Amy Peacock

The impact of alcohol and energy drink consumption on intoxication and risk-taking behavior

BACKGROUND It has been argued that consuming alcohol mixed with energy drinks (AmED) causes a subjective underestimation of intoxication and an increased level of risk-taking behavior. To date, however, there is mixed support for AmED-induced reductions in perceived intoxication, and no objective assessment of risk-taking following AmED consumption. Consequently, the present study aimed to determine the effect of alcohol and energy drink (ED) consumption on subjective measures of intoxication and objective measures of risk-taking. METHODS Using a placebo-controlled, single-blind, cross-over design, participants (n = 28) attended 4 sessions in which they were administered, in counterbalanced order: 0.5 g/kg alcohol, 3.57 ml/kg ED, AmED, and a placebo beverage. Participants completed the Biphasic Alcohol Effects Scale and a Subjective Effects Scale at baseline and 30 and 125 minutes postbeverage administration; risk-taking was measured using the Balloon Analogue Risk Task (BART). RESULTS Participants reported greater subjective intoxication, impairment, and sedation after active relative to placebo alcohol consumption, with no interactive AmED effects. However, a significant moderate magnitude increase in stimulation ratings was observed in the AmED relative to alcohol, ED, and placebo conditions. There was no independent effect of alcohol, or interactive effect with ED, on the BART. A significant, yet small magnitude, increase in risk-taking was evident in active relative to placebo ED conditions. CONCLUSIONS The interactive effect of AmED appears restricted to perceived stimulation, with alcohol-induced increases in subjective intoxication occurring regardless of presence or absence of ED. Engagement in risk-taking behavior was only increased by ED consumption; however, this effect was only of small magnitude; at these doses, alcohol consumption, with or without EDs, did not affect risk-taking. Further research assessing the dose-dependent effects of AmED on objectively measured risk-taking behavior could clarify whether the ED effect increases with higher doses and whether an interactive effect is observed with higher alcohol doses.

Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review

Summary Background Sharing of equipment used for injecting drug use (IDU) is a substantial cause of disease burden and a contributor to blood-borne virus transmission. We did a global multistage systematic review to identify the prevalence of IDU among people aged 15–64 years; sociodemographic characteristics of and risk factors for people who inject drugs (PWID); and the prevalence of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) among PWID. Methods Consistent with the GATHER and PRISMA guidelines and without language restrictions, we systematically searched peer-reviewed databases (MEDLINE, Embase, and PsycINFO; articles published since 2008, latest searches in June, 2017), searched the grey literature (websites and databases, searches between April and August, 2016), and disseminated data requests to international experts and agencies (requests sent in October, 2016). We searched for data on IDU prevalence, characteristics of PWID, including gender, age, and sociodemographic and risk characteristics, and the prevalence of HIV, HCV, and HBV among PWID. Eligible data on prevalence of IDU, HIV antibody, HBsAg, and HCV antibody among PWID were selected and, where multiple estimates were available, pooled for each country via random effects meta-analysis. So too were eligible data on percentage of PWID who were female; younger than 25 years; recently homeless; ever arrested; ever incarcerated; who had recently engaged in sex work, sexual risk, or injecting risk; and whose main drugs injected were opioids or stimulants. We generated regional and global estimates in line with previous global reviews. Findings We reviewed 55 671 papers and reports, and extracted data from 1147 eligible records. Evidence of IDU was recorded in 179 of 206 countries or territories, which cover 99% of the population aged 15–64 years, an increase of 31 countries (mostly in sub-Saharan Africa and the Pacific Islands) since a review in 2008. IDU prevalence estimates were identified in 83 countries. We estimate that there are 15·6 million (95% uncertainty interval [UI] 10·2–23·7 million) PWID aged 15–64 years globally, with 3·2 million (1·6–5·1 million) women and 12·5 million (7·5–18·4 million) men. Gender composition varied by location: women were estimated to comprise 30·0% (95% UI 28·5–31·5) of PWID in North America and 33·4% (31·0–35·6) in Australasia, compared with 3·1% (2·1–4·1) in south Asia. Globally, we estimate that 17·8% (10·8–24·8) of PWID are living with HIV, 52·3% (42·4–62·1) are HCV-antibody positive, and 9·0% (5·1–13·2) are HBV surface antigen positive; there is substantial geographic variation in these levels. Globally, we estimate 82·9% (76·6–88·9) of PWID mainly inject opioids and 33·0% (24·3–42·0) mainly inject stimulants. We estimate that 27·9% (20·9–36·8) of PWID globally are younger than 25 years, 21·7% (15·8–27·9) had recently (within the past year) experienced homelessness or unstable housing, and 57·9% (50·5–65·2) had a history of incarceration. Interpretation We identified evidence of IDU in more countries than in 2008, with the new countries largely consisting of low-income and middle-income countries in Africa. Across all countries, a substantial number of PWID are living with HIV and HCV and are exposed to multiple adverse risk environments that increase health harms. Funding Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, World Health Organization, the Global Fund, and UNAIDS.

