and 75% reported ever injecting drugs. Overall adherence, estimated from mixed-effects models using the daily timeframe, was 78% (95% CI, 75% to 81%) and was greater among participants randomly assigned to DOT (86% [CI, 80% to 92%]) than those assigned to SIT (75% [CI, 70% to 81%]; difference, 11% [CI, 5% to 18%]; Bonferroni-corrected P = 0.001). No significant difference in adherence was observed between participants randomly assigned to GT (80% [CI, 74% to 86%]) and those assigned to SIT (difference, 4.7% [CI, -2% to 11%]; Bonferroni-corrected P = 0.29). The HCV treatment completion rate was 97%, with no differences among groups (P = 0.53). Overall SVR was 94% (CI, 89% to 97%); the SVR rate was 98% in the DOT group, 94% in the GT group, and 90% in the SIT group (P = 0.152). Limitation: These findings may not be generalizable to PWID not enrolled in OAT programs. Conclusion: All models of onsite HCV care delivered to PWID in OAT programs resulted in high SVR, despite ongoing drug use. Directly observed therapy was associated with greater adherence than SIT. Primary funding source: National Institute on Drug Abuse and Gilead Sciences.
... Variables included as potential confounders were chosen based on previous literature [2,[4][5][6]20,21] and included: age; gender (male/female); recent incarceration (no/yes); recent OAT (no/yes/ineligible); and recent use of other addiction treatment services (detoxification, inpatient therapy or therapeutic community; no/yes). Age and gender were assessed at baseline; other variables were assessed at each visit with reference to the past 3 months. ...
Article
Background and Aims For most people who inject drugs (PWID), drug injecting follows a dynamic process characterized by transitions in and out of injecting. The objective of this investigation was to examine injecting cessation episodes of one‐ to three‐month duration as predictors of hepatitis C virus (HCV) acquisition. Design Cohort study. Setting Montréal, Canada. Participants 372 HCV‐uninfected (HCV RNA negative, HCV antibody positive or negative) PWID (mean age 39, 82% male, 45% HCV antibody positive) enrolled between March 2011 and June 2016. Measurements At three‐month intervals, participants completed an interviewer‐administered questionnaire and were tested for HCV particles (HCV RNA). At each visit, participants indicated whether they injected in each of the past three months (defined as three consecutive 30‐day periods). Injecting cessation patterns were evaluated on a categorical scale: persistent injecting (no injecting cessation in the past 3 months), sporadic injecting cessation (injecting cessation in 1/3 or 2/3 months), and short injecting cessation (injecting cessation in 3/3 months). Their association with HCV infection risk was examined using Cox regression analyses with time‐dependent covariates, including age, gender, incarceration, opioid agonist treatment, and other addiction treatments. Findings At baseline, 61%, 26%, and 13% of participants reported persistent injecting, sporadic injecting cessation, and short injecting cessation, respectively. HCV incidence was 7.5 per 100 person‐years (95%CI 5.9‐9.5; 916 person‐years of follow‐up). In adjusted Cox models, sporadic injecting cessation and short injecting cessation were associated with lower risks of incident HCV infection compared to persistent injecting [adjusted hazard ratios: 0.56 (95%CI 0.30‐1.04) and 0.24 (95%CI 0.09‐0.61), respectively]. Conclusion Short and sporadic injecting cessation episodes were common among a cohort of people who inject drugs in Montréal, Canada. Injecting cessation episodes appear to be protective against hepatitis C virus acquisition, particularly when maintained for at least three months.
... Opioid agonist therapy, with either methadone or buprenorphine, has been shown to reduce illicit opioid use [4] and downstream complications such as overdose [5,6], HIV [7], and HCV [8][9][10]. Buprenorphine, a partial µ-opioid receptor agonist, offers unique advantages over methadone, including less subjective euphoria and lower risk for side effects such as sedation [11]. ...
Article
Full-text available
Background Buprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program. Methods Clinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes. Results Among providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication. Conclusions Findings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.
... 8 MTP clinics employ well-established protocols for reducing opiate and other substance use and for reducing the incidence of human immunodeficiency virus (HIV) and HCV infections by reducing high-risk behavior of drug injection. [9][10][11][12] Moreover, longer retention in treatment was predictive of long term avoidance of substance use. 13,14 Although the HCV seroconversion (acquisition of new HCV infection) during MTP is low, 15 HCV seropositivity is already present in almost one-half of the patients when they enter an MTP. ...
Article
Objectives: Patient ignorance and bureaucratic obstacles prevent initiation of hepatitis C virus (HCV) treatment in patients participating in methadone treatment program. Despite high safety and efficacy of currently available oral medications, the rate of patient-initiated treatment remains low. We evaluated the impact of an interventional program on treatment success rate and factors associated with treatment engagement. Methods: An intervention performed from 2018 to 2020 included an on-site Fibroscan and hepatologist evaluation, anti-viral HCV treatment initiation, and close support and follow-up by a dedicated team. Demographic and medical data were collected and comparison between patients who completed vs. patients who did not complete HCV treatment was done. Results: Fifty-nine out of 74 HCV polymerase chain reaction-positive patients (79.7%) were willing and capable of undergoing on-site hepatologist and Fibroscan evaluations. Twelve (25%) of the participants had cirrhosis, 2 of whom were decompensated. Fifty of the 57 patients that got an anti-viral medication prescription (87%) initiated the treatment. Premature treatment discontinuation was rare (3 patients), intention-to-treat sustain virologic response (SVR) rate was 81% and per-protocol SVR rate was 97%. The rate of treatment initiation during the intervention was significantly higher than the patients' self-initiation rate (44 vs 12 patients). The main factors associated with successful completion of the care cascade was full abstinence from street drugs for 6 months before treatment initiation. Conclusions: Installing a hepatology clinic in an methadone treatment program center was associated with a 3-fold increase in the HCV treatment, with high adherence to treatment levels, and a high SVR rate. The main factor associated with low engagement to treatment was ongoing street drug use.
... In addition, while 9% of incident HIV cases in 2017 were attributed to injection drug use, recent outbreaks of HIV associated with injecting heroin and prescription opioids have additionally been reported in multiple sites around the country [66][67][68]. Treatment of OUD in office settings plays an important role in preventing spread of HCV [69][70][71] and HIV [72][73][74], as well as helping patients access screening and care for these viral infections. ...
Article
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Purpose of review: The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. Recent findings: The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.
... Medications are effective treatment for OUD. Opioid agonist therapy (OAT), namely methadone and buprenorphine, significantly reduces illicit opioid use [10], opioid overdose [11], HIV [12] and HCV infection [13][14][15]. Buprenorphine, a partial μ-opioid receptor agonist, confers some advantages over methadone, in that it provides less sedation, overdose risk and abuse potential [16]. Many patients prefer buprenorphine over methadone treatment in part, due to greater autonomy related to the system in which it is delivered in the United States (US) [17][18][19]. ...
