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Background: We aimed to assess the effect of ageing and time since first heroin/cocaine use on cause-specific mortality risk and age disparities in excess mortality among heroin (HUs) and cocaine users (CUs) in Spain.Methods: A cohort of 15,305 HUs and 11,905 CUs aged 15-49 starting drug treatment during 1997-2007 in Madrid and Barcelona was followed until December 2008. Effects of ageing and time since first heroin/cocaine use were estimated using a competing risk Cox model and the relative and absolute excess mortality compared to the general population through directly age-sex standardized rate ratios (SRRs) and differences (SRDs), respectively.Results: Mortality risk from natural causes increased with time since first heroin use, whereas that from overdose declined after having peaked in the first quinquennium. Significant effects of time since first cocaine use were not identified, although fatal overdose risk seemed higher in CUs after five years. Mortality risk from natural causes (HUs and CUs), injuries (HUs), and overdoses (CUs) increased with age, the latter without reaching statistical significance. Crude mortality rates from overdoses and injuries remained very high at age 40-59 among both HUs (595 and 217 deaths/100,000 person-years, respectively) and CUs (191 and 88 deaths/100,000 person-years). SRDs from all and natural causes were much higher at age 40-59 than 15-29 in both HUs (2134 vs. 834 deaths/100,000 person-years) and CUs (927 vs. 221 deaths/100,000 person-years), while the opposite occurred with SRRs.Conclusion: The high mortality risk among HUs and CUs at all ages from both external and natural causes, and increased SRDs with ageing, suggest that high-level healthcare and harm reduction services should be established early and maintained throughout the lifetime of these populations. [ABSTRACT FROM AUTHOR]

Objective: To assess gender and age differences in hazardous drinking and to analyse and compare the factors associated with it in men versus women, and in 50 to 64-year-old versus ≥65-year-old people in Europe.Methods: Cross-sectional study with data from 65,955 people aged ≥50 years from 18 countries (SHARE project, 2011-2013). The outcome variable, hazardous drinking, was calculated using an adaptation of the AUDIT-C test. Several individual (sociodemographic, life-style and health factors) and contextual variables (country socioeconomic indicators and alcohol policies) were analysed. The prevalence of hazardous drinking was estimated by each exposure variable. To estimate associations, multilevel Poisson regression models with robust variance were fit, yielding prevalence ratios and their 95% confidence intervals (95%CI).Results: Overall, the prevalence of hazardous drinking was 21.5% (95%CI = 21.1-22.0), with substantial differences between countries. The proportion of hazardous drinking was higher in men than in women [26.3%(95%CI = 25.6-27.1); 17.5%(95%CI = 17.0-18.0), respectively], as well as in middle-aged people than in older people [23.6%(95%CI = 23.0-24.3); 19.2%(95%CI = 18.6-19.8), respectively]. At the individual level, associations were found for migrant background, marital status, educational level, tobacco smoking, depression and self-perceived health. At the contextual level, hazardous drinking was associated with gender inequalities in society (only in women) and alcohol advertising regulations (both genders).Conclusions: One in five people aged ≥50 years in the countries studied is a hazardous drinker, with large differences by countries, gender and age group. Interventions and policies aimed at preventing or reducing alcohol use in this population should account for country, gender and age differences, as well as individual characteristics. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Previous analyses of excess mortality in drug users compared with the general population have almost always been based on mortality ratios, reporting much higher figures in women than men. This study tests the hypothesis that being a heroin or cocaine user adds more death risk in women than men in Spain.Methods: A retrospective cohort of 15,305 heroin users (HUs) and 11,905 cocaine users (CUs) aged 15-49 starting drug treatment in 1997-2007 was recruited in Spain and followed until December 2008 to determine vital status and cause of death. Excess mortality in men and women compared to the general population was assessed with directly age-standardized rate ratios (SRRs) and differences (SRDs).Results: SRR was significantly higher in women than men for all causes (14.7 vs. 9.4), natural causes (8.7 vs. 6.2), overdose (331.6 vs. 163.9) and other external causes (46.9 vs. 11.8) among HUs; and for overdose (170.8 vs. 40.5) and other external causes (21.0 vs. 4.7) among CUs. However, the opposite happened with SRD for all causes (1294 vs. 1845 deaths/100,000 person-years), natural causes (675 vs. 1016 deaths/100,000 person-years) and overdose (331 vs. 619 deaths/100,000 person-years) among HUs, while no significant SRD gender disparities were observed among CUs.Conclusion: Compared with the general population, being a heroin user adds greater absolute risk in men than women, but this does not happen with cocaine users. Similar results would likely have been found in most published cohort studies if this indicator had been used; the exclusive use of relative indices of disparity as in previous meta-analysis can be extremely misleading. [ABSTRACT FROM AUTHOR]

