Gerry V. Stimson

Methadone maintenance treatment in opiate dependence: a review.

This paper examines the changes and advances in research and clinical practice and examines the role of treatment structure and programme characteristics in the delivery of methadone maintenance. Methadone prescribing has become much more available over the past decade, both in countries with a history of its use, such as the United Kingdom and Australia, and in countries around the world which previously had not endorsed substitute prescribing.1 There is a need to examine closely the framework in which this treatment is delivered to ensure that the modes of delivery most effective from both cost and benefit perspectives are utilised. This review focuses entirely on methadone maintenance because this is the most extensively evaluated and most used treatment, with about a quarter of a million drug misusers receiving methadone treatment globally. A small number of experimental diamorphine and buprenorphine substitute programmes are being evaluated in several countries. Most studies have come from the United States and focus on the long term use of methadone in a specific setting; in contrast, methadone treatment in the United Kingdom has received virtually no formal evaluation to date bar one study.2 There is concern that a considerable amount of the methadone prescribing could be having little impact on illicit drug use or risk taking behaviour,3 a recent study of drug users in police custody echoes this.4 The Advisory Council on the Misuse of Drugs has recommended a shift to a more structured approach for delivery of oral methadone maintenance. The organisation and regulation of methadone maintenance treatment varies widely, with explicit guidelines for programme operation in the United States and Australia and a virtual absence of structure and regulation in Britain. It is likely that policy analysts and treatment providers in countries with high levels of regulation and structured programmes …

Aids and injecting drug use in the United Kingdom, 1987-1993: The policy response and the prevention of the epidemic

This paper assesses policy development, service changes and trends in HIV infection and risk behavior among injecting drug users (IDUs) in the United Kingdom. In 1986, the U.K. was faced with the possible rapid spread of HIV infection among IDUs. The combination of an outbreak of HIV infection with prevalence levels of 50% or more in Edinburgh, the recent diffusion of drug injecting, and high levels of syringe-sharing risk behaviour, suggested that HIV infection might spread rapidly through IDU populations. HIV prevention activities commenced in 1986 and developed in 1987. The first report on AIDS and Drugs Misuse by the Advisory Council on the Misuse of Drugs in 1988 was a major catalyst for change. It supported and legitimized emergent views on new ways of working with drug users. Between 1988 and 1993 innovative public health projects increased the ability to target vulnerable populations through syringe distribution, expansion of methadone treatment and outreach to hard-to-reach populations. There were major changes in service philosophy and practices, as ideas of harm minimization, accessibility, flexibility and multiple and intermediate goals were developed. There is evidence that these public health projects encouraged extensive changes in the health behaviour of IDUs. There have been major reductions in syringe-sharing risk behaviour and sharing syringes is no longer the norm. Evaluation of specific interventions (e.g. syringe-exchange) shows their importance in encouraging reductions in risk behaviour. Levels of HIV infection in IDUs remain low by international standards. Outside of London rates of about 1% have been reported; London has a low and declining prevalence of infection to around 7% in 1993; previous high levels in Edinburgh (55%) have since declined to 20%. Britain has to date avoided the rapid increase in HIV infection among injectors that has occurred in many parts of the world. The same period saw the continuation of high prevalence levels in New York and many European cities, and the explosive spread of HIV in many countries in south-east Asia. This paper acknowledges the difficulties is proving links between social interventions and epidemic prevention. It argues that there is prima facie evidence for the success of public health prevention, that the collection of intervention approaches in the U.K. had a significant impact on IDUs behaviour, and that this has helped prevent an epidemic of HIV infection among IDUs. The U.K. experience adds to the growing evidence of the significance of early interventions in encouraging behaviour change and in limiting the spread of HIV infection.

Sexual behaviour of injecting drug users and associated risks of HIV infection for Non-injecting sexual partners

The sexual behaviour of 142 clients of syringe-exchange schemes was measured using a questionnaire interview based survey method. Two to four months later the questionnaire was repeated to provide measures of behavioural change. The majority of these clients were sexually active, 77% having one or more sexual partners in the 3 months prior to the first interview. Many of these clients (46% of those sexually active) had sexual partners who did not inject drugs. There is evidence that this group modified their sexual behaviour towards reducing their own risk of HIV infection, with more having no sexual partners (from 23% to 31%), a reduction in those having multiple partners (from 26% to 21%) and a slight increase in those with regular partners (from 49% to 52%). Not all clients in this group reduced their risk of infection by modifying their sexual behaviour. Some clients continued to engage in high risk sexual behaviour, having multiple partners (21%) and not using condoms (79%). Whilst overall there is evidence of changes in the sexual behaviour of the clients towards a reduced risk of infection, we have identified an associated increase in risk of transmission from them to their sexual partners. Drug injectors who continued to have sexual partners were more likely to have sexual partners who did not inject drugs.

