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Aims: The present study investigates one-year incidence of mortality from suicide and other causes among heroin users in Taiwan., Design: A prospective national register-based cohort study., Setting: All heroin users who attended the methadone maintenance treatment (MMT) programs in all treatment centers in Taiwan., Participants: The sample comprised 10,842 heroin users attending MMT. Between Jan 2006 and Dec 2007, cases were identified through the multiple-center register system and followed until Dec 2008 for date and cause of death on the Taiwan national mortality database., Measurements: Standardized mortality ratios within one year of starting MMT were calculated as a ratio of actual versus expected numbers of deaths in the general population in Taiwan. Cox regression models were fitted to estimate the effects of gender, age, education and marital status as well as heroin related behaviors., Findings: In total, 256 cases died, 67 through suicide. The mortality rate (per 100 person-years) in the first year of all-cause and suicide was 1.71 and 0.45 respectively, representing 7.5- and 18.4-fold age- and gender-standardized mortality ratio (SMR) compared to the general population. Besides, the mortality rate in the first year of overdoses, murder, HIV, somatic was 0.19, 0.02, 0.07, and 0.75 respectively, representing 68.4-, 27.7-, 76.8-, and 4.3-fold SMR increases to the general population. Older age and unemployment were independent risk factors for mortality. Females had higher standardized mortality ratio than males for suicide and all-cause mortality., Conclusions: Results showed higher risk of suicide and other-cause mortality among heroin users in MMT than general population. Suicide is an important contributor to overall excess mortality among heroin users in MMT, and especially among women. Suicide prevention and physical health monitoring are important components of MMT programs., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: This study investigates the prevalence and correlates of hepatitis C virus (HCV) infections among heroin dependent individuals who received methadone maintenance therapy in Taiwan. Also, we investigate users' awareness of HCV., Methods: Participants were 773 heroin users entering the methadone maintenance treatment (MMT) program at Tsaotun Psychiatric Center in Taiwan. The presence of HCV antibodies was detected. Multivariate logistic regression was used to identify the relationship between HCV infection and correlates., Results: The prevalence of HCV infection was 90.8%. All participants who were HIV-positive were also infected with HCV. Multivariate logistic regression analysis showed that the route of heroin administration (injection), HIV-infection, and criminal records were significantly related to HCV infection. Few (34.8%) HCV positive heroin users were aware of their infection., Conclusion: An extremely high prevalence of HCV infection but low awareness of their infection status was found among MMT patients in Taiwan. These findings highlight the importance of education regarding risky behaviors and the necessity for HCV treatment for this population in Taiwan., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The development of instruments to assess substance use that are easy to use, valid and reliable across cultures is an important task. The present study investigates the reliability and validity of the Chinese language version of the SDS (SDS([Ch])) when used to measure severity of dependence among heroin users in Taiwan (n=522). Data were collected on demographic data, heroin use behaviours, and criminal convictions. Taiwanese heroin users recorded high SDS([Ch]) scores and the results support the validity and reliability of the Chinese version of the SDS. A positive correlation was found between SDS([Ch]) scores and DSM-IV criteria for heroin dependence. SDS([Ch]) scores were positively related to heroin injection, frequency of heroin injection, spending on heroin, earlier age of onset of heroin use and more drug-related criminal convictions. The findings support the suggestion that the concept of dependence as assessed by the SDS has cross-cultural validity.

Relatively little is known about the treatment of drug dependent parents. This study of drug misusers (n=1075) investigates the involvement of parents with treatment services, childcare arrangements before and during treatment, and outcomes at 1-year follow up. Almost half the sample (46%) were parents. Women were more likely to be responsible for the care of children. Parents, and especially women, who looked after children, were less likely to receive residential treatment. Illicit drug use and psychiatric symptoms were reduced at 1 year. Outcomes did not differ by gender or parenting status, but there was an interaction effect for psychiatric symptoms: for women, looking after children during treatment was associated with less improvement in psychiatric symptoms at follow up. Such women face special difficulties in access to services and would benefit if treatment services were able to offer improved access and childcare support.