Introduction and Aims. Although, in the laboratory, most acute adverse effects of cocaine are dose-dependent and alcohol potentiates some of these effects, there are few observational studies, and scarce awareness that the risk of acute cocaine intoxication (ACI) can increase as the amounts of cocaine and alcohol consumed increase. Our objectives were to assess if the risk of ACI increases with the level cocaine use, both in chronic and binge use; and also to determine whether it increases when a cocaine binge is combined with binge drinking or with regular excessive drinking. Design and Methods. Hypotheses were evaluated using logistic regression and case-crossover analyses in a sample of 720 young regular cocaine users who did not regularly use heroin, recruited at drug scenes in 2004-2006. All data on ACI, predictor and confounding variables were obtained through a computer-assisted personal interview. Results. The annual prevalence of ACI was 21%. In the last year 10.3% of the participants reported cocaine binges (≥ 0.5 g in 4 h). ACI risk increased considerably in the 4 h following a cocaine binge (odds ratio = 34.6; 95% confidence interval 11.5-170.8). Also, it increased with increases in the average level of cocaine used over a long period and when users regularly drank excessively. Finally, the results suggest that the high risk of ACI associated with cocaine binge may increase even more when combined with binge drinking. Discussion and Conclusions. Awareness of the dose-dependent effect of cocaine on ACI risk, as well as the possible synergistic effect of alcohol, ought to be incorporated into preventive and care strategies.[Santos S, Brugal MT, Barrio G, Castellano Y, Domingo-Salvany A, Espelt A, Bravo MJ, de la Fuente L, the ITINERE Project Group. Assessing the effect of patterns of cocaine and alcohol use on the risk of adverse acute cocaine intoxication. Drug Alcohol Rev 2012;31:439-446] [ABSTRACT FROM AUTHOR]

Background: Health Related Quality of Life (HRQL) of opiate users has been studied in treatment settings, where assistance for drug use was sought. In this study we ascertain factors related to HRQL of young opiate users recruited outside treatment facilities, considering both genders separately. Methods: Current opiate users (18-30 y) were recruited in outdoor settings in three Spanish cities (Barcelona, Madrid, Sevilla). Standardised laptop interviews included socio-demographic data, drug use patterns, health related issues, the Severity of Dependence Scale (SDS) and the Nottingham Health Profile (NHP). Results: A total of 991 subjects (73% males), mean age = 25.7 years were interviewed. The mean global NHP score differed by gender (women: 41.2 (sd:23.8); men:34.1(sd:23.6);p < 0.05). Multivariate analysis was implemented separately by gender, variables independently related with global NHP score, both for males and females, were heroin and cocaine SDS scores. For women, only other drug related variables (alcohol intake and length of cocaine use) were independently associated with their HRQL. HIV+ males who suffered an opiate overdose or had psychiatric care in the last 12 months perceived their health as poorer, while those who had ever been in methadone treatment in the last 12 months perceived it as better. The model with both genders showed all factors for males plus quantity of alcohol and an interaction between gender and HIV status. Conclusions: Heroin users were found to be at a considerable risk of impaired HRQL, even in these young ages. A score approaching severity of dependence was the factor with the strongest relation with it. [ABSTRACT FROM AUTHOR]

