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International Journal of Drug Policy
Journal Prestige (SJR): 1.441
Citation Impact (citeScore): 3
Number of Followers: 478  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0955-3959
Published by Elsevier Homepage  [3182 journals]
  • Utility of a one-step screening and diagnosis strategy for viremic HCV
           infection among people who inject drugs in Catalonia
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Verónica Saludes, Adrián Antuori, Cinta Folch, Noemí González, Núria Ibáñez, Xavier Majó, Joan Colom, Lurdes Matas, Jordi Casabona, Elisa Martró, HepCdetect II Study Group BackgroundIn Catalonia (Spain), people who inject drugs (PWID) face numerous barriers to access to mainstream healthcare services for hepatitis C confirmatory diagnosis and treatment, so simplified testing strategies for viremic infection are urgently needed. Among PWID attending harm-reduction services in Catalonia, we aimed (i) to assess the utility of an in-house HCV-RNA detection assay on dried blood spots (DBS) as a one-step screening and confirmatory diagnosis strategy for hepatitis C, (ii) to estimate the prevalence of viremic HCV infection, and (iii) to identify factors associated with unawareness of viremic infection.MethodsA cross-sectional study of current PWID (N  = 410) was performed in four harm-reduction services. All participants underwent HCV antibody point-of-care testing and parallel DBS collection for centralized RNA testing. An epidemiological questionnaire was administered. Paired EDTA-plasma samples were additionally collected for HCV viral load testing in 300 participants.ResultsHCV-RNA testing from DBS was feasible and showed 97.2% sensitivity and 100% specificity for viral loads>3000 IU/mL in real-life conditions. No significant differences in the performance when detecting viremic infections were observed between this one-step testing strategy vs. the conventional two-step algorithm involving venepuncture. Overall HCV seroprevalence was 79.8%, and prevalence of viremic infection was 58.5%. Importantly, 35.8% of viremic HCV participants were unaware of their status, and no specific socio-demographic or bio-behavioral factors independently associated with unawareness of viremic infection were identified. Among participants reporting a past or current HCV infection, 29.0% stated having received HCV antiviral treatment.ConclusionThe high viremic HCV infection burden among PWID attending HRS, estimated for the first time in Catalonia, together with the low levels of awareness of viremic status and access to treatment, suggest that scaling up this one-step screening and diagnosis strategy to the network of harm-reduction services would help to achieve HCV elimination targets set by the World Health Organization.
  • Government monopoly as an instrument for public health and welfare:
           Lessons for cannabis from experience with alcohol monopolies
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Robin Room, Jenny Cisneros Örnberg BackgroundGovernment monopolies of markets in hazardous but attractive substances and activities have a long history, though prior to the late 19th century often motivated more by revenue needs than by public health and welfare.MethodsA narrative review considering lessons from alcohol for monopolization of all or part of legal markets in cannabis as a strategy for public health and welfare.ResultsA monopoly can constrain levels of use and harm from use through such mechanisms as price, limits on times and places of availability, and effective implementation of restrictions on who can purchase, and less directly by replacing private interests who would promote sales and press for greater availability, and as a potential test-bed for new policies. But such monopolies can also push in the opposite direction, particularly if revenue becomes the prime consideration. Drawing on the alcohol experience in recent decades, the paper discusses issues relevant to cannabis legalization in monopolization of different market levels and segments – production, wholesale, import, retail for off-site and for on-site use – and choices about the structuring and governance of monopolies and their organizational location in government, from the perspective of maximizing public health and welfare interests.ConclusionWhile the historical record is mixed for government monopolies of attractive but hazardous commodities, experience with alcohol in recent decades shows that for public health and welfare public monopolization is generally a preferable option.
  • Attitudes and availability: A comparison of naloxone dispensing across
           chain and independent pharmacies in rural and urban areas in Alabama
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Michelle L. Sisson, Kristina B. McMahan, Keith R. Chichester, James W. Galbraith, Karen L. Cropsey BackgroundFatal opioid overdoses remain the leading cause of accidental deaths in the United States, which have contributed to implementation of standing order laws that allow pharmacists to dispense naloxone to patients. Although pharmacy distribution of naloxone is a promising approach to increase access to this intervention, understanding barriers preventing greater uptake of this service is needed.MethodsData for the current study were collected via telephone survey assessing the availability of various formulations of naloxone at chain and independent pharmacies in rural and urban areas in Birmingham, Alabama (N = 222). Pharmacists’ attitudes toward naloxone and potential barriers of pharmacy naloxone distribution were also assessed. One-way analysis of variance (ANOVA) and logistic regression analyses were utilized to examine differences in stocking of naloxone in chain and independent pharmacies and to determine predictors of the number of kits dispensed by pharmacies.ResultsIndependent pharmacies were less likely to have naloxone in stock, especially those in rural areas. Furthermore, rural pharmacies required more time to obtain all four formulations of naloxone, and offered less extensive training on naloxone use. Pharmacists endorsing the belief that naloxone allows avoidance of emergent treatment in an overdose situation was associated with fewer dispensed kits by the pharmacies. Over 80% of pharmacists endorsed at least one negative belief about naloxone (e.g., allowing riskier opioid use). Pharmacists noted cost to patients and the pharmacy as contributing to not dispensing more naloxone kits.ConclusionThe current study demonstrates the lower availability of naloxone stocked at pharmacies in independent versus chain pharmacies, particularly in rural communities. This study also highlights several barriers preventing greater naloxone dispensing including pharmacists’ attitudes and costs of naloxone. The potential benefit of standing order laws is not being fully actualized due to the structural and attitudinal barriers identified in this study. Strategies to increase naloxone access through pharmacy dispensing are discussed.
  • Ambiguous identities of drugs and people: A scoping review of
           opioid-related stigma
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Melissa D. McCradden, Denitsa Vasileva, Ani Orchanian-Cheff, Daniel Z. Buchman BackgroundHuman beings have long consumed opiates and opioids for pleasure and as a treatment for numerous ailments, most notably pain. North America is currently in the grips of a crisis of opioid-related overdoses, and stigma is considered a major driver of the harms. While it is well established that substance use in general is highly stigmatized, stigma is a complex concept and opioid-related stigma is not well understood. A lack of clarity on opioid-related stigma has practice and policy implications in terms of understanding the sources of opioid stigma, how it manifests in various contexts, its impact on affected groups, and the development of effective strategies to redress it.MethodsWe performed a scoping review of the academic literature to develop a typology of opioid-related stigma. A charting process identified the type, agent, and recipient of stigma as well as the methodology and substances considered.ResultsOur search yielded 8,543 articles, from which 49 were included in the analysis. Based on the findings, we developed a typology of four main themes: (1) interpersonal and structural stigma toward people accessing opioid agonist therapy (OAT); (2) stigma related to opioids for the treatment of chronic pain; (3) stigma in healthcare settings; and (4) self-stigma.ConclusionHow opioid-stigma is (re)produced depends on the context of opioid use, the social identity and networks of the person who is consuming the opioid, and what type of opioid is being consumed, including medically-sanctioned forms of treatment. Opioid-related stigma permeates intrapersonal, interpersonal, structural, and societal levels, and people who consume opioids are marginalized at all levels. Our review describes our typology of stigma and illuminates multi-level considerations for reducing opioid-related stigma in healthcare settings.
