Kirsten Meyer

Hepatitis C Virus Infection and Injection Drug Users: Prevention, Risk Factors, and Treatment

Injection drug users (IDUs) are the largest group of persons infected with hepatitis C virus (HCV), with a prevalence of 50%-90%. The transmission of HCV is not the effect of the drug injected but of sharing contaminated equipment. For the sake of prevention, we have to know which factors are more likely to lead to HCV seroconversion and which particular situations and environments are risk factors for equipment sharing. As far as therapy is concerned, some studies have shown that treatment for HCV infection in IDUs during substitution treatment for drug dependency is as successful as is treatment of patients who are not IDUs. Screening and early treatment of IDUs could play an important role in controlling HCV infection. The rate of reinfection may not as high as supposed. All studies dealing with treatment for HCV infection in IDUs have stressed the necessity of collaboration among hepatologists and specialists in addiction medicine, social workers, and psychotherapists.

Infrequent Reinfection after Successful Treatment for Hepatitis C Virus Infection in Injection Drug Users

We followed-up 18 injection drug users for a mean of 33.8 months (range, 4-55 months) after successful treatment for hepatitis C virus (HCV) infection. Fifteen (83%) of the patients remained HCV RNA-negative, 1 patient was not tested, and 2 patients had test results positive for HCV RNA. The estimated rate of reinfection as a result of injection drug use was 0-4.1 cases per 100 person-years (cumulative incidence, 0%-12.6% at 48 months after completion of treatment). Of 50 patients originally treated, 15 (30%) were HCV RNA-negative 3 years later.

Hepatitis C virus infection in injection drug users in Bavaria: risk factors for seropositivity.

Background: Hepatitis C Virus (HCV) infection is the most common disease among intravenous drug users (IDUs). Patients and method: All patients admitted to the detoxification unit 1991–1997 and meeting ICD-10 diagnosis of opioid dependency were tested for anti-HCV serology. Results: Thousand and forty nine patients were included in the study. About 61.3% of the IDUs were anti-HCV positive. Increasing age (PR: 1.46; 95% CI: 1.34–1.60), living with a significant other drug user (PR: 1.17; 95% CI: 1.05–1.31), history of therapy (PR: 1.62; 95% CI: 1.50–1.74), history of imprisonment (PR: 1.48; 95% CI: 1.36–1.61), history of emergency treatment (PR: 1.23; 95% CI: 1.12–1.35), additional daily consumption of benzodiazepines (PR: 1.10; 95% CI: 1.00–2.21) or alcohol (PR: 1.26; 95% CI: 1.14–1.38), frequency of injecting heroin (daily: PR: 0.86; 95% CI: 0.78–0.96; previously: PR: 1.14; 95% CI: 1.03–1.26) and type of opioid dependency (methadone: PR: 1.26; 95% CI: 1.13–1.41) were significant factors, considered as individual factors, for positive anti-HCV serology. Using multiple logistic regression we found that older age (OR: 3.54, 95% CI: 1.30–9.67), longer duration of opioid use (OR: 5.74; 95% CI: 1.82–18.13), living with a significant other drug user (OR: 1.47; 95% CI: 1.01–2.16), history of therapy (OR: 4.87; 95% CI: 1.67–14.20), history of imprisonment (OR: 1.92; 95% CI: 1.12–3.28), history of emergency treatment (OR: 1.45; 95% CI: 1.06–1.99) and additional daily consumption of alcohol (OR: 1.49; 95% CI: 1.04–2.13) remained independently associated with positive anti-HCV serology. Conclusions: These data support the need for early prevention strategies, namely, education of teachers in schools and further training of counsellors informing IDUs of what they can do to minimise the risk of becoming infected or of transmitting infectious agents to others.

Predictors for completing an inpatient detoxification program among intravenous heroin users, methadone substituted and codeine substituted patients

Up to 1999 more opioid dependent patients in Germany were substituted with codeine or dihydrocodeine (summarised as codeine) than with methadone. The current retrospective study compares the differences in detoxification treatment outcome for codeine-substituted patients, methadone-substituted patients and patients injecting illicit heroin. The study is based on the medical records of 1070 patients admitted consecutively for opioid and polytox detoxification between 1991 and 1997. The main hypothesis was that injecting illicit-heroin users would complete detoxification treatment less often than codeine- or methadone- substituted patients, and that methadone-substituted patients who had received more structured treatment would complete more often than codeine-substituted patients who did not receive any structured treatment beyond the prescription of codeine. We analysed a number of demographic and drug related variables as possible predictors. Our bivariate analyses confirmed our main hypothesis: 50.4% (OR: 1.8) of the methadone-substituted patients, 45.5% (OR: 1.5) of the codeine-substituted patients and 35.9% (OR: 1 comparison group) of the injecting illicit-heroin users completed the detoxification program (P=0.006). This finding remained significant even after correcting for a number of confounders. Using stepwise multiple logistic regression analyses, we found age, education, history of imprisonment, regular contact with a counsellor, currently being on probation and reported plans for participating in an abstinence treatment program to be significant predictors of completing detoxification treatment. Although the current analysis did not rule out differences in pharmacological effects as a contributing factor, the results are consistent with an interpretation of a dose-response association between psychosocial/psychotherapeutic support and detoxification outcome. More psychosocial/psychotherapeutic support leads to better detoxification treatment response.