Aim: To evaluate differences between young cocaine users and heroin users (HUs) regarding the prevalence of sexual and injection risk behavior, and HIV, HCV and HBV infection. Methods: Two community cohorts were recruited in Madrid, Barcelona and Seville; 720 cocaine users, of whom 586 had never used heroin (CUs), and 991 HUs were interviewed. Dried blood spot samples were tested. Results: CUs were less marginalized socially than HUs. Only 0.9% had ever injected versus 64.3%; none had ever injected with borrowed syringes versus 25%; 2.2% had an injecting steady partner in the last 12 months versus 24.9%; 4.8% had ever traded sex versus 16.0%. However, 31.0 versus 12.7% had unprotected sex with more than two occasional partners in the last 12 months; 45.0 versus 21.9% had sniffed through tubes used by more than 10 persons. Only 32.3% knew their HIV status versus 80.3%; 0.4 versus 18.1% were HIV positive; 0.9 versus 51.9% were HCV positive, and 1.5 versus 17.0% were HBV positive. Conclusions: The intense cocaine epidemic has hitherto had little impact on either HIV, HBV or HCV in Spain. However, surveillance should be intensified given the high percentage of CUs having unprotected sex with occasional partners. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

ABSTRACT Aims To examine risk factors associated with non-fatal heroin overdose, particularly frequency and route of heroin administration. Design Data from cross-sectional surveys were analysed as a case–control and as a case cross-over design. Setting and participants 2556 subjects treated for heroin dependence in 164 outpatient facilities in Spain. Measurements Prevalence of overdose involving emergency care in the 12 months before treatment admission. Case control design Odds ratio (OR) adjusted by logistic regression. Case–crossover design Estimated relative risk (RR) of transient risk of injecting heroin. Findings The prevalence of overdose was 10%. In the case control analysis the cumulative risk of overdose increased as the frequency of heroin use decreased. However, among daily heroin users this risk increased as the frequency of heroin injection rose, with an OR of 6.0 (95% CI: 3.9–9.6) for daily injectors versus non-injectors. Sniffers had a higher risk than smokers among non-daily users, but not among daily users. Other factors associated with increased risk of overdose were: tranquillizers, alcohol or cocaine use, living in certain regions and being long-term HIV+ 0. In the case–crossover analysis, the RR for injecting heroin versus using other routes immediately before overdose was 15.9 (95%CI: 9.5–26.6), and was much higher for non-daily heroin users than for daily users. Conclusions These findings suggest that the rapid entry of a large quantity of heroin into the blood (as occurs when injecting) involves a high risk of overdose, especially when the heroin tolerance level is low (as occurs in sporadic users). [ABSTRACT FROM AUTHOR]

Objective: To analyse deprivation and AIDS among three AIDS transmission groups (men who have sex with men - MSM, heterosexuals, and intravenous drug users - IDUs) in Barcelona, Spain, during the period 1990-95. Methods: This is an ecological study, the unit of analysis being the neighbourhoods. Included were AIDS cases residents in Barcelona. The association among AIDS rate and deprivation was studied using Spearman correlation coefficients and Poisson regression. Results: For MSM, inner city neighbourhood residence meant a greater risk of AIDS; but lower educational level was inversely related with AIDS rates. For heterosexuals, variables related with AIDS rates were younger age, inner city areas and social unrest for women, and extreme poverty for men. Among UDIs variables related with AIDS were unemployment and social unrest for both sexes. Conclusion: The association between AIDS rates and deprivation differs across transmission groups in a southern European city. [ABSTRACT FROM AUTHOR]

