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Harm Reduction for Injection Drug Users with Infective Endocarditis: A Systematic Review
Abstract
Background:
Infective endocarditis in the setting of injection drug use (IDU-IE) can be managed medically and surgically, but the greatest risk to short-term survival are complications of continued use. Despite this, harm reduction interventions have not been widely adopted in inpatient settings for individuals with IDU-IE.
Objectives:
The aim of this systematic review was to determine the types, effectiveness, and availability of targeted harm reduction interventions for individuals with IDU-IE. In this review, harm reduction was defined as any practice aimed at reducing negative consequences associated with substance use.
Methods:
In accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) Guidelines, 5 electronic databases were systematically searched to identify studies targeting harm reduction interventions for individuals with IDU-IE. Study quality was appraised using the Cochrane Risk of Bias Tool. Key findings of studies were summarized descriptively as a quantitative meta-analysis could not be undertaken.
Results:
Four studies (involving 221 participants) met eligibility criteria. The mean age was 39.3 ± 16.7 years, 69.8% were males and 80.7% had an opioid use disorder. Harm reduction interventions included inpatient addictions consultations, needle hygiene interventions, and outpatient parenteral antibiotic therapy. Such interventions were associated with decreased morbidity and mortality for individuals with IDU-IE: 19% of patients receiving inpatient addictions consultation subsequently accepted residential treatment, 38% engaged in follow-up, and monthly illicit opioid use was lowered from 16.5 days to 1.5 days. Six-month mortality was 7.1%. Of the patients who received outpatient parenteral antibiotics, 93% did not experience any recurrent infections during follow-up and there were no patient deaths. Needle hygiene interventions reduced the rate of bacterial infections over a 6-month follow-up period (hazard ratio: 0.80; 95% confidence interval, 0.37–1.74).
Conclusion:
Harm reduction interventions are potentially effective means for reducing morbidity and mortality in patients with IDU-IE.
... Full texts of the remaining 94 papers and of the additional three papers found by searching bibliographies were screened for eligibility, and 85 papers that were non-relevant or did not meet the eligibility criteria were removed. Twelve SRs were eligible (25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36). Appendix 3 provides a list of the excluded full-text papers with the description of the reasons for exclusion (ordered by most to least common). ...
... As reflected in the Citation Matrix ( Table 2), among the eligible SRs, twenty primary studies were overlapping and 64 were included only in one SR. In six SRs, the use of opioids was confirmed in all primary studies relevant to our review question (25,26,30,(32)(33)(34)(35)(36). In the other five SRs (27-29, 31, 35), use of opioids was confirmed in 73-88% of relevant primary studies. ...
... Overall, we identified 8 different types of preventive interventions (Figure 2). Eleven studies (25-36) evaluated opioid substitution therapy (OST) and needle and syringe exchange programs (NSP) to prevent HCV and/or HIV along with several other interventions, and one SR evaluated interventions to prevent infectious endocarditis (25). All included SRs targeted persons who inject drugs, recruited in different settings ( Tables 3, 4). ...
Background
The North American opioid crisis is marked by high opioid-related mortality and morbidity, including opioid use-associated infections (OUAIs). Users of pharmaceutical and non-pharmaceutical opioids are at an increased risk of acquiring hepatitis C (HCV), human immunodeficiency virus (HIV), and other infections. No high-level evidence, however, has been synthesized regarding effectiveness of interventions to prevent OUAIs in legal, and illegal/mixed opioid users. The aim of the study is to synthesize available systematic review (SR)–level evidence on the scope and effectiveness of interventions to prevent OUAIs among opioid users.
Methods
A SR of SRs approach was applied. We searched PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos and Google Scholar from inception to September 2020. Data selection and extraction were performed independently by three researchers. Risk of bias and quality of evidence were assessed using the AMSTAR2 tool. Results were narratively synthesized. Strength of evidence for each category was reported.
Results
Eleven of twelve identified SRs included interventions to prevent HCV/HIV transmission in persons who inject drugs (PWID), including opioids. One SR evaluated interventions to prevent recurrent infectious endocarditis. There was sufficient and tentative SR of SRs-level evidence for the effectiveness of opioid substitution therapy (OST) in preventing HIV and HCV, respectively. We found tentative evidence to support effectiveness of needle/syringe exchange programs (NSP) in HIV prevention, and sufficient evidence to support effectiveness of the combined OST and NSP in HCV prevention. There was insufficient SR-level evidence to support or discount effectiveness of other interventions to prevent OUAIs. No SR focused on non-PWID populations.
Conclusion
SR-level evidence supports the use of OST, NSP, and combined interventions for the reduction of HCV and HIV transmission in PWID. More research on prevention of other OUAIs and on prevention of OUAIs in non-PWID populations is urgently needed.
Systematic Review Registration
Registered in PROSPERO on July 30, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=195929, identifier: #195929.
... Providing patients with naloxone kits can further improve their health and safety. Some programs offer sterile needles, syringes, and other supplies to patients, which has proven to be an effective method of reducing blood-borne infections like human immunodefi ciency virus and hepatitis C. 16 These initiatives aim to reduce the number of discarded needles and syringes in the community and provide a unique access point for health and social services that may not be readily available to this patient population. 16 Additional harm-reduction practices include contingency management, which is behavioral therapy where the patient is rewarded (eg, a raffl e ticket) for positive change such as a negative drug screen, and supervised consumption sites, which are sterile environments where individuals can use illicit substances under the observation of trained staff, emphasizing overdose prevention. ...
... Some programs offer sterile needles, syringes, and other supplies to patients, which has proven to be an effective method of reducing blood-borne infections like human immunodefi ciency virus and hepatitis C. 16 These initiatives aim to reduce the number of discarded needles and syringes in the community and provide a unique access point for health and social services that may not be readily available to this patient population. 16 Additional harm-reduction practices include contingency management, which is behavioral therapy where the patient is rewarded (eg, a raffl e ticket) for positive change such as a negative drug screen, and supervised consumption sites, which are sterile environments where individuals can use illicit substances under the observation of trained staff, emphasizing overdose prevention. 17 Better outpatient access A harm-reduction approach can also help improve outpatient parenteral antimicrobial therapy access for people who inject drugs. ...
... As a result, the importance of multidisciplinary management, including treatment of substance use disorder, is well recognised. [25][26][27] The understanding of the impact of continued substance use has also led to complicated discussions regarding the appropriateness of surgical referral in patients with active IDU, especially those who have already relapsed. [28][29][30] In Canada, one-half of cardiac surgeons reported being less likely to operate on IE patients in the context of IDU, 30 although surgeons may be important allies in helping to address the underlying problems that patients with IDU-IE face. ...
... 31 While a primary objective of abstinence has generally been the focus, efforts to incorporate harm reduction strategies are also being explored. 26 In this review, we highlight features of IE distinct in IDU-IE in terms of clinical presentation, diagnosis, and medical, surgical, and multidisciplinary social management, and review ethical and resource utilisation considerations. ...
North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use-related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-sided IE compared to those with non-IDU-IE and a majority are a result of S. aureus. While most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part related to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons but also infectious disease specialists, drug addiction experts, social workers, neurologists and/or neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns such as overdoses. In this review, we describe the pathophysiological, clinical, surgical, social, and ethical characteristics of IDU-IE and the management thereof. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.
... Hospitalization for IDU-IE is a "reachable moment" to effectively engage patients in addiction treatment and harm reduction care, including opioid agonist treatment (OAT; e.g. methadone, buprenorphine) and access to sterile drug injecting equipment [7][8][9][10][11]. OAT is associated with large reductions in all-cause mortality among patients with IDU-IE [12] and may be associated with reduced risk of IDU-IE recurrence [13][14][15][16]. ...
... Unfortunately, despite these standards of care and convincing evidence of their effectiveness, hospital care for patients with IDU-IE often focuses on management of the infection and its sequelae without addressing the underlying substance use disorder [19,23,32,36,38,39]. Our findings of poor access to OAT at the hospital in Halifax are consistent with several other studies from North American hospitals [9]. Among 37 patients admitted to a Maine hospital for IDU-IE who were not on OAT, five (19%) initiated OAT in hospital [40]. ...
Background
Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs.
Methods
Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months.
Results
We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients’ own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients’ own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice.
Conclusions
Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.
... By helping people who use drugs access resources to become healthier and protect their lives, harm reduction is also protecting their loved ones and communities [4]. Importantly, it has been highlighted as a cost-effective intervention for people who use AOD [5][6][7]. ...
