Toby Lea

Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia

BACKGROUND This study aimed to investigate the prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid pharmacotherapy treatment at community pharmacies in New South Wales (NSW), Australia. METHODS A multi-site cross-sectional survey design was utilised using a self-complete questionnaire. Participants were 508 clients receiving supervised methadone (n=442) and buprenorphine (n=66) at 50 community pharmacies. Participants were surveyed about whether they had diverted their currently prescribed pharmacotherapy, whether they had injected methadone or buprenorphine, the frequency, desirability and duration of action of injecting, and the ease of availability of street-purchased pharmacotherapies. RESULTS The prevalence of recent diversion was more than 10 times higher among those receiving buprenorphine compared to methadone, with 23.8% of buprenorphine-maintained participants reporting diverting their dose in the preceding 12 months. Seventeen percent of methadone clients had injected methadone in the preceding 12 months compared with 9.1% of buprenorphine clients over the same time period. CONCLUSION The higher prevalence of buprenorphine diversion compared to methadone diversion is likely to be due to its sublingual tablet formulation and difficulty associated with supervising its consumption compared to that of an oral liquid. Methadone diversion is also less prevalent likely due to the high levels of methadone take away provision, which also helps to explain the higher levels of recent methadone injecting compared to buprenorphine injecting. A clearer understanding of the motivations for diversion and injection of opioid pharmacotherapies, and the relationship between them is required.

Trends in drug use among gay and bisexual men in Sydney, Melbourne and Queensland, Australia.

INTRODUCTION AND AIMS The findings of Australian drug surveys are typically not stratified by sexual orientation, despite the higher prevalence of drug use generally reported among gay and bisexual men. This paper aims to examine trends in drug use among gay and bisexual men in eastern Australia between 2004 and 2011. DESIGN AND METHODS Data from the cross-sectional, ongoing Gay Community Periodic Surveys (GCPS) were used to analyse drug trends among gay and bisexual men in Sydney, Melbourne and Queensland. Between 2004 and 2011, 45,273 eligible questionnaires were completed. RESULTS There was a downward trend in recent drug use (previous 6 months) between 2004 and 2011 from 62.2% to 57.5%. However, this trend was not found among men in Queensland, bisexual men, men aged over 40 years or HIV-positive men. Club drug use peaked in 2006 (45.1%), before steadily declining to 32.4% in 2011. There were significant reductions in use of ecstasy, methamphetamine, ketamine and cannabis, increased use of cocaine, gamma hydroxybutyrate, erectile dysfunction medications, amyl nitrite and lysergic acid diethylamide, and no change in heroin use. Recent injecting drug use fluctuated over time but experienced an overall downward trend from 5.5% in 2004 to 4.0% in 2011. DISCUSSION AND CONCLUSIONS Drug use trends among gay and bisexual men in Australia are broadly consistent with downward and upward drug trends reported in other Australian drug surveys. The risks associated with drug use in this population and high rates of use supports the ongoing role of the GCPS in monitoring drug trends among homosexually active men.

Lithium carbonate in the management of cannabis withdrawal in humans: an open-label study

Cannabis is the most widely used illicit substance in the world. Estimates suggest that approximately 10—20% of cannabis users meet criteria for cannabis dependence and a significant proportion experience withdrawal discomfort on cessation of use. To date, there has been an absence of any clinically validated treatments to manage withdrawal. The current study is an open-label trial exploring the utility of lithium carbonate for the management of cannabis withdrawal symptoms in treatment seeking adult humans. In total, 20 participants were recruited to the study (19 men). All met DSM-IV cannabis-dependence criteria and had been smoking cannabis daily or almost daily for a mean 9 years. Participants were admitted to an inpatient detoxification facility and prescribed lithium 500 mg b.d. for 7 days. Cannabis withdrawal was assessed daily with the Marijuana Withdrawal Checklist (MWC). Two participants were withdrawn from the trial because of possible adverse effects. Sixty percent of participants completed the 7-day treatment program. Follow-up was conducted at a mean of 107 days following treatment. The mean percentage of days abstinent in the period between treatment cessation and follow-up was 87.57%. Twenty-nine percent of participants (n = 5) reported continuous abstinence that was biochemically verified at follow-up. Agreement between self-reported cannabis use and urinalysis at follow-up was moderate (κ = 0.47). Significant reductions in symptoms of depression and anxiety and cannabis-related problems were also reported. This study provides evidence for the potential clinical utility and safety of lithium in the management of cannabis withdrawal. A randomised, placebo-controlled trial is recommended.

