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Article of the Month- International Harm Reduction Association IHRA regularly selects and highlights recently published journal articles, studies or resources which are of particular significance for harm reduction. These are featured in the IHRA newsletters and the IHRA website and, wherever possible, are made freely available to download. The articles are chosen for their capacity to advance the scientific basis of harm reduction, and their potential value for harm reduction advocates, policy makers, practitioners and researchers. If you would like to recommend an 'Article of the Month', please contact IHRA.
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| September 2009 Article of the Month
| Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A & Schechter MT (2009) Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction. New England Journal of Medicine, Volume 361 (8), pages 777 – 786.
| This paper presents the results of the North American Opiate Medication Initiative (NAOMI) – a clinical trial from Canada which began in 2005 to assess the benefits of heroin prescription for people who use drugs who have not responded to alternative treatments. Around 65 countries currently provide opioid substitution treatments – but normally in the form of methadone or buprenorphine. It has been documented that a significant portion of severely dependent people do not respond well to these treatments, raising the issue of how to successfully treat these individuals. Studies and services from countries such as Germany, Switzerland and the United Kingdom suggest that prescribing diacetylmorphine – the active ingredient of street heroin – can be an effective solution, and this new paper lends further support to this claim.
Published in the prestigious New England Journal of Medicine, this randomised controlled trial directly compared the provision of injectable diacetylmorphine with the provision of oral methadone for 226 opioid-dependent patients who had not benefited from at least two previous attempts at treatment. The trial was conducted in two Canadian cities – Montreal and Vancouver. After 12 months, “patients assigned to receive injectable diacetylmorphine were more likely to stay in treatment and to reduce their use of illegal drugs and other illegal activities than patients assigned to receive oral methadone” – although both treatments demonstrated positive impacts. The authors concluded, therefore, that injectable diacetylmorphine was more effective than oral methadone. However, due to the inherent increased risks of injecting and an identified risk of overdose or seizure, this treatment should be delivered in settings where medical support is available.
Historically, doctors in the UK have been able to prescribe heroin or morphine, and this was the basis of the so-called ‘British System’ from the 1920s to the 1960s. However, this treatment has recently received heightened attention around the world. In May 2009, following a multi-city trial, the German Parliament voted in favour of this treatment as a therapeutic option for severely dependent opiate users who had not benefited from any previous treatments. In Britain (where very few doctors prescribe diacetylmorphine despite being allowed to), a recent multi-site Randomised Injectable Opioid Treatment Trial (RIOTT) demonstrated that it is possible to engage and retain ‘hard-to-treat’ drug users. This trial also reported reduced use or abstinence from ‘street’ heroin, reduced spending on illicit drugs, reduced criminal activity, and improvements in physical, mental health and social functioning. In Switzerland doctors have been prescribing heroin to patients since the 1990s, citing a major reduction in crime and improved rehabilitation success rates, and recently approved a nationwide programme. The Netherlands and Spain also provide – and have positively evaluated – this treatment, and Denmark is expected to begin soon.
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| July 2009 Article of the Month
| Sharma M, Oppenheimer E, Saidel T, Loo V & Garg R (2009) A situation update on HIV epidemics among people who inject drugs and national responses in South-East Asia Region. AIDS, Volume 23 (11), pages 1405 – 1413.
| Over the last year, the team at the World Health Organization South East Asia Regional Office (WHO-SEARO) has been assessing the local situation in terms of HIV transmission, people who inject drugs, and the national policy and practice responses. This paper – in AIDS, the official journal of the International AIDS Society – presents the initial results of this work from seven “high-burden countries” in the region. Drawing data from published literature, routine surveillance systems, ‘key informants’ and other sources (including IHRA), this article is a good review of the situation in Asia in terms of HIV-related harm reduction interventions such as needle and syringe programmes and opioid substitution treatments.
