Francis Wolf

Linkage with methadone treatment upon release from incarceration: A promising opportunity

Abstract Injection drug users (IDUs) are at increased risk for HIV, viral hepatitis, and tuberculosis, and making up more than a quarter of the incarcerated population in the United States. Methadone maintenance treatment of opiate addiction is highly effective at reducing drug use, drug-related criminal activity, and risk of HIV transmission. Recently released inmates are at particularly high risk for overdose and disease transmission. Linkage to methadone treatment immediately upon release from incarceration is a promising opportunity to combat disease transmission, facilitate reentry into the community, and reduce recidivism.

A syringe prescription program to prevent infectious disease and improve health of injection drug users

Injection drug users (IDUs) are at increased risk for many health problems, including acquisition of human immunodeficiency virus (HIV) and hepatitis B and C. These risks are compounded by barriers in obtaining legal, sterile syringes and in accessing necessary medical care. In 1999, we established the first-ever syringe prescription program in Providence, Rhode Island, to provide legal access to sterile syringes, reduce HIV risk behaviors, and encourage entry into medical care. Physicians provided free medical care, counseling, disease testing, vaccination, community referrals, and prescriptions for sterile syringes for patients who were not ready to stop injecting. We recruited 327 actively injecting people. Enrolled participants had limited stable contact with the health care system at baseline; 45% were homeless, 59% were uninsured, and 63% did not have a primary care physician. Many reported high-risk injection behaviors such as sharing syringes (43% in the last 30 days), reusing syringes (median of eight times), and obtaining syringes from unreliable sources (80%). This program demonstrates the feasibility, acceptability, and unique features of syringe prescription for IDUs. The fact that drug use is acknowledged allows an open and frank discussion of risk behaviors and other issues often not disclosed to physicians. The syringe prescription program in Providence represents a promising and innovative approach to disease prevention and treatment for IDUs.

Demographic, geographic, and temporal patterns of ambulance runs for suspected opiate overdose in Rhode Island, 1997-2002

We examine ambulance runs for suspected opiate overdose from 1997 to 2002 using a Rhode Island Department of Health database. Of the 8,763 ambulance runs for overdoses, 18.6% were for suspected opiate overdoses. Most cases were males under age 54. Suspected opiate overdoses were more likely to occur in a private residence, were more frequent on Fridays and Saturdays, and peaked in incidence around 9:00 p.m. The incidence rate of suspected opiate overdose by year was similar. The study results may help identify areas for preventive intervention and demonstrate the limitation of using naloxone as a marker of opiate overdose events.

A comparison of syringe prescription and syringe exchange in Rhode Island, USA

Prior to the year 2000, strict laws regulated the purchase and possession of syringes in Rhode Island, USA. More than 50% of the state’s AIDS cases were related to injection drug use, and injecting drug users (IDUs) in Rhode Island reused each syringe, on average, over 20 times. Rhode Island’s syringe exchange programme began in 1995, and has served over 1700 clients. In 2001, the programme exchanged almost 45,000 syringes. Participation in the syringe exchange programme is anonymous, and the programme provides education, outreach, and referral to substance abuse treatment. A syringe prescription programme for IDUs began in Rhode Island in 1999; it has served over 350 patients and prescribed more than 72,000 syringes. In addition to expanding access to sterile syringes, the syringe prescription programme also expanded patients’ access to disease screening and treatment, vaccination, primary medical care, and referral to specialists. Since 1995, there have been three major programmatic and policy approaches adopted in Rhode Island to address the issue of syringe access for injection drug users: syringe exchange, legal reform, and syringe prescription. Each approach offers different ancillary services and appears to appeal to different populations of IDUs. Adopting multiple approaches to syringe access may best serve this high-risk population.