  • ‘It's our safe sanctuary’: Experiences of using an unsanctioned
           overdose prevention site in Toronto, Ontario
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Annie Foreman-Mackey, Ahmed M. Bayoumi, Miroslav Miskovic, Gillian Kolla, Carol Strike BackgroundOverdose prevention sites (OPSs) are spaces where people can consume drugs under the supervision of trained volunteers or staff and receive help in the event of an overdose. Unsanctioned OPSs are a grassroots response to the current opioid crisis in Canada.MethodsWe used rapid evaluation methods to study the experiences of 30 individuals accessing the smoking and injection services at the first unsanctioned OPS in Toronto, Ontario using semi-structured interviews. Data were analyzed using an applied thematic analysis approach to identify emergent themes related to service user experiences, characteristics of the risk environment, and recommended changes to the service model.ResultsThe OPS represented a safe sanctuary and brought a sense of belonging to a community that often experiences discrimination. Valued aspects included: shelter; protection from violence; safety from overdoses; free equipment; information about health and social services; food and beverages; and socializing and connecting with others. Integrating peer workers in the design and delivery of services encouraged service users to visit the site. The OPS changed the risk environment by: providing access to the first supervised smoking service in Toronto; having few explicit rules and a communal approach to making new rules; allowing assisted injection, and negotiating with police to allow people to access the site with minimal contact. Service users noted the need to ensure a safe space for women and recommended extended hours of operation and moving to a more permanent space with heat and lighting for both smoking and injecting drugs.ConclusionThe unsanctioned OPS in Toronto served an important role in defining new, community-led, flexible responses to opioid overdose-related deaths at a time of markedly increasing mortality. Providing harm reduction services in diverse settings and expanding services to include smoking and assisted injection may increase access for marginalized people who use drugs.
  • Drug use and risk behaviour profile, and the prevalence of HIV, hepatitis
           C and hepatitis B among people with methamphetamine use in Iran
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Ghobad Moradi, Behzad Hajarizadeh, Khaled Rahmani, Amjad Mohamadi-Bolbanabad, Sonia Darvishi, Bushra Zareie, Fatemeh Azimian Zavareh, Heidar Sharafi, Seyed Moayed Alavian, Rashid Ramazani, Mehrdad Eftekhar, Seyed Ramin Radfar, Bakhtiar Piroozi, Mohammad-Mehdi Gouya BackgroundStimulants substances use, particularly methamphetamine use, is increasing globally, including in Iran. This study assessed the drug use and risk behaviour profile, and prevalence of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) among a large population using methamphetamine as their primary drug in Iran.MethodsThis cross-sectional study was conducted in eight provinces of Iran. Individuals using methamphetamine for ≥3 months during the past three years, with no life-time history of injecting opioid drugs were enrolled. Drug use and risk behaviour data were collected through interviews. Blood samples were tested for HIV antibodies (HIV Ab), HCV antibodies (HCV Ab), and HBV surface antigen (HBs Ag).ResultAmong 567 participated, 84% were men and mean age was 36 years. Smoking with pipe was the most common method of methamphetamine use (53%), while 13% had a history of injecting methamphetamine, among whom 30% shared needles or syringes. Among those having sex during intoxication phase (n = 270), 48% never used condom. The prevalence of HIV Ab, HCV Ab and HBs Ag was 6.7% (95%CI: 4.7–9.1), 19.4% (95%CI: 16.2–22.9) and 1.4% (95%CI: 0.6–2.7), respectively. Age ≥ 30 years (adjusted OR [aOR]: 2.10, 95%CI: 1.18–3.76), lower education (high school vs. tertiary education, aOR: 13.95, 95%CI: 1.90–102.60), and injecting methamphetamine (aOR: 1.92, 95%CI 1.10–3.35) were significantly associated with HCV exposure. No factor was found associated with HIV infection. Among those reporting no potential injecting or sexual risk factors, 19.8% and 6.8% have HCV Ab positive and HIV Ab positive, respectively.ConclusionHigh prevalence of injecting and sexual risk behaviours, HIV infection and HCV exposure were found among individuals using methamphetamine as their primary drug, demonstrating them as an emerging population at risk of HIV and HCV in Iran. Targeted screening and harm reduction programs for this population are required.
  • ‘For pain, no shame’ and ‘My secret solace’: Accounts of
           over-the-counter codeine dependence using Q methodology
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Melissa Kirschbaum, Tony Barnett, Merylin Cross BackgroundDependence on over-the-counter (OTC) codeine is recognised internationally as a rising public health issue. The effectiveness of health intervention strategies may be influenced by the beliefs held by those who are dependent. Applying Q methodology, this study aimed to identify shared accounts of OTC codeine dependence.MethodsTwenty-six participants from Tasmania, Australia, met eligibility criteria for the study as long-term OTC codeine users with a Severity of Dependence Score of five or higher. Forty-six opinion statements about OTC codeine dependence were sourced from the literature and online discussion forums. These were rank-ordered by participants from least to most agree and explanatory comments for the most strongly positioned statements were provided. By-person factor analysis was used to group participants who had sorted the statements similarly.ResultsTwo distinct accounts of OTC codeine dependence were identified. Participants representing Factor One, ‘For pain, no shame’, were not ashamed of their OTC codeine use, believed access should not be restricted and regarded it as necessary for the relief of physical pain. In contrast, Factor Two, ‘My secret solace’, was characterized by feelings of guilt and shame. Participants in this group intentionally used codeine for its effects on mood; to help them relax and to relieve stress, rather than solely for pain relief. They did not consider regular use of codeine to be socially acceptable and hid their use from others.ConclusionThe way in which OTC codeine use is viewed by those who are dependent is not uniform. Two distinct accounts were identified in this sample. Participants from each group varied in their beliefs about access, causality, reasons for use and feelings of legitimacy and shame. An understanding of these differences can be used to better target interventions and guide policy for the prevention and management of OTC codeine dependence.
  • Cannabis legalization in Canada: What are the potential implications and
           barriers for people living with HIV'
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Marilou Gagnon, Adrian Guta
  • Pleasure and HIV biomedical discourse: The structuring of sexual and
           drug-related risks for gay and bisexual men who Party-n-Play
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Rusty Souleymanov, David J. Brennan, Carmen Logie, Dan Allman, Shelley L. Craig, Perry N. Halkitis Party-n-Play (PNP) is a social practice that refers to sex that occurs under the influence of drugs. This study critically examined the risk and pleasure discourses of gay and bisexual men who PNP to explore how epistemic shifts associated with advancements in HIV biomedical sciences influence gay and bisexual men's perceptions of HIV risks and their sexual and drug-related practices. This study also aims to provide a more nuanced understanding of how sexual and drug-related risk practices of gay and bisexual men are entangled with their search for pleasure.The study was framed within poststructural Critical Discourse Analysis (CDA) methodology. In-depth one-hour interviews were conducted with 44 self-identified gay, bisexual, queer, or Two-Spirit men, who lived in Toronto, and who reported using drugs before or during sex with another man.The findings from this study demonstrated the capacity of biomedical discourses to affect respondents’ HIV risk perceptions and practices. The transition from condom-centered prevention to today's context where new highly effective biomedical tools for HIV prevention are available created possibilities for greater intimacy, increased pleasure, and less anxiety about HIV tranmission, while challenging many years of preventive socialization among gay and bisexual men. However, this new context also rekindled deep-seated fears about HIV risk and viral load verifiability, reinforced unequal forms of biomedical self-governance and citizenship, and reproduced practices of biopolitics. While discourses on risk and pleasure were interwoven within complex PNP assemblages, the notion of pleasure was mobilized as a discursive tactic of self-control, and the division between normative and non-normative pleasures highlighted the consequence of biopolitical forces governing the production of discourses on sex and drugs.Future HIV social science research needs to attend to the fluid nature of the discursive environments of HIV prevention science, and consider how both the material context of PNP and its social/discursive elements operate together.