Article
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Background: Office-based buprenorphine treatment of opioid use disorder (OUD) does not typically include in-person directly observed therapy (DOT), potentially leading to non-adherence. Video DOT technologies may safeguard against this issue and thus enhance likelihood of treatment success. We describe the rationale and protocol for the Trial of Adherence Application for Buprenorphine treatment (TAAB) study, a pilot randomized controlled trial (RCT) to evaluate the effects of video DOT delivered via a smartphone app on office-based buprenorphine treatment outcomes, namely illicit opioid use and retention. Methods: Participants will be recruited from office-based opioid addiction treatment programs in outpatient clinics at two urban medical centers and randomized to either video DOT (intervention) delivered via a HIPAA-compliant, asynchronous, mobile health (mHealth) technology platform, or treatment-as-usual (control). Eligibility criteria are: 18 years or older, prescribed sublingual buprenorphine for a cumulative total of 28 days or less from the office-based opioid treatment program, and able to read and understand English. Patients will be considered ineligible if they are unable or unwilling to use the intervention, provide consent, or complete weekly study visits. All participants will complete 13 in-person weekly visits and be followed via electronic health record data capture at 12- and 24-weeks post-randomization. Data gathered include the following: demographics; current and previous treatment for OUD; self-reported diversion of prescribed buprenorphine; status of their mental and physical health; and self-reported lifetime and past 30-day illicit substance use. Participants provide urine samples at each weekly visit to test for illicit drugs and buprenorphine. The primary outcome is percentage of weekly urines that are negative for opioids over the 12-weeks. The secondary outcome is engagement in treatment at week 12. Discussion: Video DOT delivered through mHealth technology platform offers possibility of improving patients' buprenorphine adherence by providing additional structure and accountability. The TAAB study will provide important preliminary estimates of the impact of this mHealth technology for patients initiating buprenorphine, as well as the feasibility of study procedures, thus paving the way for further research to assess feasibility and generate preliminary data for design of a future Phase III trial. Trial Registration ClinicalTrails.gov, NCT03779997, Registered on December 19, 2018.
... The use of medications for opioid use disorder has been shown to reduce the risk of HCV transmission by as much as 50% [32]. Methadone, buprenorphine, and naltrexone are all Food and Drug Administration (FDA) approved treatments, although methadone maintenance therapy is more highly regulated in the United States and must be administered in dedicated dispensing clinics. ...
Article
The opioid epidemic in the United States, along with a lack of adequate harm reduction services, has contributed to a sharp rise in hepatitis C virus (HCV) infections. Despite considerable evidence of the effectiveness of HCV treatment in people who inject drugs (PWID), and recommendations from clinical guidelines to prioritize treatment in PWID, there are multiple barriers to broad uptake of HCV treatment. These barriers exist at the systems level, as well as at the level of medical providers and patients. Interventions to remove treatment barriers in the United States include harm reduction services, simplifying HCV testing algorithms, improved linkage to HCV care services, and application of new treatment models including colocating services at substance use disorder treatment programs. By following the lead of other countries who have addressed the barriers to HCV treatment, the United States has opportunities to do better in addressing the consequences of the opioid epidemic, including chronic HCV infection.
... A systematic review of 38 observational studies (sample sizes: 18-726 people) found that receipt of either methadone or buprenorphine was associated with less injection drug use, less sharing of injection (Gowing et al., 2011). Two cohort studies found that receipt of methadone or buprenorphine was associated with lower risk of hepatitis C among persons with opioid use disorder (Nolan et al., 2014;Tsui et al., 2014). ...
Technical Report
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For commercial/CalPERS enrollees with coverage for outpatient prescription medications, Senate Bill (SB) 854 would require on-formulary, low-tier coverage of Food and Drug Administration (FDA) approved substance use disorder (SUD) medications and would prohibit some utilization management. It would also prohibit requiring prior authorization for coverage of counseling, the behavioral health treatment used “in conjunction” with those medications. In 2020, 62% of the 21.7 million Californians enrolled in state-regulated health insurance would have health insurance required to comply with SB 854.
... Research has found medication for opioid use disorder (MOUD) employing methadone maintenance therapy (MMT) or buprenorphine maintenance therapy (BMT) to have multiple positive effects, including reducing patients' illegal activity, drug use frequency, HIV risk behaviors, hepatitis C (HCV) transmission, and overdose episodes (Altice et al., 2011;Magura et al., 1998;Mlunde et al., 2016;Nolan et al., 2014;Palepu et al., 2006;White et al., 2014). However, these benefits can only be attained if prospective patients enroll in and adhere to treatment. ...
Article
Background Research has shown medication for opioid use disorder (MOUD) to have positive effects, including reducing HIV and HCV transmission, but important barriers to access remain among people who inject drugs (PWID). Barriers include lack of social and familial support, bureaucracy, distance to treatment, poverty, and homelessness. However, we know little about how these barriers interact with each other to shape PWID's drug treatment access and retention. Methods We used qualitative methods with a dataset from a study conducted during 2019 with 31 active PWID residing in rural Puerto Rico. The study gathered ethnographic data and narratives about treatment trajectories to document the lived experiences of PWID as they moved in and out of treatment. Results Participants were at least 18 years old; 87.7% were male, the mean age was 44.1 years, and the mean age at first injection was 22 years. Participants identified homelessness, lack of proper ID or other identifying documents, and previous negative experiences with MOUD as the main barriers to treatment entry and retention. In addition, PWID's belief that MOUD simply substitutes an illegal drug for a legal one, while furthering drug dependence by chronically subjecting patients to treatment, constitutes an additional barrier to entry. Findings from this study demonstrate that MOUD barriers to access and retention compound and are severely affected by poverty and other forms of vulnerability among PWID in rural Puerto Rico. Conclusion Policies to increase access and retention should consider barriers not in isolation but as an assemblage of many factors.
... Retention on buprenorphine is associated with enhanced HCV outcomes leading to cure. 14 Treatment of OUD with medications is also associated with lower rates of HCV [15][16][17] and HIV 18,19 transmission. ...
Article
Background: Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. Objective: To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. Design: Retrospective observational cohort study using electronic health record and insurance data. Participants: Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). Main measures: The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. Key results: The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). Conclusions: Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.
... The most commonly used OAT medication are methadone (Methadose®) and buprenorphine/naloxone (Suboxone®), and less commonly slow-release oral morphine, injectable hydromorphone (iOAT), and prescribed injectable diacetylmorphine (heroin). Use of OAT, recommended in combination with harm reduction services and psychosocial supports (70)(71)(72)(73)(74), has been shown to reduce illicit opioid use and risk of overdose (72,(75)(76)(77)(78)(79)(80)(81)(82)(83), prevent transmission of bloodborne pathogens such as HIV and HCV (84)(85)(86)(87), and increasing engagement with health care (72,(88)(89)(90)(91). ...
... If the results of such studies align with previous research, these data can be used to argue for a less punitive approach that may ultimately lead to better rates of patient use and retention. Since MMT is associated with a number of benefits, including reduced rates of overdose (Gerra, Saenz, Busse, Maremmani, Ciccocioppo et al., 2011;Sordo, Barrio, Bravo, Indave, Degenhardt, et al., 2017;Degenhardt, Randall, Hall, Law, Butler, & Burns, 2009), reduced transmission of blood-borne viruses like HIV and HCV (Nolan, Dias Lima, Fairbairn, Kerr, et al., 2014;Uhlmann, Milloy, Kerr, Zhang, et al., 2010;Palepu, Tyndall, Joy, Kerr, Wood, et al., 2006;Litwin, Harris, Nahvi, Zamor, Soloway, et al., 2009), and recidivism (Macswain, Farrell-MacDonald, Cheverie, & Fischer, 2014;Bellin, Wesson, Tomasino, Nolan, et al., 1999), greater participation could have significant public health value (Bellin, Wesson, Tomasino, Nolan, et al., 1999). Moreover, the implementation of these regulatory changes has to be examined in greater detail. ...
Article
Methadone maintenance treatment (MMT) in the United States, and particularly the clinic system of distribution, is often criticized as punitive, over-regulated, and misaligned to the needs of many patients. However, changes to the regulations that COVID-19 caused may have provided an opportunity for improving service. This commentary uses literature and my own experience to provide a brief description of how MMT programs responded to the threat of Covid-19 and how such responses fit into the larger context of attempts to reform treatment. It discusses, in particular, opportunities for liberalizing “take-home” doses and implementing office-based MMT.