Energy drink ingredients. Contribution of caffeine and taurine to performance outcomes

While the performance-enhancing effects of energy drinks are commonly attributed to caffeine, recent research has shown greater facilitation of performance post-consumption than typically expected from caffeine content alone. Consequently, the aim of the present study was to investigate the independent and combined effect of taurine and caffeine on behavioural performance, specifically reaction time. Using a double-blind, placebo-controlled, crossover, within-subjects design, female undergraduates (N=19) completed a visual oddball task and a stimulus degradation task 45min post-ingestion of capsules containing: (i) 80mg caffeine, (ii) 1000mg taurine, (iii) caffeine and taurine combined, and (iv) matched placebo. Participants completed each treatment condition, with sessions separated by a minimum 2-day washout period. Whereas no significant treatment effects were recorded for reaction time in the visual oddball task, facilitative caffeine effects were evident in the stimulus degradation task, with significantly faster reaction time in active relative to placebo caffeine conditions. Furthermore, there was a trend towards faster mean reaction time in the caffeine condition relative to the taurine condition and combined caffeine and taurine condition. Thus, treatment effects were task-dependent, in that independent caffeine administration exerted a positive effect on performance, and co-administration with taurine tended to attenuate the facilitative effects of caffeine in the stimulus degradation task only.

Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review

Summary Background People who inject drugs (PWID) are a key population affected by the global HIV and hepatitis C virus (HCV) epidemics. HIV and HCV prevention interventions for PWID include needle and syringe programmes (NSP), opioid substitution therapy (OST), HIV counselling and testing, HIV antiretroviral therapy (ART), and condom distribution programmes. We aimed to produce country-level, regional, and global estimates of coverage of NSP, OST, HIV testing, ART, and condom programmes for PWID. Methods We completed searches of peer-reviewed (MEDLINE, Embase, and PsycINFO), internet, and grey literature databases, and disseminated data requests via social media and targeted emails to international experts. Programme and survey data on each of the named interventions were collected. Programme data were used to derive country-level estimates of the coverage of interventions in accordance with indicators defined by WHO, UNAIDS, and the UN Office on Drugs and Crime. Regional and global estimates of NSP, OST, and HIV testing coverage were also calculated. The protocol was registered on PROSPERO, number CRD42017056558. Findings In 2017, of 179 countries with evidence of injecting drug use, some level of NSP services were available in 93 countries, and there were 86 countries with evidence of OST implementation. Data to estimate NSP coverage were available for 57 countries, and for 60 countries to estimate OST coverage. Coverage varied widely between countries, but was most often low according to WHO indicators (<100 needle-syringes distributed per PWID per year; <20 OST recipients per PWID per year). Data on HIV testing were sparser than for NSP and OST, and very few data were available to estimate ART access among PWID living with HIV. Globally, we estimate that there are 33 (uncertainty interval [UI] 21–50) needle-syringes distributed via NSP per PWID annually, and 16 (10–24) OST recipients per 100 PWID. Less than 1% of PWID live in countries with high coverage of both NSP and OST (>200 needle-syringes distributed per PWID and >40 OST recipients per 100 PWID). Interpretation Coverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics. Funding Open Society Foundations, The Global Fund, WHO, UNAIDS, United Nations Office on Drugs and Crime, Australian National Drug and Alcohol Research Centre, University of New South Wales Sydney.