  • Adulterants and altruism: A qualitative investigation of “drug
           checkers” in North America
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Joseph J. Palamar, Patricia Acosta, Rachel Sutherland, Michele G. Shedlin, Monica J. Barratt Background“Drug checking” has become a common harm reduction method used to test illicit substances, such as ecstasy, for purity and/or the presence of adulterants. Formal drug-checking services have been operating for decades, and the use of personal reagent test kits appears to be relatively common; however, little attention has been devoted to understanding the role and broader experiences of ‘drug-checkers’ (i.e., people who test their own and/or other people's substances). As such, it remains unknown who is engaging in this practice, their motivations for drug-checking, and what barriers they may experience. We addressed this research gap by interviewing people who check drugs about their experiences, with a goal of better understanding drug checking practices.MethodsWe conducted in-depth interviews with 32 adults in North America who reported testing drugs. Coding was conducted in an inductive manner and thematic analysis was used to identify relevant themes.ResultsOver half (56.2%) of our sample was affiliated with a drug checking organization. Among non-affiliated checkers (43.8%), the majority (57.1%) tested for friends, 21.4% tested only for themselves, and 21.4% were people who sold drugs and tested for their clients. Motivations were driven largely by altruism, described by checkers as wanting to protect their peers from exposure to adulterants. People interviewed who sold drugs were altruistic in the same manner. Barriers to checking—particularly at nightclubs and festivals—included perceived illegality of test kits and denied approval to test drugs at venues, although many checkers circumvented this barrier by checking drugs without such approval.ConclusionsDrug checkers in North America seek to educate people who use drugs about the risk of exposure to unexpected substance types, but they face various barriers. Policy change could help ensure that these potentially life-saving services can be provided without fear of fines and/or criminal prosecution.
  • The ever-changing narrative: Supervised injection site policy making in
           Ontario, Canada
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Bianca R Ziegler, Alexander JD Wray, Isaac Luginaah BackgroundWe analyze the ongoing debate surrounding supervised injection sites in Ontario, Canada and changing policies that impact host communities. Despite a plethora of evidence proving the effectiveness of supervised injection sites on harm reduction strategy, the topic remains highly controversial with constantly changing rhetoric in the Ontario drug policy landscape.MethodsWe reviewed government reports, policies, and media sources spanning from prior to the establishment of the first Canadian supervised injection site in 2000 to early 2019, adopting an advocacy coalition framework approach to this policy analysis. Various advocacy coalitions emerge from this analysis, including all three levels of government, law enforcement, health practitioners, and community groups. We describe the narratives constructed by these coalitions, analyzing the supervised injection site model as a harm reduction strategy within a continually shifting socio-political landscape.ResultsEmerging from the analysis are competing narratives put forward by various stakeholders within the policy subsystem. We find policy-makers tend to leverage scientific uncertainty as a tool to defend the interests of the most powerful actor in the subsystem. Despite an increase in the number of deaths due to the opioid crisis and evidence highlighting the efficacy of supervised injection sites as a harm reduction tool, various stakeholders are locked in a battle of claims and counter-claims about the appropriate policy response to opioids.ConclusionsThese findings have broad implications for drug policy in other contexts. Our case study demonstrates the strength of stopgap measures, like supervised injection, to reduce harm from controlled substances.
  • ‘It's too much, I'm getting really tired of it’: Overdose response and
           structural vulnerabilities among harm reduction workers in community
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Gillian Kolla, Carol Strike BackgroundIn response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) – who experience social and structural vulnerabilities due to their drug use – enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice.MethodsData were drawn from an ethnographic study of “Satellite Sites”, a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose.ResultsOEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use.ConclusionOEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.
  • Public policy, attitudes and willingness to pay for treatment of substance
           dependence in Iran
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Samaneh Ahmadian Moghaddam, Ali Mazyaki, Emran M. Razaghi BackgroundEvaluation of costs and benefits of substance use treatment programs through a standard economic framework is necessary for optimal policy making. However, drug policy making is seldom supported by economic justification. Measurement of willingness to pay is a tool to provide better understanding of intangible substance use treatment outcomes and to help a balanced policy in treatment of substance use between maintenance treatment and abstinence-based approach.AimTo assess the reciprocal association between economic indexes and attitudes about substance use and its treatment as indicators of tendency toward the two different treatment.MethodWillingness to pay for treatment was measured by contingency valuation method among 109 treatment cost payers of which 78 subjects were from outpatient methadone maintenance clinics and 31 were from abstinence-based residential facilities. To analyze predictors of willingness to pay, we used income to capture heterogeneity of purchasing power among subjects. Further, we checked bivariate correlation of different attitudes of cost payers with willingness to pay. In the next step using backward regression equation we tried to reach the best specification of the model. Selected variables include cost payers’ attitudes toward substance use and its treatment, effectiveness of treatment, social attitude toward the condition of substance use in Iran, fairness of treatment prices, and government financial support for addiction treatment.ResultsIn methadone maintenance clinics the payers’ income had a pivotal role in determining willingness to pay for substance use treatment by 50% (p
  • The effect of cannabis laws on opioid use
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Jamie L. Flexon, Lisa Stolzenberg, Stewart J. D'Alessio BackgroundMany Americans rely on opioids at varying dosages to help ameliorate their suffering. However, empirical evidence is mounting that opioids are ineffective at controlling non-cancer related chronic pain, and many argue the strategies meant to relieve patient suffering are contributing to the growing opioid epidemic. Concurrently, several states now allow the use of medical cannabis to treat a variety of medical conditions, including chronic pain. Needing more exploration is the impact of cannabis laws on general opioid reliance and whether chronic pain sufferers are opting to use cannabis medicinally instead of opioids.MethodsThis study investigates the effect of Medical Marijuana Laws (MML)s on opioid use and misuse controlling for a number of relevant factors using data from several years of the National Survey on Drug Use and Health and multivariate logistic regression and longitudinal analysis strategies.ResultsResults provide evidence that MMLs may be effective at reducing opioid reliance as survey respondents living in states with medical cannabis legislation are much less apt to report using opioid analgesics than people living in states without such laws, net other factors. Results further indicate that the presence of medicinal cannabis legislation appears to have no influence over opioid misuse.ConclusionMMLs may ultimately serve to attenuate the consequences of opioid overreliance.
  • Leveraging the value of online data and methods: Drug policy research at
           the cutting edge
    • Abstract: Publication date: Available online 3 October 2019Source: International Journal of Drug PolicyAuthor(s): Judith Aldridge, Martin Bouchard
  • Taking opioids in times of crisis: Institutional oversight, chronic pain
           and suffering in an integrated healthcare delivery system in the U.S.
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Inga Gruß, Alison Firemark, Meghan Mayhew, Carmit K. McMullen, Lynn L. DeBar BackgroundOpioid treatment for chronic pain has garnered heightened public attention and political pressure to control a devastating public health crisis in the United States (U.S.). Resulting policy changes, together with ongoing public and political attention, have pushed health care systems and providers to lower doses or deprescribe and taper patients off opioids. However, little attention has been paid to the impact of such practice changes on patients who had relied on opioid treatment to manage their chronic pain. The aim of this article is to explore experiences with opioid-related care under aggressive tapering efforts and concomitant heightened monitoring and institutional oversight among patients with chronic pain in an integrated delivery system through in-depth interviews.MethodsWe interviewed 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. These patients had been prescribed opioids as part of their treatment regimens and taken opioids closely monitored by their health care providers. We followed the framework method for coding and analysing transcripts using NVivo 12.ResultsThe experiences of these patients during this period of change can be understood through three interconnected themes: (1) many patients taking opioids experience debilitating physical side effects; (2) navigating opioid treatment contributes to significant emotional distress among many patients with chronic pain and; (3) the quality of patients’ relationship with their primary care provider can be negatively affected by negotiations regarding long-term opioid treatment for chronic pain.ConclusionWe highlight the importance of utilizing communication approaches that are patient-centered and include shared decision making during the tapering and/or deprescribing processes of opioids and ensuring alternative pain treatments are available to patients with chronic pain.
