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The incidence of opioid use disorder (OUD) is increasing worldwide, and the opioid-related overdose crisis is currently a major global challenge. This study investigated the effects of adjuvant laser meridian massage (LMM) in men with OUD undergoing methadone maintenance treatment (MMT).A case-controlled study was conducted from February 2019 to April 2020. Fourteen men with OUD on MMT were enrolled from an addiction treatment center as an experimental group. An age-matched control group comprising 13 men was also enrolled. The experimental group received LMM on the back, including over the Bladder meridian and Governor Vessel, three times weekly for 4 weeks. The control group received only MMT. Urinary morphine levels, patients' self-reports of the number of episodes or days of heroin use, and visual analog scale scores for heroin craving/refusal to use heroin during the previous week were evaluated. Quality of life was reported using the Short Form (SF)-12v2.The experimental group showed a significant decrease in heroin use (p 0.05), whereas the control group showed a significant increase in heroin craving (p 0.05). The SF-12v2 Health Survey revealed a significant improvement in physical health in the experimental group (P 0.05).The results of this study suggest that laser meridian massage can be considered a safe, well-tolerated, and potentially useful adjuvant intervention for opioid use disorder.

Objectives To determine the prevalence of substance abuse among our pregnant women and the characteristics of their pregnancies, deliveries and new-born infants. Methods Retrospective observational study of infants born between January 1, 2009 and December 31, 2017 in our centre to substance-abusing mothers and compared with our 2002–2008 study. Results Heroin use is decreasing, while cannabis and methamphetamine use are increasing. We observed a decrease in withdrawal associated with methadone and benzodiazepine use and an increase in breastfeeding in benzodiazepine and cannabis users. The infants of mothers who use heroin and cocaine are discharged to the mother’s home less often. We observed a predominance of substance abuse among Spanish women except for methamphetamines, where the majority of users are Filipino. Conclusions The increase in cannabis use and the decrease in heroin and cocaine use have improved gestational control. Methamphetamine use is associated with serious social risks.

Objectives Difficulties in emotion regulation (DER) may be important in heroin craving in individuals with heroin dependence who have experienced childhood trauma (CT). However, no research has been performed on DER in the context of heroin dependence. The aim of this study was to evaluate direct and indirect relations of CT to the subscales of heroin craving (i.e., heroin thoughts and interference, intention to use heroin and control of its consumption, and resistance to thoughts and decisions to use heroin) via DER dimensions in individuals with a DSM diagnosis of heroin dependence. Methods In a cross-sectional design, 330 males with heroin dependence completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Obsessive-Compulsive Drug Use Scale-Form Heroin (OCDUS-Form Heroin), and the Depression Anxiety Stress Scales (DASS). Results The results revealed that CT had no direct relations to the subscales of heroin craving, but it indirectly was related to all three subscales of heroin craving via one of the DER dimensions named limited access to emotion regulation strategies (Strategies) after adjusting for demographic and clinical factors. Conclusions The findings suggest that Strategies may be related to heroin craving in individuals with heroin dependence who have CT. This proposes that treatment and prevention attempts focused on training the use of effective emotion regulation strategies may be useful to reduce heroin craving in individuals with heroin dependence who have experienced a history of CT.

Aims Globally, women who use drugs often practice sex work and experience multiple health and social harms that complicate their drug treatment needs. In East Africa, understanding the emergence of heroin use among women is critical in efforts to build effective drug treatment programming, including the ongoing scale-up of medication-assisted treatment (MAT). We explored heroin use among women engaged in sex work in Kenya to inform services. Methods In a qualitative study of 45 female sex workers reporting substance use in Kisumu, Kenya, 32 reported lifetime heroin use and comprise the focus of this analysis. Semi-structured interviews explored histories of substance use and sex work and health programming needs. Thematic analysis focused on the contexts and meanings of heroin use. Results Among 32 women, median age was 28 (range: 18–37). Women commonly smoked cocktails containing heroin while using alcohol and other drugs prior to sex work. Most women perceived heroin to engender “morale” and “courage” to engage in sex work and “fight” potentially abusive clients. Sex work reinforced drug use in ways that both managed and created new risks. Conclusions Drawing on the concept of “paradoxical autonomy,” we suggest that heroin use engenders new forms of autonomy allowing women to support themselves in conditions of uncertainty, yet does not enable them to entirely overcome their vulnerabilities. Drug treatment programs for sex workers should address the situated logics of substance use in contexts of sexual risk, including patterns of poly-substance use that may render MAT inappropriate for some women who use heroin.