The study estimated that there are 800,000 people who inject drugs in the region, with HIV prevalence among this population ranging from 0% in the Maldives to over 50% in Indonesia. There were “significant epidemics of HIV” in six of the seven examined countries, with three showing “high and stagnant” levels (India, Myanmar and Thailand), two showing rising prevalence (Bangladesh and Indonesia) and just one showing a measurable decrease over time (Nepal). One possible explanation for these concerning results is the poor coverage of evidence-based harm reduction approaches. The study estimated, for example, that only around 1.5% of the region’s injecting drug users have access to opioid substitution therapy, with around a quarter reached by needle and syringe programmes. When mapped geographically, there were clear gaps and weaknesses in programme reach, which was “not always in tune with the magnitude and trends of the epidemic”. In particular, the extent of harm reduction approaches in the region’s prisons was especially poor.
This is an important paper for the region and demonstrates that, even where countries accept and endorse harm reduction in policy and/or practice, people who inject drugs must have sufficient access in order to have the desired impact on national HIV prevalence. This means that political and programmatic barriers to achieving increased coverage – including issues around funding, advocacy and civil society capacity – must be overcome. The authors conclude that “HIV epidemics among PWID [people who inject drugs] remain uncontrolled in south-east Asia. Harm reduction interventions reach too few PWID. To make a dent in the HIV epidemics among PWID, national AIDS programmes should urgently scale up OST [opioid substitution therapy] and NSP [needle and syringe programme] services to cover at least 50-60% of the population”.
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| WHO-SEARO has also produced an accompanying policy brief for this study, which aims to present the key messages and themes in an even more accessible manner.
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| March 2009 Article of the Month
| Wiessing L, van de Laar MJ, Donoghoe MC, Guarita B, Klempova D & Griffiths P (2008) HIV Among Injecting Drug Users in Europe: Increasing Trends in the East. Eurosurveillance, Volume 13 (50).
| This ‘Rapid Communication’ report – from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization Regional Office for Europe (WHO-EURO) – presents the latest data on HIV and injecting drug use for ‘Europe’ (which, for the purposes of the WHO, contains 53 countries from Iceland to Turkey and Israel to Uzbekistan, Kyrgyzstan and the Pacific Ocean).
The data shows a marked geographical divide in Europe – with rates of newly diagnosed HIV infections among injecting drug users remaining stable or decreasing in most ‘Western’ countries (ie, those in the European Union or the European Free Trade Association), but increasing in many ‘Eastern’ countries. In Ukraine, there were over 7,000 new cases of HIV reported among injecting drug users – the highest in the region (although data were not available for the Russian Federation in 2007, but there had been over 11,000 new cases there in 2006).
The report estimates that over half (57%) of all new HIV infections in this region are due to injecting drug use, and expresses grave concerns about the continuing increases. The authors comment that the stable HIV rates in the ‘West’ “may partly follow from the increased availability of prevention, treatment and harm reduction measures, including opioid substitution treatment and needle and syringe programmes”, and warn that existing public health measures in the ‘East’ “are likely insufficient and need to be reinforced”. The report concludes by urging European countries to collaborate in order to tackle this major problem.
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| January 2009 Article of the Month
| Jürgens R, Ball A & Verster A (2009) Interventions to Reduce HIV Transmission Related to Injecting Drug Use in Prisons. Lancet Infectious Diseases, Volume 9(1), 57-66.
| This comprehensive literature review examines the use of, and evidence for, various harm reduction interventions to reduce the transmission of HIV through injecting drug use in prison settings. Harm reduction in prisons has always been a controversial area of work – with many policy-makers reluctant to be seen as acknowledging the existence of drug use in prisons. However, as this review notes, “Existing data show that injecting drug use is a reality in many prison systems and that most incarcerated injecting drug users (IDUs) share injecting equipment. This creates environments that promote the transmission of blood-borne infections among prisoners”. Prisons, therefore, are a crucial risk environment that must be targeted in order to achieve universal access to HIV prevention – especially given that the size of the global incarcerated population is increasing.