  • “Another thing to live for”: Supporting HCV treatment and cure among
           Indigenous people impacted by substance use in Canadian cities
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): M.E. Pearce, K. Jongbloed, L. Demerais, H. MacDonald, W.M. Christian, R. Sharma, N. Pick, E.M. Yoshida, P.M. Spittal, M.B. Klein BackgroundColonization and colonial systems have led to the overrepresentation of Indigenous people impacted by substance use and HCV infection in Canada. It is critical to ensure Indigenous people's equitable access to new direct acting antiviral HCV treatments (DAAs). Identifying culturally-safe, healing-centered approaches that support the wellbeing of Indigenous people living with HCV is an essential step toward this goal. We listened to the stories and perspectives of HCV-affected Indigenous people and HCV treatment providers with the aim of providing pragmatic recommendations for decolonizing HCV care.MethodsForty-five semi-structured interviews were carried out with Indigenous participants affected by HCV from the Cedar Project (n = 20, British Columbia (BC)) and the Canadian Coinfection Cohort (n = 25, BC; Ontario (ON); Saskatchewan (SK)). In addition, 10 HCV treatment providers were interviewed (n = 4 BC, n = 4 ON, n = 2 SK). Interpretive description identified themes to inform clinical approaches and public health HCV care. Themes and related recommendations were validated by Indigenous health experts and Indigenous participants prior to coding and re-contextualization.ResultsTaken together, participants’ stories and perceptions were interpreted to coalesce into three overarching and interdependent themes representing their recommendations. First: treatment providers must understand and accept colonization as a determinant of health and wellness among HCV-affected Indigenous people, including ongoing cycles of child apprehension and discrimination within the healthcare system. Second: consistently safe attitudes and actions create trust within HCV treatment provider-patient relationships and open opportunities for engagement into care. Third: treatment providers who identify, build, and strengthen circles of care will have greater success engaging HCV-affected Indigenous people who have used drugs into care.ConclusionThere are several pragmatic ways to integrate Truth and Reconciliation as well as Indigenous concepts of whole-person wellness into the HCV cascade of care. By doing so, HCV treatment providers have an opportunity to create greater equity and support long-term wellness of Indigenous patients.
  • Medical marijuana. What can we learn from the experiences in Canada,
           Germany and Thailand'
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Jürgen Rehm, Tara Elton-Marshall, Bundit Sornpaisarn, Jakob Manthey Cannabis policies are changing globally, and medical marijuana programs are part of these changes. Drawing from the examples of two high-income (Canada, an early adopter of medical marijuana, and Germany, a late adopter) and one middle-income (Thailand) countries, we illustrate two main pressures underlying these recent changes. First, in many high-income countries, cannabis has been used to self-medicate for different ailments and diseases, even though there is no evidence of effectiveness for many of these conditions. Second, the cannabis industry is pressuring governments and decision-makers to allow for medical marijuana use with lenient regulations—without specifying medical conditions (indications) and requiring only a prescription from a health professional to obtain it. As a result, demand is likely to increase, even in countries with low prevalence of use. Cannabis policy-makers need to consider a balance between the medical benefits of medical marijuana and the potential public health consequences and cost.
  • Young men's alcohol consumption experiences and performances of
    • Abstract: Publication date: Available online 12 September 2019Source: International Journal of Drug PolicyAuthor(s): Samantha Wilkinson, Catherine Wilkinson BackgroundBy creating a dichotomy between those who are ‘out-of-control’ ‘binge drinkers’ and those for whom alcohol contributes to friendship fun, academic and alcohol policy literature often fail to acknowledge the nuances in the diverse drinking practices of men.MethodsThis paper engages with findings from a multiple qualitative method research project (comprising of individual and friendship group interviews; diaries; and participant observation), conducted with 16 young men, aged 15–24: eight living in the middle-class area of Chorlton, and eight living in the working-class area of Wythenshawe, Manchester, United Kingdom.ResultsThis paper provides fine-grained insights into the doings, complexities and contradictions of masculinity in the context of drinking. Young men are shown to tap into different co-existing versions of masculinity, one of which is based on the exclusion of femininity (i.e. they act as tough guys), while another version is more inclusive (i.e. it allows for displays of care).ConclusionThis paper shows a much more complex image of young men's drinking practices than has hitherto been conceptualised in the existing literature, and brings to the fore doings of alternative masculinities. This has important implications for alcohol policy interventions targeting men, in that the complexities and contradictions of masculinity in relation to drinking must be taken seriously.
  • The limits of single-group interrupted time series analysis in assessing
           the impact of smoke-free laws on short-term mortality
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Gregorio Barrio, María J. Belza, Rocío Carmona, Juan Hoyos, Elena Ronda, Enrique Regidor BackgroundDecreases in circulatory/respiratory morbimortality after the January-2006 Spanish partial smoke-free law have been found using designs without control groups, such as single-group interrupted time series (ITS), which are prone to biases. The aim was to reassess the law’s impact on mortality using ITS designs with robustness checks.MethodsA comprehensive cohort of people aged ≥25 in each calendar-year of 2002–2007, living in 13 of 18 Spanish regions, was followed up between 01/2002 and 12/2007. The law included a smoking ban in indoor public and workplaces, allowing exceptions in catering, hospitality and leisure venues, and other interventions. Post-law changes in monthly coronary/respiratory mortality were estimated using segmented regression, adjusting for relevant covariates, including seasonality, extreme temperatures, influenza incidence and air pollution. The validity of results was assessed using control outcomes, hypothetical law dates, and non-equivalent control groups, analysing their results as difference-in-differences (DID) designs.ResultsSignificant immediate post-law decreases in coronary, respiratory and non-tobacco-related mortality were observed among people aged ≥70. A significant immediate post-law decrease in respiratory mortality (−12.7%) was also observed among people age 25–69, although this was neutralized by a subsequent upward trend before 1.5 years. More favourable post-law changes in coronary/respiratory mortality among the target (people aged 25–69) than control groups (people aged ≥70 or women aged ≥80) were not identified in DID designs. Establishing hypothetical law dates, immediate decreases began in February/March 2005 with maxima between April and July 2005.ConclusionsAfter robustness checks, the results do not support a clear positive impact of the 2006 Spanish smoke-free law on short-term coronary/respiratory mortality. The favourable immediate changes observed pre- and post-law could derive mainly from the harvesting effect of the January-2005 cold wave. This highlights the risks of assessing the impact of health interventions using both morbimortality outcomes and designs without a control group and adequate robustness checks.
  • Evidence that social-economic factors play an important role in drug
           overdose deaths
    • Abstract: Publication date: Available online 28 August 2019Source: International Journal of Drug PolicyAuthor(s): Gene M. Heyman, Nico McVicar, Hiram Brownell BackgroundDrug overdose deaths in the United States increased from approximately 16,000 per year in 2001 to 41,000 per year in 2014. Although every US state witnessed an increase, the increases were much larger in some states than others. There was also variation as a function of race and ethnicity. Non-Hispanic Whites accounted for more than 80% of the deaths, and in some states their rates were about ten times greater per capita than Hispanics and Non-White rates. State and temporal differences provide an opportunity to evaluate explanations of what is driving drug overdose deaths. In this report, we evaluate the degree to which state level variation in opioid prescription rates and social-economic conditions explain state level variation in overdose death rates.Methods and dataWe used publicly available data from the Center for Disease Control (CDC), Bureau of Labor Statistics (BLS), Drug Enforcement Agency (DEA) and the Opportunity Insights project.ResultsLegally prescribed opioids, social capital and work force participation accounted for 53–69% of the between-state variation in overdose deaths in Non-Hispanic Whites. Prescriptions and the two social economic measures accounted for about the same amounts of unique variation, but shared variation among the three independent variables was the strongest predictor of overdose deaths. Panel regression results of the year-to-year changes in overdose deaths were similar. However, the pattern of correlations for Hispanics and Non-Whites was quite different. Neither opioid prescriptions nor social capital were significant predictors of overdose deaths in the between-state and between-year Hispanic and Non-White regression analyses.ConclusionsCommon variation in opioid prescriptions rates, social capital, and work force participation proved the strongest predictor of drug overdose deaths in Non-Hispanic Whites. We discuss reasons why the same did not hold for the Hispanic/Non-White population.