Background Jail is frequently described as a “revolving door,” which can be profoundly destabilizing to people moving in and out of the system. However, there is a dearth of research attempting to understand the impacts of the accumulation of incarceration events on women who use drugs. We examined the association of the frequency of jail incarceration with hardship, perceived health status, and unmet health care need among women who use drugs. Methods Our community-based sample included women who use heroin, methamphetamine, crack cocaine, and/or powder cocaine (N = 624) in Oakland, California, from 2012 to 2014. Poisson regression models with robust variances were built to estimate adjusted prevalence ratios between the frequency of jail incarcerations and measures of hardship, perceived health, and unmet health care need, adjusting for a set of a priori specified covariates. Results We observed associations between high levels of jail frequency and higher levels of homelessness (p = .024), feeling unsafe in their living situation (p = .011), stress (p = .047), fair to poor mental health (p = .034), unmet mental health care need (p = .037), and unmet physical health care need (p = .041). We did not observe an association between jail frequency and unmet subsistence needs score or fair to poor physical health. Conclusions We observed associations between higher levels of jail frequency and a higher prevalence of hardship, poor mental health, and unmet health care need. Our findings suggest areas for additional research to untangle the impacts of frequent incarceration on women's health and well-being.

Background Drug overdose is the leading cause of accidental death in the United States. Nationally, opioids are the primary drugs associated with accidental overdoses. In response to increasing overdose deaths, 40 states and the District of Columbia have enacted Good Samaritan Laws (GSLs). Generally, these policies attempt to encourage witnesses or those experiencing an overdose to call 911 by providing limited immunity from arrest, charge and/or prosecution of possession of narcotics. The aim of the current study is to evaluate the effectiveness of New York State’s 911 GSL. Methods We exploit a difference in state law between New York State, where the policy was adopted in 2011, and New Jersey, where the policy was not adopted until 2013, to provide a reasonable comparison condition. We examine variation in accidental opioid overdose emergency department visits and inpatient admissions from 2010 to 2012 across 270 hospitals in New York and New Jersey at the quarterly level controlling for hospital fixed effects and time trends using State Emergency Department Databases (SEDD) and State Inpatient Databases (SID). Results Accidental opioid overdose emergency department visits and inpatient hospital admissions were increasing in both New York and New Jersey. After the enactment of New York’s 911 GSL, emergency department visits and inpatient hospital admissions for accidental heroin overdoses increased differently in New York and New Jersey, with an incident rate ratio (IRR) of 1.34 (95% CI = 1.00, 1.86). The results were inconclusive for accidental non-heroin opioid overdoses (IRR = 0.98, 95% CI = 0.86, 1.13). Conclusions Accidental heroin overdose emergency department visits and inpatient hospital admissions increased in New York State after the enactment of the 911 GSL, consistent with the intended effect of the GSL. Preliminary evidence suggests that either persons who use heroin and/or those around them were impacted by the policy change.

Objectives To evaluate the efficacy of a couple-based integrated HIV/HCV and overdose prevention intervention on non-fatal and fatal overdose and overdose prevention behaviors among people who use heroin or other opioids in Almaty, Kazakhstan. Methods We selected 479 participants who reported lifetime heroin or opioid use from a sample of 600 participants (300 couples) enrolled in a randomized controlled trial (RCT) conducted between May 2009 and February 2013. Participants were randomized to either (1) a 5-session couple-based HIV/HCV and overdose prevention intervention condition or (2) a 5-session Wellness Promotion and overdose prevention comparison condition. We used multilevel mixed-effects model with modified Poisson regression to estimate effects of the intervention as risk ratios (RR) and the corresponding 95% CIs. Results About one-fifth (21.9%) of the sample reported that they had experienced an opioid overdose in the past 6 months at baseline. At the 12-month follow-up, both the intervention and comparison conditions reported significant reductions in non-fatal overdose and injection heroin/opioid use and significant increases in drug treatment attendance and naloxone use to prevent death from overdose. However, we found no differences between the study arms on any of these outcomes. There were three intervention condition participants (1.3%), compared to seven comparison condition participants (2.9%) who died from opioid overdose during the 12-month follow up period although this difference was not significant. Discussion There were no significant conditions on any outcomes: both conditions showed promising effects of reducing non-fatal overdose and overdose risks. Integrating overdose prevention into a couple-based HIV/HCV intervention may be an efficient strategy to target the syndemic of opioid overdose, HIV and HCV in Kazakhstan.