... For example, we have previously reported on transitions out of homelessness among ARYS participants [85] and injection cessation among VIDUS participants [86,87]. In addition, ARYS and VIDUS have previously been combined in quantitative and qualitative analyses [72,[88][89][90]. Third, social desirability and recall bias may have resulted in erroneous reporting of our outcome and independent variables. ...
Article
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Background: Nonmedical prescription opioid use (NMPOU) is a serious public health problem in North America. At a population-level, previous research has identified differences in the prevalence and correlates of NMPOU among younger versus older age groups; however, less is known about age-related differences in NMPOU among people who use illegal drugs. Methods: Data were collected between 2013 and 2015 from two linked prospective cohort studies in Vancouver, Canada: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Factors independently associated with NMPOU among younger (ARYS) and older (VIDUS) participants were examined separately using bivariate and multivariate generalized estimating equations. Results: A total of 1162 participants were included. Among 405 eligible younger participants (Median age = 25; Inter-Quartile Range [IQR]: 22-28), 40% (n = 160) reported engaging in NMPOU at baseline; among 757 older participants (Median age = 48, IQR: 40-55), 35% (n = 262) reported engaging in NMPOU at baseline. In separate multivariate analyses of younger and older participants, NMPOU was positively and independently associated with heroin use (younger: Adjusted Odds Ratio [AOR] = 3.12, 95% Confidence Interval [CI]: 2.08-4.68; older: AOR = 2.79, 95% CI: 2.08-3.74), drug dealing (younger: AOR = 2.22, 95% CI: 1.58-3.13; older: AOR = 1.87, 95% CI: 1.40-2.49), and difficulty accessing services (younger: AOR = 1.47, 95% CI: 1.04-2.09; older: AOR = 1.74, 95% CI: 1.32-2.29). Among the youth cohort only, NMPOU was associated with younger age (AOR = 1.12, 95% CI: 1.05-1.19), crack use (AOR = 1.56, 95% CI: 1.06-2.30), and binge drug use (AOR = 1.41, 95% CI: 1.00-1.97); older participants who engaged in NMPOU were more likely to report crystal methamphetamine use (AOR = 1.97, 95% CI: 1.46-2.66), non-fatal overdose (AOR = 1.76, 95% CI: 1.20-2.60) and sex work (AOR = 1.49, 95% CI: 1.00-2.22). Discussion: The prevalence of NMPOU is similar among younger and older people who use drugs, and independently associated with markers of vulnerability among both age groups. Adults who engage in NMPOU are at risk for non-fatal overdose, which highlights the need for youth and adult-specific strategies to address NMPOU that include better access to health and social services, as well as a range of addiction treatment options for opioid use. Findings also underscore the importance of improving pain treatment strategies tailored for PWUD.
... Near similar results were found by Fareed et al. [14] in their study, which reported that patients experiencing opioid dependence may have several factors that could increase their risk for DM. Nolan et al. [15] reported that HCV infection among drug users especially heroin was common. ...
Article
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Background Pulmonary problems result from either the pharmacological effects of the drug or are related to the method by which it is administered. Drugs can be administered either orally, inhaled, or given parentally usually by the intravenous route. Ingested drugs are generally safer, whereas injected drugs carry the greatest health risk. Aim To study the respiratory complications of addiction among civilian patients at Maadi Military Hospital. Settings and design This was a prospective comparative study. Patients and methods This study was conducted on 60 addicts who met the criteria for addiction among civilian patients who sought medical advice at Maadi Military Hospital during 6 months. All were investigated for sociodemographic, clinical, laboratory, and radiological data and outcome, for example, mortality. Statistical analysis Statistical package for social sciences program (SPSS) software version 18.0 was used for statistical analysis. Results Overall, 75% of addicts were males, 90% of patients were smokers, 61.7% of patients were intravenous drug abusers, and 33.3% had hepatitis C virus infection. All patients had cough and expectoration, 81.7% had chest pain, 80% of patients had dyspnea, and 41.7% had hemoptysis. Bacterial lung abscesses, tuberculosis, and pneumonia were present in 16.7, 21.7, and 33.3%, respectively. Overall, 33.3% of addicts had infective endocarditis, with highly significant increase in infective endocarditis in heroin, opioid, and polysubstance groups. Mortality rate was 25%, with no statistical significant difference between any of the groups (P=0.06). Conclusion Pleuropulmonary complications associated with drug abuse represent a serious medical and social problem nowadays. Keywords: addiction, drug abuse, pulmonary complications
... This is especially concerning given the high proportion of HIV uninfected individuals who had potential HCV transmission partners who were HIV infected. Our findings reinforce the need for interventions to increase uptake of harm reduction interventions, including syringe service programs, medication assisted treatment, frequent testing for both HIV and HCV, and immediate treatment to prevent and break transmission cycles for both HIV and HCV among PWID [29][30][31][32]. ...
Article
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Background The availability of effective, oral direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has put elimination of HCV as a public health challenge within reach. However, little is known about the characteristics of transmission networks of people who inject drugs (PWID). Methods Sequencing of a segment of the HCV genome was performed on samples collected from a community-based cohort of PWID between August 2005 and December 2016. Phylogenetic trees were inferred, and clusters were identified (70% bootstrap threshold; 0.04 maximum genetic distance threshold). We describe sex, race, age difference, and HIV infection status of potential transmission partners. Logistic regression was used to assess factors associated with being in an HCV cluster. Results Of 508 HCV genotype 1 viremic PWID, 8% (n = 41) were grouped into 20 clusters, consisting of 19 pairs and 1 triad. In adjusted analyses, female sex (odds ratio [OR] 2.3 [95% confidence interval (CI) 1.2–4.5]) and HIV infection (OR 5.7 [CI 2.7–11.9]) remained independently associated with being in an HCV infection cluster. Conclusions Molecular epidemiological analysis reveals that, in this cohort of PWID in Baltimore, HIV infection and female sex were associated with HCV clustering. Combination HCV prevention interventions targeting HIV infected PWID and addressing HCV infection prevention needs of women have potential to advance HCV elimination efforts.
Article
Background Evidence that opioid agonist therapy (OAT) is associated with increased odds of hepatitis C virus (HCV) treatment initiation among people who use drugs (PWUD) is emerging. The objective of this study was to determine the association between current OAT and HCV treatment initiation among PWUD in a population-level linked administrative dataset. Methods The British Columbia (BC) Hepatitis Testers Cohort was used for this study, which includes all people tested for or diagnosed with HCV in BC, linked to medical visits, hospitalizations, laboratory, prescription drug, and mortality data from 1992 until 2019. PWUD with injecting drug use or opioid use disorder and chronic HCV infection were identified for inclusion in this study. HCV treatment initiation was the main outcome, and subdistribution proportional hazards modeling was used to assess the relationship with current OAT. Results 13,803 PWUD with chronic HCV were included in this study. Among those currently on OAT at the end of the study period, 47% (2,704/5,770) had started HCV treatment, whereas 22% (1778/8033) of those not currently on OAT has started HCV treatment .. Among PWUD with chronic HCV infection, current OAT was associated with higher likelihood of HCV treatment initiation in time to event analysis (adjusted hazard ratio 1.84 [95%CI, 1.50, 2.26]). Conclusions Current OAT was associated with a higher likelihood of HCV treatment initiation. However, many PWUD with HCV currently receiving OAT have yet to receive HCV treatment. Enhanced integration between substance use care and HCV treatment is needed to improve the overall health of PWUD.
Article
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Introduction Buprenorphine–naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation. Methods and analysis We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive–deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation. Ethics and dissemination This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.