The study investigates excessive drinking and associations with other problem behaviours in 2078 school students aged 14-16 years in seven London secondary schools. Using a cross-sectional design, a self-completion questionnaire assessed lifetime and recent (past month) alcohol and drug consumption, attitudes to alcohol use education, alcohol-related problems, psychological problems, educational aspirations, truancy, and delinquent behaviour. Excessive drinking was operationally defined as 10 or more units of alcohol per drinking occasion. At least one episode of excessive drinking was reported by 32% of the sample, with 10% reporting five or more episodes. Excessive drinking was positively associated with frequency of cigarette smoking, use of cannabis, positive attitudes towards illicit drugs, low educational aspirations, higher depression scores, frequent truancy, and involvement in delinquent behaviours. Excessive drinking is a problematic behaviour in its own right but it is also a marker for other problem behaviours, including illicit drug misuse and delinquency. Understanding and responding to alcohol misuse among adolescents requires attention to psychological, social and developmental factors other than alcohol consumption alone.

This study investigates the type and extent of changes in route of drug administration among heroin users after treatment: whether injectors move to other routes of use; whether changes in route for one drug influence routes used for other drugs; and associations between changes in route of administration and other substance use outcomes. The sample comprised 641 heroin users recruited to 54 UK treatment programmes. At intake, the main routes of heroin use were injecting (61%) and "chasing the dragon" (37%). After 1 year, 81% of those using heroin took it by the same route as at intake, while 19% reported a change, with 14% switching from injecting to chasing. Changes from injecting to chasing were associated with improvements in other substance use behaviours. Changes in route represent an important aspect of drug-taking behaviours. Interventions to prevent the change to injecting should be developed and offered to noninjectors. "Reverse transitions" (from injecting to chasing) may represent a useful intermediate treatment goal for drug injectors who cannot achieve abstinence.

This cross-sectional survey investigates the frequency of adverse cocaine reactions and associated factors among regular cocaine misusers. A sample of 332 cocaine misusers from a range of treatment and nontreatment settings in São Paulo, Brazil, were interviewed using a questionnaire that includes the Severity of Dependence Scale (SDS), the General Health Questionnaire (GHQ-28), the CAGE, and an eight-item questionnaire investigating the frequency of specific adverse cocaine reactions. The most commonly described reactions were hot flushes (84%), uncontrollable shaking (76%), and feeling ill (75%). The most severe symptoms and least common were convulsions or fits (18%) and passing out (21%). Frequency of adverse reactions to cocaine was positively associated with out-of-treatment status, severity of cocaine dependence, ever having injected cocaine, using tranquilisers with cocaine, and GHQ score. Adverse reactions to cocaine are common among regular cocaine users. Some of the adverse effects, especially those on the heart and central nervous system, are potentially fatal. Preventive strategies should be developed to reduce the risk of adverse cocaine reactions. The findings are discussed in relation to the type of interventions that might be developed and lines of future research.

A reluctance of nonspecialists to work with drug and alcohol misusers have focused upon belief-based systems, including therapeutic commitment (TC) and situation-specific constraints. This paper describes the development and assessment of a theoretical model for nonspecialist drug workers, characterised as a synthesis of attitudinal and constraints explanations. A cohort of 189 nonspecialist drug workers completed self-report measures of overall TC and situational constraints scales. Predictive analysis of associations between TC, role security (RS), role requirements, and situational constraints was performed to explore direct and indirect effects. Such assessment allowed for the identification of a predictive process by which TC may be established, manipulated, and maintained. Levels of TC were found to be explained by the direct effects of self-esteem (SE), situational constraints, role support, and RS. Role support and situational constraints were also found to have indirect effects. Experience with working with drug users and education on drug-related issues were found to have predominantly indirect effects on TC via situational constraints and RS. Findings show the synthesised model to be partially supported. Implications for the development of a process-driven theoretical understanding of TC and situational constraints are discussed, and applied recommendations for training intervention are presented.

This paper investigates changes in injecting and shared use of needles and syringes among 732 drug misusers recruited to residential and community treatment programmes as part of the National Treatment Outcome Research Study (NTORS). Specifically, it investigates whether reductions in these behaviours were due to a move away from injecting among drug users or whether they could be accounted for by drug users becoming abstinent. Injecting and sharing of injecting equipment were substantially reduced after treatment. Outcomes were due to reduced sharing among injectors, reduced injecting among continuing users and to users becoming abstinent. Clients from residential programmes were more likely to be abstinent at follow-up: methadone clients were more likely to be injecting but not sharing. Abstinence and intermediate risk reduction outcomes were achieved by many drug injectors from both treatment settings. Both outcomes confer benefits, though the benefits of abstinence are greater. Users who were injectors at intake but who had stopped injecting at follow-up consistently achieved superior outcomes across a range of problem behaviours.