Heroin users in opioid agonist treatment (OAT) show markedly reduced heroin consumption, less crime and a lower mortality rate. However, the extent of long-term OAT participation over subsequent treatment episodes remains unclear. We analysed the annual proportion of patients in treatment (at least 1 day) since the start of first OAT in 4 European regions: Barcelona (BA) 1996-2012: 8,602 patients; Czech -Republic (CZ) 2000-2014: 4,377 patients; Netherlands (NL) 1994-2014: 33,235 patients, Zurich (ZU) 1992-2015: 11,795. We estimated the long-term decline of treatment need due to mortality or abstinence and also a "nuisance" short-term decline until the equilibrium level of cycling in and out of OAT is reached to obtain the adjusted treatment participation value. The adjusted treatment participation was around 50% (BA: 47.4-51.4%; CZ: 49.8-53.9%; NL: 52.3-54.0%; ZU: 46.4-49.3%), and the annual decline of treatment need was close to 4%. Non-nationals (NL patients with a migrant background) showed substantial lower adjusted treatment participation (rate ratio BA: 0.059-0.343; NL: 0.710-0.751; ZU: 0.681-0.797; CZ: n.a.). Our method may provide a policy-relevant indicator of long-term provision, quality and access to OAT following first treatment. [ABSTRACT FROM AUTHOR]

Background: The aim was to compare alcohol drinking patterns in economically active people aged 50-64 years before the last economic crisis (2006) and during the crisis (2013). Methods: Cross-sectional study with data from 25 479 economically active people aged 50-64 years resident in 11 European countries who participated in wave 2 or wave 5 of the SHARE project (2006 and 2013). The outcome variables were hazardous drinking, abstention in previous 3 months and the weekly average number of drinks per drinker. The prevalence ratios of hazardous drinking and abstention, comparing the prevalence in 2013 vs. 2006, were estimated with Poisson regression models with robust variance, and the changes in the number of drinks per week with Poisson regression models. Results: The prevalence of hazardous drinking decreased among both men (PR = 0.75; 95%CI = 0.63-0.92) and women (PR = 0.91; 95%CI = 0.72-1.15), although the latter decrease was smaller and not statistically significant. The proportion of abstainers increased among both men (PR = 1.11; 95%CI = 0.99-1.29) and women (PR = 1.18; 95%CI = 1.07-1.30), although the former increase was smaller and not statistically significant. The weekly average number of drinks per drinker decreased in men and women. The decreases in consumption were larger in Italy and Spain. Conclusion: From 2006 to 2013, the amount of alcohol consumed by late working age drinkers decreased in Europe, with more pronounced declines in the countries hardest hit by the economic crisis. [ABSTRACT FROM AUTHOR]