Aims: To analyse predictors of heroin abstinence in opiate substitution therapy (OST) based on frequency of crack use and its interactions with other predictors in a clinical non-experimental setting. Design: Retrospective study. Setting: A community drug service in London, UK. Participants: 325 clients starting OST between 2010 and 2014 (197 methadone and 128 buprenorphine). Measurements: Logistic regression models (a general model and separate models for methadone and buprenorphine) assessed demographic and clinical data as predictors of heroin abstinence at one year after treatment start (or at the date of transfer to another service). Findings: For the general model participants choosing methadone were more likely to use heroin at follow up (OR=2.36, 95% CI: 1.40–3.17) as were daily crack users on methadone (OR=2.62, 95% CI: 0.96 – 7.16). For the methadone model only daily crack use predicted heroin use at follow up (OR = 2.62, 95% CI: 0.96 – 7.16). For buprenorphine, higher amounts of baseline heroin use, lower buprenorphine dose and daily drinking predicted heroin use at follow up (OR=0.85, 95% CI: 0.75–0.95; OR=1.31, 95% CI: 1.06–1.60 and OR=6.04, 95% CI: 1.26–28.92). Both use of cannabis and depression increased likelihood of heroin abstinence for clients not using crack compared to occasional (OR=6.68, 95% CI: 0.37–119.59; OR=106.31, 95% CI: 3.41–3313.30) and daily (OR=57.49 (95% CI: 2.37–1396.46; OR=170.99 (95% CI: 4.61–6339.47) users. Conclusions: Most of the predictors in the general model were found significant only in the buprenorphine but not in the methadone model, suggesting that a general model has little predictive value. Crack use was a significant predictor of heroin abstinence at follow up in all models, however for buprenorphine only when depression or cannabis use was present. Further research is needed to assess effective treatment approaches for the growing population of dual users.

Background The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30–50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as ‘heroin' and to observe the drugs and their use. Methods A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin. Results (1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin ‘types' have proliferated with several products being sold as ‘heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin–fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new ‘heroin' typology based on users' reports. Conclusion Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.

Background Fentanyl dominates the heroin supply in many regions of the United States. One harm reduction response has been the distribution of fentanyl test strips to people who use heroin to test for the presence of fentanyl. Reports increasingly indicate that fentanyl contamination is occurring in the illicit stimulant market, but whether people who use stimulants would use fentanyl test strips is unknown. Methods Between January 2019 and January 2020, fifteen people in Philadelphia, PA who reported stimulant use completed a semi-structured interview with questions about their perceptions of fentanyl and willingness to use fentanyl test strips. Data were coded and analyzed for thematic content using constructs from the Health Belief Model and risk environment theory. Results Participants primarily reported using crack cocaine or crack cocaine/heroin, while some used methamphetamine, powder cocaine, or prescription opioids. All were aware of fentanyl and believed they were susceptible to a fentanyl overdose as stimulant users. Participants perceived benefits of using test strips but reported barriers, such as the unpredictable nature of buying or using drugs and not wanting to delay drug use to test. Structural conditions impeded participant actions to reduce overdose risk if their drugs tested positive for fentanyl. Conclusion Fentanyl test strips were a desired harm reduction tool by many participants who used stimulants. In addition to providing access to the strips, programs should tailor overdose prevention education to these clients by acknowledging susceptibility, amplifying benefits, and addressing drug-specific barriers to use of fentanyl test strips.