Background
Although harm reduction is highlighted as an effective intervention for alcohol and drug use, a funding gap for harm reduction interventions has been identified, mainly in low- and middle-income countries. In these countries, tensions between abstinence and harm reduction models have impaired the shift from punitive practices to evidence-based interventions committed to guaranteeing the human rights of people who use drugs. Since 2015, the Brazilian government has adopted a more punitive and abstinence-focused drug policy that jeopardizes the care of people who use alcohol and other drugs and the comprehension of the harm reduction workers' perspective in relation to their practice. Therefore, this study aimed to comprehend the meanings constructed by Brazilian harm reduction workers regarding their practices with vulnerable populations amidst a context of political tension.
Methods
We conducted 15 in-depth semi-structured qualitative interviews with harm reduction workers employed in public health services for at least 6 months. Data were analyzed using thematic analysis.
Results
The thematic axis "The joy and pain of being a harm reduction worker in Brazil" was constructed and divided into four major themes: (1) Invisibility of harm reduction work; (2) Black, poor, and people who use drugs: identification with the service users; (3) Between advocacy and profession: harm reduction as a political act; (4) Small achievements matter. Despite the perceived invisibility of harm reduction workers in the public health and alcohol and drug fields, valuing small achievements and advocacy were important resources to deal with political tension and punitive strategies in Brazil. The findings also highlight the important role of harm reduction workers due to their personal characteristics and understanding of drug use behavior, which bring the target audience closer to actions within the public health system.
Conclusion
There is an urgent need to acknowledge harm reduction based on peer support as a professional category that deserves adequate financial support and workplace benefits. Additionally, expanding evidence-based harm reduction interventions and community-based voluntary drug use treatment centers should be prioritized by public policies to address the human rights violations experienced by people who use drugs.
... Harm reduction programmes reduce PWUD's risk of these adverse health outcomes, [21][22][23][24][25][26][27][28][29][30] but access to these services in the USA and globally remains insufficient. 31 In the USA, inadequate harm reduction infrastructure is especially problematic in the medically underserved epicentres of the nation's intertwined overdose and hepatitis C virus (HCV) crises. ...
Introduction
Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia.
Methods and analysis
KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness.
Ethics and dissemination
The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings.
Trial registration number
NCT05657106.
... A successful harm reduction strategy includes both engagement with opioid maintenance therapy programs such as methadone or buprenorphine, and education on harm-reduction strategies including skin and needle hygiene as well as safe-injection sites. Furthermore, addiction services should be involved during initial inpatient management, as this has been shown to increase follow-up with opioid maintenance programs and to reduce morbidity and mortality in IDU-associated IE [12]. Addiction services, both inpatient and outpatient, were key in our patient's case, and her successful abstinence ended up being an important factor in her candidacy for surgery. ...
We report a rare case of native tricuspid valve infective endocarditis caused by Neisseria mucosa/sicca, a gram-negative diplococcus which colonizes the upper respiratory tract. A female in her late 20 s with a history of injection drug use (IDU) who recently completed treatment for methicillin-sensitive Staphylococcus aureus (MSSA) native tricuspid valve infective endocarditis presented to the hospital with a 6-week history of increasing chest pain, shortness of breath and night sweats. Blood cultures grew Neisseria mucosa/sicca species in 3 of 3 sets. Transthoracic echocardiogram showed a large 3 cm × 2.2 cm vegetation on the tricuspid valve with severe regurgitation. The patient was initially treated with ceftriaxone and gentamicin. Her case was complicated by ongoing septic pulmonary emboli ultimately require pulmonary endarterectomy and repair of her tricuspid valve. We hope this case highlights a rare but known cause of infective endocarditis especially in patients with a history of IDU who may lick their needles, which predisposes those individuals to intravenous introduction of oral bacteria.
... 9,18 Multidisciplinary approaches can also improve outcomes among patients with SUD-related complications, such as infective endocarditis. 21,22 ACS can also help bridge treatment initiated in the hospital to the outpatient or community setting so that there is no interruption in treatment upon discharge, often deemed a "reachable moment" for improving care. 23 Although initiating ACS can be challenging and resourceintensive, previous studies have outlined successful approaches and identified a "business case" to help motivate hospital administrators to finance ACS. ...
Background
Addiction Consult Services (ACS) have become an emergent clinical intervention for persons with substance use disorders (SUD) requiring hospital-based care. However, there have been few recent evaluations of the evidence for the effectiveness of ACS on SUD outcomes.
Objective
We aimed to assess the effectiveness of ACS for persons with SUD on a range of SUD-related outcomes.
Methods
We systematically reviewed peer-reviewed scientific literature measuring ACS outcomes. We searched 5 electronic sources (PubMed, MEDLINE, CINAHL, Cochrane, and EMBASE) from database inception through April 2021 and hand-searched article bibliographies for additional records. In addition, we considered any interventional or observational study design presenting original data and appraised study quality with the Joanna Briggs Institute checklist. Assessed outcomes included pharmacotherapy initiation in-hospital and postdischarge, retention in addiction treatment, length of hospital stay, 30-day readmissions, deaths, and patient-directed discharges. Finally, we conducted a narrative synthesis due to study design and outcome measurement heterogeneity.
Results
From the initial pool of 1057 records, 26 studies (n=12,823 participants; 60% male; mean age: 41 y) met review inclusion criteria. Most ACS provided pharmacotherapy, usually medications for opioid use disorder; add-on services varied, with some also providing psychotherapy (69%), discharge planning services (23%), and infectious disease consultation and treatment (19%). Overall, 7 studies (27%) observed positive impacts of ACS compared with control interventions on postdischarge engagement in addiction treatment and reduced addiction severity. Four studies (15%) reported no significant impacts of ACS versus control interventions on postdischarge care utilization or injection drug use frequency. The remaining 15 studies (58%) described the uptake of ACS-delivered treatments by hospital-based samples of patients with SUD but did not compare against a control condition.
Conclusions and Scientific Significance
While there is limited high-quality evidence for ACS-delivered treatment for persons with SUD, several signals from the available studies indicate some improvement across various SUD-related outcomes. Given the importance of providing hospital-based addiction treatment, there is a further need for the rigorous scientific evaluation of ACS-delivered care.
Contexte
Les services de consultation en addiction (SCA) sont devenus une intervention clinique émergente pour les personnes souffrant de troubles liés à l’utilization de substances (TUS) nécessitant des soins en milieu hospitalier. Cependant, il y a eu peu d'évaluations récentes des preuves de l’efficacité des SCA pour des résultats sur les TUS.
Objectif
Nous avons cherché à évaluer l’efficacité des SCA pour les personnes souffrant de TUS sur une série de résultats liés aux TUS.
Méthodes
Nous avons procédé à une revue systématique de la littérature scientifique des résultats des SCA évalué par les pairs. Nous avons consulté cinq sources électroniques (PubMed, MEDLINE, CINAHL, Cochrane et EMBASE) depuis la création de la base de données jusqu’en avril 2021 et nous avons effectué une recherche manuelle des bibliographies d’articles pour obtenir des données supplémentaires. En outre, nous avons pris en compte toutes études de méthodologie interventionnelle ou observationnelle présentant des données originales et nous avons évalué la qualité des études à l’aide de la liste de contrôle du Joanna Briggs Institute. Les résultats évalués comprenaient l’instauration d’une pharmacothérapie durant et après la sortie de l’hôpital, la rétention dans le traitement de l’addiction, la durée du séjour à l’hôpital, les réadmissions dans les 30 jours, les décès, et les sorties à l’initiative du patient. Enfin, nous avons réalisé une synthèse narrative en raison de l’hétérogénéité de la conception des études et de la mesure des résultats.
Résultats
À partir de l’ensemble initial de 1 057 dossiers, 26 études (n=12 823 participants ; 60% d’hommes ; âge moyen de 41 ans) ont satisfait aux critères d’inclusion de l'étude. La plupart des SCA proposaient une pharmacothérapie, généralement des médicaments contre les troubles liés à l’utilization d’opioïdes ; les services complémentaires variaient, certains proposant également une psychothérapie (69%), des services de planification de la sortie (23%), ainsi que des consultations et des traitements pour les maladies infectieuses (19%). Dans l’ensemble, sept études (27%) ont observé des impacts positifs des SCA par rapport aux interventions de contrôle sur l’engagement dans le traitement des addictions après la sortie de l’hôpital et sur la réduction de la gravité des addictions. Quatre études (15%) n’ont pas rapporté d’impact significatif des SCA par rapport aux interventions de contrôle sur l’utilization des soins après la sortie ou sur la fréquence d’utilization des drogues injectables. Les autres 15 études (58%) décrivent l’adoption des traitements dispensés par les SCA par des échantillons hospitaliers de patients souffrant de TUS, mais n’ont pas comparé les résultats de ces études avec ceux d’autres études.