Background Cohort studies on hepatitis C virus (HCV) among drug injectors are scarcer than studies on HIV. Combined harm reduction interventions (HRIs) can prevent HCV infection. Spain has a medium-high coverage of HRIs. Methods 513 young heroin users who injected drugs in the past 12 months (recent injectors) were streetrecruited in 2001-2003 and followed until 2006 in three Spanish cities; 137 were anti-HCV seronegative, 77 of whom had ≥1 follow-up visit. Dried blood spots were tested for anti-HCV. HCV incidence and predictors of infection were estimated using Poisson models. Results At baseline, 73% were anti-HCV positive. Overall incidence (n=77) of HCV seroconversion was 39.8/100 person-years ( py) (95% CI 28.7 to 53.8). Excluding non-injectors during follow-up from the analysis (n=57), HCV incidence was 52.9/100 py (95% CI 37.4 to 72.5). Injecting at least weekly (incidence rate ratio (IRR)=5.2 (95% CI 2.5 to 11.1)) and having ≥2 sexual partners (IRR=2.2 (95% CI 1.1 to 4.7)) were independent predictors of HCV seroconversion; druginjection history <2 years was marginally associated (IRR=2.4 (95% CI 0.9 to 4.7)). HCV incidence may have been underestimated due to differential attrition. Conclusions Despite fairly high HRI coverage among Spanish drug injectors, a distressingly high incidence of HCV in a context of high HCV prevalence was found among young heroin injectors. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims To show the utility of analysing time trends of need and coverage of needle-exchange programmes (NEPs) and opioid substitution treatment (OST) to assess harm reduction policies targeting drug injectors or heroin users. Design Multiple methods applied to secondary data. Setting Spain. Participants Thousands of drug injectors or heroin users included in administrative registers, surveys and published studies during 1987-2010. Measurements Coverage for the general population was calculated as the ratio between interventions provided (obtained directly from the sources) and interventions needed (estimated by multiple methods), and as the difference between the two. Timeliness was estimated by time elapsed between year of highest need and year in which coverage reached a reference level. Findings In 2010 NEPs provided 138 syringes per drug injector [95% confidence interval (CI) 100-223], covering 25.7% (95% CI 18.3-43.3) of their need. OST coverage was 60.3% (95% CI 44.3-94.2). Syringe and OST provision increased between 1991 and 2001 and then declined. Syringe and OST coverage also increased substantially during this period and then stabilized, due mainly to decreases in drug injection or heroin use. Medium-level coverage for both syringes and OST was not achieved until 2000, 8 years after the peak in need (1992). Conclusions In Spain, the expansion of harm reduction interventions was greatly delayed, although the concomitant decrease in heroin and injecting drug use led to reasonable coverage after 2000. A longitudinal measurement of need and coverage provides insight into the timeliness and potential population impact of interventions, enabling better assessment of their adequacy. [ABSTRACT FROM AUTHOR]

Background: The objectives of the study were to estimate the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae and sexual risk practices, and to identify factors associated with infection by C. trachomatis/N. gonorrhoeae. Methods: Injecting drug users were interviewed at harm reduction centers and biological samples were collected to estimate the prevalence of C. trachomatis and N. gonorrhoeae. Results: The prevalence of C. trachomatis was 2.3%, and this was higher among immigrants (3.6%); the prevalence of N. gonorrhoeae was 0.7% (no differences between Spanish-born and immigrants). Respondents aged ≤25 years had a higher risk of sexually transmitted infections (STIs) (OR 3.39), as did women (OR 3.08). Also associated with having an STI were not having registered employment (OR 4.70), injecting drugs daily (OR 4.21), and having unprotected sex with a stable partner (OR 3.37). Conclusion: Although the prevalence of STIs observed is low, scant condom use makes it necessary for prevention programs to include messages related to sexual risk practices, especially among young people and women. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: A prospective study was carried out in Barcelona, Spain, to determine the incidence of mental disorders including substance use disorders (SUDs). From a cohort of 288 young adult (aged 18–30 years) cocaine and/or heroin users recruited in nonclinical settings, 158 were reinterviewed 18 months later using the Psychiatric Research Interview for Substance and Mental Disorders. During follow-up, 18% of subjects presented a new SUD, and nearly 11% a new non-SUD Axis I disorder. Incidence was highest for mood disorders (8%). Being a woman, a lower frequency of substance use at baseline, a younger age of heroin first use, and a worsening of SUD were associated with a higher likelihood of presenting a new Axis I disorder. Having received drug treatment ever (at baseline) or during follow-up was not associated with progress of SUD. An overall improvement in the psychiatric status of these young substance users was observed. [Copyright &y& Elsevier]

Abstract: Objectives: To assess the validity of self-reported hepatitis B virus vaccination status in young heroin users. Study design: Cross-sectional study among 949 street-recruited young injection heroin users (IHUs) and non-injection heroin users (NIHUs) in Madrid, Barcelona and Seville. Face-to-face interviews and dried blood spot tested for anti-HBc and anti-HBs. The validity of self-reported vaccination status was assessed comparing with the serological status. The percentage of agreement with the kappa (κ) statistic and the positive predictive value were calculated. Results: The percentage of agreement between self-reported and serologic vaccination status was 51.9% overall, with little difference by city (53.1% in Barcelona, 49.0% in Madrid and 51.5% in Seville) or between IHUs (51.3%) and NIHUs (53.0%). All the κ scores were lower than 0.1. The positive predictive value of self-reports was less than 25% in all categories analysed, except in the city of Barcelona (37%). Among those who indicated that they had been vaccinated, 31% were actually susceptible. Conclusions: In areas with a high prevalence of infection and rising coverage of vaccination the policy “don’t ask, take a blood sample, give a dose of vaccine and try to schedule another visit” should be recommended in clinical practice. [Copyright &y& Elsevier]