Article
Pharmacotherapy, or medication-assisted treatment (MAT), is a critical component of a comprehensive treatment plan for the pregnant woman with opioid use disorder (OUD). Methadone and buprenorphine are two types of opioid-agonist therapy which prevent withdrawal symptoms and control opioid cravings. Methadone is a long-acting mu-opioid receptor agonist that has been shown to increase retention in treatment programs and attendance at prenatal care while decreasing pregnancy complications. However methadone can only be administered by treatment facilities when used for OUD. In contrast, buprenorphine is a mixed opioid agonist-antagonist medication that can be prescribed outpatient. The decision to use methadone vs buprenorphine for MAT should be individualized based upon local resources and a patient-specific factors. There are limited data on the use of the opioid antagonist naltrexone in pregnancy. National organizations continue to recommend MAT over opioid detoxification during pregnancy due to higher rates of relapse with detoxification.
Article
Background: While opioid agonist therapy (OAT) reduces the risk of HCV acquisition among people who inject drugs (PWID), protective effects may be attenuated in females compared to males. This study assessed sex disparities in HCV incidence among PWID exposed to OAT and factors independently associated with decreased protective efficacy. Methods: Inc3 pools biological and behavioural data from prospective observational studies examining incident HIV and HCV. Independent predictors were identified using Cox regression models with random effects after accounting for the clustering effect of study sites. Unadjusted and adjusted hazard ratios (aHR) and 95% Confidence Intervals are presented in sex-specific analyses. Results: Among 701 participants exposed to OAT observed over 3,003 visits and 1,427 person-years observation (PYO), HCV incidence was 16.5 PYO (95%CI 13.1-20.7) in females and 7.6 PYO (95%CI 6.0-9.5) in males (F:M aHR 1.80, 95%CI 1.37-2.22, p<0.001). Factors associated with HCV acquisition among females exposed to OAT included non-white race (aHR 1.79, 95%CI 1.25-2.56, p=0.001), recent unstable housing (aHR 4.00, 95%CI 3.62-4.41, p<0.001), recent daily or more frequent injection (aHR 1.45, 95%CI 1.01-2.08, p=0.042) and recent receptive syringe sharing (aHR 1.43, 95%CI 1.33-1.53, p<0.001). Conclusions: Female PWID exposed to OAT are twice as likely as their male counterparts to acquire HCV. While there is a need for better understanding of sex differences in immune function and opioid pharmacokinetic and pharmacodynamic parameters, structural and behavioural interventions that target women, including affordable housing and safe injection self-efficacy, are required to bolster the efficacy of OAT in preventing HCV transmission.
Article
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Objectives People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID. Design This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada. Results This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction. Conclusions These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care. PROSPERO registration number CRD42020142947.
Article
Background We conducted a pilot study to assess feasibility of using video directly-observed therapy (DOT) for patients initiating buprenorphine to evaluate whether it is associated with better opioid use disorder (OUD) outcomes when compared to treatment-as-usual (TAU). Methods Pilot randomized controlled trial of adult patients with OUD initiating buprenorphine treatment (n = 78) at two sites (Seattle, WA and Boston, MA) from January 2019 to May 2020. Intervention was video DOT using a HIPAA-compliant smartphone application to record taking daily buprenorphine. Study smartphones, text reminders to upload a video, and calendar summaries of video DOT adherence were provided. Main outcomes were 1) percentage of 12 weekly urine drug tests (UDT) negative for illicit opioids and 2) engagement in treatment at week 12 (i.e., having an active prescription for buprenorphine within the last 7 days). Results Of 78 enrolled, 20 (26%) were female; 29 (37%) non-white; and 31 (40%) homeless. The mean (standard deviation) number of doses confirmed by video was 31% (34%). In intention-to-treat analysis, the average percentage of weekly opioid negative UDT was 50% (95% CI: 40-63%) in the intervention arm versus 64% (95% CI: 55-74%) among controls; RR = 0.78 (95% CI: 0.60-1.02, p = 0.07). Engagement at week 12 was 69% (95% CI: 56-86%) v. 82% (95% CI: 71-95%) in the intervention vs. TAU arms, respectively; RR = 0.84 (95% CI: 0.65-1.10, p = 0.20). Conclusions The video DOT intervention did not result in improvements in illicit opioid use and treatment engagement compared to TAU. The study was limited by low rates of intervention use. Trial registration ClinicalTrails.gov, NCT03779997, Registered on December 19, 2018.
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Cambridge Core - Psychiatry and Clinical Psychology - Seminars in Clinical Psychopharmacology - edited by Peter M. Haddad
Article
Background and objectives People who inject drugs (PWID) are disproportionately affected by chronic hepatitis C (HCV) in high-income countries. The advent of direct-acting antivirals (DAAs) makes treatment of this underserved population more possible than ever. The dearth of programs adapted to the needs of PWID and stigma associated with drug use and chronic HCV pose significant barriers to the effective uptake of treatment among this population. We employed “life projects” as a conceptual framework to examine the social incentives of PWID being treated for HCV. This study advances the existing literature on the transformative potential of HCV treatment among PWID, explores how these transformations may affect treatment success, and discusses implications for decisions around whether and when to treat PWID. Methods We conducted in-depth interviews with participants of a pilot clinical trial testing the effective delivery of DAA treatment to PWID within two healthcare for the homeless clinic settings – one group receiving opioid agonist therapy (OAT) and another group frequenting a needle and syringe exchange program (NSP). A purposive sample of 27 participants was selected based on place of care. Interviews were transcribed, coded, and analysed for patterns using a priori domains and emergent themes. Results Participants in both treatment groups described significant life projects that motivated them to complete HCV treatment. These projects included social redemption, strengthening of relationships, pursuit of abstinence from substance use, and harm reduction. These themes were consistent between treatment groups, though more participants in the syringe exchange group relied on harm reduction than on pursuing abstinence to prevent reinfection after achieving virologic cure. Conclusion Understanding the incentives that propel PWID to complete HCV treatment could help to enhance treatment uptake and adherence through dedicated programs that address current barriers to care. Keywords HCV Life projects People who inject drugs Harm reduction Qualitative research Hepatitis C treatment
Article
Introduction Strategies of harm reduction (HR) include policies and community-based measures aimed to reduce the risk of self-harm while continuing potentially hazardous behaviors, such as illegal drug, alcohol, and tobacco use. Objectives To assess whether and to which extent strategies of HR could have beneficial, or harmful, effects on sexual and reproductive health, for general and at-risk populations. Methods A literature research was performed between July 2020 and January 2021, investigating the association between harm reduction strategies and sexual and reproductive health. Results HR strategies are mostly aimed at providing support to at-risk population, such as injection drug users or sex workers. Alcohol and drug use, smoking and high-risk sexual behaviors are among the main targets for HR strategies. Barriers to access, such as stigma, marginalization or lacking awareness, are often present as negative risk factors and require attention from professionals. Preventing sexually transmitted infections (STIs), early/unwanted pregnancies and violence are the most important results HR programs could provide for sexual and reproductive health. However, evidence is limited and often qualitative, rather than quantitative. Conclusion HR strategies are important measures to improve sexual and reproductive health in at-risk populations. Increasing personal and social awareness is a key factor for the success of HR programs. A Sansone, E. Limoncin, E Colonnello, et al. Harm Reduction in Sexual Medicine. Sex Med Rev 2021;XX:XXX–XXX.