Objectives Transitioning from injecting to non-injecting routes of drug administration can provide important individual and community health benefits. We assessed characteristics of persons who had ceased injecting while continuing to use heroin and/or cocaine in New York City. Methods We recruited subjects entering Mount Sinai Beth Israel detoxification and methadone maintenance programs between 2011 and 2015. Demographic information, drug use histories, sexual behaviors, and "reverse transitions" from injecting to non-injecting drug use were assessed in structured face-to-face interviews. There were 303 "former injectors," operationally defined as persons who had injected at some time in their lives, but had not injected in at least the previous 6 months. Serum samples were collected for HIV and HCV testing. Results Former injectors were 81% male, 19% female, 17% White, 43% African-American, and 38% Latino/a, with a mean age of 50 (SD=9.2), and were currently using heroin and/or cocaine. They had injected drugs for a mean of 14 (SD=12.2) years before ceasing injection, and a mean of 13 (SD=12) years had elapsed since their last injection. HIV prevalence among the sample was 13% and HCV prevalence was 66%. The former injectors reported a wide variety of reasons for ceasing injecting. Half of the group appeared to have reached a point where relapse back to injecting was no longer problematic: they had not injected for three or more years, were not deliberately using specific techniques to avoid relapse to injecting, and were not worried about relapsing to injecting. Conclusions Former injectors report very-long term behavior change toward reduced individual and societal harm while continuing to use heroin and cocaine. The behavior change appears to be self-sustaining, with full replacement of an injecting route of drug administration by a non-injecting route of administration. Additional research on the process of long-term cessation of injecting should be conducted within a "combined prevention and care" approach to HIV and HCV infection among persons who use drugs.

Background Prevalence of self-reported methamphetamine use has remained relatively stable over the past decade; however, deaths and seizures involving methamphetamine have been increasing. Research is needed to determine if select subgroups in the US are at increased risk for use. Methods We examined data from individuals ages ≥12 from the 2015–2018 National Survey on Drug Use and Health (n = 226,632), an annual nationally representative cross-sectional survey of non-institutionalized individuals in the US. Log-linear trends in past-year methamphetamine use were examined, stratified by demographic and drug use characteristics. Results Methamphetamine use increased in the US from 2015 to 2018, including among those reporting past-year use of ecstasy/MDMA (6.1 % to 10.8 % [p = .018], a 78.2 % increase), cocaine (8.4 % to 11.8 % [p = .013], a 40.1 % increase), and among those reporting past-year prescription opioid misuse (5.4 % to 8.0 % [p = .019], a 49.2 % increase). Increases were particularly pronounced among those reporting past-year use of heroin (22.5 % to 37.4 % [p = .032], a 66.2 % increase) and LSD (5.1 %–= to 10.3 % [p = .002], a 100.4 % increase). Small increases were also detected among heterosexuals (0.6 % to 0.7 % [p = .044], a 16.2 % increase), those with a high school diploma or less (1.0 % to 1.2 % [p = .020], a 22.0 % increase), and among those receiving government assistance (1.4 % to 1.8 % [p = .046], a 26.2 % increase). Conclusions Methamphetamine use is increasing among people who use other drugs with sharp increases among people who use heroin or LSD in particular, and this could have serious public health consequences. Results may signal that methamphetamine use may continue to increase in the general population.

Recent celebrity deaths have been widely reported in the media and turned the public attention to the coexistence of mood, psychiatric and substance-abuse disorders. These tragic and untimely deaths motivated us to examine the scientific and clinical data, including our own work in this area. The self-medication hypothesis states that individuals with psychiatric illness tend to use heroin to alleviate their symptoms. This study examined the correlations between heroin use, mood and psychiatric disorders, and their chronology in the context of dual diagnosis.Out of 506 dual diagnosed heroin addicts, 362 patients were implicated in heroin abuse with an onset of at least one year prior to the associated mental disorder (HER-PR), and 144 patients were diagnosed of mental illness at least one year prior to the associated onset of heroin use disorder (MI-PR). The retrospective cross-sectional analysis of the two groups compared their demographic, clinical and diagnostic characteristics at univariate and multivariate levels.Dual diagnosis heroin addicts whose heroin dependences existed one year prior to their diagnoses (HER-PR) reported more frequent somatic comorbidity (p≤0.001), less major problems at work (p=0.003), more legal problems (p=0.004) and more failed treatment for their heroin dependence (p0.001) in the past. More than 2/3 reached the third stage of heroin addiction (p=0.001). Their length of dependence was longer (p=0.004). HER-PR patients were diagnosed more frequently as affected by mood disorders and less frequently as affected by psychosis (p=0.004). At the multivariate level, HER-PR patients were characterized by having reached stage 3 of heroin dependence (OR=2.45), diagnosis of mood disorder (OR=2.25), unsuccessful treatment (OR=2.07) and low education (OR=1.79).The main limitation is its retrospective nature. Nonetheless, it does shed light on what needs to be done from a clinical and public health perspective and especially prevention.The data emerging from this study, does not allow us to determine a causal relation between heroin use and mental illness onset. However, this data, even if requiring longitudinal studies, suggest that self-medication theory, in these patients, can be applied only for chronic psychoses, but should not be applied to patients with mood disorders using heroin.