Study objective. To provide information on MMP patient's characteristics, particularly those related with Health Related Quality of Life (HRQoL) and gender. DESIGN: Cross-sectional study. Data were collected on socio-demographic, toxicological variables, HIV risk behaviors, and HRQoL through the Nottingham Health Profile (NHP). Patients and setting. Over a 30-month period (1996–1999) Barcelona's Municipal Drug Care Centres recruited 586 patients. Main results. Mean age of patients was 31 years, 70% were males and 25% were HIV-infected. Rates of unemployment, criminal records and low educational level were high. Most poly-drug users used cocaine. NHP mean score was related with poly-drug use, educational level and HIV status. Consistent condom use was related with HIV status. Females’ route of administration was less likely to be injection, even though they were more frequently HIV-positive and manifested contemporary poorer general health. CONCLUSIONS: Patients QoL was poor. Nowadays harm reduction health strategies would need to face cocaine use, and sexual risk behaviors mainly among females and sexual partners. [ABSTRACT FROM AUTHOR]

The Spanish Information System on Drug Abuse (SEIT) was established in 1987 by the National Plan on Drugs, based on three indirect indicators that reflect the health effects of drug use: treatment, emergency and mortality. The treatment indicator is the core of the system, the one with the best consolidation, higher coverage and greater quantity of reliable data accumulated. The configuration of the system has a regional basis (Autonomous Communities), which strongly influences its potentialities, operation, results, strengths and limitations. Only outpatient treatment admissions, reported by ambulatory treatment centres and prison units, are recorded. Double counting is eliminated at the regional level. Over a decade of existence, the SEIT, and mainly its treatment indicator, has proven to be an excellent tool for public health action, planning and decision making, as well as for research and co-operation between regions.Copyright © 1999 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aims To estimate the prevalence of hazardous drinking in individuals aged 50 and older who had or had had cancer in 17 European countries and Israel and to analyze the factors associated with their consumption. Methods Cross-sectional study based on data from 2011 to 2013 SHARE surveys. A total of 69,509 individuals aged 50 or more from 17 European countries and Israel participated in the study. Prevalence of hazardous drinking in people with cancer was estimated (adapting the SHARE questionnaire to the AUDIT-C). To ascertain whether type of cancer or time since diagnosis were associated with hazardous drinking, Poisson regression models with robust variance were estimated, obtaining prevalence ratios (PR). Results Overall, 5.4% of participants reported having been diagnosed with cancer. Prevalence of hazardous drinking in people with cancer was 18% in women and 23% in men. After adjusting for various socioeconomic and health variables, no significant differences were observed between hazardous drinking and type of cancer [PR = 0.99 (95% confidence interval (95% CI) = 0.83–1.17) in people with alcohol-related cancers compared to non-alcohol related cancers] and time since diagnosis [PR = 1.01 (95% CI = 0.82–1.25) in people with a cancer diagnosed >5 years ago compared to those diagnosed ≤5 years ago]. Significant differences were found between hazardous drinking and smoking status and self-perceived health. Conclusion In total, 20% of people diagnosed with cancer were hazardous drinkers, despite the known relationship between alcohol use and a worse prognosis of the disease and an increased likelihood of recurrence. Short Summary Overall, 20% of people diagnosed with cancer were hazardous drinkers. There were no significant differences in the prevalence of hazardous drinking depending on the type of cancer (alcohol-related versus non-alcohol related cancers). Highest prevalence of hazardous drinking in people with cancer is found in smokers and people with good self-perceived health. [ABSTRACT FROM AUTHOR]