Article
Background Opioid use disorder is a serious health condition for which buprenorphine is proven effective, yet providers substantially underutilize buprenorphine. We present two approaches to measuring treatment duration, factors associated with retention, and patterns of care. Methods The study determined incident buprenorphine prescribing for all Washingtonians utilizing prescription monitoring program data from 2012 to 2019. The study calculated episode of care and cumulative time in care. Generalized linear models estimated associations among the length of the first episode of care and cumulative time in care with sex, age, and rurality. Cox proportional hazards models estimated the time to discontinuing buprenorphine for the first four episodes of care and time to discontinuing the last episode of care. Results Mean and median duration of the first episode were 320 and 84 days, respectively, and for cumulative time in care 308 and 195 days. A minority of peoples' first episodes exceeded 180 days (37%). Being female and older were significantly associated with longer first episodes and cumulative time in care. Survival analyses indicated that the proportion of those still in care at 6, 12, and 24 months into their first episode of care declined for those with more than one episode of care; conversely the study found much smaller differences in retention for the last episode of care, indicating that many people were eventually able to be retained in care for longer periods of time. Conclusion Episodes of care and cumulative time on buprenorphine were both short compared to minimum quality recommendations of 180 days. Median cumulative time in care was double that of the first episode, highlighting that many people engage in subsequent episodes of substantial length. Episode of care and cumulative care analyses should inform states, payers, health care systems and providers in measuring and setting treatment duration goals.
Article
Background: Methamphetamine use is increasing in parts of the U.S., yet its impact on treatment for opioid use disorder is relatively unknown. Methods: The study utilized data on adult patients receiving buprenorphine from Washington State Medication Assisted Treatment-Prescription Drug and Opioid Addiction program clinics between November 1, 2015 and April 31, 2018. Past 30-day substance use data were collected at baseline and 6-months, as well as date of program discharge. Cox proportional hazards regression was used to estimate the relative hazards for treatment discharge comparing methamphetamine users at baseline with non-users, adjusting for site, time period, age, gender, race, ethnicity, and education. For a subset of patients with data, we describe the proportion of individuals reporting methamphetamine use at baseline versus 6-months. Results: The sample included 799 patients, of which 237 (30%) reported using methamphetamine in the past 30 days; of those, 156 (66%) reported 1-10 days of use, 46 (19%) reported 11-20 days of use, and 35 (15%) reported 21-30 days of use. Baseline methamphetamine use was associated with more than twice the relative hazards for discharge in adjusted models (aHR = 2.39; 95% CI: 1.94-2.93). In the sub-sample with data (n = 516), there was an absolute reduction of 15% in methamphetamine use: 135 (26%) reported use at baseline versus 57 (11%) at follow-up. Conclusions: In summary, this study found that patients who concurrently used methamphetamine were less likely to be retained in buprenorphine treatment compared to non-users. For persons who were retained, however, methamphetamine use decreased over time.
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Seminars in Clinical Psychopharmacology - edited by Peter M. Haddad June 2020
Article
Background The US opioid crisis is associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID), and yet the uptake of HCV curative therapy among PWID is low. Purpose To explore potential solutions to overcome barriers to HCV treatment uptake among individuals at a drug detoxification center. Methods Qualitative study with in-depth interviews and thematic analysis of coded data. Results Patients (N = 24) had the following characteristics: mean age 37 years; 67% White, 13% Black, 8% Latinx, 4% Native Hawaiian/Pacific Islander, 8% other; 71% with a history of injecting drugs. Most patients with a positive HCV test had not pursued treatment due to few perceived immediate consequences from a positive test and possible complications arising in a distant poorly imagined future. Active substance use was a major barrier to HCV treatment uptake because of disruptions to routine activities. In addition, re-infection after treatment was perceived as inevitable. Patients had suggestions to improve HCV treatment uptake: high-intensity wraparound care characterized by frequent interactions with supportive services; same-day/walk-in options; low-barrier access to substance use treatment; assistance with navigating the health care system; attention to immediate needs, such as housing; and the opportunity to select an approach that best fits individual circumstances. Conclusions Active substance use was a major barrier to treatment initiation. To improve uptake, affected individuals recommended that HCV treatment be integrated within substance use treatment programs. Such a model should incorporate patient education within low-barrier, high-intensity wraparound care, tailored to patients’ needs and priorities.
Article
Background: Hepatitis C virus (HCV) is the most common viral infection among illicit drug users in the world. Although intervention of needle and syringe program and opioid substitution therapy had engaged to prevent HCV infection, the prevalence of HCV infection seem not declined. The aim of this study was to estimate risk of HCV infection in injection drug uses (IDUs) and non-injection drug users (NIDUs) receiving opioid substitution therapy. Methods: We recruited 1179 heroin-dependent patients (age: 20 - 66 years) under opioid substitution therapy from 2012 to 2015 in a Psychiatric Center, Southern Taiwan. The data of HCV, hepatitis B virus (HBV) and HIV infection and liver biochemical examination were obtained. We used multivariate logistic regression analysis to predict the risk of HCV infection. Results: There were 93.1% of IDUs and 68.1% of NIDUs positive for HCV infection. In IDUs, HIV infection, age of heroin initiation, duration and dose of heroin use, frequency of detoxification and number of criminal conviction were significantly associated with HCV infection. In NIDUs, snort/sniff heroin exhibited a significantly increased risk of HCV infection. Intravenous injecting (OR = 23.10; 95% CI = 8.04, 66.40, p < 0.001), intravenous injecting combined snort/sniff (OR = 12.95; 95% CI = 3.90, 42.97, p < 0.001) and snort/sniff (OR = 4.14; 95% CI = 1.30, 13.18, p = 0.016) were significantly associated with increased risk of HCV infection compared with smoking. The trend was significant (p for trend < 0.001) CONCLUSION.: In Taiwan, IDUs had harmful characteristics compared with NIDUs and both had extremely high prevalence of HCV infection. We provided evidence that snort/sniff is a possible way of leak in HCV infection despite needle-syringes supplement program been provided. Opioid substitution therapy program should include HCV assessment and treatment in the new direct-acting antiviral therapy era.
Article
Context: Few substance use disorder (SUD) treatment programs provide on-site human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) testing, despite evidence that these tests are cost-effective. Objective: To understand how methadone maintenance treatment (MMT) programs that offer on-site HIV/HCV testing have integrated testing services, and the challenges related to offering on-site HIV/HCV testing. Design: We used the 2014 National Drug Abuse Treatment System Survey to identify outpatient SUD treatment programs that reported offering on-site HIV/HCV testing to 75% or more of their clients. We stratified the sample to identify programs based on combinations of funding source, type of drug treatment offered, and Medicaid-managed care arrangements. We conducted semi-structured qualitative interviews with leadership and staff in 2017-2018 using a directed content analysis approach to identify dominant themes. Setting: Seven MMT programs located in 6 states in the United States. Participants: Fifteen leadership and staff from 7 MMT programs with on-site HIV/HCV testing. Main outcome measure: Themes related to integration of on-site HIV/HCV testing. Results: Methadone maintenance treatment programs identified 3 domains related to the integration of HIV/HCV testing on-site at MMT programs: (1) payment and billing, (2) internal and external stakeholders, and (3) medical and SUD treatment coordination. Programs identified the absence of state policies that facilitate medical billing and inconsistent grant funding as major barriers. Testing availability was limited by the frequency at which external organizations could provide services on-site, the reliability of those external relationships, and MMT staffing. Poor electronic health record systems and privacy policies that prevent medical information sharing between medical and SUD treatment providers also limited effective care coordination. Conclusion: Effective and sustainable integration of on-site HIV/HCV testing by MMT programs in the United States will require more consistent funding, improved billing options, technical assistance, electronic health record system enhancement and coordination, and policy changes related to privacy.