Diversion and Injection of Methadone and Buprenorphine Among Clients in Public Opioid Treatment Clinics in New South Wales, Australia

A survey of 448 clients receiving opioid treatment in public clinics in Australia was conducted during 2005, exploring diversion and injection of supervised methadone and buprenorphine, frequency and reported effects of injecting, and the cost and availability of street-purchased pharmacotherapies. The rates of diversion in the preceding 12 months were over three times higher among participants receiving supervised buprenorphine (15.3%%) than among those receiving supervised methadone (4.3%%). While 26.5%% of participants currently prescribed buprenorphine had ever injected buprenorphine, 65.9%% of those prescribed methadone reported ever injecting methadone. The majority of participants did not appear to have extensive experience of injecting their medication and most expressed a preference for taking it as directed. Further research is required to determine the optimal approach for the supervised administration of buprenorphine that maximizes the benefits of treatment and minimizes harm and the risk of diversion. The studys limitations are noted.

Should I stay or should I go? Coming off methadone and buprenorphine treatment.

BACKGROUND This study aimed to investigate patient perspectives regarding coming off maintenance opioid substitution treatment (OST). The study explored previous experiences, current interest and concerns about stopping treatment, and perceptions of how and when coming off treatment should be supported. METHODS A cross-sectional survey was used. Participants were 145 patients receiving OST at public opioid treatment clinics in Sydney, Australia. RESULTS Sixty-two percent reported high interest in coming off treatment in the next 6 months. High interest was associated with having discussed coming off treatment with a greater number of categories of people (OR=1.72), not citing concern about heroin relapse (OR=3.18), and shorter duration of current treatment episode (OR=0.99). Seventy-one percent reported previous withdrawal attempts and 23% had achieved opioid abstinence for ≥3 months following a previous withdrawal attempt. Attempts most commonly involved jumping off (59%), and doctor-controlled (52%) or self-controlled (48%) gradual reduction. For future attempts respondents were most interested in doctor-controlled (68%) or self-controlled (41%) gradual reduction. Concerns regarding coming off treatment included withdrawal discomfort (68%), increased pain (50%), and relapse to heroin use (48%). CONCLUSION While some patients may require lifetime maintenance, the issue of coming off treatment is important to many patients and should be discussed regularly throughout treatment and where appropriate supported by a menu of clinical options.

Sexual identity and prevalence of alcohol and other drug use among Australians in the general population

BACKGROUND International research assessing differences in the prevalence of alcohol and other drug (AOD) use among Lesbian Gay Bisexual and Transgender (LGBTI) and heterosexual populations shows elevated prevalence rates of substance use among LGBTI people. To date no research has been published investigating these differences at a population level among both men and women in Australia. METHODS The 2013 National Drug Strategy Household Survey, a multistage stratified population sample collecting data on AOD use in the Australian population over 14 years of age, was analysed for differences between gay and bisexual (GB) men and lesbian/gay and bisexual (LGB) women and their heterosexual counterparts in: (1) the prevalence of lifetime and past year tobacco and AOD use; (2) age of initiation of tobacco and AOD use; and (3) frequency of alcohol and cannabis use, and history of AOD treatment. RESULTS There were elevated rates of past year cannabis (22.4%), ecstasy (11.8%) and methamphetamine (9.7%) use among GB men compared to heterosexual men (12.4%, 2.9% and 2.5%). LGB women also reported elevated rates of past year use (tobacco - 23.7%; cannabis - 24.6%) compared to heterosexual women (10.6% and 7.1%). LGB women initiated tobacco (15.2 years) and alcohol (15.5 years) at an earlier age than heterosexual women (16.6 and 17.7 years), and were significantly more likely to report daily alcohol consumption (OR 3.2, 95% CI: 2.1, 5.1), and weekly or more frequent cannabis use (OR 1.7, 95%CI: 1.1, 3.1). CONCLUSIONS These findings are indicative of the need for more responsive and targeted AOD harm reduction and treatment services for LGBTI communities in Australia. Of concern is the elevated risk among LGB women for earlier initiation of substance use, and the development of problematic consumption patterns. Further research, investigating the risk and protective factors for AOD use among LGB women is warranted.

Alcohol and club drug use among same-sex attracted young people: associations with frequenting the lesbian and gay scene and other bars and nightclubs.