Conclusions et signification scientifique
Bien qu’il y ait peu de données probantes de haute qualité sur les traitements dispensés par les SCA pour les personnes souffrant de TUS, plusieurs signaux provenant des études disponibles indiquent une certaine amélioration de divers résultats liés aux TUS. Compte tenu de l’importance de fournir un traitement de l’addiction en milieu hospitalier, il est nécessaire de procéder à une évaluation scientifique rigoureuse des soins dispensés par les SCA.
... There is evidence that concurrent disorder models are beneficial when considering the medical complications of SUDs, such as infective endocarditis in the setting of injection drug use. [14][15][16] To maintain continuity of care, we must ensure access to concurrent disorder consult services and champions in all settings, including inpatient and outpatient spheres, as well as in specialty psychiatry clinics and shared care services to ensure that the approach initiated in 1 domain is translated to the next domain, thereby avoiding conflicting paradigms In this regard, we must pair inpatient treatment needs with community services to maximize the value of therapy started during the index hospitalization. 17 Concurrent disorder consult models have an active role to play in outpatient settings as well. ...
Despite increased awareness of the prevalence and burden of substance use disorders, there is limited access to addiction treatment services in Canada, including in psychiatric settings. While substance use disorders are highly comorbid and confer a poorer prognosis on psychiatric illnesses, psychiatric services are often ill-equipped in managing comorbid addictions. While there has slowly been an increase in recognition of this deficit in psychiatric training, there continues to be a deficit in concurrent disorder services in psychiatric care. A potential strategy to address this gap in clinical services is a concurrent disorder consult model. Herein, we outline a model for improved access to addiction treatment in psychiatric care and outline considerations for developing concurrent disorder consult services.
... As missing even a single dosage at the time of lockdown could lead to relapse, 29 continued access to OAT during the pandemic is a critical public health priority, 40,42,44,59 particularly for individuals with medical morbidities, such as endocarditis. [60][61][62] Primary care providers can support OUD exacerbation by COVID-19 by providing physically distanced office visits for OAT treatment. 63 Several agencies have already advocated for increased access to OAT during the pandemic. ...
Background: Persons who use drugs (PWUD) are facing an epidemic during the global COVID-19 pandemic. In recent months, many medical institutions have released guidance documents to inform the management of PWUD as it pertains to COVID-19. Given the flurry of increasing guidance documents, we sought to synthesize the recommendations and identify consensus strategies to support PWUD during the pandemic.
Aim: To review existing COVID-19 guidelines for PWUD to synthesize evidence and identify consensus and disagreement areas.
Methods: We rapidly reviewed the grey literature (documents produced by organizations, including reports, working papers, government documents, white papers, and clinical guidelines) and published peer- reviewed articles using the World Health Organization guidelines. We organized recommendations by the substance use disorder considered (eg, opioid, stimulant, and alcohol), recommendation type (eg, pharmacothera- py and psychosocial), nature (eg, harm-reduction and abstinence), and score the responsibility (eg, physicians and allied health practitioners).
Results: We identified 85 representative articles span- ning alcohol, opioid, tobacco, stimulant, and cannabis use disorders. Most reports involved opioid use disorder, generated by Canadian institutions, such as the British Columbia Centre for Substance Use, the Canadian Centre for Substance Use and Addiction, and the Canadian Research Initiative in Substance Misuse. An overview of the problem typically prefaced guideline documents (eg, increasing numbers of opioid overdose deaths), followed by a structured approach to management (eg, addressing intoxication and withdrawal) using multiple forms of interventions (eg, harm-reduction, pharmacotherapy, and psychosocial services). Across guidelines, there was consensus regarding the importance of maintaining access to evidence-based treatment through various creative means, such as virtual platforms, take-home medications, and home delivery services. However, there was controversy regarding safe-supply, supervised con- sumption sites, and alcohol retailers’ designation as “essential services” during the pandemic.
Conclusions: With these challenges and insights in mind, the critical issue facing PWUD and their providers during the pandemic is maintaining access to evidence- based treatment and securing food, housing, and income. Along those lines, appropriate care should continue to be patient-centred, collaborative, and mindful of resources. Above all, we must continue to consider a biopsychosocial framework while providing evidence-based care. While these recommendations are helpful, we must apply our clinical judgment individually to weigh the risks and benefits to the patient and the public and destigmatize PWUD.
... We organized study findings into tables according to the PICOS framework (Methley et al., 2014). Our review's methods were consistent with previous narrative reviews with addiction themes (Bahji, 2019;Bahji et al., 2020;Bahji andBajaj, 2018, 2019;Bahji and Mazhar, 2016;Bahji and Stephenson, 2019). ...
Background
Dimenhydrinate (DMH) is an antihistamine used to treat nausea and vomiting. Although widely available in pharmacies as an over the counter medication, there have been reports of potential DMH tolerance and dependence and a possible euphoric potential accompanying heavy use (>100 mg/day). Despite the potential for misuse, there is a gap in the literature concerning patterns, characteristics, and potential mechanisms of DMH misuse.
Aims
This review aimed to synthesize evidence on the pharmacology, clinical effects, and management of DMH misuse and dependence to inform clinical decision making and relevant drug policy.
Methods
We conducted a systematic review in accordance with the PRISMA guidelines and using Cochrane collaboration methods. We searched seven databases from their inception through July 2019. To be included in the review, studies needed to measure or focus on one or more dimensions of morbidity or mortality related to the misuse of DMH. Quantitative, qualitative and mixed-method studies were included in order to capture the breadth of possible studies. Studies were excluded if they did not fit into the conceptual framework of the study of if they focused primarily on the misuse of other substances. A narrative synthesis of study findings was pursued given the limited capacity for a quantitative meta-analysis.
Findings
We identified 24 studies, which described a range of neuropsychiatric sequelae related to DMH consumption, including seizures, psychosis, depression, intoxication (resembling anticholinergic syndrome) and withdrawal. The sedative and euphoric properties, readily available nature, and low cost of DMH appear to facilitate DMH dependence, which were more commonly reported among individuals who had concurrent psychiatric disorders, displaying symptoms such as low motivation, poor concentration, and delirium. The overall quality of studies identified by this review was low—largely because the majority of studies were case reports or review articles, with few intervention or cohort studies.
Conclusions
There is some evidence to suggest the existence of DMH-related syndromes involving intoxication, withdrawal, and dependence, more commonly among long-term, heavy DMH consumers. However, higher quality studies are needed to confirm preliminary findings that there may be a biological basis for such syndromes.
Importance
Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff.
Objective
To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge.
Design, Setting, and Participants
This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles.
Exposure
Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services.
Main Outcomes and Measures
Interviews were analyzed using thematic analysis to identify key themes.
Results
A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals.
Conclusions and Relevance
In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.
Background
Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions.
Methods
The “Six Moments of Harm Reduction” provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool’s effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction.
Results
N=75 respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling patients who inject drugs (PWID). 60 respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP) and, of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (p<0.0001), 65 respondents (86.6%) reported they planned to use the “Six Moments” model in their own practice, and 100% said they would consider referring patients to a SSP in the future.
Conclusions
The “Six Moments” model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.
Introduction
Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone.
Methods
This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ² tests.
Results
Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005).
Discussion and Conclusions
The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.
Importance
Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis. Many centers do not perform valvular surgery on these patients owing to concerns about poor outcomes. Addiction services are underused in hospitals.
Objectives
To compare clinical characteristics in first-episode infective endocarditis in PWID who are surgically vs medically managed and to identify variables associated with mortality.
Design, Setting, and Participants
This case series studied PWID treated for a first episode of infective endocarditis between April 1, 2007, and March 30, 2016. Participants were adult patients (aged ≥18 years) admitted to any of 3 hospitals in London, Ontario, Canada. Analysis occurred between July 2016 and November 2017.
Main Outcomes and Measures
Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management.