OBJECTIVE: The purpose of the present study was to examine the motivations underlying the use of buprenorphine outside of therapeutic channels and the factors that might account for the reported rapid increase in buprenorphine misuse in recent years. METHODS: This study used: (1) a mixed methods approach consisting of a structured, self-administered survey (N=10,568) and reflexive, qualitative interviews (N=208) among patients entering substance abuse treatment programs for opioid dependence across the country, centered on opioid misuse patterns and related behaviors; and (2) interviews with 30 law enforcement agencies nationwide about primary diverted drugs in their jurisdictions. RESULTS: Our results demonstrate that the misuse of buprenorphine has increased substantially in the last 5 years, particularly amongst past month heroin users. Our quantitative and qualitative data suggest that the recent increases in buprenorphine misuse are due primarily to the fact that it serves a variety of functions for the opioid-abusing population: to get high, manage withdrawal sickness, as a substitute for more preferred drugs, to treat pain, manage psychiatric issues and as a self-directed effort to wean themselves off opioids. CONCLUSION: The non-therapeutic use of buprenorphinehas risen dramatically in the past five years, particularly in those who also use heroin. However, it appears that buprenorphine is rarely preferred for its inherent euphorigenic properties, but rather serves as a substitute for other drugs, particularly heroin, or as a drug used, preferable to methadone, to self-medicate withdrawal sickness or wean off opioids. Language: en

This review reports on the results of a comprehensive literature search of studies examining the physical and mental health characteristics of older adults in the United States who use heroin. Multiple databases were searched for papers meeting the inclusion criteria of heroin users who were age 50 years or older. A total of 14 articles covering 9 different studies met the review inclusion criteria. All of the studies were convenience samples, and seven of the nine studies (77.8%) were entirely drawn from substance abuse treatment programs, primarily methadone maintenance programs. Findings from the qualitative studies suggest that the marginalization of older heroin users was a predominant experience that impacted the intent to seek treatment as well as treatment retention. While articles reported high levels of physical and psychological/psychiatric comorbidities with substance misuse, research on heroin use and methadone treatment among older adults is scant and the quantitative findings are inconsistent. The articles reviewed in this study demonstrate that the needs of this population will be significant, yet the development of appropriate interventions and treatment for older adult heroin users will be contingent on empirical research that adequately describes mental and physical health problems.

Background Drug problems are reemerging in China since the nation implemented economic reform and an "open door" policy in the early 1980s. This is causing both national and international concern. However, knowledge and understanding of the Chinese drug problem is fairly limited because of the nation's unique social and political history. In response to this shortage of information, our study presents a profile of Chinese drug users. Methods Data were collected from a survey of drug users attending mandatory treatment centres in a large city in 2009. We present a demographic profile of the drug users, describe their patterns of drug use, their access to drugs and their history of drug treatment. Results Chinese drug users, like those from the U.S., are likely to be unemployed and have a low level of education. However, they are more likely than those in the U.S. to use heroin, Bingdu (methamphetamine) and Maguo (a derivative of methamphetamine), and they pay less for their drugs. Conclusion This profile of drug users is informative and valuable for drug prevention, intervention, and treatment in the Chinese setting because knowing and understanding the drug population is essential for effective control.

Introduction and aims To examine differences in the characteristics and histories of male and female dependent heroin users, and in the clinical characteristics associated with multiple substance dependence diagnoses. Design and methods 1513 heroin dependent participants underwent an interview covering substance use and dependence, psychiatric history, child maltreatment, family background, adult violence and criminal history. Family background, demographic and clinical characteristics were analysed by sex. Ordinal regression was used to test for a relationship between number of substance dependence diagnoses and other clinical variables. Results Women were more likely to experience most forms of child maltreatment, to first use heroin with a boyfriend or partner, to experience ongoing adult violence at the hands of a partner, and to have a poorer psychiatric history than men. Males had more prevalent lifetime substance dependence diagnoses and criminal histories and were more likely to meet the criteria for ASPD. Predictors of multiple substance dependence diagnoses for both sexes were mental health variables, antisocial behaviour, childhood sexual abuse, victim of adult violence, younger age at first cannabis use and overdose. As the number of dependence diagnoses increased, clinical and behavioural problems increased. Childhood emotional neglect was related to increasing dependence diagnoses for females but not males, whereas PTSD was a significant predictor for males but not females. Discussion and conclusions Mental health problems, other substance dependence, childhood and adult trauma were common in this sample, with sex differences indicating different treatment needs and possible different pathways to heroin dependence for men and women.