This study aimed to determine whether the lesbian and gay “scene” of bars and nightclubs is a more common site for club drug use than other bars and clubs. A cross-sectional, online survey was conducted with 254 same-sex attracted women and 318 men aged 18–25 in Sydney, Australia. Drug use was more likely in those who attended any venue type more frequently. Men, but not women, were more likely to report drug use in lesbian and gay venues than other venues. Club drug use may be more normalized within the lesbian and gay scene than elsewhere, particularly among young men. The studys limitations are noted.

Problems experienced by community pharmacists delivering opioid substitution treatment in New South Wales and Victoria, Australia

AIMS To explore service provision and the range of problems that New South Wales (NSW) and Victoria (VIC) community pharmacists providing opioid substitution treatment (OST) have experienced with clients and prescribers. DESIGN ross-sectional postal survey. SETTING All community pharmacies providing OST in NSW (n = 593) and VIC (n = 393), Australia. PARTICIPANTS Completed questionnaires were received from 669 pharmacists (68% response rate). MEASUREMENTS The questionnaire addressed pharmacy characteristics, recent problems experienced with clients including refusal to dose, provision of credit for dispensing fees, termination of treatment, responses of pharmacists to problems experienced with clients, as well as problems experienced with OST prescribers. FINDINGS In the preceding month, 41% of pharmacists had refused to dose a client for any reason, due most commonly to expired prescriptions (29%), or > or issed doses (23%). Terminating a clients treatment in the past month was reported among 14% of respondents, due most commonly to inappropriate behaviour and missed doses. Treatment termination was reported by a significantly higher proportion of pharmacists in VIC (P < 0.001). Treatment termination in last month was predicted having more clients (P < 0.001), the provision of buprenorphine treatment (P = 0.008), having a separate dosing area (P = 0.021), and being a female pharmacist (P = 0.013). Past month refusal to dose was predicted by the pharmacy being in VIC (P < 0.001) and having more clients (P < 0.001). Problems experienced most commonly in the past month with prescribers were difficulty contacting prescriber (21%) and provision of takeaway doses to clients considered unstable by the pharmacist (19%) (higher in VIC: both P < 0.001). CONCLUSIONS This study highlights the range of problems experienced by community pharmacists in the delivery of OST and the consequences for people in treatment. Particular attention should be focused upon considering number of clients per pharmacy and improving professional communication between pharmacists and prescribers.

The prevalence and correlates of undiagnosed HIV among Australian gay and bisexual men: results of a national, community-based, bio-behavioural survey

Gay and bisexual men (GBM) with undiagnosed HIV are believed to contribute disproportionately to HIV transmission in Australia but national prevalence estimates have been lacking.

Comprehensive testing for, and diagnosis of, sexually transmissible infections among Australian gay and bisexual men: findings from repeated, cross-sectional behavioural surveillance, 2003–2012

Objectives To analyse changes in testing for sexually transmissible infections (STI) among gay and bisexual men in Melbourne, Sydney and Queensland, Australia, particularly comprehensive STI testing (at least four tests from different anatomical sites in the previous year), and the characteristics of men who had such testing. Method Data were analysed from repeated, cross-sectional, community-based surveys conducted during 2003–2012. Trends in specific STI tests and comprehensive testing were assessed and the characteristics of participants who reported comprehensive STI testing were identified using multivariate logistic regression, stratified by HIV status. Results Among HIV-negative and unknown status men (n=51 009), comprehensive STI and HIV testing increased substantially from 13% in 2003 to 34% in 2012. During the same period, comprehensive STI testing (excluding HIV testing) increased from 24% to 57% among HIV-positive men (n=5532). In both HIV status groups, comprehensive testing was more commonly reported by men who had unprotected anal intercourse with casual partners, and men with higher numbers of partners. Among HIV-negative/unknown status participants, comprehensive STI and HIV testing was also associated with education level, regional location and finding partners online. Among HIV-positive men, comprehensive STI testing was also associated with free time spent with gay men and illicit drug use. Comprehensive testing was related to a high annual rate of diagnosis with STIs (20% of HIV-negative/unknown status men and 38% of HIV-positive men). Conclusions There has been a substantial improvement in the proportion of gay and bisexual men in Melbourne, Sydney and Queensland who report comprehensive testing. Comprehensive testing is most likely among men whose practices put them at increased risk of infection, and is associated with a high rate of STI diagnosis. However, opportunities for comprehensive testing are still being missed, suggesting a need for its ongoing promotion.