Article
Background: Hepatitis C virus (HCV) remains endemic among people who use drugs (PWUD). Measures of HCV community viral load (CVL) and HCV care continuum outcomes may be valuable for ascertaining unmet treatment need and for HCV surveillance and control. Methods: Data from patients in an opioid treatment program during 2013-2016 were used to (1) identify proportions of antibody and viral load (VL) tested, linked-to-care, and treated, in 2013-2014 and 2015-2016, and pre- and postimplementation of qualitative reflex VL testing; (2) calculate engaged-in-care HCV CVL and "documented" and "estimated" unmet treatment need; and (3) examine factors associated with linkage-to-HCV-care. Results: Among 11 267 patients, proportions of HCV antibody tested (52.5% in 2013-2014 vs 73.3% in 2015-2016), linked-to-HCV-care (15.7% vs 51.8%), and treated (12.0% vs 44.7%) all increased significantly. Hispanic ethnicity was associated with less linkage-to-care, and Manhattan residence was associated with improved linkage-to-care. The overall engaged-in-care HCV CVL was 4 351 079 copies/mL (standard deviation = 7 149 888); local HCV CVLs varied by subgroup and geography. Documented and estimated unmet treatment need decreased but remained high. Conclusions: After qualitative reflex VL testing was implemented, care continuum outcomes improved, but gaps remained. High rates of unmet treatment need suggest that control of the HCV epidemic among PWUD will require expansion of HCV treatment coverage.
Article
Background: Hepatitis C virus (HCV) incidence has increased in the worsening opioid epidemic. We examined the HCV preventive efficacy of medication-assisted treatment (MAT), and geographic variation in HCV community viral load (CVL) and its association with HCV incidence. Methods: HCV incidence was directly measured in an open cohort of patients in a MAT program in New York City between 1 January 2013 and 31 December 2016. Area-level HCV CVL was calculated. Associations of individual-level factors, and of HCV CVL, with HCV incidence were examined in separate analyses. Results: Among 8352 patients, HCV prevalence was 48.7%. Among 2535 patients seronegative at first antibody test, HCV incidence was 2.25/100 person-years of observation (PYO). Incidence was 6.70/100 PYO among those reporting main drug use by injection. Female gender, drug injection, and lower MAT retention were significantly associated with higher incidence rate ratios. Female gender, drug injection, and methadone doses <60 mg were independently associated with shorter time to HCV seroconversion. HCV CVLs varied significantly by geographic area. Conclusions: HCV incidence was higher among those with lower MAT retention and was lower among those receiving higher methadone doses, suggesting the need to ensure high MAT retention, adequate doses, and increased HCV prevention and treatment engagement. HCV CVLs vary geographically and merit further study as predictors of HCV incidence.
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The goal of harm reduction is to reduce both the individual and societal harms of drug use through knowledge-based interventions that change risks, risk behaviours and risk settings. This chapter describes the main harm-reduction interventions implemented in many countries around the world, synthesises evidence on their effectiveness and risks and summarises key lessons learned. The focus is on illegal drugs, especially opioids and the central nervous system stimulants. The interventions covered are opioid substitution treatment; needle and syringe programmes; supervised drug consumption facilities; drug overdose prevention; outreach, peer education and health promotion; testing, vaccination and treatment of drug-related infectious diseases; and interventions for stimulant users. Key themes stressed include the following: that harm reduction does not replace the need for treatment but adds to the capacity to respond effectively to the wide range of health and social challenges raised by drug use; that the scientific evidence shows that harm-reduction interventions are effective in terms of their stated goals, as long as they are implemented appropriately within their contextual settings, and that single interventions are far more effective when implemented together as part of a broader public health policy, including steps to facilitate healthier living and safer social environments.
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Context.— In British Columbia, human immunodeficiency virus (HIV)–infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown.Objective.— To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users.Design.— Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program.Setting.— British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50×109/L (500/µL) and/or HIV-1 RNA levels higher than 5000 copies/mL.Subjects.— A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996.Main Outcome Measures.— Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection.Results.— After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37).Conclusions.— Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.
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Hepatitis C virus (HCV) represents a serious public health concern. People who inject drugs (PWID) are at particular risk and nearly half (45%) of PWID in England may be infected. HCV prevention interventions have only had moderate impact on the prevalence of HCV in this population. Using qualitative methods, we sought to detail the protective practices potentially linked to HCV avoidance among PWID, and explore the motivations for these. The study used a life history approach allowing participants to detail their lived experience both before and during the course of their injecting careers. Thirty-seven participants were recruited from drug services in London, and from referrals within local injecting networks. A baseline and follow-up in-depth qualitative interview was carried out with each participant, and for half, a third interview was also undertaken. All underwent testing for HCV antibody. Analyses focused on developing a descriptive typology of protective practices potentially linked to HCV avoidance. Practices were deemed to be protective against HCV if they could be expected a priori to reduce the number of overall injections and/or the number of injections using shared injecting equipment. Participants reported engaging in various protective practices which fell into three categories identified through thematic analysis: principles about injecting, preparedness, and flexibility. All participants engaged in protective practices irrespective of serostatus. It is important to consider the relative importance of different motivations framing protective practices in order to formulate harm reduction interventions which appeal to the situated concerns of PWID, especially given that these protective practices may also help protect against HIV and other blood borne infections.
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Injecting drug users (IDUs) are a major and most important risk factor for rising hepatitis C virus (HCV) prevalence in Iran. The objective of this study was to determine the effectiveness of methadone maintenance treatment (MMT) in prevention of HCV infection transmission among IDUs. A mathematical modeling has been used to estimate number of HCV infections averted. The input parameters used in the model were collected by self-reported method from 259 IDUs before registering and one year after MMT. Nonparametric statistical tests have been used to compare risky injecting and sexual behaviors among IDUs before and after participating in MMT program. Deterministic sensitivity analyses were done to show the effects of parameters' uncertainty on outcome. Of the 259 participants, 98.4% (255) were men, the mean age ± SD was 33.1 ± 7.58 years and HCV prevalence was 50%. The studied IDUs reported lower rate of risky injecting and sexual behavior after participation in MMT program. The cumulative incidence of HCV per 100 IDUs due to sharing injection and unsafe sexual contact with MMT program were 13.84 (95% CI: 6.17 -21.51), 0.0003 (0.0001 - 0.0005) and without it 36.48 (25.84 - 47.11) and 0.0004 (0.0002-0.0006) respectively. The MMT program is an effective intervention to prevent HCV infection transmission, although it is essential to compare its effectiveness with other interventions before implementing it in nationwide.
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Worldwide, an estimated 130-170 million people have HCV infection. HCV prevalence is highest in Egypt at >10% of the general population and China has the most people with HCV (29.8 million). Differences in past HCV incidence and current HCV prevalence, together with the generally protracted nature of HCV disease progression, has led to considerable diversity in the burden of advanced liver disease in different countries. Countries with a high incidence of HCV or peak incidence in the recent past will have further escalations in HCV-related cirrhosis and hepatocellular carcinoma (HCC) over the next two decades. Acute HCV infection is difficult to detect because of the generally asymptomatic nature of the disease and the marginalization of at-risk populations. Around 25% of patients with acute HCV infection undergo spontaneous clearance, with increased rates among those with favourable IL28B genotypes, acute symptoms and in women. The remaining 75% of patients progress to chronic HCV infection and are subsequently at risk of progression to hepatic fibrosis, cirrhosis and HCC. Chronic hepatitis C generally progresses slowly in the initial two decades, but can be accelerated during this time as a result of advancing age and co-factors such as heavy alcohol intake and HIV co-infection.