Background Social support is a multi-dimensional construct that is important to drug use cessation. The present study identified types of supportive friends among the social network members in a community-based sample and examined the relationship of supporter-type classes with supporter, recipient, and supporter–recipient relationship characteristics. We hypothesized that the most supportive network members and their support recipients would be less likely to be current heroin/cocaine users. Methods Participants (n = 1453) were recruited from low-income neighborhoods with a high prevalence of drug use. Participants identified their friends via a network inventory, and all nominated friends were included in a latent class analysis and grouped based on their probability of providing seven types of support. These latent classes were included as the dependent variable in a multi-level regression of supporter drug use, recipient drug use, and other characteristics. Results The best-fitting latent class model identified five support patterns: friends who provided Little/No Support, Low/Moderate Support, High Support, Socialization Support, and Financial Support. In bivariate models, friends in the High, Low/Moderate, and Financial Support were less likely to use heroin or cocaine and had less conflict with and were more trusted by the support recipient than friends in the Low/No Support class. Individuals with supporters in those same support classes compared to the Low/No Support class were less likely to use heroin or cocaine, or to be homeless or female. Multivariable models suggested similar trends. Conclusions Those with current heroin/cocaine use were less likely to provide or receive comprehensive support from friends.

Summary Objectives To determine: (a) whether Scottish drug users on methadone maintenance use heroin less frequently than their peers following other forms of drug treatment; and (b) to what extent those on methadone maintenance ‘top up’ with heroin. Design A cohort study followed-up for 33 months from 2001 to 2004. Methods Four hundred and ten interviewees who responded at all four interview sweeps, recruited as new treatment entrants from 28 drug treatment agencies across Scotland. Results Sixty-eight of the 401 interviewees had commenced an episode of methadone-maintenance treatment at the start of the study. There was no significant difference between the methadone-maintained sample and the other interviewees in their propensity to abstain from heroin use, nor was there any difference between the two groups in the mean reduction over time in their self-reported dependence on drugs. However, if the outcome measure used is the change (between baseline and 33 months) in the number of days that the interviewee reported having used heroin in the previous 3 months, the reduction in the number of days that heroin was used was significantly greater (52 days) in the methadone-maintained group than in the rest of the sample (36.4 days). This fall in the number of days of heroin use was greater still if the comparison was restricted to those who had continued on methadone-maintenance treatment, although 67.4% of those still on methadone maintenance had ‘topped up’ with heroin at some point in the 3 months prior to 33-month follow-up. Those on higher maintenance doses were not significantly more likely to have reduced the number of days on which they used heroin compared with those on lower doses, and those still on methadone maintenance were not more likely to have reduced their criminality (measured by the number of days on which they committed acquisitive crimes in the previous 3 months) compared with the rest of the sample. Conclusions Methadone-maintained drug users are not more likely to achieve abstinence than drug users receiving other forms of treatment, but they are significantly more likely to achieve a reduction in the frequency of their illicit drug use; they ‘top up’ on methadone, but the frequency of their illicit drug use is less than that of drug users in other treatment modalities. These data confirm the value of methadone-maintenance services as part of a ‘mixed economy’ of services for the treatment of drug use.

Purpose We examined whether inhalant use was associated with heroin and injection drug use (IDU) among adolescents aged 12 to 17 in the United States. Methods Data were drawn from the 2002/2003 administrations of the National Survey on Drug Use and Health (NSDUH). We conducted logistic regression analyses to estimate associations of inhalant use with heroin use, heroin injection, and IDU, respectively, among adolescent drug users (N = 8161). Results Approximately 30.9% of adolescents had ever used at least one illicit drug. More than one-fifth (22.2%) of adolescents were past-year or recent drug users. Among past-year adolescent drug users, 1.4% had progressed to heroin use and 1.2% reported IDU. Adolescents who had used inhalants and marijuana were 2.8 and 2.9 times as likely as adolescents who had used marijuana but not inhalants to report heroin use and any IDU, respectively. Adolescents who had used inhalants or other drugs but not marijuana were unlikely to use heroin. However, inhalant users, irrespective of their marijuana use histories, had greater odds of IDU than drug users who had not used inhalants. Adolescent drug users who were females, school dropouts, whites, or delinquents had significantly increased odds of heroin use and IDU. Cigarette smoking before the age of 15 was strongly associated with heroin use, and a history of foster care placement was associated with IDU. Conclusions This national study of American adolescents identifies several subgroups of recent drug users, such as females, school dropouts, and youth who have used inhalants and marijuana, which have substantially increased odds of heroin use and IDU. Screening, prevention, and treatment interventions targeted to these groups might reduce medical and social complications of heroin use and IDU.