  • Narratives of people who inject drugs on factors contributing to opioid
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Jamie Suki Chang, Emily Behar, Phillip O. Coffin BackgroundIn recent years, there has been increasing national and global attention to opioid overdoses. In San Francisco, it is estimated that the population of people who inject drugs (PWID) has more than doubled in the past ten years. The risk factors for opioid overdose have been examined closely, but firsthand accounts of PWID who have experienced overdoses are less documented. In this paper, we use two theories - lay expertise and structural vulnerabilities - as frameworks to frame and qualitatively examine the narratives of PWID surrounding their recent overdose experiences.MethodsAudio-recorded semi-structured open-ended motivational interviewing counseling sessions were conducted with PWID in San Francisco who have experienced at least one non-fatal overdose event (N = 40). Participants discussed the context of recent opioid overdoses, either witnessed or personally experienced, focusing on their perceptions of unique contributing factors. Interview data were coded and analysed using ATLAS.ti. We used a thematic content analysis approach to qualitatively analyze data queries and generate themes. We used theories of structural vulnerability and lay expertise to frame the analysis.ResultsUsing quotes from the participants, we report four central themes that contributed to participants' overdose experiences: 1) Social Dynamics and Opioid Expertise; 2) Uncertain Supply, Composition, Source; 3) Balancing Polysubstance Use, and 4) Emotional Pain.ConclusionAs PWID described their overdose experiences, many factors that contributed to their overdoses were situated at the structural level. The everyday, lived experiences of PWID often competed or conflicted with public health messages and approaches. The accumulated expertise of PWID about everyday risk factors can be leveraged by public health practitioners to inform and improve overdose prevention interventions and messages.
  • Cost-effectiveness analysis of alternative naloxone distribution
           strategies: First responder and lay distribution in the United States
    • Abstract: Publication date: Available online 19 August 2019Source: International Journal of Drug PolicyAuthor(s): Tarlise Townsend, Freida Blostein, Tran Doan, Samantha Madson-Olson, Paige Galecki, David W. Hutton BackgroundThe U.S. is facing an unprecedented number of opioid-related overdose deaths, and an array of other countries have experienced increases in opioid-related fatalities. In the U.S., naloxone is increasingly distributed to first responders to improve early administration to overdose victims, but its cost-effectiveness has not been studied. Lay distribution, in contrast, has been found to be cost-effective, but rising naloxone prices and increased mortality due to synthetic opioids may reduce cost-effectiveness. We evaluate the cost-effectiveness of increased naloxone distribution to (a) people likely to witness or experience overdose (“laypeople”); (b) police and firefighters; (c) emergency medical services (EMS) personnel; and (d) combinations of these groups.MethodsWe use a decision-analytic model to analyze the cost-effectiveness of eight naloxone distribution strategies. We use a lifetime horizon and conduct both a societal analysis (accounting for productivity and criminal justice system costs) and a health sector analysis. We calculate: the ranking of strategies by net monetary benefit; incremental cost-effectiveness ratios; and number of fatal overdoses.ResultsHigh distribution to all three groups maximized net monetary benefit and minimized fatal overdoses; it averted 21% of overdose deaths compared to minimum distribution. High distribution to laypeople and one of the other groups comprised the second and third best strategies. The majority of health gains resulted from increased lay distribution. In the societal analysis, every strategy was cost-saving compared to its next-best alternative; cost savings were greatest in the maximum distribution strategy. In the health sector analysis, all undominated strategies were cost-effective. Results were highly robust to deterministic and probabilistic sensitivity analysis.ConclusionsIncreasing naloxone distribution to laypeople and first responder groups would maximize health gains and be cost-effective. If feasible, communities should distribute naloxone to all groups; otherwise, distribution to laypeople and one of the first responder groups should be emphasized.
  • “A spray bottle and a lollipop stick”: An examination of policy
           prohibiting sterile injecting equipment in prison and effects on young men
           with injecting drug use histories
    • Abstract: Publication date: Available online 16 August 2019Source: International Journal of Drug PolicyAuthor(s): Shelley Walker, Kate Seear, Peter Higgs, Mark Stoové, Mandy Wilson BackgroundAustralian young male prisoners with histories of injecting drug use are more likely to report injecting in prison, to do so more frequently, and to be involved in more un-safe injecting-related practices than their older counterparts. Despite international evidence that prison needle and syringe programs are both feasible and effective in reducing the harms associated with injecting drug use in prison, these young men do not have access to such equipment.MethodsWe critically analyse the interview transcripts of 28 young men with histories of injecting drug use who were recently released from adult prisons in Victoria, Australia, and prison drug policy text. We use Bacchi’s ‘What’s the problem represented to be'’ approach to examine how the ‘problem’ of injecting drug use in prison is represented in prison drug policy, including the assumptions that underpin these problematisations, and the subjectification and lived effects that are produced for the young men in our study.ResultsOur analysis reveals how prison drug policy enables the creation and re-use of homemade injecting equipment crafted from unsterile items found in prison, and that in doing so the policy produces a range of stigmatising subjectification effects and other harmful material effects (such as hepatitis C virus transmission and injecting related injury and harms). Findings highlight, how injecting drug use is represented in policy silences other ways of understanding the ‘problem’ that may have less harmful effects for incarcerated young men who inject drugs.ConclusionWe argue that somewhat paradoxically, the approach of prohibiting access to sterile injecting equipment in prison—which is constituted as a solution for addressing such harms—in fact helps to produce them.
  • Trajectories of alcohol use problems based on early adolescent alcohol
           use: Findings from a 35 year population cohort
    • Abstract: Publication date: December 2019Source: International Journal of Drug Policy, Volume 74Author(s): Joseph M. Boden, Giles Newton-Howes, James Foulds, Janet Spittlehouse, Susan Cook BackgroundEarly exposure to alcohol in adolescence is associated with a range of long term harms. Better understanding of trajectories of alcohol use from adolescence to early adulthood would help target prevention strategies to high risk groups.MethodsChristchurch (New Zealand) general population birth cohort (n = 1265). A latent trajectory model of drinking behaviour at age 14–16 was used to predict drinking outcomes at age 18–35, net of covariate factors known to be associated with substance use outcomes in this cohort.ResultsThree classes of adolescent alcohol use were identified. These were: occasional drinkers, emergent binge drinkers and increasing heavy drinkers.ConclusionsThis analysis identifies three groups of adolescent alcohol users with differing patterns of use. Emergent binge drinkers likely require public policy responses to alcohol use whereas increasing heavy drinkers are potentially able to be identified individually on the basis of patterns of alcohol use and social variables. This group may benefit from psychosocial interventions and are unlikely to respond to a broad public health approach.
  • Potential public health impacts of medical cannabis availability on
           opioid-related harms' Urgent but un-answered questions from Canada
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Benedikt Fischer, Wayne Jones, Wayne Hall, Paul Kurdyak
  • Divergent estimates of HIV incidence among people who inject drugs in
    • Abstract: Publication date: Available online 10 August 2019Source: International Journal of Drug PolicyAuthor(s): Olga Morozova, Robert E. Booth, Sergii Dvoriak, Kostyantyn Dumchev, Yana Sazonova, Tetiana Saliuk, Forrest W. Crawford BackgroundDivergent estimates of HIV incidence among people who inject drugs (PWID) in Ukraine have been reported in modeling studies, longitudinal cohort studies, and recent infection assays used in cross-sectional surveys. Estimates range from 0.65 to 24.8 infections per 100 person-years with substantial regional variation. In this paper, we study the sources of this discrepancy.MethodsWe compared baseline characteristics of study subjects recruited in the cross-sectional integrated bio-behavioral surveillance surveys (IBBS) in 2011 and 2013, with those from the longitudinal network intervention trial (network RCT) conducted between 2010 – 2013, the study that found a remarkably high incidence of HIV among PWID in Ukraine. The analysis was conducted for two cities: Mykolaiv and Odesa.ResultsSignificant differences were found in the characteristics of study subjects recruited in the IBBS surveys and the network RCT, in particular in Odesa, where the mismatch in the estimates of HIV incidence is greatest. In Odesa, recent syringe sharing was about three times as prevalent in the network RCT as in the IBBS; 39% of the network RCT and 16–18% of the IBBS participants indicated stimulants rather than opiates as their drug of choice; 97% of respondents in the network RCT and 45% in the IBBS-2013 reported injecting in a group over half of the time; and the average monthly number of injections in the network RCT was about twice that in the IBBS studies.ConclusionsDifferences in study designs and sampling methodologies may be responsible for the substantial differences in HIV incidence estimates among PWID in Ukraine. The potential sources of selection bias differed between the studies and likely resulted in the recruitment of lower risk individuals into the IBBS studies compared to the network RCT. Risk stratification in the population of PWID may have implications for future surveillance and intervention efforts.