Results
Of 370 total first-episode cases of infective endocarditis, 202 (54.6%) were in PWID. Among PWID, 105 (52%) were male, the median (interquartile range) age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202]). Right-sided infection was more common (61.4% [124 of 202]), and most infections were caused by Staphylococcus aureus (77.2% [156 of 202]). Surgery occurred in 19.3% of patients (39 of 202). The all-cause mortality rate was 33.7% (68 of 202). Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality (hazard ratio [HR], 0.44; 95% CI, 0.23-0.84; P = .01), as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008). Higher mortality was associated with left-sided infection (HR, 3.26; 95% CI, 1.82-5.84; P < .001) and bilateral involvement (HR, 4.51; 95% CI, 2.01-10.1; P < .001).
Conclusions and Relevance
This study presents the demographic characteristics of first-episode infective endocarditis in PWID. Results highlight the potentially important role of addictions treatment in this population. Further study to optimize selection criteria for surgery in PWID is warranted.
Background
Canada is in the midst of an opioid epidemic. In 2016, there were more than 2800 apparent opioid-related deaths. Although improved access to naloxone has saved countless lives, it is unclear if there are other effective pharmacological or nonpharmacological interventions for the treatment and prevention of opioid overdose. In this systematic review, we aim to synthesize published findings on such interventions.
Methods
We searched 5 electronic databases for randomized controlled studies using either pharmacological or nonpharmacological interventions to treat or prevent opioid overdose, and subsequently extracted and synthesized data from appropriate studies.
Results
Twelve studies met our inclusion criteria. Naloxone, nalmefene, and physostigmine were effective in reversing opioid overdose, whereas naltrexone was effective in preventing opioid overdose. Opioid agonists, including methadone, buprenorphine, and diacetylmorphine, were effective in improving secondary outcomes with variable effects on overdose prevention. No trials using primarily nonpharmacological interventions were identified.
Conclusions
In this systematic review, naloxone, nalmefene, and physostigmine emerged as effective in treating opioid overdose, whereas naltrexone showed evidence in preventing opioid overdose. Opioid agonists were found to be effective in improving retention in treatment and in reducing illicit opioid use. Pharmacological interventions play a key role in addressing the opioid epidemic; however, evidence for a multidisciplinary approach involving harm reduction and addressing psychosocial barriers could be the topic of subsequent literature reviews.
Purpose of review:
The purpose of this article is to provide a brief overview of the medical and surgical management of infective endocarditis secondary to IDU, with a focus on the underlying substance use disorder.
Recent findings:
Patients with infective endocarditis secondary to IDU are often young with unique comorbidities including mental illness, chronic hepatitis C, HIV infection, which are often compounded by limited social and familial supports. The focus of management has been treatment of endocarditis using IV antibiotics alongside surgery. Surgical outcomes compare favorably with those of infective endocarditis in the general population but long-term outcomes of IDUs are significantly worse. This is primarily due to the high rate of recidivism of drug use and the risk of prosthetic valve infective endocarditis. Contemporary management of addiction utilizes an integrative approach, combining both pharmacologic and nonpharmacologic strategies while remaining patient-centered. Given the complexity of care required, we advocate for a multidisciplinary team-based approach including psychiatry, infectious disease, cardiology, cardiac surgery and social services.
Summary:
Infective endocarditis secondary to IDU remains a medical and surgical challenge with dismal outcomes. Here we offer practical suggestions on the multidisciplinary management of this challenging and high-risk patient cohort.
Despite the high rates of hospitalization among people who use drugs (PWUD), harm reduction interventions have not been widely adopted in inpatient settings. We list several harm reduction practices that we believe should be considered in hospitals. Interventions to decrease stigma, including guidance regarding language and partnering with people with lived experience of drug use, can be implemented expeditiously. Hospitals with a high prevalence of drug use can establish addiction consultation services to address issues including initiation of medication-assisted therapy. Prescription opioids as a treatment for opioid addiction for select patients require further implementation science research to determine how to adapt this intervention for inpatient settings. While the evidence base for needle and syringe programs in the community is strong, implementation science research is required to address how best to integrate such programs in hospitals. Such research is also required to determine the optimal programs to ensure continuity of care post-discharge and retention in addiction-related care. We believe that new evidence generation is required to address the optimal use of peripherally inserted central venous catheters, to determine the relative benefits and harms of treatment contracts for inpatients, and to assess the efficacy of supervised injection services for inpatients. The need for harm reduction programs in hospitals emphasizes the need for a pragmatic, patient-centered, non-judgmental approach to the care of PWUD.
Non-randomised studies of the effects of interventions are critical to many areas of healthcare evaluation, but their results may be biased. It is therefore important to understand and appraise their strengths and weaknesses. We developed ROBINS-I ("Risk Of Bias In Non-randomised Studies-of Interventions"), a new tool for evaluating risk of bias in estimates of the comparative effectiveness (harm or benefit) of interventions from studies that did not use randomisation to allocate units (individuals or clusters of individuals) to comparison groups. The tool will be particularly useful to those undertaking systematic reviews that include non-randomised studies.
People who inject drugs (PWID) are at risk for infective endocarditis (IE). Hospitalization rates related to misuse of prescription opioids and heroin have increased in recent years, but there are no recent investigations into rates of hospitalizations from injection drug use-related IE (IDU-IE). Using the Health Care and Utilization Project National Inpatient Sample (HCUP-NIS) dataset, we found that the proportion of IE hospitalizations
from IDU-IE increased from 7% to 12.1% between 2000 and 2013. Over this time period, we detected a significant increase in the percentages of IDU-IE hospitalizations among 15- to 34-year-olds (27.1%–42.0%; P < .001) and among whites (40.2%–68.9%; P < .001). Female gender was less common when examining all the IDU-IE (40.9%), but it was more common in the 15- to 34-year-old age group (53%). Our findings suggest that the demographics of inpatients hospitalized with IDU-IE are shifting to reflect younger PWID who are more likely to be white and female than previously reported. Future studies to investigate risk behaviors associated with IDU-IE and targeted harm reduction strategies are needed to avoid further increases in morbidity and mortality in this rapidly growing population of young PWID.
Background. A culture of stringent drug policy, one-size-fits-all treatment approaches, and drug-related stigma has clouded clinical HIV practice in the United States. The result is a series of missed opportunities in the HIV care environment. An approach which may address the broken relationship between patient and provider is harm reduction—which removes judgment and operates at the patient’s stage of readiness. Harm reduction is not a routine part of care; rather, it exists outside clinic walls, exacerbating the divide between compassionate, stigma-free services and the medical system.
Methods. Qualitative, phenomenological, semi-structured, individual interviews with patients and providers were conducted in three publicly-funded clinics in Chicago, located in areas of high HIV prevalence and drug use and serving African-American patients (N = 38). A deductive thematic analysis guided the process, including: the creation of an index code list, transcription and verification of interviews, manual coding, notation of emerging themes and refinement of code definitions, two more rounds of coding within AtlasTi, calculation of Cohen’s Kappa for interrater reliability, queries of major codes and analysis of additional common themes.
Results. Thematic analysis of findings indicated that the majority of patients felt receptive to harm reduction interventions (safer injection counseling, safer stimulant use counseling, overdose prevention information, supply provision) from their provider, and expressed anticipated gratitude for harm reduction information and/or supplies within the HIV care visit, although some were reluctant to talk openly about their drug use. Provider results were mixed, with more receptivity reported by advanced practice nurses, and more barriers cited by physicians. Notable barriers included: role-perceptions, limited time, inadequate training, and the patients themselves.
Discussion. Patients are willing to receive harm reduction interventions from their HIV care providers, while provider receptiveness is mixed. The findings reveal critical implications for diffusion of harm reduction into HIV care, including the need to address cited barriers for both patients and providers to ensure feasibility of implementation. Strategies to address these barriers are discussed, and recommendations for further research are also shared.
Extra-medical prescription opioid (EMPO) use—intentional use without a prescription or outside of prescribed parameters—is a public health crisis in the United States and around the world. Epidemiological evidence suggests that the prevalence of EMPO use and adverse sequelae, including opioid overdose and hepatitis C infection, are elevated among people aged 18 to 25. Despite these preventable health risks, many harm reduction interventions are underutilized by, or inaccessible to, EMPO-using youth. In this commentary, we describe key harm reduction strategies for young people who use prescription opioids. We examine individual, social, and policy-level barriers to the implementation of evidence-based approaches that address EMPO use and related harms among young people. We highlight the need for expanded services and new interventions to engage this diverse and heterogeneous at-risk population. A combination of medical, social, and structural harm reduction interventions are recommended. Furthermore, research to inform strategies that mitigate particularly high-risk practices (e.g., polysubstance use) is warranted. Finally, we discuss how the meaningful involvement of youth in the implementation of harm reduction strategies is a critical component of the public health response to the prescription opioid epidemic.
Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.
Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.
The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
Infective endocarditis is a life threatening complication of intravenous drug abuse, which continues to be a major burden with inadequately characterised long-term outcomes. We reviewed our institutional experience of surgical treatment of infective endocarditis in active intravenous drug abusers with the aim of identifying the determinants long-term outcome of this distinct subgroup of infective endocarditis patients.
A total of 451 patients underwent surgery for infective endocarditis between January 1993 and July 2013 at the University Hospital of Heidelberg. Of these patients, 20 (7 female, mean age 35 +/- 7.7 years) underwent surgery for infective endocarditis with a history of active intravenous drug abuse. Mean follow-up was 2504 +/- 1842 days.
Staphylococcus aureus was the most common pathogen detected in preoperative blood cultures. Two patients (10%) died before postoperative day 30. Survival at 1, 5 and 10 years was 90%, 85% and 85%, respectively. Freedom from reoperation was 100%. Higher NYHA functional class, higher EuroSCORE II, HIV infection, longer operating time, postoperative fever and higher requirement for red blood cell transfusion were associated with 90-day mortality.
In active intravenous drug abusers, surgical treatment for infective endocarditis should be performed as extensively as possible and be followed by an aggressive postoperative antibiotic therapy to avoid high mortality. Early surgical intervention is advisable in patients with precipitous cardiac deterioration and under conditions of staphylococcal endocarditis. However, larger studies are necessary to confirm our preliminary results.
The role of oral antibiotic therapy in treating infective endocarditis (IE) is not well established.
We searched MEDLINE, EMBASE and Scopus for studies in which oral antibiotic therapy was used for the treatment of IE.
Seven observational studies evaluating the use oral beta-lactams (five), oral ciprofloxacin in combination with rifampin (one), and linezolid (one) for the treatment of IE caused by susceptible bacteria reported cure rates between 77% and 100%. Two other observational studies using aureomycin or sulfonamide, however, had failure rates >75%. One clinical trial comparing oral amoxicillinversus intravenous ceftriaxone for streptococcal IE reported 100% cure in both arms but its reporting had serious methodological limitations. One small clinical trial (n = 85) comparing oral ciprofloxacin and rifampin versus conventional intravenous antibiotic therapy for uncomplicated right-sided S. aureus IE in intravenous drug users (IVDUs) reported cure rates of 89% and 90% in each arm, respectively (P =0.9); however, drug toxicities were more common in the latter group (62% versus 3%; P <0.01). Major limitations of this trial were lack of allocation concealment and blinding at the delivery of the study drug(s) and assessment of outcomes.
Reported cure rates for IE treated with oral antibiotic regimens vary widely. The use of oral ciprofloxacin in combination with rifampin for uncomplicated right-sided S. aureus IE in IVDUs is supported by one small clinical trial of relatively good quality and could be considered when conventional IV antibiotic therapy is not possible.
Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression;
A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers;
All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism). Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness;
Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.
Many opioid-dependent patients do not receive care for addiction issues when hospitalized for other medical problems. Based on 3 years of clinical practice, we report the Transitional Opioid Program (TOP) experience using hospitalization as a "reachable moment" to identify and link opioid-dependent persons to addiction treatment from medical care.
A program nurse identified, assessed, and enrolled hospitalized, out-of-treatment opioid-dependent drug users based on their receipt of methadone during hospitalization. At discharge, patients transitioned to an outpatient interim opioid agonist program providing 30-day stabilization followed by 60-day taper. The nurse provided case management emphasizing HIV risk reduction, health education, counseling, and medical follow-up. Treatment outcomes included opioid agonist stabilization then taper or transfer to long-term opioid agonist treatment.
From January 2002 to January 2005, 362 unique hospitalized, opioid-dependent drug users were screened; 56% (n = 203) met eligibility criteria and enrolled into the program. Subsequently, 82% (167/203) presented to the program clinic post-hospital discharge; for 59% (119/203) treatment was provided, for 26% (52/203) treatment was not provided, and for 16% (32/203) treatment was not possible (pursuit of TOP objectives precluded by medical problems, psychiatric issues, or incarceration). Program patients adhered to a spectrum of medical recommendations (e.g., obtaining prescription medications, medical follow-up).
The Transitional Opioid Program (TOP) identified at-risk hospitalized, out-of-treatment opioid-dependent drug users and, by offering a range of treatment intensity options, engaged a majority into addiction treatment. Hospitalization can be a "reachable moment" to engage and link drug users into addiction treatment.
Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying 'abstinence' as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited 'reduced drug use', and 7.4% cited 'stabilization' only. Less than 1% of respondents identified 'safer drug use' or 'another goal', whilst just over 4% reported having 'no goals'. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.
Introduction
Canada is experiencing a new era of harm reduction policymaking and investment. While many provinces and territories are expanding access to these services, harm reduction policy and policymaking varies across the country. The present study, part of the Canadian Harm Reduction Policy Project (CHARPP), described policy actors’ views on formal harm reduction policies in Canada’s 13 provinces and territories.
Methods
As part of CHARPP’s mixed-method, multiple case study, we conducted qualitative interviews with 75 policy actors, including government officials, health system leaders, senior staff at community organizations, and advocates with self-identified lived experience of using drugs. Interviews were conducted in English or French, and recorded and transcribed verbatim. We used latent content analysis to inductively code the data and generate main findings. NVivo 11 was used to organize the transcripts.
Results
Participants expressed divergent views on formal provincial/territorial policies and their impact on availability of harm reduction programs and services. While some identified a need to develop new policies or improve existing ones, others resisted bureaucratization of harm reduction or felt the absence of formal policy was instead, advantageous. Instances where harm reduction was advanced outside of formal policymaking were also described.
Discussion
Previous CHARPP research documented wide variability in quantity and quality of formal harm reduction policies across Canada, and characterized official policy documents as serving largely rhetorical rather than instrumental functions. The present findings highlight diverse ways that actors used their discretion to navigate these weak policy contexts. Participants’ views and experiences sometimes referred to strengthening policy support, but institutionalization of harm reduction was also resisted or rejected. Results suggest that actors adopt a range of pragmatic strategies to advance harm reduction services in response to policy vacuums characteristic of morality policy domains, and challenge assumptions about the utility of formal policies for advancing harm reduction.
Keywords
Harm reductionPolicymakingCanadaOpioid crisisQualitative researchKey informant interviews
In Reply In discussing the topic of injection drug use–associated infective endocarditis in our review,¹ our intent was to highlight the lack of certainty with respect to the use of surgery and outcomes in these patients. Cardiac surgery in patients with injection drug use–associated infective endocarditis has been associated with higher mortality and reoperation in the first 6 months after surgery than in patients with infective endocarditis not related to injection drug use.² Surgical decision-making about infective endocarditis is complicated in general. For example, approximately 1 in 4 patients with infective endocarditis (regardless of whether they use intravenous drugs) with indications for surgery do not receive surgery as part of their management, particularly those with infective endocarditis due to Staphylococcus aureus.³ An important and challenging aspect of managing infective endocarditis is addressing host factors that impede the use of surgery when indications are present. With injection drug use–associated infective endocarditis, the risks of ongoing addiction, injection drug use, and infection relapse or recurrence adds greater complexity that needs to be addressed. We agree that addiction treatment is a crucial aspect of care for patients with injection drug use–associated infective endocarditis and is often suboptimally addressed.⁴ Also, we regret if readers perceived any unintended negativity or judgment with respect to the terminology used in our brief discussion of injection drug use–associated infective endocarditis.
Importance
Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings.
Observations
Community–associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct roles in the diagnosis of infective endocarditis when blood culture have tested negative with the highest yield obtained from serological studies. Increasing antibiotic resistance, particularly to S aureus, has led to a need for different antibiotic treatment options such as newer antibiotics and combination therapy regimens. Surgery can confer a survival benefit to patients with major complications; however, the decision to pursue surgery must balance the risks and benefits of operations in these frequently high-risk patients.