Prescribing Syringes to Injection Drug Users with HIV: An Important Clinical and Public Health Tool

Injection drug use is a major risk factor for infection with HIV and other viral illnesses including hepatitis B and C. There are an estimated 1 million active injection drug users (IDUs) in the United States; 50% to 80% become infected with hepatitis C in the first 6 to 12 months of injecting (Thomas et al., 1995). In 1999, 36% of all U.S. AIDS cases and the majority (58%) of AIDS cases in women were associated with injection drug use (Centers for Disease Control and Prevention, 2000b). IDUs become infected through sharing contaminated syringes and other injection equipment and can pass on the viruses to their sexual partners and children. The reuse of syringes has caused IDUs to face additional health problems including tetanus, abscesses, cellulitis, wound botulism, and endocarditis (Friedland & Selwyn, 1998). By using sterile syringes, IDUs can avoid many injection-related health complications, and those IDUs who have already acquired HIV or hepatitis can protect themselves against co-infection with hepatitis or another strain of HIV and protect others from getting infected. The average IDU injects approximately 1,000 times per year (Centers for Disease Control and Prevention, 2000a), and although rinsing syringes with bleach can decrease transmission of HIV (Abdala, Gleghorn, Carney, & Heimer, 2001), it is difficult to sterilize used syringes completely. Using syringes that have been cleaned with bleach is not as effective as using a new sterile syringe (Normand, Vlahov, & Moses, 1995). For this reason, the Centers

23. Are persistent changes in SEPs and MEPs sensitive for predicting postoperative limb motor deficit during cerebral aneurysm surgery

Introduction Motor evoked potentials (MEPs) can be used as an adjunct to somatosensory evoked potentials (SEPs) to identify brain ischemia during surgical treatment of cerebral aneurysms. Persistent changes (failure to return to baseline by end of surgery) can be used to predict postoperative deficit. The sensitivity, specificity, positive and negative predictive value of persistent changes in SEPs/MEPs for predicting neurologic deficit is still being defined. In a separate study, the sensitivity of persistent changes in SEPs for predicting new limb paresis was 13%, and MEPs was 32%. In this study we evaluated those patients with new postoperative motor deficits to determine the reason for the low sensitivity. Material and methods This was a retrospective study based on 446 cerebral aneurysm patients who underwent clipping at our institution from 2009–2011. Twenty-eight patients with new postoperative motor deficits were identified. The neuromonitoring reports and medical records were reviewed in more detail in these patients. Results In the 28 patients, ten patients (36%, sensitivity) were predicted by persistent SEPs/MEPs changes. In the 18 patients whose deficits were not predicted, five patients (18%) had delayed deficits; eight (29%) had mild temporary motor deficits; in two patients (7%), monitoring was stopped less than ten minutes after aneurysms were clipped; in one patient (3.6%), no reliable SEPs were recorded on the surgery side at baseline. If the last three cases are eliminated, the sensitivity of predicting for all deficit at time when patient wake up is 50% (10/20 patients); to severe and persistent motor deficit is 83% (10/12 patients). Conclusion This study demonstrates that the reason for the low sensitivity of SEPs/MEPs is that these methods are not sensitive to delayed and/or mild temporary deficits. However, the study also shows that SEPs/MEPs have better predictability in cases of severe and persistent postoperative limb paresis.

Research Note: Acceptability and Utility of a Hand-Held Syringe Disposal Device for Active Injection Drug Users

Efforts to prevent the spread of HIV and hepatitis among injection drug users (IDUs) by improving access to sterile syringes can raise questions about syringe disposal. This study sought to evaluate the acceptability and utility of the Voyager, a newly approved, hand-held syringe disposal device for active injection drug users (IDUs). We offered the Voyager to active IDUs (n = 97), and interviewed them upon receiving the device and one month later. Almost all (90%) accepted the device. At follow-up, 78% had used the Voyager and 44% reported using it all the time; 65% reported they would like to continue using the Voyager and 77% rated the device “somewhat better” or “much better” than other methods of syringe disposal. Many IDUs care about safe syringe disposal and are willing and able to use a convenient disposal device such as the Voyager. Communities concerned about needlestick injuries and re-use of contaminated syringes should explore increasing the availability of such a device for IDUs as part of an overall approach to prevent improperly discarded syringes.