Michelle McKenzie

Obstacles to needle exchange participation in Rhode Island

OBJECTIVEnThis study explores obstacles to participation in needle exchange programs (NEPs) among injection drug users (IDUs) in the state of Rhode Island, U.S.A.nnnMETHODSnA written questionnaire was administered at two Rhode Island drug detoxification sites in 1998.nnnRESULTSn488 self-administered surveys were completed, 226 (46.3%) respondents had injected drugs in the past 6 months. 62.1% reported sharing syringes in the past 6 months, and each syringe was used a mean of 10.7 times. Major obstacles to NEP participation were a lack of awareness of the program (25.6%), inconvenient location or hours (15.9%), and fear of identification and/or police harassment (12.2%). Non-white race was a significant predictor of being unaware of the NEP (p = .01) and not participating in the NEP (p = .03). 13.1% of IDUs who used the NEP were referred to the detoxification program by the NEP. Among all IDUs surveyed, 51.0% had participated in a NEP.nnnCONCLUSIONSnNEPs are important in reducing the spread of bloodborne pathogens among IDUs and are effective referral sources for drug treatment. Surveys of IDUs at sites other than NEPs, such as detoxification facilities, can identify obstacles to the use of NEPs.

A randomized trial of methadone initiation prior to release from incarceration.

Individuals who use heroin and illicit opioids are at high risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens, as well as incarceration. The purpose of the randomized trial reported here is to compare outcomes between participants who initiated methadone maintenance treatment (MMT) prior to release from incarceration, with those who were referred to treatment at the time of release. Participants who initiated MMT prior to release were significantly more likely to enter treatment postrelease (P < .001) and for participants who did enter treatment, those who received MMT prerelease did so within fewer days (P = .03). They also reported less heroin use (P = .008), other opiate use (P = .09), and injection drug use (P = .06) at 6 months. Initiating MMT in the weeks prior to release from incarceration is a feasible and effective way to improve MMT access postrelease and to decrease relapse to opioid use.

Modified Directly Observed Therapy for the Treatment of HIV-Seropositive Substance Users: Lessons Learned from a Pilot Study

Highly active antiretroviral therapy (HAART) can dramatically decrease human immunodeficiency virus (HIV) load in plasma, increase CD4+ cell counts, and prolong life for HIV-seropositive persons. However, the need for optimal adherence has been recognized. We implemented a pilot community-based program of directly observed therapy (DOT) with HAART among persons with substance use disorders and a history of failure of HAART. A near-peer outreach worker initially delivered and observed once-daily HAART doses on up to 7 days per week. Many participants tapered the frequency of visits. Participants were assessed by a brief questionnaire and determination of their CD4+ cell count and plasma HIV load. Twenty-five HIV-seropositive persons were enrolled and followed-up for a mean of 6.6 months (standard deviation, 3.9 months). We found that once-daily dosing of HAART by DOT is feasible in this population; in addition to observation of the majority of doses, most participants achieved virus suppression and felt favorably about the intervention. Tapering the intensity of visits with maximum flexibility was necessary to enhance the acceptability of the program to participants.

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.

Development of an incarceration-specific overdose prevention video: Staying Alive on the Outside

Objectives: The first 2 weeks following release from prison are associated with extraordinary risk of fatal drug overdose. However, bystanders can reverse opioid overdoses using rescue breathing and naloxone, an overdose antidote. We reviewed overdose prevention and naloxone administration training videos for incarceration-specific and behaviour change theory–specific content and then developed a video that addressed these gaps. Design: Systematic review of educational videos and community-based participatory video development process. Setting: Community-based organisations, correctional health programmes. Method: Video development proceeded as a community-informed, iterative process of creating and testing the acceptability of a new DVD among end-user populations, community and correctional staff. Data collection and video development advisory process included three focus groups with opioid users and formerly incarcerated individuals, two consultations with national expert groups and overdose prevention programme staff and ongoing informal presentations to correctional staff and leadership. Results: Of nine eligible and reviewed videos, three contained theory-based learning components, and only one also contained peer-based content; none directly addressed post-incarceration overdose prevention. The created 19-minute film, Staying Alive on the Outside, uses interviews, conversation and model training sessions by peers, who candidly discuss the challenges of re-entry from prison, opioid addiction and relapse and misconceptions about opioid tolerance and overdose. Viewers learn strategies to avoid overdose while using opioids and what to do in an overdose. Peer ‘learners’ and peer ‘trainers’ model the dissemination of education and naloxone administration. Conclusion: The DVD is currently used in several prisons and jails; a multi-site evaluation of programme effectiveness is discussed.