This paper is part of a broader review programme of prison interventions – commissioned by the World Health Organization, United Nations Office on Drugs and Crime and UNAIDS – to “guide countries in their efforts to scale up towards universal access to HIV prevention, treatment, care and support by 2010”. As well as looking at data on drug use, injecting and HIV and HCV transmission in prisons, the paper examines the evidence base for the following harm reduction interventions:
| Needle and Syringe Programmes (NSP)
| Prison NSP schemes were found to exist in over 50 prisons in 12 different countries. The overwhelming evidence from these programmes was that NSPs in prisons helped to reduce (or even prevent) the sharing of injecting equipment, and to prevent new cases of injecting-related HIV in prisons. There was also evidence that these interventions helped to reduce overdoses, engage drug using prisoners into health services, increase the awareness of risks, and increase staff safety. Crucially, there was no evidence to support some of the common objections to NSP in prisons – there was no recorded incidence of syringes being used as weapons in prisons, and no reported increases in injecting drug use or the amount of drugs in prisons. The authors also noted that “Once in place, the acceptance of NSPs is generally high among staff and prisoners”.
| Opioid Substitution Therapies (OST)
| The provision of OST – usually in the form of methadone maintenance treatments – is much more common in prisons that NSP. Again, however, the evidence was very positive in favour of these interventions – especially when they were provided to prisoners in sufficiently high doses and for a suitably long duration of time. OST in prisons was associated with reductions in injecting, drug-seeking behaviours, HCV infection and mortality, as well as positive impacts on criminal recidivism, re-incarceration, and entry into post-release treatment.
| Bleach and Decontamination Strategies
| Many prison services – reluctant to provide NSP interventions due to unfounded fears about safety and drug use – provide instead bleach kits to disinfect and clean used injecting equipment. However, the research indicates that these interventions are “not supported by evidence” and that they “cannot replace NSPs” in terms of preventing HIV transmission in prisons.
Overall, this review outlines the clear evidence in support of harm reduction interventions in prisons, and – in the absence of randomised clinical trails which are unethical in these settings – provides the strongest available scientific support for this approach. As the authors note, “The rationale for establishing NSPs in prisons where injecting drug use takes place is even stronger than in the community”, and the same could be said about OST. Yet many countries do not have services and healthcare for prisoners that match those outside of these settings – presenting a huge challenge for advocates of harm reduction and for universal access to HIV prevention, treatment and care.
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| September 2008 Article of the Month
| Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, Tyndall M, Toufik A & Mattick RP, for the 2007 Reference Group to the UN on HIV and Injecting Drug Use (2008) Global Epidemiology of Injecting Drug Use and HIV Among People who Inject Drugs: A Systematic Review. The Lancet, 372.
| The Reference Group to the United Nations on HIV and Injecting Drug Use has published the results of a comprehensive global evidence review, and have concluded that there are 15.9 million injecting drug users (IDU) around the world, around three million (one in five) of whom could have HIV. Almost 40% of the IDU were estimated to be living in China, the USA and Russia. In addition, nine countries have HIV rates amongst IDU of 40% or more – Argentina, Brazil, Burma, Estonia, Indonesia, Kenya, Nepal, Ukraine and Thailand (the location for Harm Reduction 2009: IHRA’s 20th International Conference.
The report indicates that – although there are huge discrepancies worldwide – HIV as driven by injecting drug use is a widespread, global dilemma. The authors call for increases in the coverage of harm reduction and HIV prevention activities for injecting drug users (such as needle exchange and substitution treatments), as well as increases in the coverage of HIV treatment and care. In an accompanying commentary in The Lancet, Kamyar Arasteh and Don Des Jarlais state that “if HIV-prevention efforts are implemented on a large scale… it is possible to avert HIV epidemics… Thus, it should be an imperative – for both resource-constrained countries and international donors – to implement large-scale evidence-based programmes for HIV prevention”.