A national telephone survey was conducted to investigate public opinions and attitudes toward drugs issues in France ( N =2009). This article aims to study: (a) how French people perceive heroin users and (b) how this perception shapes opinions toward risk reduction policy, alcohol and tobacco. Overall, 73% of respondents considered that heroin users are a danger to their friends and relatives, 59% thought that they try to lead young people to use heroin, 22% labelled them as ‘hangers-on'. A cluster analysis led to distinguish a significant minority who endorsed a stereotyped perception of heroin users, described as ‘dope fiends'. These respondents were more likely to disagree with risk reduction policy and less prone to label alcohol and tobacco as drugs, as well as to consider that cigarette smoking and alcohol abuse cause more problems in society than illegal substance use. Factors associated with these opinions and implications for public health policy are discussed.

One hundred clients receiving methadone substitution treatment participated in an investigation of the relationship between methadone dose, time of daily self-administration and reported illicit heroin and other drug use. The study was conducted at two outpatient clinics operating from a single site at the Maudsley Hospital, London. Forty-seven per cent of clients reported using illicit heroin on one or more occasions in the week before interview. Multivariate analysis of methadone dose, time of methadone administration and duration of treatment indicated that the time of methadone administration was the most important predictor of illicit heroin use. Clients who took their methadone before 1500 h were less likely to use heroin than those who consumed methadone later in the day. This finding suggests the possibility of reducing illicit heroin use by methadone maintenance clients through the structuring of treatment programmes so that supervision of methadone consumption occurs during the early part of the day.

A reanalysis was undertaken of survey and retrospective urinalysis data on patients remaining in an abstinence-oriented, public methadone maintenance program in Sydney, Australia. A comparison of urinalysis results with those of previous reports of Australian methadone programs suggests that the clinic's disciplinary program failed to reduce detected heroin use; morphine was detected in 27% of urine specimens. Women, those with a partner in methadone maintenance, and exprisoners were significantly more likely to submit morphine positive urines. When account was taken of subjects' General Health Questionnaire scores in a second logistic regression model, the more psychologically disturbed patients were one fifth as likely to submit a morphine positive specimen as the less disturbed. This and other findings are interpreted as indicating that psychologically disturbed patients who continued to use heroin were more likely to be expelled from or otherwise leave treatment than the less psychologically disturbed who continued to use heroin.

Introduction The present study aimed to use the syringe exchange setting in order to facilitate transfer or heroin users into evidence-based substitution treatment with methadone or buprenorphinenaloxone. Out-of-treatment heroin-dependent patients were recruited from a syringe exchange program and actively referred to a research substitution treatment facility. Among 75 patients who were included and underwent baseline evaluation, 71 were successfully referred and started treatment. Segmental hair analysis was used to investigate previous drug abuse, abstinence from drugs of abuse during treatment as well as to confirm compliance to substitution treatment. Hair samples were taken at admission and then after approximately 3 months of treatment. Methods Hair samples were segmented into 5 segments (5, 5, 5, 10, 10 mm) and subjected to qualitative UHPLC-TOF screening for 30 drugs of abuse to elucidate previous drug use patterns. Hair samples were also segmented into 5 segments, washed and quantitation of mu-agonists and sedatives were performed using LC-MSMS including the substitution medications methadone and buprenorphine. Results Base line results from the UHPLC-TOF screening indicated an extensive poly-drug abuse of different opioids including heroin (74%), methadone (79%), fentanyl (16%), buprenorphine (16%) and tramadol (26%) as well as use of stimulants such as amphetamine (32%) together with sedatives (74%) of both the common benzodiazepine group and zopiclone and zolpidem. The segmental analysis showed even or decreasing concentrations of 6-acetylmorphine in the hair confirming continuous use of heroin but suggesting infrequent use or lower doses prior to inclusion. After the initiation of treatment the use of illicit opioids decreased dramatically and most subjects abstained from heroin when given methadone or buprenorphine. 50% had no positive segment during the treatment period and 15% were only positive in one or two of the distal segments which could be interpreted as remnants from dormant hair. However, the use of benzodiazepines and other sedatives (80%) was very common during treatment with alprazolam and clonazepam as the most frequent encounters. The mean methadone dose was 85 mg/d (N=12) and the mean concentrations of EDDP and methadone were 0.46 ng/mg and 8.8 ng/mg, respectively. The concentrations of methadone in hair did not correlate to the dose between subjects but there were clear relationships within patients when doses were escalated during titration. Three patients continued to use heroin and two continued their use of amphetamine. In two of these subjects the methadone concentrations from decreased to half the initial concentrations suggesting that the prescribed dose was diverted rather than taken. Buprenorphine was only detected in 1 patient and norbuprenorphine in 3 patients even though doses between 8 and 24 mg/d was given (N=7). Conclusion We conclude that segmental hair analysis was a good clinical tool to assess drug use histories prior to inclusion into substitution treatment and to prove abstinence from other drugs during treatment. The dose concentration relationship was weak but may be used within a patient to investigate dose changes or non-compliance for methadone. We believe that data from living subjects entering treatment may provide a basis for interpretation of acute heroin overdoses where abstinence have been suggested as a major factor contributing to death.