  • Drinking comfortably' Gender and affect among Danish pre-partiers
    • Abstract: Publication date: Available online 7 August 2019Source: International Journal of Drug PolicyAuthor(s): Maria Dich Herold, Geoffrey Hunt BackgroundThe aim of this paper is to examine the relationship between youthful drinking practices and gender within the domestic pre-party (prior to a night out), an arena, which has been relatively ignored in existing qualitative research on youthful alcohol use. An examination of the relationships between gender and drinking practices in this context is important for three reasons. First, pre-parties are associated with heavy drinking, which has traditionally been associated with masculinity. Second, because pre-drinking takes place in the private sphere of the home, it is therefore ‘controlled’ in terms of who can participate and hence what precisely is the gender composition. Third, whilst being located in the private sphere of the home, pre-party practices are nevertheless informed by the (hyper) gendered environments of public drinking spaces in the Night-Time Economy (NTE), most dominantly mainstream clubs and bars. We suggest that such characteristics allow for the emergence of specific gendered relationships, activities and affectivities, thereby demarcating the pre-party as a particular gendered drinking space.MethodsWe draw on narrative data from 140 in-depth face-to-face interviews with young Danish alcohol users between 18–25 years of age. The interviews were part of a large-scale research project on the gendered aspects of youthful alcohol use and intoxication. Theoretically, we draw on a combination of the ‘doing gender’ paradigm (West & Zimmerman, 1987) and affect theoretical notions on (un)comfortability (Ahmed, 2014). We propose that these perspectives mark out the pre-party as a particularly gendered drinking space.ResultsWhile our analysis supports the observation of existing qualitative studies, that pre-partying is not merely motivated by the possibility of becoming intoxicated in a cheap and un-surveilled way before going out, we especially argue that pre-partying is fueled by a desire for 'comfortability', which seems almost impossible to disassemble from the gendering that pre-partying also entails. Our analysis therefore contributes to the ongoing academic discussion around the relationship between ‘intoxicated femininity’ and ‘intoxicated masculinity’ by suggesting that we need to take the affective implications of young people’s (gendered) drinking practices into account in a thorough discussion of the relationship between youthful alcohol use and gender.
  • Young women’s narratives on sex in the context of heavy alcohol use:
           Friendships, gender norms and the sociality of consent
    • Abstract: Publication date: Available online 7 August 2019Source: International Journal of Drug PolicyAuthor(s): Mie Birk Jensen, Geoffrey Hunt BackgroundAlthough young women’s friendships remain understudied in drinking contexts, some researchers have pointed to how young women can make use of each other to manage sexual advances when drinking. In this paper, we explore how young women make use of friends to negotiate their sexual boundaries, and construct the meaning of sexual experiences in a context of heavy alcohol use.MethodsThe data stems from a large scale research project at the Centre for Alcohol and Drug Research, Aarhus University, which included 140 interviews with young Danes between the ages of 18–25. In the present study, we primarily use narratives from 33 in-depth interviews with young women, who recall their personal sexual experiences with men in the context of heavy alcohol use.ResultsWe find that these young women make meaning of their sexual experiences in relation to friends through a negotiation of their emotional response as well as dominant gender norms. We argue that friends may serve to prevent sexual regret and offer support in instances where young women feel regret after engaging in sex when drinking heavily. However, we also argue that friends may encourage a more humorous approach in recounting sexual encounters in the context of heavy alcohol use, which may contradict their initial feelings of the encounter and gloss over issues of sexual consent.ConclusionWith this article we point to how young women's ability to negotiate the meaning of their sexual experiences as well as that of sexual consent more generally, are interlinked with prevalent gender norms that play out in the context of friendships. The young women in our study narrated friends as more central to negotiations of sexual boundaries than sexual partners when in a context of heavy alcohol use.On this basis, we develop the term ‘social consent’, which we suggest that future studies and preventive efforts should take into account in order to challenge the gender norms that can serve to normalize sexual violence in drinking contexts.
  • How the U.S.-Mexico border influences adolescent substance use: Youth
           participatory action research using photovoice
    • Abstract: Publication date: Available online 26 July 2019Source: International Journal of Drug PolicyAuthor(s): Elizabeth Salerno Valdez, Josephine Korchmaros, Samantha Sabo, David O. Garcia, Scott Carvajal, Sally Stevens IntroductionThe purpose of this study is to use Youth Participatory Action Research (YPAR) methods and Photovoice to identify the perceived environmental factors that influence substance use among adolescents living at the U.S.-Mexico border.MethodsOne academic and a local youth health coalition engaged in Youth Participatory Action Research (YPAR) using Photovoice and qualitative methods to examine the perceived factors influencing adolescent substance use in their border community.ResultsIdentified novel risk factors for adolescent substance use on the border included the normalization of drug trafficking, normalization of substance use, and cross-border access to substances. Novel protective factors included living in a close-knit binational community and having strong binational family and social support systems. The findings also illustrate a nexus of 'factors' wherein risk and protective elements overlap.ConclusionThis study contributes to the broader literature on international border health and how living in a border space influences adolescent substance use. The examination of influential border-bound factors provides a more complete understanding of the experiences of youth living on the U.S.-Mexico border, and informs the field of the importance of considering the border experience for future prevention and risk reduction efforts with border adolescents.
  • Communicating THC levels and ‘dose’ to consumers: Implications for
    • Abstract: Publication date: Available online 25 July 2019Source: International Journal of Drug PolicyAuthor(s): David Hammond In a well-regulated drug market, consumers should be able to understand and titrate their dose with little difficulty. In the cannabis market, despite substantial increases in THC levels over time, users have had limited information on the strength of their products. In principle, cannabis legalization provides greater opportunity to communicate clear, accurate information to consumers through packaging and labelling standards. However, jurisdictions that have legalized cannabis have experienced an increase in adverse events from higher strength products, particularly from edibles and other concentrates. What little research exists suggests that current regulatory practices of labelling THC levels on packages may be ineffective due to consumer difficulties understanding numbers (e.g., mg vs. percentage), and the different ways THC levels are communicated across product categories. In particular, current labelling practices provide little guidance in terms of ‘dose expression’—how THC ‘dose’ translates into consumption amounts for specific products. The current paper identifies five principles to guide cannabis labelling and packaging regulations, including considerations for numeric THC labelling, the use of standard servings or dose across different product forms, strategies to communicate ‘dose expression’, and ‘dose-unit packaging’. Overall, there is a need for regulated cannabis markets to develop more effective packaging and labelling standards to allow consumers to effectively titrate their THC intake, with the goal of promoting lower-risk cannabis use.
  • The prevalence of non-fatal overdose among people who inject drugs: A
           multi-stage systematic review and meta-analysis
    • Abstract: Publication date: Available online 24 July 2019Source: International Journal of Drug PolicyAuthor(s): Samantha Colledge, Amy Peacock, Janni Leung, Sarah Larney, Jason Grebely, Matthew Hickman, Evan Cunningham, Adam Trickey, Jack Stone, Peter Vickerman, Louisa Degenhardt BackgroundPeople who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event.MethodsWe conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence.ResultsAn estimated 3.2 (1.8–5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0–26.1%) and 41.5% (34.6–48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America.ConclusionAround one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.