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Unlabelled: In efforts to inform public health decision makers, the Global Burden of Diseases, Injuries, and Risk Factors 2010 (GBD2010) Study aims to estimate the burden of disease using available parameters. This study was conducted to collect and analyze available prevalence data to be used for estimating the hepatitis C virus (HCV) burden of disease. In this systematic review, antibody to HCV (anti-HCV) seroprevalence data from 232 articles were pooled to estimate age-specific seroprevalence curves in 1990 and 2005, and to produce age-standardized prevalence estimates for each of 21 GBD regions using a model-based meta-analysis. This review finds that globally the prevalence and number of people with anti-HCV has increased from 2.3% (95% uncertainty interval [UI]: 2.1%-2.5%) to 2.8% (95% UI: 2.6%-3.1%) and >122 million to >185 million between 1990 and 2005. Central and East Asia and North Africa/Middle East are estimated to have high prevalence (>3.5%); South and Southeast Asia, sub-Saharan Africa, Andean, Central, and Southern Latin America, Caribbean, Oceania, Australasia, and Central, Eastern, and Western Europe have moderate prevalence (1.5%-3.5%); whereas Asia Pacific, Tropical Latin America, and North America have low prevalence (<1.5%). Conclusion: The high prevalence of global HCV infection necessitates renewed efforts in primary prevention, including vaccine development, as well as new approaches to secondary and tertiary prevention to reduce the burden of chronic liver disease and to improve survival for those who already have evidence of liver disease.
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High rates of hepatitis C virus (HCV) transmission are found in samples of people who inject drugs (PWID) throughout the world. The objective of this paper was to meta-analyze the effects of risk-reduction interventions on HCV seroconversion and identify the most effective intervention types. We performed a systematic review and meta-analysis of published and unpublished studies. Eligible studies reported on the association between participation in interventions intended to reduce unsafe drug injection and HCV seroconversion in samples of PWID. The meta-analysis included 26 eligible studies of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions. Interventions using multiple combined strategies reduced risk of seroconversion by 75% (pooled relative risk, .25; 95% confidence interval, .07-.83). Effects of single-method interventions ranged from .6 to 1.6. Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion. Determining the effective dose and combination of interventions for specific subgroups of PWID is a research priority. However, our meta-analysis shows that HCV infection can be prevented in PWID.
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Hepatitis C virus (HCV) infection, clearance, and reinfection are best studied in injection drug users (IDUs), who have the highest incidence of HCV and are likely to represent most infections. A prospective cohort of HCV-negative young IDUs was followed up from January 2000 to September 2007, to identify acute and incident HCV and prospectively study infection outcomes. Among 1,191 young IDUs screened, 731 (61.4%) were HCV negative, and 520 (71.1%) of the 731 were enrolled into follow-up. Cumulative HCV incidence was 26.7/100 person-years of observation (95% confidence interval [CI], 21.5-31.6). Of 135 acute/incident HCV infections, 95 (70.4%) were followed; 20 (21.1%) of the 95 infections cleared. Women had a significantly higher incidence of viral clearance than did men (age-adjusted hazard ratio, 2.91 [95% CI, 1.68-5.03]) and also showed a faster rate of early HCV viremia decline (P < .01). The estimated reinfection rate was 24.6/100 person-years of observation (95% CI, 11.7-51.6). Among 7 individuals, multiple episodes of HCV reinfection and reclearance were observed. In this large sample of young IDUs, females show demonstrative differences in their rates of viral clearance and kinetics of early viral decline. Recurring reinfection and reclearance suggest possible protection against persistent infection. These results should inform HCV clinical care and vaccine development.
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Highly active antiretroviral therapy (HAART) is often withheld from injection drug users (IDUs) infected with the human immunodeficiency virus (HIV) based on the belief that their unstable lifestyles may predetermine a markedly inferior outcome with HAART. However, long-term evaluations of HIV treatment outcomes among IDUs in comparison with other risk groups are not available. To compare survival rates among HIV-infected patients initiating HAART with and without a history of injection drug use. Population-based, prospective cohort study (HAART Observational Medical Evaluation and Research [HOMER]) of 3116 antiretroviral-naive HIV-infected patients in a province-wide HIV/AIDS treatment program in British Columbia, Canada. Of the 3116 patients, 915 were IDUs (29.4%), 579 were female (18.6%), and the median age was 39.4 years (interquartile range, 33.3-46.4 years). Treatment with HAART was initiated between August 1, 1996, and June 30, 2006. The median duration of follow-up was 5.3 years (interquartile range, 2.8-8.3 years) for IDUs and 4.3 years (interquartile range, 2.0-7.6 years) for non-IDUs. Patients were followed up until June 30, 2007. Data were analyzed between November 1, 2007, and May 26, 2008. All-cause mortality. Overall, 622 individuals died (20.0%) during the study period (232 IDUs and 390 non-IDUs), for a crude mortality rate of 20.0% (95% confidence interval [CI], 18.4%-21.5%). At 84 months after the initiation of HAART, the product limit estimate of the cumulative all-cause mortality rate was similar between the 915 IDUs (26.5%; 95% CI, 23.2%-29.8%) and 2201 non-IDUs (21.6%; 95% CI, 16.9%-26.2%) (Wilcoxon P = .47). In multivariate time-updated Cox regression, the hazard ratio of mortality was similar between IDUs and non-IDUs (1.09; 95% CI, 0.92-1.29). In this study population, injection drug use was not associated with decreased survival among HIV-infected patients initiating HAART.
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In the absence of prior knowledge about population relations, investigators frequently employ a strategy that uses the data to help them decide whether to adjust for a variable. The authors compared the performance of several such strategies for fitting multiplicative Poisson regression models to cohort data: 1) the "change-in-estimate" strategy, in which a variable is controlled if the adjusted and unadjusted estimates differ by some important amount; 2) the "significance-test-of-the-covariate" strategy, in which a variable is controlled if its coefficient is significantly different from zero at some predetermined significance level; 3) the "significance-test-of-the-difference" strategy, which tests the difference between the adjusted and unadjusted exposure coefficients; 4) the "equivalence-test-of-the-difference" strategy, which significance-tests the equivalence of the adjusted and unadjusted exposure coefficients; and 5) a hybrid strategy that takes a weighted average of adjusted and unadjusted estimates. Data were generated from 8,100 population structures at each of several sample sizes. The performance of the different strategies was evaluated by computing bias, mean squared error, and coverage rates of confidence intervals. At least one variation of each strategy that was examined performed acceptably. The change-in-estimate and equivalence-test-of-the-difference strategies performed best when the cut-point for deciding whether crude and adjusted estimates differed by an important amount was set to a low value (10%). The significance test strategies performed best when the alpha level was set to much higher than conventional levels (0.20).
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In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown. To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users. Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program. British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x 10(9)/L (500/microL) and/or HIV-1 RNA levels higher than 5000 copies/mL. A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996. Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection. After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37). Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.
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An association between needle exchange attendance and higher HIV prevalence rates among injecting drug users (IDU) in Vancouver has been interpreted by some to suggest that needle exchange programmes (NEP) may exacerbate HIV spread. We investigated this observed association to determine whether needle exchange was causally associated with the spread of HIV. Prospective cohort study of 694 IDU recruited in the downtown eastside of Vancouver. Subjects were HIV-negative at the time of recruitment and had injected illicit drugs within the previous month. Of 694 subjects, the 15-month cumulative HIV incidence was significantly elevated in frequent NEP attendees (11.8+/-1.7 versus 6.2+/-1.5%; log-rank P = 0.012). Frequent attendees (one or more visits per week) were younger and were more likely to report: unstable housing and hotel living, the downtown eastside as their primary injecting site, frequent cocaine injection, sex trade involvement, injecting in 'shooting galleries', and incarceration within the previous 6 months. The Cox regression model predicted 48 seroconversions among frequent attendees; 47 were observed. Although significant proportions of subjects reported obtaining needles, swabs, water and bleach from the NEP, only five (0.7%) reported meeting new friends or people there. When asked where subjects had met their new sharing partners, only one out of 498 respondents cited the needle exchange. Paired analysis of risk variables at baseline and the first follow-up visit did not reveal any increase in risk behaviours among frequent attendees, regardless of whether they had initiated drug injection after establishment of the NEP. We found no evidence that this NEP is causally associated with HIV transmission. The observed association should not be cited as evidence that NEP may promote the spread of HIV. By attracting higher risk users, NEP may furnish a valuable opportunity to provide additional preventive/support services to these difficult-to-reach individuals.