Two Cases of Intranasal Naloxone Self-Administration in Opioid Overdose

BACKGROUNDnOverdose is a leading cause of death for former prisoners, exacting its greatest toll during the first 2 weeks post release. Protective effects have been observed with training individuals at high risk of overdose and prescribing them naloxone, an opioid antagonist that reverses the effects of the opioid-induced respiratory depression that causes death.nnnCASESnThe authors report 2 people with opiate use histories who self-administered intranasal naloxone to treat their own heroin overdoses following release from prison. Patient A is a 34-year-old male, who reported having experienced an overdose on heroin the day after he was released from incarceration. Patient B is a 29-year-old female, who reported an overdose on her first injection of heroin, 17 days post release from incarceration. Both patients self-administered the medication but were assisted at some point during the injury by a witness whom they had personally instructed in how to prepare and administer the medication. Neither patient experienced withdrawal symptoms following exposure to naloxone.nnnDISCUSSIONnSelf-administration of naloxone should not be a goal of overdose death prevention training. A safer, more reliable approach is to prescribe naloxone to at-risk patients and train and also equip members of their household and social or drug-using networks in overdose prevention and response.

Opioids and deaths.

To the Editor: We applaud the article by Okie (Nov. 18 issue)1 on the increasing number of overdose deaths, since we have seen far too many patients die prematurely of opioid overdoses. One topic was missing from this article: the usefulness of providing access to naloxone to be administered by laypersons to prevent death from an opioid overdose. Several studies involving illicit-drug users have confirmed that training laypeople to recognize and respond appropriately to an overdose situation is feasible, safe, and effective.2-4 Thousands of lives have been saved with either intramuscular injection or intranasal spray of naloxone.5 If it were the standard of care for physicians who prescribe long-acting opiates to also prescribe accompanying naloxone and provide access to brief training on its use, there would be far fewer overdose deaths. Improving access to prescribed naloxone is one fundamental lifesaving response within a clinician’s reach to directly address the unprecedented “flood of opioids” and “rising tide of deaths.”

Unknown quantities: HIV, viral hepatitis, and sexually transmitted infections in community corrections.

To the Editor: A t year-end 2011, 4.8 million adults in the United States were serving terms of probation or parole, collectively referred to as ‘‘community corrections.’’ As with incarcerated populations, people in community corrections are disproportionately from backgrounds of social and economic disadvantage, and racial and ethnic minorities are heavily overrepresented. These risk factors for poor health combine with behavioral risk factors, particularly substance use, to produce a population that is at high risk for infectious diseases. We sought to review the prevalence of HIV, viral hepatitis, and sexually transmitted infections (STI) among the US community corrections population. In March 2013, we searched PubMed and the National Criminal Justice Reference Service for articles reporting data on the prevalence of HIV, hepatitis B virus, hepatitis C virus (HCV), or other STI (including syphilis, gonorrhea, chlamydia, trichominiasis, human papillomavirus, or genital herpes). Searches were limited to articles published from 2000 onward. We identified just 8 relevant studies (9 publications). These suffered from various methodological weaknesses including nonrandom sampling, low response rates, and the use of self-reported data rather than serological testing. Of 3 studies that conducted HCV antibody testing, none undertook confirmatory testing to assess current infection. We conclude that there are insufficient data to permit a meaningful assessment of the prevalence of the selected infectious diseases in the community corrections population. The lack of data regarding HIV, viral hepatitis, and STI prevalence in community corrections clients is concerning. In 2011, around 1 in every 50 US adults was under community corrections supervision. If just 1 in 5 of these is at risk for blood-borne viral infections or STI, this equates to almost a million people. Inconsistent condom use with casual sex partners has been reported by 17% to 79% of community corrections clients, and around onequarter report lifetime injection drug use. 3,4,9,13 The lack of infectious disease prevalence data in the presence of these risk behaviors suggests an urgent need for largescale epidemiological studies. Ideally, these would include a complete or sufficiently large random sample of community corrections clients in a city, region, or state, with serological testing to provide an accurate estimate of past exposures and current infections. An alternative or complement to epidemiological studies may be the introduction of routine infectious disease screening in community corrections settings. At present, only 18% of community corrections clients receive HIV or HCV screening and just 0.02% receive STI testing. Screening could be accompanied by brief educational interventions focusing on risk reduction, tailored to include referrals to relevant local services. In addition to the benefits of screening to individuals, infectious disease screening would generate valuable data describing risk behaviors and disease burden in the community corrections population, providing an evidence base from which to develop harm reduction and treatment interventions that are specific to the local context.

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.

A randomized, open label trial of methadone continuation versus forced withdrawal in a combined US prison and jail: Findings at 12 months post-release

Recently, incarcerated individuals are at increased risk of opioid overdose. Methadone maintenance treatment (MMT) is an effective way to address opioid use disorder and prevent overdose; however, few jails and prisons in the United States initiate or continue people who are incarcerated on MMT. In the current study, the 12 month outcomes of a randomized control trial in which individuals were provided MMT while incarcerated at the Rhode Island Department of Corrections (RIDOC) are assessed. An as-treated analysis included a total of 179 participants-128 who were, and 51 who were not, dosed with methadone the day before they were released from the RIDOC. The results of this study demonstrate that 12 months post-release individuals who received continued access to MMT while incarcerated were less likely to report using heroin and engaging in injection drug use in the past 30 days. In addition, they reported fewer non-fatal overdoses and were more likely to be continuously engaged in treatment in the 12-month follow-up period compared to individuals who were not receiving methadone immediately prior to release. These findings indicate that providing incarcerated individuals continued access to MMT has a sustained, long-term impact on many opioid-related outcomes post-release.