HIV risk behaviors among female IDUs in developing and transitional countries

BackgroundA number of studies suggest females may be more likely to engage in injection and sex risk behavior than males. Most data on gender differences come from industrialized countries, so data are needed in developing countries to determine how well gender differences generalize to these understudied regions.MethodsBetween 1999 and 2003, 2512 male and 672 female current injection drug users (IDUs) were surveyed in ten sites in developing countries around the world (Nairobi, Beijing, Hanoi, Kharkiv, Minsk, St. Petersburg, Bogotá, Gran Rosario, Rio, and Santos). The survey included a variety of questions about demographics, injecting practices and sexual behavior.ResultsFemales were more likely to engage in risk behaviors in the context of a sexual relationship with a primary partner while males were more likely to engage in risk behaviors in the context of close friendships and casual sexual relationships. After controlling for injection frequency, and years injecting, these gender differences were fairly consistent across sites.ConclusionGender differences in risk depend on the relational contexts in which risk behaviors occur. The fact that female and male risk behavior often occurs in different relational contexts suggests that different kinds of prevention interventions which are sensitive to these contexts may be necessary.

HIV prevalence and HIV risk behaviour among injecting drug users in London and Glasgow.

This paper reports on the British findings from a cross-national study of HIV prevalence and HIV risk behaviour among 1,037 injecting drug users (IDUs) recruited from a variety of treatment- and community-based settings during 1990. Confirmed HIV saliva test results show 12.8% (63) of London respondents and 1.8% (8) of Glasgow respondents to be HIV antibody positive. Among London respondents, a higher rate of prevalence was found in those with no experience of drug treatment. A greater proportion of Glasgow respondents (68%) than London respondents (47%) reported sharing used injecting equipment in the 6 months prior to interview. The majority (88% in both cities) attempted cleaning borrowed equipment, although less than a third (31% in London and 30% in Glasgow) usually used bleach. The majority of respondents (71% in London and 82% in Glasgow) were sexually active with partners of the opposite sex in the last 6 months, and respondents had a mean number of 2.4 non-commercial sexual partners in London and 2.1 in Glasgow. Levels of reported condom use were comparable with reports in the heterosexual population as a whole, with 70% of London respondents and 75% of Glasgow respondents never using condoms with primary partners, and 34% of London and 52% of Glasgow respondents never using condoms with casual partners. Half (48%) of London respondents and 42% of Glasgow respondents reported sexual intercourse with non-injecting private sexual partners, while 14% of female respondents in London and 22% in Glasgow had engaged in prostitution. Levels of risk-taking in each of the two cities indicate the potential for further transmission of HIV among drug injectors, and their sexual and sharing partners.

Disruptive innovations: the rise of the electronic cigarette.

The history of psychoactive substances is replete with examples of technologies that change the production and consumption of drugs, alcohol and tobacco. Business analysts use the term ‘disruptive innovation’ to describe innovations that lead to relatively rapid and dramatic transformations in manufacture, marketing, and consumer behaviour (Christensen, 2003). A classic instance is the ‘Kodak moment’ when, with the rise of digital processes, photographic film manufacturers were left with an obsolete technology. But as we will suggest, disruption is far broader than the technical impact of the innovation, for it has social ramifications affecting a wide range of social groups. This is especially the case with psychoactive substances where innovations can challenge the position of powerful groups and established wisdoms.

Qualitative social research in addictions publishing: Creating an enabling journal environment