Conclusions and Relevance
The epidemiology and management of infective endocarditis are continually changing. Guidelines provide specific recommendations about management; however, careful attention to individual patient characteristics, pathogen, and risk of sequela must be considered when making therapeutic decisions.
: In this issue of the Journal of Addiction Medicine, 2 studies fill an important gap in knowledge by examining predictors of leaving against medical advice from inpatient withdrawal management settings. The studies identify important risk factors for leaving against medical advice and highlight important areas for inpatient withdrawal management. These include the use of substance specific standardized protocols and initiation of opioid agonist treatment instead of opioid detoxification given harms associated with opioid withdrawal. Further need for increased training in addiction medicine for primary care physicians, and use of inpatient addiction medicine consult services as part of early intervention for substance withdrawal are also discussed.
Objective:
To conduct a pilot needs assessment of underlying substance use disorders (SUD), motivation for SUD treatment, and willingness to enter residential SUD treatment in hospitalized adults who inject drugs with complex infections requiring intravenous (IV) antibiotics, and to assess the presence of in-hospital illicit substance use.
Patients and methods:
From March 8, 2016 through August 25, 2016 hospitalized, English-speaking, adult patients not currently in SUD treatment with a history of injection drug use and a current infection requiring treatment with IV antibiotics, were prospectively enrolled. Participants were followed weekly during the hospitalization and for 60 days after discharge via interview and medical record review.
Results:
Of the 42 participants, 8 (19.0%) accepted discharge to residential SUD treatment, 16 (38.0%) completed at least one follow-up research visit after hospital discharge, and 3 (7.1%) died during the 5-month study period. The majority (33; 78%) were hospitalized with endocarditis, and 37 (88.0%) had an opioid use disorder (DSM-5). Mean days of self-reported IV opioid use in the 30 days before hospitalization compared to 30 days after discharge decreased significantly (16.5 to 1.5, P = .001) despite not receiving SUD treatment. Illicit in-hospital drug use was identified in 17 (40.5%) participants, with opioids most commonly detected.
Conclusion:
Hospitalization is a 'reachable moment' and critical opportunity to initiate evidence-based treatment for opioid use disorder. The ongoing in-hospital illicit drug use and high short-term mortality observed in this study contribute to the mandate to expand access to effective pharmacotherapy for opioid use disorder and integrate it into health care settings.
Backgrounds:
Georgia faces high HCV rates (5.4% of chronic cases in general population) with an epidemic concentrated among people who inject drugs (PWID). A National HCV Elimination Program (NHCEP), was launched in April 2015, aiming to eliminate HCV by 2020. To succeed, this program must develop tailored interventions to enroll PWID in treatment.
Intervention:
We implemented a pilot intervention to facilitate access to and retention of PWID in the NHCEP, and to prevent reinfection after treatment. Screening was offered at a harm reduction center. PWID with positive results were followed by peer-workers during medical assessment, which lasted 73days in average, and throughout the treatment by Sofosbuvir and Ribavirin+/- PegInterferon for 12, 24 or 48 weeks delivered at a medical center. Additional prevention sessions and PCR checks were delivered to PWID 6 and 12 months after the confirmation of sustained virologic response.
Results:
The pilot intervention screened 554 people in 5 months with 244 starting treatment. The majority of participants (98.0%, n=239) completed the treatment. The intervention, initially implemented in the capital, was replicated in a rural area.
Conclusion:
Peer-supported and strongly integrated, comprehensive HCV care will help PWID reach high uptake and adherence to care.
A young adult with severe opioid use disorder (OUD) secondary to long-standing intravenous (IV) heroin use was admitted to the hospital with encephalopathy, respiratory failure, and septic shock. Two sets of blood cultures were positive for methicillin-sensitive Staphylococcus aureus, as were cultures of his cerebrospinal fluid. He was found to have mitral valve infective endocarditis with a subannular abscess, acute mitral regurgitation, and septic cerebral emboli. He underwent mitral valve replacement and placement of a pericardial patch. During the hospitalization he was diagnosed as having chronic hepatitis C virus infection, which he most likely contracted from sharing needles. Six weeks of appropriate antibiotics were completed outside of the hospital through a peripherally inserted central catheter (PICC) under the supervision of a family member. During this hospitalization, no treatment for OUD was offered or initiated.
U.S. hospitalizations for severe infections associated with illicit opioid use have doubled over the past decade and are often prolonged and resource-intensive, but medication-assisted treatment for opioid use disorder can be integrated into hospital care.
This JAMA Clinical Guidelines Synopsis summarizes the British Columbia Ministry of Health’s 2015 guidelines on clinical management of opioid use disorder in adults. Box Section Ref ID
Guideline title
Guideline for the Clinical Management of Opioid Addiction
Developer
Vancouver Coastal Health, Providence Health Care, and Ministry of Health, British Columbia, Canada
Release date
November 2015
Funding source
Funded publicly through governmental grants
Target population
Nonpregnant adult patients with opioid use disorder
Major recommendations
• Opioid withdrawal alone is not recommended for treatment of opioid use disorder in most patients because of increased risks of overdose death and infectious disease, particularly HIV through intravenous drug use, following detoxification (moderate-quality evidence; strong recommendation).
• In the absence of contraindications, medically supervised opioid agonist treatment should be offered to patients. Buprenorphine/naloxone is the preferred first-line treatment. Methadone is an alternative in certain patient populations (high-quality evidence; strong recommendation).
• Psychosocial supports tailored to patient needs may be offered as an adjunct to medical treatment (moderate-quality evidence; conditional recommendation).
Background and objectives:
A feared complication of opioid use disorder (OUD) is intravenous drug use related infective endocarditis (IDU-IE). We report on our experience engaging hospitalized IDU-IE patients to initiate medication-assisted treatment (MAT).
Methods:
A retrospective study (n = 29) using descriptive statistics.
Results:
Overall, 9 (31.0%) successfully initiated buprenorphine maintenance during the hospitalization, and 9 (31.0%) accepted a referral to methadone maintenance following discharge. Eleven (37.9%) declined MAT altogether.
Discussion and conclusions:
Hospitalizations may represent an important opportunity to engage IDU-IE patients to initiate MAT.
Scientific significance:
The study provides preliminary support of engaging hospitalized IDU-IE patients to initiate MAT. (Am J Addict 2016;XX:1-4).
Background:
Infective endocarditis is a serious infection often resulting from injection drug use. Inpatient treatment regularly focuses on management of infection without attention to the underlying addiction. We aimed to determine the addiction interventions done in patients hospitalized with injection drug use associated infective endocarditis.
Methods:
This is a retrospective review of patients hospitalized with injection drug use associated infective endocarditis from January, 2004 through August, 2014 at a large academic tertiary care center in Boston, Massachusetts. For the initial and subsequent admissions, data was collected regarding addiction interventions, including consultation by social work, addiction clinical nurse and psychiatry, documentation of addiction in the discharge summary plan, plan for medication-assisted treatment and naloxone provision.
Results:
102 patients were admitted with injection drug use associated infective endocarditis, 50 patients (49.0%) were readmitted and 28 (27.5%) patients had ongoing injection drug use at readmission. At initial admission, 86.4% of patients had social work consultation, 23.7% had addiction consultation, and 24.0% had psychiatry consultation. Addiction was mentioned in 55.9% of discharge summary plans, 7.8% of patients had a plan for medication-assisted treatment, and naloxone was never prescribed. Out of 102 patients, 26 (25.5%) are deceased. The median age at death was 40.9 years (IQR 28.7-48.7).
Conclusions:
We found that patients hospitalized with injection drug use associated infective endocarditis had high rates of readmission, recurrent infective endocarditis and death. Despite this, addictions interventions were suboptimal. Improved addiction interventions are imperative in the treatment of injection drug use associated infective endocarditis.
Deep tissue infection is a serious sequela that often demands intravenous (IV) antibiotic treatment. With respect to IV drug users (IDU’s), research and lived experience demonstrates a trend of failed treatment outcomes, most notably associated with leaving hospital against medical advice (LAMA) prior to treatment completion, increased adverse outcomes and patient hardship. This paper examines an alternative model for delivering and completing IV antibiotic treatment to IDU’s in a community care setting. A retrospective study was designed to review client characteristics. A total of 33 in-depth interviews were conducted with clients, clinicians and with staff. The impact of treatment adherence and completion, as well as client satisfaction of care was explored. A total of 165 patients were admitted during the study period. Osteomyelitis was the primary cause for IV antibiotics. Risk of leaving AMA was significantly lower for community model (p value
Introduction and aims:
People who inject drugs (PWID) engage in practices that put them at risk for various infections and overdose. The primary aim of this study was to examine common barriers to engaging in two risk reduction practices - cleaning one's skin at the injection site and always using new needles to inject - among heroin injectors in Denver, CO.