A systematic review of injecting-related injury and disease among people who inject drugs

BACKGROUND Non-viral injecting-related injuries and diseases (IRID), such as abscesses and vascular damage, can result in significant morbidity and mortality if untreated. There has been no systematic assessment of the prevalence of non-viral IRID among people who inject drugs; this review aimed to address this gap, as well as identify risk factors for experience of specific IRID. METHODS We searched MEDLINE, Embase and CINAHL databases to identify studies on the prevalence of, or risk factors for, IRID directly linked to injecting in samples of people who inject illicit drugs. RESULTS We included 33 studies: 29 reported IRID prevalence in people who inject drugs, and 17 provided data on IRID risk factors. Skin and soft tissue infections at injecting sites were the most commonly reported IRID, with wide variation in lifetime prevalence (6-69%). Female sex, more frequent injecting, and intramuscular and subcutaneous injecting appear to be associated with skin and soft tissue infections at injecting sites. Cleaning injecting sites was protective against skin infections. Other IRID included infective endocarditis (lifetime prevalence ranging from 0.5-12%); sepsis (2-10%); bone and joint infections (0.5-2%); and thrombosis and emboli (3-27%). CONCLUSIONS There were significant gaps in the data, including a dearth of research on prevalence of IRID in low- and middle-income countries, and potential risk and protective factors for IRID. A consistent approach to measurement, including standardised definitions of IRID, is required for future research.

The characteristics of a cohort who tamper with prescribed and diverted opioid medications

AIMS To describe the methods and baseline characteristics of a cohort of people who tamper with pharmaceutical opioids, formed to examine changes in opioid use following introduction of Reformulated OxyContin®. METHODS Participants were 606 people from three Australian jurisdictions who reported past month injecting, snorting, chewing or smoking of a pharmaceutical opioid and had engaged in these practices at least monthly in the past 6 months. Baseline interviews were conducted prior to introduction of Reformulated OxyContin® in April 2014. Patterns of opioid use and cohort characteristics were examined according to whether participants were prescribed opioid medications, or exclusively used diverted medication. RESULTS The cohort reported high levels of moderate/severe depression (61%), moderate/severe anxiety (43%), post-traumatic stress disorder (42%), chronic pain or disability (past 6 months, 54%) and pain (past month, 47%). Lifetime use of oxycodone, morphine, opioid substitution medications and codeine were common. Three-quarters (77%) reported ICD-10 lifetime pharmaceutical opioid dependence and 40% current heroin dependence. Thirteen percent reported past year overdose, and 70% reported at least one past month opioid injection-related injury or disease. The cohort displayed complex clinical profiles, but participants currently receiving opioid substitution therapy who were also prescribed other opioids particularly reported a wide range of risk behaviors, despite their health service engagement. CONCLUSIONS Findings highlight the heterogeneity in the patterns and clinical correlates of opioid use among people who tamper with pharmaceutical opioids. Targeted health interventions are essential to reduce the associated harms.

Self-reported physiological and psychological side-effects of an acute alcohol and energy drink dose

OBJECTIVE There have been repeated calls from health professionals and policy-makers to clarify the side-effects of the increasingly popular consumption trend of alcohol mixed with energy drinks (AmED). There is a dearth of research assessing the differential effects of AmED relative to alcohol by comparing self-reported psychological and physiological outcomes whilst under the influence of these substances. The aim of the present study was to examine the acute effects of a moderate alcohol and energy drink (ED) dose on self-reported psychological and physiological outcomes. METHOD Using a single-blind, placebo-controlled, crossover design, 28 adults completed four sessions where they were administered: (i) 0.50g/kg alcohol, (ii) 3.57mL/kg ED, (iii) AmED, and (iv) placebo. Participants independently completed the Profile of Mood States and a Somatic Symptom Scale at baseline and at 30 and 125min after beverage administration. RESULTS Breath alcohol concentration peaked at .068% and .067% in the alcohol and AmED conditions, respectively. There were no interactive alcohol and ED effects on self-reported psychological outcomes. Treatment effects for physiological outcomes generally only related to alcohol or ED administration, with the exception of a moderate magnitude decrease in heart palpitation ratings following alcohol relative to AmED. Decreased muscular tension ratings were evident when the two constituents were consumed separately relative to placebo. CONCLUSIONS The results provide evidence of few subjective changes in physiological and psychological state after consuming AmED relative to alcohol. The majority of treatment-based changes arose from the independent effects of alcohol or ED, rather than being modified by their interaction. However, research extending into higher dosage domains is required to increase outcome generalisability for consumers in the night-time economy.