In 2005, the journal Addiction, one of the highest-ranking addiction journals, published a review of qualitative methods in addictions research (Neale, Allen, & Coombes, 2005). This review noted that Addiction had published only three qualitative research papers in the previous year; around 2% of the research papers it had published in 2004. Accepting that “such marginality prompts uncomfortable questions”, the authors posed the possibility that some addiction journals might “directly or indirectly militate against the publication of qualitative research” (p. 1584). To begin to remedy this situation, the authors emphasised two challenges. First, they argued that qualitative researchers “should have confidence in the scientific rigor and value of their methods” and thus, should “not hesitate in writing up their data for any journal that will reach their target audience”. And second, they called upon addiction journals to “adopt policies and practices that will potentially encourage more qualitative submissions” (p. 1591). Of course, the extent to which qualitative research is published in any particular journal is shaped by a variety of factors, including: the rate at which such papers are submitted; the scientific quality of submissions; the amount of research funding available to qualitative researchers; the scientific capital and impact accorded such work in any given addiction research culture; as well as how journal policy and disciplinary leanings shape reviewing and editorial decisions. Interested to see how a selection of addiction journals compared, and taking a single year (2009), we estimated the proportion of published original research papers that employed qualitative methods (Table 1). We selected the top eight ranked journals in the ‘social science’ category of the Thomson ISI impact factor (IF) ratings, supplemented by journals of relative high impact in the field of drug use or known to attract social research submissions. Accepting the limits of such a snapshot exercise, what we found overall is probably of little surprise: Qualitative research – at 7% (100/1338) of papers published – is a minority output of addiction journal publication. The proportion would have been even lower if we had sampled addiction journals outside the ‘social science’ category. Table 1 Qualitative research in addiction journals, 2009. We also found that some journals publish more qualitative work than others. The addiction journal publishing the highest proportion of qualitative research papers – at 57% in 2009 – is the International Journal of Drug Policy (Table 1), followed by Drugs: Education, Prevention and Policy (36%) and the Journal of Psychoactive Drugs (34%). The addiction journals contributing least – at 1% or less – to qualitative research are Psychology of Addictive Behaviours, Addictive Behaviors, Addiction, and Drug and Alcohol Dependence. With the exception of the International Journal of Drug Policy, which has an IF of 2.5, the proportion of qualitative research published in any given journal is roughly inversely proportional to that journal’s IF. With the exception of one, all journals with an IF of over 2 published 3% or less research articles reporting qualitative data.

Is there any legal and scientific basis for classifying electronic cigarettes as medications

The rapid growth in the use of electronic cigarettes has been accompanied by substantial discussions by governments, international organisations, consumers and public health experts about how they might be regulated. In the European Union they are currently regulated under consumer legislation but new legislation will regulate them under the Tobacco Products Directive. However, several countries have sought to regulate them under medicines regulations. These claims have been successfully challenged in 6 court cases in European states. Under European legislation a product may be deemed to be a medicine by function if it is used in or administered to human beings either with a view to restoring, correcting or modifying physiological functions by exerting a pharmacological, immunological or metabolic action, or to making a medical diagnosis. It is a medicine by presentation if it is presented (e.g. by a manufacturer or distributor) as having properties for treating or preventing disease in human beings. We assess the legal and scientific basis for the claim that electronic cigarettes should be regulated as medicines. We conclude that they are neither medicine by function nor necessarily by presentation The main reason for their existence is as a harm reduction product in which the liking for and/or dependence on nicotine is maintained, and adoption of use is as a substitute for smoking and not as a smoking cessation product. In reality, they are used as consumer products providing pleasure to the user. They are not used to treat nicotine addiction or other disease, but to enable continued use of nicotine. Their use is adjusted individually by each consumer according to his or her perceived pleasure and satisfaction. Gaps in current regulation regarding safety and quality can be met by tailored regulations.

WHO USES COCAINE? SOCIAL PROFILES OF COCAINE USERS

Despite the long history of cocaine use in the UK, little is known about which groups use it. This paper describes contemporary cocaine users in England of both its powder and crack form, in the 1990s. A classification, based on social context of use, was developed from ethnographic data collected on 82 users between 1990 and 1992. Three distinct groups of cocaine users were identified: recreational cocaine users, poly-drug cocaine users and salient cocaine users. The recognition of the heterogeneity of cocaine users could inform service providers. Recreational users are unlikely to make demands on services. Poly-drug users may already be in contact with existing services but may not have reported their cocaine use. Consequently problematic cocaine use, as a confounder of other drug problems, may go unnoticed. Salient cocaine users are less likely to identify themselves with other drug users such as opiate users, are less likely to have knowledge of drug services, and evidence suggests that drug agencies ...

A Qualitative Study of the Purchasing and Distribution Patterns of Cocaine and Crack Users in England and Wales

This paper presents primarily ethnographic data on the evolution of the cocaine and crack drug scene in Britain between 1990 and 1992. The introduction and marketing of crack as a new commodity has led to distinct market outlets and altered the shape and patterns of the distribution of cocaine. We noted great variety in purchasing patterns, dependent upon availability, market knowledge and the profile of individuals and groups of users. Friends were important contacts for obtaining both cocaine and crack. Crack was more commonly bought from dealers and from street-scenes than was cocaine, a trend which increased during the study period. Emerging supply outlets were built on the existing structure of the irregular or illicit economy.We identified categories for the purchasing and selling of cocaine and crack based on specific settings (or “arenas”). These were characterised in terms of (heir accessibility to potential drug purchasers and would often be interlinked. We developed a typology of purchasing and...