Method:
In 2010, 48 PWIDs were recruited through street outreach and completed a structured interview that included questions on the frequency of specific risk reduction practices (skin cleaning and using new needles) and barriers associated with these practices.
Results:
Though many of the reported barriers were similar across the two practices, the most common barriers associated with skin cleaning included being in withdrawal and not being prepared with materials prior to injection. Fear of being arrested and being in withdrawal were most frequently reported for using new needles. Multivariate and t-test analyses demonstrated that individuals who skin cleaned and used new needles more frequently reported less barriers to these practices.
Conclusions:
Participants reported a number of barriers to risk reduction, including those that are within the personal control of the injector, barriers that are consequences of addiction or psychological problems, and those that are structural or a function of the risk environment. Statistical analysis found that PWIDs who were more likely to skin clean and use new needles reported less barriers. Addressing barriers when intervening with PWID appears important to increase the success of risk reduction interventions.
We tested the efficacy of a brief intervention based on motivational interviewing (MI) to reduce high-risk injection behaviours over a 6-month period among people who inject drugs (PWID).
A single site 2-group parallel randomized controlled trial comparing MI with a brief educational intervention (EI).
A study office located in downtown Montréal, Canada, close to the community-based harm reduction programs where PWID were recruited.
PWID who had shared drug injection equipment or shared drugs by backloading or frontloading in the month prior to recruitment were randomized to either the MI (112) or EI (109) group.
The MI aimed to 1) encourage PWID to voice their desires, needs and reasons to change behaviours; 2) boost motivation to change behaviours; and 3) when the person was ready, support the plan he or she chose to reduce injection risk behaviours. The EI consisted of an individual session about safe injection behaviours.
The primary outcome was defined as having any of these risk behaviours at 6 months: having shared syringes, containers, filters or water to inject drugs in the previous month, and backloading/frontloading; each behaviour was examined separately, as secondary outcomes.
The probability of reporting a risk injection behaviour decreased in both the MI and the EI groups. At 6-month follow-up, participants who reported any risk behaviours were 50% (OR = 0.50; CI:0.13-0.87) less likely to be in the MI group than in the EI group as well as those who reported sharing containers (OR = 0.50; CI:0.09-0.90). PWID who reported sharing equipment excluding syringes, were 53% less likely to be in the MI group (OR = 0.47; CI: 0.11-0.84).
A brief motivational interviewing intervention was more effective than a brief educational intervention in reducing some high risk injecting behaviours up in the subsequent 6 months. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
Whilst it used to affect mostly intravenous drug users and patients who underwent valvular surgery with suboptimal infection control procedures, fungal endocarditis is now mostly observed in patients with severe immunodeficiency (onco-haematology), in association with chronic central venous access and broad-spectrum antibiotic use. The incidence of fungal endocarditis has probably decreased in most developed countries with access to harm-reduction policies (i.e. needle exchange programmes) and with improved infection control procedures during cardiac surgery. Use of specific blood culture bottles for diagnosis of fungal endocarditis has decreased due to optimisation of media and automated culture systems. Meanwhile, the advent of rapid techniques, including fungal antigen detection (galactomannan, mannan/anti-mannan antibodies and β-1,3-d-glucans) and PCR (e.g. universal fungal PCR targeting 18S rRNA genes), shall improve sensitivity and reduce diagnostics delays, although limited data are available on their use for the diagnosis of fungal endocarditis. New antifungal agents available since the early 2000s may represent dramatic improvement for fungal endocarditis: (i) a new class, the echinocandins, has the potential to improve the management of Candida endocarditis owing to its fungicidal effect on yeasts as well as tolerability of increased dosages; and (ii) improved survival in patients with invasive aspergillosis with voriconazole compared with amphotericin B, and this may apply to Aspergillus sp. endocarditis as well, although its prognosis remains dismal. These achievements may allow selected patients to be cured with prolonged medical treatment alone when surgery is considered too risky.
Introduction and Aims: Increasing the frequency with which injecting drug users (IDUs) engage in self-initiated harm reduction strategies could improve their health, but few investigations have examined IDUs’ perceived barriers to engaging in these behaviors.
Method: We interviewed 90 IDUs recruited from needle exchanges to assess: (a) perceived obstacles to their use of two specific harm reduction strategies (i.e., test shots and pre-injection skin cleaning) designed to reduce two unhealthy outcomes (i.e., overdose and bacterial infections, respectively) and (b) their use of other risk-reduction practices.
Results: The most frequently cited barrier for both test shots and skin cleaning was being in a rush to inject one's drugs. Other, less commonly cited barriers were strategy-specific (e.g., buying drugs from a known dealer as a reason not to do a test shot; not having access to cleaning supplies as a reason not to clean skin). Regarding other risk reduction practices, participants most frequently reported using new or clean injecting supplies and avoiding sharing needles and injecting supplies.
Discussion and Conclusions: Some, but not all, of the barriers generated by participants in our study were similar to those frequently reported in other investigations, perhaps due to differences in the type of sample recruited or in the harm reduction behaviors investigated.
Bacterial infections are widespread problems among drug injectors, requiring novel preventive intervention. As part of a NIDA-funded study, we developed an intervention based on the Information-Motivation-Behavioral Skills model, past research, injection hygiene protocols, and data collected from focus groups with 32 injectors in Denver in 2009. Qualitative responses from focus groups indicated that most participants had experienced skin abscesses and believed that bacterial infections were commonly a result of drug cut, injecting intramuscularly, and reusing needles. Access to injection supplies and experiencing withdrawal were the most frequently reported barriers to utilizing risk reduction. Implications for intervention development are discussed.
OBJECTIVE: To determine the feasibility of primary care-based ambulatory opioid detoxification (AOD) using two protocols: clonidine
and clonidine plus naltrexone.
SETTING: The Central Medical Unit (CMU)—a freestanding primary care medical clinic staffed by physicians and nurse practitioners.
PATIENTS: Injection drug users (IDUs) seeking substance abuse treatment between the ages of 18 and 50 years who were addicted to opioids
(e.g., heroin) and not currently in drug treatment.
INTERVENTIONS: In the clonidine protocol, clonidine was administered every 4 hours “as needed” for up to 12 days. In the clonidine plus
naltrexone protocol, clonidine was administered and naltrexone was administered in increasing doses over five days. Both protocols
included “adjuvant” medications for muscle cramps, insomnia, and vomiting. Successfully detoxified patients were referred
to ongoing drug treatment.
DESIGN: A prospective nonrandomized clinical trial.
MEASUREMENTS AND MAIN RESULTS: One hundred forty opioid-addicted IDUs were referred to the medical clinic for AOD. Among the 125 patients who enrolled in
the study, 57 selected clonidine and 68 selected clonidine/naltrexone. The treatment groups (clonidine vs clonidine/naltrexone)
were similar at baseline with respect to: age at first heroin use (21 years vs 23 years), mean admission opioid craving score
(45/100 vs 49/100), and withdrawal symptom score (19/72 vs 18/72). Overall, 70% (88/125) of the AODs were successful, including
42% (24/57) for clonidine and 94% (64/68) for clonidine/naltrexone (p<0.001).
CONCLUSIONS: This study suggests that primary care-based AOD can be safely and effectively carried out by primary care providers and that
clonidine/naltrexone may be more effective in this setting than is clonidine alone. Ambulatory opioid detoxification can give
internists a larger role in initiating drug treatment for IDUs who are addicted to opioids.
Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis and is predominantly encountered among injecting drug users (IDUs). RSIE diagnosis requires a high index of suspicion as respiratory symptoms predominate. Prognosis of isolated RSIE is favourable, and most cases (70-80%) resolve following antibiotic administration. Surgical intervention is indicated in patients with persistent infection that does not respond to antibiotic therapy, recurrent pulmonary emboli, intractable heart failure and if the size of a vegetation increases or persists at >1 cm. Techniques can be divided into 'prosthetic' (valve replacement or prosthetic annular implantation) or 'non-prosthetic' ones (Kay's or De Vega's annuloplasty, bicuspidalization or valvectomy). In IDUs who run a high risk of complications, vegetectomy and valve repair, avoiding artificial material should be considered as the first line of surgical management as is associated with better late survival.