Co-Consumption of Benzodiazepines in Heroin Users, Methadone-Substituted and Codeine-Substituted Patients

Abstract Concomitant consumption of benzodiazepines (BZDs) and opioids is a major problem in patients with opioid dependence. It may have substantial impact on morbidity, mortality and clinical course. The current retrospective study aims to determine whether there are differences in the additional use of BZDs among addicts regularly taking methadone or codeine medications in treatment and untreated addicts injecting heroin. The records of 1,685 patients admitted for detoxification were analyzed using bivariate analysis and multiple logistic regression analysis. Demographic and drug related variables were considered, both as possible confounders and predictors of concomitant BZD use. Daily intake of BZDs was reported in 44.4% of the patients. Patients treated with methadone or codeine medications report daily intake of BZDs significantly more often than the heroin-dependent patients (p < 0.01). Using multiple regression analyses, the results were confirmed as independent from the assessed possible confounders. Further we found that daily use of alcohol or barbiturates, early onset of opioid use (p < 0.01), unemployment, having a substance dependent family member with, and a history of imprisonment (for all p < 0.05) were associated with concomitant daily consumption of BZDs in opioid dependent subjects. These finding underline the need to further explore the causes, interactions and consequences of concomitant BZD and opiate use.

Risk Factors and Predictors of Human Immunodeficiency Virus Infection among Injection Drug Users

Background/Aim: Injection drug users (IDUs) have a high risk of acquiring an infection with the human immunodeficiency virus (HIV). To improve counseling and prevention, a better understanding of risk factors and predictors for an infection must be gained. This retrospective study has the aim to determine the risk factors for acquisition of HIV infection other than sharing of needles/syringes. Methods: The study population consisted of all patients admitted to the detoxification unit between 1991 and 1996 who met ICD-10 criteria for opioid dependency, who reported to share needles, and who agreed to have an antibody test. Possible risk factors were assessed by interview. Cross tables based on bivariate logistic regression were constructed to estimate the relative odds. Multiple logistic regression modeling procedures were used to adjust possible confounding factors. Results: A total of 1,049 out of 1,656 patients admitted were included into the study. 4.8% of the patients were HIV-1 seropositive. The prevalence was higher among older patients and among patients living with a significant other substance drug user with substance dependency, after a longer duration of drug use, and after coinfection with hepatitis B virus and/or hepatitis C virus (HCV). Using multiple logistic regression analyses and including all individually significant risk factors, we found only coinfection with HCV to remain significant. 92% of the HIV-infected patients were also HCV infected. In the group younger than 23 years of age, a total of 53.5% of the IDUs were still seronegative for HIV, hepatitis A and B virus, and HCV. Conclusions: Despite the high rate of HCV coinfection (92%) in HIV-infected patients, we found more than 50% of IDUs younger than 23 years to be neither infected with HCV nor with HIV. Early prevention strategies against infectious diseases should especially focus on young IDUs.

Myocardial Infarction Associated with Methadone and/or Dihydrocodeine

Chest pain and myocardial infarction occurring in young people with angiographically normal coronary arteries is well documented. Opiates have a cardioprotective effect and are used in acute heart attacks. We described a 22-year-old opioid addicted male patient who suffered a myocardial infarction following the consumption of methadone and dihydrocodeine.

Ofloxacin causes false-positive immunoassay results for urine opiates.

Immunoassay drug screening tests are usually used as a control during methadone maintenance programmes, to check cleanliness of drugs during detoxification treatment and abstinence programmes. False‐positive results can have catastrophic consequences for the patient, as shown in the case report. False‐positive results were reported for opioids following ofloxacin or rifampicin and for LSD following mucolytic. Since inpatient and outpatient units usually employ an urine quick test (immunoassay), positive results should be checked with gas chromatography/mass spectroscopy (GC‐MS) or high pressure liquid chromatography (HPLC) before conclusions from the positive urine screening results can be drawn.

Efficacy of a Polyethylene Glycol Marker System in Urine Drug Screening in an Opiate Substitution Program

Aims: Screening for concomitant drug consumption is necessary in opiate substitution therapy of opiate-dependent patients. Adulteration of samples is a common problem in this setting. A recently developed polyethylene glycol marker system allows reliable identification of urine samples. In this study, we aimed to compare the rates of drug detection in conventional and marker urine samples. Design: This cross-sectional evaluation was performed in an ambulatory opiate substitution program. We studied 55 opiate-dependent patients (32 men, 23 women). In all patients we compared the rates of drugs detected in the marker urine with the most recent conventional urine control. Additionally we assessed the rate of marker urine manipulation. Findings: In the conventional urine controls, opiates and benzodiazepines were found in 3.6 and 27%, respectively, whereas in the marker urine controls, these rates were 33 and 40%, respectively. Signs of urine manipulation were present in 35%. The rates of concomitant consumption and urine manipulation were higher among the patients without than among those with take-home substitution. Conclusions: With the marker urine, an unexpectedly high prevalence of concomitant consumption can be found. Marker urine testing has a significantly higher sensitivity for the detection of concomitant drug use.

A Randomized Double-Blind Placebo Controlled Study of Methadone and Diazepam with or without Carbamazepine for Combined Opioid and Benzodiazepine Detoxification

Methods: We included patients with a diagnosis of opiate and benzodiazepine dependence, admitted for detoxification of both substances, in this randomized, double-blind, placebo controlled trial. Patients were randomized to either one of the treatment protocols methadone, diazepam, and carbamazepine (group 1) versus methadone, diazepam, and placebo (group 2). Treatment retention and adverse events (AE) served as primary endpoints.