This study investigates the links between social networks of drug users and criminal activity. Opiate misusers (n=128) receiving in-patient treatment were interviewed about substance use, social networks, and crime in the month before treatment. Almost 60% of participants reported an average of more than 70 crimes each. Less than one-fifth of the subjects spent no time with other users, while just over half spent either "quite a lot" or "a lot" of time with drug users. Time with users increased the risk of crime. Spending no time with users provided a protective effect. Time with criminally involved drug users was associated with greater levels of crime. Social networks represent an important marker for integration in criminal networks in treatment-seeking drug users and a long-term barrier to rehabilitation.

In a study of patients attending a methadone maintenance clinic in South London, 66 of 114 (58%) had previously attempted to detoxify themselves from opiates without medical assistance. The total number of self-detoxification attempts was 237, an average of 3.6 attempts per individual. Forty subjects (61%) reported attempting self-detoxification with the help of drugs or alcohol. The drugs most commonly used were diazepam, alcohol, and cannabis. The most commonly reported reasons for attempting self-detoxification were "fed-up with the lifestyle" (61%) and "for their family" (12%). The reasons given for why patients had decided to detoxify themselves rather than access treatment services included 23% who reported that "they could cope on their own and that they didn't need any help." The short-term success rate (abstinent for at least 24 hours) was moderate, at 41% (97/237). Patients who had been unsuccessful were asked why their last self-detoxification attempt had not resulted in abstinence, with 27% reporting that they were "tempted to use again" and 23% reported that they "didn't know why they started using again." The prevalence of both attempts and success suggests that, for some opiate users, self-detoxification may be a pathway to abstinence.

The National Treatment Outcome Research Study (NTORS) is a longitudinal, multisite, prospective cohort study that assesses changes in illicit drug use and other problems after treatment in national (UK) drug misuse treatment programmes. Clients were recruited from 54 residential and community-based drug treatment programmes throughout England. Four modalities were studied: inpatient drug dependence units, residential/rehabilitation programmes, methadone maintenance, and methadone reduction programmes. Data on substance use behaviours and physical and psychological health were collected by structured face-to-face interviews at intake, 1- and 2-year follow-up. Data are presented for 549 clients. A majority of clients achieved widespread improvements across a range of outcome measures after treatment in existing treatment services. For most outcomes, reductions in problem behaviours at the group level occurred within the first year and were maintained at 2 years. Considerable stability of outcomes at the individual level was also found. Abstinence from illicit drugs was substantially increased among clients from both residential and community programmes, and there were also substantial reductions in frequency of use of heroin, nonprescribed methadone, benzodiazepines, and crack cocaine. Injecting and shared use of injecting equipment was also reduced. Heavy drinking was common at intake and was not reduced at follow-up. Psychological and physical health problems were reduced on both groups at follow-up. These changes represent important clinical benefits to the individual clients, to their families, and to society.

There are substantial gaps in knowledge about treatment outcomes for stimulant misuse. This paper investigates patterns of stimulant use and outcomes of stimulant misusers one year after starting treatment at 54 agencies within United Kingdom national services. In a prospective, longitudinal cohort study of 1,075 drug misusers, 637 were current users of stimulant drugs at intake to treatment. Most of the clients were multiple drug users. Stimulants were the main problem drug for 13% of the sample. The two most frequently used drugs were crack cocaine and amphetamine sulphate. The most frequently reported pattern of stimulant use was among heroin dependent clients who also used stimulants. The clients for whom stimulants were the main problem drug were most likely to approach residential rehabilitation programs for treatment. Overall, the stimulant users showed satisfactory outcomes with marked reductions in substance use and other problem behaviors at follow-up. Many clients with stimulant misuse problems were able to achieve substantial improvements after treatment within existing services.

Route of administration has important implications for the understanding of drug addiction and related-problems. This cross-sectional study investigates patterns of consumption and cocaine-related problems among snorting and crack cocaine users in São Paulo and outlines changes in route of cocaine administration in Brazil between 1980-1997. Crack cocaine users had more social and health problems and higher involvement in crime than intranasal users. These problems, compounded by the larger doses being used and their greater involvement in prostitution, place crack cocaine users at higher risk from HIV infection and other sexually transmitted diseases as well as other physical risks.