This ethnographic study describes part of the social context in which heterosexual transmission of the human immunodeficiency virus (HIV) may be taking place. Based on interviews with sex partners of intravenous (IV) drug users in an urban, African American community of the United States, the study documents the personal experience of 35 men and women to show how living with one's own and/or one's partner's heroin habit may structure one's response to public health information and one's possibility of becoming infected with HIV. As described by sex partners of intravenous drug users, people who use heroin habitually are drawn into social networks that are loosely organized according to their preferred route of drug administration, i.e. ‘shooters’ (intravenous) and ‘tooters’ (intranasal), both of which tend to exclude ‘squares’ (non-use). Social divisions such as these may slow rates of HIV transmission to those outside the drug life. But nevertheless, as sex partners explain, there are many types of social and sexual exchanges taking place among shooters, tooters and squares, including but not limited to the exchange of bodily fluids. Ethnography analyzes discursive representations of such exchanges, filling in and questioning the empty categories of epidemiological prediction. How does risky behavior actually figure in the lives of individuals who happen to fall in the category of ‘sex partner”? How is sexual behavior shaped by drug use behavior? Being sexually involved with an IV drug user for some years alters a person's relative position betwixt and between the drug subculture, on the one hand, and mainstream pursuits of family, work and church, on the other. Differences in personal need and group identity create conflicts. Couples in long-term relationships develop rules to manage these. But in which terms will they interpret and negotiate the new threat of AIDS? If the strategic aspect of discursive representations of experience is taken into account, and if discursive representations are interpreted within appropriate social and historical contexts, they can provide a rich source of material for understanding the social impact of the AIDS epidemic. Without this discursive dimension, analytic power to interpret seroprevalence data cross-culturally would be lacking. In addition, and independently of the problem of interpreting seroprevalence data, ethnographic analysis links local, culturally-specific meanings through which AIDS is interpreted to our understanding of AIDS as a global phenomena.

The increasing incidence of drug-addicted adults has resulted in a more visible group of children born of them. These children are the product of a special experience. Some have had intrauterine exposure to addictive drugs from the time of their conception. Many have had to experience withdrawal symptoms at birth. Nearly all have been exposed to their parents' use of drugs during the critical formative period of early life and have experienced some of the consequences of family deterioration and social disorder accompanying drug use. There has been a significant rise in the number of these children in recent years and many have been referred to child placement agencies for shortor long-term care away from their drug-using parents. Their need for placement has created a group with substantial social and clinical records extending over the major portion of their lives. This increase and the availability of clinical records prompted this review of such children being cared for by the Jewish Child Care Association of New York. Only known heroin addiction by the parents with dependence was considered for purposes of this review. It was recognized that most heroin addicts use many other drugs and that other kinds of chronic drug users may occasionally use heroin. Alcohol addiction, another serious problem of many parents of children in placement, was excluded from this survey. The Jewish Child Care Association of New York is a voluntary agency devoted to the care of children in need of placement. Its origins go back to the early 19th century with the care of orphans and