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Because many persons with chronic hepatitis C virus (HCV) infection are asymptomatic, population-based serologic studies are needed to estimate the prevalence of the infection and to develop and evaluate prevention efforts. We performed tests for antibody to HCV (anti-HCV) on serum samples from 21,241 persons six years old or older who participated in the third National Health and Nutrition Examination Survey, conducted during 1988 through 1994. We determined the prevalence of HCV RNA by means of nucleic acid amplification and the genotype by means of sequencing. The overall prevalence of anti-HCV was 1.8 percent, corresponding to an estimated 3.9 million persons nationwide (95 percent confidence interval, 3.1 million to 4.8 million) with HCV infection. Sixty-five percent of the persons with HCV infection were 30 to 49 years old. Seventy-four percent were positive for HCV RNA, indicating that an estimated 2.7 million persons in the United States (95 percent confidence interval, 2.4 million to 3.0 million) were chronically infected, of whom 73.7 percent were infected with genotype 1 (56.7 percent with genotype 1a, and 17.0 percent with genotype 1b). Among subjects 17 to 59 years of age, the strongest factors independently associated with HCV infection were illegal drug use and high-risk sexual behavior. Other factors independently associated with infection included poverty, having had 12 or fewer years of education, and having been divorced or separated. Neither sex nor racial-ethnic group was independently associated with HCV infection. In the United States, about 2.7 million persons are chronically infected with HCV. People who use illegal drugs or engage in high-risk sexual behavior account for most persons with HCV infection.
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Infection with the hepatitis C virus (HCV) is a major public health burden in Canada and globally. The literature shows that injection drug use is currently the primary transmission route for HCV, and that a majority of injection drug users (IDUs) are currently infected with HCV in Canada. This article first reviews the burden of HCV within IDU populations and the transmission risks and the treatment implications specific to IDUs. Traditionally, IDUs have been excluded from HCV treatment unless abstaining from illicit drug use. However, recent research suggests that categorical exclusion is not medically necessary. A series of key questions about the feasibility of offering HCV treatment to IDUs in the specific Canadian context are considered, including concerns related to the motivation of treatment for IDUs, treatment delivery, treatment side effects, HCV reinfection, and the social environment. The article concludes that treatment of HCV-infected illicit drug users is both feasible and may be necessary to reduce transmission and adverse outcomes in this high-risk population.
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Because of the increasing number of injecting drug users (IDUs) in Iran and the risk of the spread of HIV infection, harm reduction programs have been considered for conventional law enforcement measures. The aim of this study was to evaluate the efficacy of methadone maintenance therapy (MMT) in IDUs and the associated health and social outcomes. This case-control study was conducted at the Persepolis Harm Reduction Center in Tehran during the year 2006. Data were gathered from two groups of randomly chosen patients. The first group consisted of 75 IDU patients who had undergone at least 6 months of methadone treatment (the MMT group), and second group consisted of 75 newly admitted clients (the control group). Participants were assessed on their dangerous injection and sexual behaviors, social well-being, and patterns of drug use. The results were compared between the two groups. The mean age of participants in the two groups was almost the same (34.28 years in the control group and 35.68 years in the MMT group, p >.05). Prevalence of drug injection in the MMT group was less than that in the control group (16% vs. 100%). There was also a dramatic difference in needle and syringe sharing (40% in the control group vs. 4% in the MMT group) but not in crimes and arrests (p = .4). Those in the MMT group had a better relationship with their families, partners, coworkers, and neighbors compared with controls. There was no considerable difference in dangerous sexual behaviors between the two groups. Given the large number of HIV-positive cases among IDUs and considering that injection drug use is the main spreading factor for HIV, MMT would play a major role in controlling the HIV epidemic through reduction of heroin injection and the risk behaviors related to it. High inflation rate, lack of interorganization coordination, budget limitation, and no follow-up were the most important limitations of this study.
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To identify dose-tapering strategies associated with sustained success following methadone maintenance treatment (MMT). Population-based retrospective cohort study. Linked administrative medication dispensation data from British Columbia, Canada. From 25 545 completed MMT episodes, 14 602 of which initiated a taper, 4183 individuals (accounting for 4917 MMT episodes) from 1996 to 2006 met study inclusion criteria. The primary outcome was sustained successful taper, defined as a daily dose ≤5 mg per day in the final week of the treatment episode and no treatment re-entry, opioid-related hospitalization or mortality within 18 months following episode completion. The overall rate of sustained success was 13% among episodes meeting inclusion criteria (646 of 4917), 4.4% (646 of 14 602) among all episodes initiating a taper and 2.5% (646 of 25 545) among all completed episodes in the data set. The results of our multivariate logistic regression analyses suggested that longer tapers had substantially higher odds of success [12-52 weeks versus <12 weeks: odds ratio (OR): 3.58; 95% confidence interval (CI): 2.76-4.65; >52 weeks versus <12 weeks: OR: 6.68; 95% CI: 5.13-8.70], regardless of how early in the treatment episode the taper was initiated, and a more gradual, stepped tapering schedule, with dose decreases scheduled in only 25-50% of the weeks of the taper, provided the highest odds of sustained success (versus <25%: OR: 1.61; 95% CI: 1.22-2.14). The majority of patients attempting to taper from methadone maintenance treatment will not succeed. Success is enhanced by gradual dose reductions interspersed with periods of stabilization. These results can inform the development of a more refined guideline for future clinical practice.
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  To examine trends in prescription opioid (PO) injection and to assess its association with hepatitis C virus (HCV) seroconversion among injection drug users (IDUs).   Prospective cohort study.   Montreal, Canada.   HCV-negative IDUs at baseline, reporting injection in the past month.   Semi-annual visits included HCV antibody testing and an interview-administered questionnaire assessing risk behaviours. HCV incidence rate was calculated using the person-time method. Time-updated Cox regression models were conducted to examine predictors of HCV incidence.   The proportion of IDUs reporting PO injection increased from 21% to 75% between 2004 and 2009 (P < 0.001). Of the 246 participants (81.6% male; mean age 34.5 years; mean follow-up time 23 months), 83 seroconverted to HCV [incidence rate: 17.9 per 100 person-years; 95% confidence interval (CI) 14.3, 22.1]. Compared to non-PO injectors, PO injectors were more likely to become infected [adjusted hazard ratio (AHR): 1.87; 95%CI:1.16, 3.03]. An effect modification was also found: PO injectors who did not inject heroin were more likely to become infected (AHR: 2.88; 95%CI: 1.52, 5.45) whereas no association was found for participants using both drugs (AHR: 1.19; 95% CI: 0.61, 2.30). Other independent predictors of HCV incidence were: cocaine injection, recent incarceration and >30 injections per month.   Prescription opioid injectors who do not inject heroin are at greater risk for HCV seroconversion than are those injecting both heroin and prescription opioids. Important differences in age, behaviour and social context suggest a need for targeted outreach strategies to this population.