  • Understanding the reasons for using methamphetamine by sexual minority
           people in Dhaka, Bangladesh
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Sharful Islam Khan, Mohammad Niaz Morshed Khan, A.M. Rumayan Hasan, Samira Dishti Irfan, Lily Ming-Sha Horng, Ezazul Islam Chowdhury, Tasnim Azim BackgroundInternationally, methamphetamine use is prevalent among males who have sex with males (MSM) and transgender women (hijra), with studies showing its association with risky sexual behaviours leading to HIV transmission. This study aimed to explore the underlying reasons for methamphetamine use among MSM and hijra in Bangladesh.MethodsWe conducted 30 in-depth interviews with MSM and hijra and six focus groups with MSM, hijra and service providers. Data were thematically analysed using manual data analysis procedures.FindingReasons cited for using methamphetamine varied across feminized MSM (i.e. kothis), masculine MSM (i.e. panthis), male sex workers and hijra. For sex workers, increased sexual pleasure and consequent ability to take more clients increased their income. For panthis, methamphetamine enhanced feelings of masculinity and sexual prowess. Kothis were able to feel more feminine due to their ability to receive multiple partners each night. For all participants, methamphetamine restored self-esteem and relieved the stress resulting from stigma.ConclusionsFindings indicate that reasons for using methamphetamine are not only rooted in the individual’s psyche but also grounded in the socio-cultural expectations about masculinities and femininities in Bangladeshi society. Limited knowledge about the complexities concerning methamphetamine use mean that appropriate counselling and treatment services are non-existent in Bangladesh. The study findings can be used to refine national and international harm reduction policies so as to incorporate and address methamphetamine use.
  • The movement and translation of drug policy ideas: The case of ‘new
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Natalie Thomas, Melissa Bull, Rachel Dioso-Villa, Kate Smith Introduction'New recovery' can be conceptualised as both a social movement and a broader policy agenda to restructure treatment service systems towards 'recovery-oriented systems of care'. Emerging initially out of the United States, new recovery has gained currency as a policy agenda in other jurisdictions - perhaps most distinctly in the United Kingdom. In 2012, the ideas behind 'new recovery' were debated in the Australian alcohol and other drug field as the Victorian government sought to incorporate recovery principles into policy and service design. This paper uses the policy transfer and policy translation literature to understand how international policy ideas about 'new recovery' were negotiated in the Australian context, focusing specifically on the role of non-government actors in the process.MethodsThis paper draws on an analysis of policy documents, organisational documents and interviews with representatives from the Australian non-government alcohol and other drug sector to consider how new recovery was translated into Victorian drug policy.ResultsThe interactions between organisations and actors — including bureaucrats, governmental agencies and policy entrepreneurs — facilitated the circulation and translation of policy ideas in the Victorian context. Despite this, the analysis suggests that policy transfer was largely a symbolic exercise: overall, some of the key features of new recovery policy from the United States and the United Kingdom, such as encouraging peer-led recovery and mutual aid, were not incorporated in the Victorian policy. NGOs resisted what they considered to be some of the more problematic elements of 'new recovery', and informed the local translation of the policy.DiscussionThe results have implications for understandings of the relationship between social movements, non-government organisations and the state, as well as the dynamics of knowledge transfer in drug policy.
  • Can e-cigarettes improve the well-being of people with mental health
    • Abstract: Publication date: Available online 24 July 2019Source: International Journal of Drug PolicyAuthor(s): Julia E.H. Brown, Coral Gartner, Adrian Carter This Viewpoint considers the merits of e-cigarettes as a harm-minimisation tool for clozapine-treated schizophrenia patients. It argues that e-cigarettes may be a gateway not to smoking tobacco, but rather to engagement in more desirable health attitudes amongst this particularly marginalised population group. In our opinion, this presents clinicians with valuable opportunities to engage their patients more effectively in healthcare strategies, beginning with but not limited to tobacco-free e-cigarettes.
  • Reproducibility on science: Challenges and advances in Brazilian alcohol
    • Abstract: Publication date: Available online 24 July 2019Source: International Journal of Drug PolicyAuthor(s): Raquel B. De Boni, Mauricio T.L. de Vasconcellos, Pedro N. Silva, Carolina Coutinho, Jurema Mota, Julia N.B. Peixoto, Neilane Bertoni, Francisco I. Bastos BackgroundReproducibility in Science is challenging and may be hard to achieve in alcohol research. Previous general population surveys in Brazil have estimated the prevalence of alcohol dependence to be around 10%. We aim to estimate alcohol use and dependence using different methods and definitions.MethodsThe 3rd Brazilian Household Survey on Substance Use (BHSU-3) was a nationwide, probability sample survey that interviewed 16,273 individuals. DSM-IV-TR criteria were used to determine alcohol dependence. In the BHSU-2 (covering only Brazil’s 108 largest municipalities), alcohol dependence was defined as fulfilling 2/6 DSM-III criteria. Using the BHSU-3 data, alcohol use was estimated at: [1] the national level, [2] BHSU-2 municipalities, taking into consideration the sample design, and [3] BHSU-2 municipalities, ignoring the sample design. Alcohol dependence was calculated using: BHSU-3 and BHSU-2 definitions, two denominators ([A] population and [B] 12-month drinkers), and [1], [2], [3].ResultsLifetime alcohol use ranged from 66.4% (95%CI:64.8–68.0 [1]) to 70.1% ([95%CI:69.1–71.0], [3]). The estimated population presenting with alcohol dependence ranged from N = 2.3 million (BHSU-3 definition, [1]) to N = 4.3 million (BHSU-2 definition, [1]). In the first case, the prevalence among the general population [A] and drinkers [B] was 1.5% (95%CI:1.2–1.8) and 3.5% (95%CI:2.8–4.2), respectively. In second case, prevalence was 2.8% (95%CI:2.4–3.3, [A]) and 6.6% (95%CI:5.6–7.6, [B]).ConclusionsPrevalence of alcohol dependence may vary as much as 4.3 times, analyzing the same dataset in different ways. Brazilian research on alcohol is funded by governmental research and policy-making agencies, providing subsidies for alcohol policy in the country. It is crucial that sufficient methodological information is provided in order to guarantee reproducibility and consistency over time.
  • ‘I feel like I have to become part of that identity’: Negotiating
    • Abstract: Publication date: Available online 22 July 2019Source: International Journal of Drug PolicyAuthor(s): Emily Nicholls Whilst women’s excessive alcohol consumption has traditionally been regarded as a potential threat to health, safety and even femininity, recent research highlights the important role that alcohol plays in many young women’s lives. Drawing on data from semi-structured interviews with women aged 18–25 in Newcastle, UK, this paper will consider the role that alcohol can play in the negotiation of female friendships in the Night Time Economy, highlighting the ways in which young women may regard alcohol as a tool to enhance socialising, trust and intimacy (both when pre-drinking and in bars, pubs and clubs). The role of alcohol in ‘doing’ gender and femininity will also be explored, as young women collectively display feminine identities through particular drinking choices and practices that may include heavy drinking and drunkenness. Finally, I will consider the implications for young women who do not engage in these collective practices of alcohol consumption and suggest avenues for future work on the under-researched topic of the experiences of non-drinkers.
  • Drug sellers’ neutralizations of guiltless drug sales and avoidance of
           “drug dealer” identities
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Timothy Dickinson, Scott Jacques BackgroundDespite a wealth of empirical exploration on neutralization theory, several aspects of the theory remain underexplored. For instance, one task of neutralization research is to investigate whether and how neutralizations vary with offender characteristics. A second underexplored area is whether the neutralizations offenders present when directly asked about feelings of guilt are similar or dissimilar to those they have incorporated into their narrative identities described during interviews. A third underexplored issue is whether offenders that exhibit little guilt for committing mala prohibita crimes use neutralizations in a similar manner as those who do not express guilt for committing mala in se crimes.MethodsThe present study examines these questions by drawing from data collected from interviews with 33 active drug sellers from St. Louis, Missouri, USA and 30 active drug sellers from Atlanta, Georgia, USA.ResultsWe find that these offenders’ neutralizations vary by drug type and by differential access to resources. We also find that, in addition to the neutralizations they give when asked about guilt, these offenders also preemptively neutralize feelings of guilt by constructing identities counter to bad “drug dealers” throughout their storied identities.ConclusionWe conclude by suggesting that neutralizations vary by offender characteristics due to the differing background expectancies of offenders’ social groups. We also suggest that neutralizing the repercussions of immoral actions is not always a static, monothematic technique. It is instead an active, complex, and interactional process that occurs as persons make sense of who they are and what they are doing. Finally, we argue that studies of neutralization theory relying on direct, standardized questions or the presentation of abstract vignettes may fail to capture a sizable part of the neutralization process among offenders.