The Reference Group reviewed over 11,000 documents (including published research, government papers and non-government reports), and also held consultations with world experts in the field. The new estimate for global injecting drug users (IDU) is a significant increase on an 2004 estimate of 13.2 million – reached by the former Reference Group work which was undertaken by IHRA’s Executive Director Professor Gerry Stimson. The new data also indicates that the number of countries reporting IDU has increased from 103 countries in 1998 to 130 countries in 2004 to 148 countries in 2008. The new data are similar to IHRA’s recent Global State of Harm Reduction report, which reported IDU in 158 countries.
However, the authors warn that the true extent of the problem is still largely unknown, as “existing data are far from adequate, in both quality and quantity”. In particular, several countries at risk (including many in Africa and the Middle East) are not reporting on the problem.
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| | August 2008 Article of the Month
| Kayser B & Smith ACT (2008) Globalisation of Anti-Doping: The Reverse Side of the Medal. British Medical Journal, 337:a584 – doi: 10.1136/bmj.a584 (Published 4 July 2008).
| This analysis paper in the British Medical Journal (BMJ) critiques current international anti-doping policies in sport. These policies essentially represent costly, repressive zero-tolerance approaches for elite sport and, like similar prohibition-focussed approaches in society generally, they have very limited evidence supporting their effectiveness or success. In fact, the authors argue that this current stance in ‘elite sport’ is actually linked to increases in the illicit use of performance enhancing drugs in the general population, which has significant public health costs. The authors call for a “critical systematic examination of the impact of anti-doping policy” and the exploration of alternative policies – including harm reduction approaches.
Performance enhancement has always existed in sport but, fuelled by the World Anti-Doping Agency (WADA) – which was formed in 1999 – a global movement of repressive, punitive anti-doping policies has developed in recent years. The authors identify seven ‘postulates’ by which this current approach is flawed – including the disproportionate nature of the punishments, the weaknesses in existing drug testing technology, and the impingement on athlete’s privacy. It is also claimed that such policies are at odds with broader social values outside of sport – where “enhancement technologies like cosmetic surgery and eye surgery and use of substances like caffeine, fluoxetine, modafinil, sildenafil and anti-ageing drugs are an increasingly accepted social behaviour”.
Timed to coincide with the 2008 Olympics in China, this paper provides an interesting insight into a traditionally under-emphasised area of drug use and harm reduction.
The main points of the article have also been supported by a number of key scholars in the field – including Gerry Stimson (the IHRA Executive Director), Pat O’Hare (the IHRA Honorary President) and Nick Crofts (a member of the IHRA Executive Committee). To conclude their analysis, the authors point to harm reduction interventions such as anabolic steroid user clinics as part of an alternative policy which “might involve making legal the use of drugs associated with low harms and testing health rather than testing for drugs”. This issue is something that IHRA hopes to explore at Harm Reduction 2009 in Bangkok, Thailand.
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| | July 2008 Article of the Month
| Schottenfeld RS, Chawarski MC & Mazlan M (2008) Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: A randomised, double-blind, placebo-controlled trial. The Lancet, 371(9631), 2192-2200.
| This paper reports the results of a randomised controlled trial of 126 detoxified heroin-dependent patients in Malaysia, and directly compares three treatment options - naltrexone, buprenorphine, and a placebo. The results clearly demonstrated the significant effectiveness of buprenorphine compared to placebo in terms of a range of outcomes (including ‘days in treatment’, ‘days in treatment without heroin use’, ‘days in treatment without heroin relapse’ and ‘maximum consecutive days abstinent’). In fact, the superiority of buprenorphine over the other treatment options was so marked that the study was terminated after only 22 months (when 70% of the participants had completed their six month courses). Predictably, the outcomes were worst for placebo, although the differences between naltrexone and the placebo were not statistically significant. For all three treatment options, drug-related HIV risk behaviours were significantly reduced after the study, with no significant differences between the treatments.