Day-by-day variation in affect, arousal and alcohol consumption in young adults

INTRODUCTION AND AIMS Alcohol consumption has a well-established relationship with mood, with higher positive and negative affect predicting alcohol use. More recently, researchers have explored whether alcohol consumption occurs as a response to affect variability as an attempt to self-medicate and stabilise affect. Studies have revealed a positive association between alcohol use and intra- and inter-individual affect variability in clinical and university student samples; however not much is known of this relationship among the general community. DESIGN AND METHODS Ecological Momentary Assessment (EMA) methods were used to investigate the relationship between affect and arousal variability and alcohol use in 53 community volunteers. Participants self-reported affect and arousal at three to five randomly timed moments throughout the day, as well as every time they drank. RESULTS On a day-to-day basis, higher positive affect was associated with increased alcohol consumption. When analyses were restricted to self-reported affect prior to alcohol consumption, only increased arousal and decreased variability in arousal predicted the likelihood of alcohol consumption. Mean level of arousal was associated with the extent of alcohol consumed. DISCUSSION AND CONCLUSIONS In this moderate drinking sample day-to-day affect and arousal, and arousal variability, were associated with alcohol consumption. Analyses restricted to pre-drinking observations provide further evidence that self-medication accounts of alcohol consumption may explain drinking initiation but that the relationship between affect factors and drinking behaviour may change around the point of first drink.

Methods and predictors of tampering with a tamper-resistant controlled-release oxycodone formulation

BACKGROUND In April 2014, a tamper-resistant controlled-release oxycodone formulation was introduced into the Australian market. This study aimed to identify the level and methods of tampering with reformulated oxycodone, demographic and clinical characteristics of those who reported tampering with reformulated oxycodone, and perceived attractiveness of original and reformulated oxycodone for misuse (via tampering). METHODS A prospective cohort of 522 people who regularly tampered with pharmaceutical opioids and had tampered with the original oxycodone product in their lifetime completed two interviews before (January-March 2014: Wave 1) and after (May-August 2014: Wave 2) introduction of reformulated oxycodone. RESULTS Four-fifths (81%) had tampered with the original oxycodone formulation in the month prior to Wave 1; use and attempted tampering with reformulated oxycodone amongst the sample was comparatively low at Wave 2 (29% and 19%, respectively). Reformulated oxycodone was primarily swallowed (15%), with low levels of recent successful injection (6%), chewing (2%), drinking/dissolving (1%), and smoking (<1%). Participants who tampered with original and reformulated oxycodone were socio-demographically and clinically similar to those who had only tampered with the original formulation, except the former were more likely to report prescribed oxycodone use and stealing pharmaceutical opioid, and less likely to report moderate/severe anxiety. There was significant diversity in the methods for tampering, with attempts predominantly prompted by self-experimentation (rather than informed by word-of-mouth or the internet). Participants rated reformulated oxycodone as more difficult to prepare and inject and less pleasant to use compared to the original formulation. CONCLUSION Current findings suggest that the introduction of the tamper-resistant product has been successful at reducing, although not necessarily eliminating, tampering with the controlled-release oxycodone formulation, with lower attractiveness for misuse. Appropriate, effective treatment options must be available with increasing availability of abuse-deterrent products, given the reduction of oxycodone tampering and use amongst a group with high rates of pharmaceutical opioid dependence.

Jurisdictional differences in opioid use, other licit and illicit drug use, and harms associated with substance use among people who tamper with pharmaceutical opioids

INTRODUCTION AND AIMS The harms associated with non-medical use of pharmaceutical opioid analgesics are well established; however, less is known about the characteristics and drug-use patterns of the growing and hidden populations of people using pharmaceutical opioids illicitly, including the frequency of pharmaceutical opioid injection. This paper aimed to undertake a detailed examination of jurisdictional differences in patterns of opioid use among a cohort of people who regularly tamper with pharmaceutical opioids in Australia. DESIGN AND METHODS Data were drawn from the National Opioid Medications Abuse Deterrence study. The cohort was recruited from New South Wales (NSW; n = 303), South Australia (SA; n = 150) and Tasmania (TAS; n = 153) to participate in face-to-face structured interviews collecting data on use of pharmaceutical opioids, benzodiazepines, other sedative drugs and illicit substances, as well as the harms associated with substance use. RESULTS TAS participants reported greater use and injection of certain pharmaceutical opioids (particularly morphine and methadone tablets), and limited heroin use, with lower rates of engagement in opioid substitution treatment, compared with NSW participants. NSW participants were more socially disadvantaged and more likely to report risky injecting behaviours and injecting-related injuries and diseases compared with SA and TAS participants. SA participants reported greater rates of pain conditions, greater use of pain-based services, as well as broader use of pharmaceutical opioids in regards to forms and route of administration, compared with NSW participants. DISCUSSION AND CONCLUSIONS Distinct jurisdictional profiles were evident for people who tamper with pharmaceutical opioids, potentially reflecting jurisdictional differences in prescribing regulatory mechanisms and addiction treatment models.