  • Seeking legitimacy for broad understandings of substance use
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Niki Kiepek, Katinka Van de Ven, Matthew Dunn, Cynthia Forlini This commentary invites discussion about implicit and explicit factors that impede research about substance use from a nuanced perspective that recognises potential benefits and advantages. It is argued that explicit efforts to engage in scholarship beyond those informed by theoretical and philosophical assumptions that substance use is inherently risky and problematic can enhance genuine inquisition about substance use and transform which discourses and interpretations are legitimised. Prioritisation of scholarly funding and publication has largely been predicated on the notion that illicit substances pose an inherent risk for individual and social harm. This has implicitly and explicitly influenced what type of research has been conducted and how substance use is constructed. Researchers who engage in scholarship that suspends assumptions of risk and problems associated with substance use may become subject to judgement about their credibility, ethics, and expertise. Moving forward, we suggest that conscientiously attending to broad, nuanced experiences associated with substance use will contribute to a stronger evidence base. Equal opportunity should be given to examine the complexity of lived experiences. It may also be timely to consider what brings value to scholarly pursuit, recognising that health is but one valued social outcome. Perhaps other outcomes, such as human rights, compassion, and justice are equally commendable. To advance substance use scholarship, it is essential that decision-makers (e.g., funding bodies, editors) embrace research that does not conform to assumptions of risk or inherent problems as exclusively legitimate, advocate for scholarship that resists conforming to dominant discourses, and create spaces for critical perspectives and interpretations.
  • Legal and policy changes urgently needed to increase access to opioid
           agonist therapy in the United States
    • Abstract: Publication date: November 2019Source: International Journal of Drug Policy, Volume 73Author(s): Corey S. Davis, Derek H. Carr The United States continues to face a public health crisis of opioid-related harm, the effects of which could be dramatically reduced through increased access to opioid agonist therapy with the medications methadone and buprenorphine. Despite overwhelming evidence of their efficacy, unduly restrictive federal, state, and local regulation significantly impedes access to these life-saving medications. We outline immediate, concrete steps that federal, state, and local governments can take to change law from barrier to facilitator of evidence-based treatment for opioid use disorder. These include removing onerous restrictions on the prescription and dispensing of buprenorphine and methadone for opioid agonist therapy, requiring insurance coverage of these medications, and mandating that they be provided in correctional settings and promoted by drug courts. Finally, we argue that jurisdictions should proactively offer opioid agonist therapy to individuals at high risk of overdose, remove barriers to establishing methadone treatment facilities, and address underlying social determinants and barriers to treatment. These changes have the ability to save thousands of lives annually.
  • Who or what do young adults hold responsible for men’s drunken
    • Abstract: Publication date: Available online 19 July 2019Source: International Journal of Drug PolicyAuthor(s): Sarah MacLean, Jakob Demant, Robin Room BackgroundMen are more likely than women to perpetrate serious violence when they have consumed alcohol, but alcohol does not affect all men in the same way. This paper considers young adults’ attribution about agency (the capacity to act) in men’s drunken violence.MethodsInterviews about alcohol use in night-time venues, streets or private parties were conducted with 60 young adults aged 18–24 in Melbourne, Australia, and analysed thematically. Participants included seven men who identified as having initiated violence when drunk.ResultsSome interviewees stated that men chose to be violent, or that men’s violence when they were drunk was purposeful and therefore involved some component of choice. However, much alcohol-related violence enacted by young men was understood (both by men who reported violence and by other young adults) as impelled by forces outside their control. These forces were: diffusely defined effects of drinking alcohol; proclivities of men and masculinity, and the interaction of alcohol and men’s bodies to override capacity for judgement and produce an irresistible urge to fight. The latter was at times explained as caused by the mutually reinforcing actions of alcohol and testosterone, providing a particularly persuasive account of men’s violence as biologically-determined.ConclusionThese categories encapsulate a set of discursive resources that contribute to the rationalisation, naturalisation and production of men’s violence. Participants tended to regard alcohol, masculinities and testosterone as inciting violence predictably and consistently, suggesting that men themselves had relatively little agency over its occurrence. In contrast, research evidence indicates that these actors do not cause violence in any uniform way and that their effects are contingent on changing configurations of factors. Highlighting discrepancies between young adults’ understandings of responsibility for men’s drunken violence, and those expressed in research, presents additional opportunities for intervention.
  • E-cigarette use is associated with susceptibility to tobacco use among
           Australian young adults
    • Abstract: Publication date: Available online 27 June 2019Source: International Journal of Drug PolicyAuthor(s): Michelle I. Jongenelis, Elizabeth Jardine, Caitlin Kameron, Daniel Rudaizky, Simone Pettigrew BackgroundCalls have been made to relax current Australian regulations related to e-cigarettes to increase the accessibility of the devices for smoking cessation purposes. However, e-cigarettes have been found to increase risk of initiation of conventional cigarette smoking, especially among young adults. To assist in guiding the development of policy in Australia, the present study examined whether e-cigarette use among Australian young adults who have never smoked a tobacco cigarette is associated with susceptibility to future tobacco cigarette use.MethodAn online web panel provider recruited 519 never smokers aged 18–25 years (55% female; average age = 21.21 years, SD = 2.32). Respondents completed an online survey that assessed their curiosity about tobacco smoking, willingness and intentions to smoke, and a number of individual and social factors. Cross-sectional regression analyses were conducted to assess the association between e-cigarette use and susceptibility to tobacco cigarette use while controlling for multiple covariates.ResultsCuriosity about tobacco smoking, willingness to smoke, and intentions to smoke were significantly higher among users of e-cigarettes than never users. The relationship between e-cigarette use and susceptibility to future tobacco cigarette use remained significant after controlling for numerous covariates.ConclusionE-cigarette use, even just one or two puffs, has the potential to increase susceptibility to tobacco cigarette use among Australian young adults. Findings suggest that increasing the availability of e-cigarettes by relaxing current strict regulations surrounding their sale may have unintended consequences.
  • ‘It’s good being part of the community and doing the right thing’:
           (Re)problematising ‘community’ in new recovery-oriented policy and
           consumer accounts
    • Abstract: Publication date: Available online 20 June 2019Source: International Journal of Drug PolicyAuthor(s): Renae Fomiatti The renewed focus on ‘recovery’ in alcohol and other drug policy over the last decade has been subject to sustained international attention and academic critique. However, little scholarly work has addressed how new recovery discourse has harnessed the ideals of community participation and cohesion and how people who use drugs, the targets of such proposals, experience these injunctions. Analysing the two most recent Australian National Drug Strategies – in which new recovery has featured – and interviews with people who inject drugs, I draw on Bacchi’s problematisation approach to make visible the politics of community in new recovery. My analysis demonstrates that there has been a shift in the way new recovery is framed from recovery through community reintegration and reconnection to recovery through ‘evidence-based’ treatment. However, community endures as an important dividing practice that targets people who regularly use drugs as dependent, unproductive and marginal to social life, while also claiming to be the solution to the disorder attributed to alcohol and other drug use. In the second half of this article, I draw on people’s accounts of regular drug use and recovery to explore the ‘lived effects’ of these problematisations and to pursue a critical practice of thinking otherwise. I argue that these accounts disrupt and contest the problematisations and promises underpinning recovery through community reintegration by: 1) drawing attention to the way in which the boundaries of community exclude inclusion for people who use drugs, and emphasising people’s already existing social relationships; 2) making present hitherto silenced and unproblematised barriers to social connection; and 3) critiquing the normative fantasies of healthy society and citizenship that underpin recovery. In concluding I consider the politics of appeals to community in new recovery-oriented policy, and suggest the need to foreground consumer accounts in problematisation-oriented analyses in order to better contest authoritative enactments of drug ‘problems’ that bear little resemblance to the challenges people face.
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
Tel: +00 44 (0)131 4513762
Fax: +00 44 (0)131 4513327
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