We examined whether perceived susceptibility to and severity of two injection-related health conditions (i.e., non-fatal overdose and bacterial infections), and perceived benefits of, barriers to, self-efficacy to, social acceptance of, and recent use of two harm-reduction behaviors (i.e., injecting test shots and pre-injection skin cleaning), predicted injecting drug users' near-term intentions to engage in these two strategies. Recent past use of these two behaviors consistently and positively predicted near-term intentions in each of four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, and with others). Perceived susceptibility to non-fatal overdose predicted intentions to do test shots, but only when participants imagined not being in withdrawal or injecting when alone. Perceived self-efficacy to clean one's skin predicted intentions to engage in this behavior, but only when participants imagined injecting while not in withdrawal. Participants' ratings of how often other injectors in their social network engage in pre-injection skin cleaning was also a significant positive predictor of intentions to clean one's skin, but only when they imagined being in withdrawal. Finally, length of time attending the needle exchange program was negatively associated with intention to engage in skin cleaning when not in withdrawal.
The enrollment of intravenous drug users (IVDUs) into an outpatient parenteral antibiotic treatment (OPAT) service using a peripherally inserted central catheter (PICC) is controversial and often avoided. The National University Hospital in Singapore has a policy of permitting OPAT-based treatment of IVDU patients with appropriate medical indications. We report on our experiences.
A prospective observational study was conducted on IVDU patients requiring parenteral antibiotics via an OPAT service from January 2005 to December 2009. Clinically appropriate patients were screened using pre-defined criteria and enrolled into our service, where standardized measures were enforced to prevent and detect PICC abuse and optimize treatment. Outcomes measured included mortality, completion of therapy, PICC abuse, and readmission for infective or treatment-related complications during OPAT and a 30 day follow-up period.
Twenty-nine IVDU patients received treatment in our OPAT service (total 675 patient-days). The median duration of therapy was 18 days (range 1-85). Infective endocarditis was the primary diagnosis in 42% of cases. Two patients (7%) had recrudescent infection after absconding during their inpatient stay. These two patients subsequently completed treatment in OPAT. There were no deaths or cases of PICC abuse. Five patients (17%) during OPAT and one patient (3%) during the 30-day follow-up period required readmission for infective or treatment-related complications.
Appropriately selected, counselled and monitored patients with a history of being an IVDU can be treated safely and successfully via OPAT centres. It is likely that some will respond better to treatment in an outpatient setting.
Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors. Although harm reduction was originally and most frequently associated with substance use, it is increasingly being applied to a multitude of other behavioral disorders. This article reviews the state of empirical research on harm reduction practices including alcohol interventions for youth, college students, and a variety of other adult interventions. We also review nicotine replacement and opioid substitution, as well as needle exchanges and safe injection sites for intravenous drug users. Dozens of peer-reviewed controlled trial publications provide support for the effectiveness of harm reduction for a multitude of clients and disorders without indications of iatrogenic effects. Harm reduction interventions provide additional tools for clinicians working with clients who, for whatever reason, may not be ready, willing, or able to pursue full abstinence as a goal.
There is great need to sustain harm reduction programmes for opiate-dependent persons, given variable retention of opioid agonist treatment (OAT) enrolees. Resource challenges may lead some health organizations to discontinue such programmes, though just as programmatic evaluation may determine efficacy and cost-effectiveness so to does it aid in examining impacts of programme dissolution.
This retrospective evaluation investigated impacts of the dissolution of a 'Minimal Services' (MS) harm reduction programme for substance-abusing OAT clientele at an urban U.S. Veterans Affairs Medical Centre. Targeted clinical data concerning treatment retention, substance use and service utilization was abstracted from medical records of MS-assignees (N=32) and a matched comparison group of standard OAT enrolees. Chart reviewers gathered data for a two-year period encompassing baseline, transitional, and dissolution study phases.
Relative to matched-controls, MS-assignees exhibited: (1) disproportionately poor treatment retention over the two-year period; (2) high and temporally stable rates of documented substance use across study phases, and (3) increased utilization of resource-laden VAMC services after MS dissolution.
Collective results suggest MS programme dissolution was associated with adverse conditions for assignees and the larger treatment setting, and reinforce the need for pragmatic, humane treatment policies to facilitate retention of opiate-dependent persons.
Six hundred patients from a Washington, D.C. population of 20,000 heroin addicts were admitted to D.C. General Hospital between November 1967 and April 1971. Bacterial endocarditis was found in 50 of them (8 per cent). The presenting features were fever (50 patients), pulmonary embolism (32 patients), positive blood cultures (39 patients), subcutaneous abscesses (2 patients), empyema (1 patient), septic arthritis (1 patient) and pericardial effusion (1 patient). The tricuspid valve alone was involved in 36 patients (72 per cent) and with other valves in 6 patients. Staphylococcus aureus was found in 28 patients, Streptococcus viridans in 4 and Streptococcus faecalis in 3. There was an over-all mortality rate of 28 per cent but pure right-sided lesions were found in only 16 per cent (6 of 38 patients). Attention to the auscultatory features of acute tricuspid regurgitation was the predominant factor leading to early diagnosis.
To determine the feasibility of primary care-based ambulatory opioid detoxification (AOD) using two protocols: clonidine and clonidine plus naltrexone.
The Central Medical Unit (CMU)--a freestanding primary care medical clinic staffed by physicians and nurse practitioners.
Injection drug users (IDUs) seeking substance abuse treatment between the ages of 18 and 50 years who were addicted to opioids (e.g., heroin) and not currently in drug treatment.
In the clonidine protocol, clonidine was administered every 4 hours "as needed" for up to 12 days. In the clonidine plus naltrexone protocol, clonidine was administered and naltrexone was administered in increasing doses over five days. Both protocols included "adjuvant" medications for muscle cramps, insomnia, and vomiting. Successfully detoxified patients were referred to ongoing drug treatment.
A prospective nonrandomized clinical trial.
One hundred forty opioid-addicted IDUs were referred to the medical clinic for AOD. Among the 125 patients who enrolled in the study, 57 selected clonidine and 68 selected clonidine/naltrexone. The treatment groups (clonidine vs clonidine/naltrexone) were similar at baseline with respect to: age at first heroin use (21 years vs 23 years), mean admission opioid craving score (45/100 vs 49/100), and withdrawal symptom score (19/72 vs 18/72). Overall, 70% (88/125) of the AODs were successful, including 42% (24/57) for clonidine and 94% (64/68) for clonidine/naltrexone (p < 0.001).
This study suggests that primary care-based AOD can be safely and effectively carried out by primary care providers and that clonidine/naltrexone may be more effective in this setting than is clonidine alone. Ambulatory opioid detoxification can give internists a larger role in initiating drug treatment for IDUs who are addicted to opioids.
Advantage was taken of a natural experiment to compare the outcome of abstinence-oriented and indefinite methadone maintenance. Subjects assigned to an abstinence-oriented program were significantly more likely than those assigned to indefinite maintenance to use heroin (OR 1.3) and amphetamines (OR 2.8) during the first 2 years of methadone treatment but less likely to use benzodiazepines (OR 0.7). Subjects discharged from the abstinence-oriented program were significantly more likely to relapse and return to maintenance treatment (RR, first 6 months, 4.2). The abstinence-oriented program was also less able to attract heroin addicts into maintenance treatment.
Infections, in particular soft tissue infections (cellulitis, skin abscesses), are the leading cause for emergency department visits and hospital admissions of drug injection users (IDUs).
Staphylococcus aureus is the most relevant bacterial pathogen in this population. It is the main cause of soft tissue infections and of severe infections such as endocarditis and bacteremia. Moreover, epidemic spread of methicillin-resistant S. aureus (MRSA) among IDUs has occurred in Europe and North America. Nasal carriage of S. aureus is associated with an increased risk of subsequent S. aureus infections, and it has been shown that active IDUs have a higher rate of colonization with S. aureus than the general population. However, it is still unknown why an individual carries S. aureus. In particular, repeated injections do not appear to be the main predisposing factor for S. aureus carriage.
Infections associated with injection drug use are frequently the consequence of the illegal status of street drugs. Harm reduction programs, including needle exchange programs, safer injecting facilities and injection opiate substitution programs can reduce the incidence of infections among severely addicted IDUs.