This paper investigates the impact of a training course for Employment Service staff which was designed to provide basic level training on the identification and appropriate management of clients with drug and alcohol problems. The 2-day course was specially designed to meet the needs of staff working with unemployed people with substance abuse problems. The primary aims of the course were to help employment staff to be able to identify drug and alcohol problems, to assess their severity, and where necessary, to refer clients on to more specialized agencies. One hundred and forty-five people attended the training course and a random sample of 60 were followed-up 6 months after the course. Results showed substantial improvements in the confidence and ability of staff to deal with clients presenting with drug and alcohol problems. There was also a clear improvement in the willingness of staff to intervene with such clients.

Given the high relapse rate of opiate addicts following detoxification, it is pertinent to identify whether any subjective variables mediate outcome, since these may then be targets of treatment. The present study assessed personality, cue-elicited craving, outcome expectancies for drug use, and self-efficacy for resisting drug use, in 43 opiate addicts receiving inpatient detoxification in either a specialist drug-dependence unit or a behavioral/general psychiatric ward, within the context of a randomised, controlled-treatment trial. Subjects were followed-up at between 1 and 3 months and again at 6 months after discharge. Frequency of drug use was not predicted by any of the subjective variables at the first follow-up; but at 6 months, subjects with lower self-efficacy and higher positive outcome expectancies were found to be using less often. Latency to first lapse was greater in subjects with higher anxiety and neuroticism scores. Precipitants to the first lapse were identified, but none of the predicted relationships between subjective variables and circumstances of lapse emerged. It is suggested that greater awareness of personal vulnerability may promote effective coping strategies.

A linear methadone detoxification procedure is compared with an inverse exponential reduction curve in a double-blind study. The inverse exponential curve resulted in withdrawal symptomatology which was significantly greater during the acute phase of the opiate withdrawal curve and was not significantly different during the recovery phase. There was no difference between groups in the time course of the withdrawal syndrome, in peak symptom severity, nor in patient compliance. Separate analyses for high-dose and for low-dose addicts show variation in the suitability of the two curves according to dose. The implications for future research and treatment of the opiate withdrawal syndrome are discussed.

In previous studies a 32-item Opiate Withdrawal Scale was found to provide a reliable and valid means of measuring the signs and symptoms of withdrawal among heroin (and other opiate) addicts. This paper describes the processes whereby a shorter 10-item version of the same scale was developed. The Short Opiate Withdrawal Scale (SOWS) is simple to understand and easy to administer, and it avoids the redundancy of items contained in the original scale. It is suggested that the SOWS provide a useful instrument which can be used both in research and clinical practice with opiate addicts.

The attitudes, beliefs and expectations of the addict have received surprisingly little research attention. The present study looks at the relationship between the addict's perception of their own drug taking and their behaviour in treatment. The subjects who took part in the study were receiving treatment at a London drug dependence unit: 60 were inpatients, 40 were outpatients. All completed an attitude questionnaire and a personality inventory, the EPQ). Several attitudinal differences were found between inpatient and outpatient groups, the outpatients being more generally resistant to the prospect of giving up drugs. Among the inpatients, those subjects who saw their addiction as a sort of sickness were least likely to remain in treatment. The attitude items related more clearly to the addict's behaviour in treatment than did the personality measures. The implications of these findings for the treatment of drug addicts are discussed.

Methadone detoxification procedures are widely accepted as a satisfactory way of withdrawing opiate addicts from drugs. There have, however, been comparatively few empirical studies which have examined the development and course of withdrawal symptoms in opiate addicts in response to such detoxification procedures. This study investigates the opiate withdrawal syndrome in a group of 116 opiate addicts during and subsequent to a gradual oral methadone detoxification programme. Withdrawal symptoms peak at the end of the methadone schedule and decline steadily thereafter. Not until 40 days after the beginning of the withdrawal regime have symptom levels returned to normal. It is suggested that this protracted withdrawal response is not entirely satisfactory and alternative clinical and research options are proposed. The results fail to support the accepted view that dose is a major determinant of withdrawal severity. Low dose users did not experience less severe withdrawal symptoms than high dose users. This finding together with those of a previous study suggest that this issue also warrants further research attention.