This study is particularly important due to its setting, as it is one of very few major, high-quality scientific studies conducted in the developing world in order to demonstrate the effectiveness of harm reduction interventions. It was also one of the first Malaysian studies to directly compare opiate ‘agonist’ treatments (direct substitutes for street heroin – such as buprenorphine) as opposed to opiate ‘antagonist’ treatments (which deter street heroin use rather than replacing it – such as naltrexone). On the basis of their findings, the authors claim that the “expansion of access to effective treatments for heroin dependence is a worldwide health priority”, and recommend the widespread dissemination of buprenorphine maintenance treatment in developing countries to reduce the problems associated with heroin dependence.
According to IHRA’s recent Global State of Harm Reduction report, there are an estimated 195,000 injecting drug users in Malaysia, with an adult HIV prevalence amongst this group of between 10% and 40% (there was a HIV prevalence of 22% reported amongst the participants in this particular study – and a prevalence of 95% for hepatitis C). Despite this, however, key opiate medications are currently illegal in the country (and many other countries in the region) and treatment programmes are limited. This issue of the Lancet also includes an accompanying editorial comment by Wayne Hall & Richard Mattick (pages 2150 – 2151), which recommends that prudent health authorities in developing countries such as Malaysia should offer methadone and/or buprenorphine as the preferred maintenance treatments (rather than providing no treatment or relying on naltrexone alone).
| Click here to view The Lancet (Volume 371, Number 9631)
| | February 2008 Article of the Month
| Van Den Berg C, Smit C, Van Brussel G, Coutinho R, Prins M (2007) Full Participation in Harm Reduction Programmes is Associated with Decreased Risk for Human Immunodeficiency Virus and Hepatitis C Virus: Evidence from the Amsterdam Cohort Studies among Drug Users. Addiction, 102(9), 1454–1462.
| This research, published in a recent issue of Addiction, is from an open, large-scale, and prospective voluntary cohort study and seems to indicate that “full participation” in harm reduction programmes is associated with a reduction in the risk of HIV and hepatitis C (HCV) infection. The study sample was 714 “ever-injected” drug users at risk for HIV and/or HCV in Amsterdam, the Netherlands. The study explored five levels of harm reduction and, interestingly, no statistically significant effects were found for needle exchange programmes or methadone programmes alone. However, “full harm reduction” (defined as 60mg or more of daily methadone treatment in the past six months and either no injecting drug use in the past six months, or injecting drug use in the past six months and “always” utilisation of needle exchanges) was associated with significant reductions in risks – “not only on injecting but also on sexual risk behaviour”.
This paper supports the implementation of a broad range of harm reduction interventions in order to have the required impact on drug-related harms. This is important, as many countries and regions have had an over-reliance on individual interventions (such as needle exchange). A comprehensive package of harm reduction includes the exchange of a full range of paraphernalia (not just needles and syringes), the provision of (ideally peer-led) safer drug use advice and information, outreach services and advice, a range of opiate substitution treatment programmes, counselling, condom distribution, and overdose prevention education.
Although this research is based on self-reported behaviour, only two harm reduction interventions (albeit it the “two most important components” according to the authors – needle exchange and methadone) and a very restrictive definition of “full” participation (only using needles from a needle exchange in the last six months), the findings are very encouraging for the on-going advocacy efforts towards a conducive global environment for harm reduction. The authors conclude that their research “is most important for countries with recent and sometimes explosive outbreaks of HIV and/or HCV among [drug users], as in the former Soviet Union and Asia. To provide needles and syringes only or methadone only will not be sufficient to curb the rapid spread of these and other blood-borne infections… It is essential to offer a comprehensive programme in which both measures are combined”.
| Click here to view the full, Open Access Article courtesy of Blackwell Synergy
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