Objective: To provide information on persons treated for alcohol use disorders (AUD) over 20 years in a large city in a Southern European country and its trends, adding knowledge on the frequency of treatment from a population perspective.Methods: This is a study of the number of annual admissions to ambulatory addiction treatment centers funded by the public sector in Barcelona (Catalonia, Spain) for the years 1996-2015. Descriptive analyses of AUD admissions were conducted, comparing changes in the number of patients entering treatment by different independent variables across periods. For city residents, sex and age-specific population annual treatment initiation rates were estimated.Results: The number of ambulatory admissions to AUD treatment increased over the study period. There were about 2100 treatment admissions per year in 2011-2015, of which one fourth were women. About half of these patients had never been treated before for any substance use disorder. Annual rates of treatment initiation among city residents were 208 and 68 per 100,000 people aged 15 and older for men and women respectively, almost the double among 45-54 years old citizens. Rates of total AUD treatment admission increased moderately, but declined among younger adult men.Conclusions: These figures provide a basic population-based estimation for formal AUD treatment use in a Southern European urban setting with services available free of charge. The development of ambulatory publicly funded addiction centers may have improved access to treatment for people with AUD. age-related changes in treatment admissions may either be related to trends in the population pattern of drinking or to changes in the city demographics. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To study mortality in a cohort of cocaine use disorder patients, and compare results in those with concurrent alcohol or opiates disorder. Design, Setting and Participants: A cohort of 10 539 cocaine use disorder individuals entering drug treatment in public out‐patient centres in the city of Barcelona was followed from 1997 to 2011. Participants were divided at baseline into three groups: those with only cocaine use disorder (CUD), those with cocaine and alcohol use disorder but not opioid (CAUD) and those with cocaine and opioid use disorder (COUD). Mortality was assessed through the Spanish National Mortality Register. Measurements: Crude mortality rates (CMR), standardized mortality ratios (SMR) and rate ratios (RR) were calculated for each group. A multivariable Cox regression model was fitted to obtain adjusted mortality hazard ratios (aHR) of CAUD and COUD with respect to CUD. Specific mortality causes were also examined. Findings: The total of 716 deaths registered resulted in a CMR = 6.0/1000 person‐years (PY); 95% confidence interval (CI) = 5.1–7.0 for CUD, CMR = 5.8/1000 PY (95% CI = 4.9–6.7) for CAUD and CMR = 20.7/1000 PY (95% CI = 18.8–22.8) for COUD, with no significant differences among sexes. Compared with the general population, mortality was four times higher (SMR = 4.1, 95% CI = 3.5–4.8) among CUD, more than three times among CAUD (SMR = 3.4, 95% CI = 2.9–3.9) and more than 10 times among COUD (SMR = 11.6, 95% CI = 10.5–12.8), being always higher in women. External injuries, led by overdose, accumulated the biggest percentage of deaths among the three groups, but infectious diseases showed the highest excess mortality. Some differences regarding causes of death were observed between the three groups. Conclusions: Mortality risk and excess mortality are significantly greater among those with cocaine and opiates use disorder than among people with only cocaine use disorder or cocaine and alcohol use disorder. [ABSTRACT FROM AUTHOR]

Aims: To estimate the prevalence of hazardous drinking in individuals aged 50 and older who had or had had cancer in 17 European countries and Israel and to analyze the factors associated with their consumption. Methods: Cross-sectional study based on data from 2011 to 2013 SHARE surveys. A total of 69,509 individuals aged 50 or more from 17 European countries and Israel participated in the study. Prevalence of hazardous drinking in people with cancer was estimated (adapting the SHARE questionnaire to the AUDIT-C). To ascertain whether type of cancer or time since diagnosis were associated with hazardous drinking, Poisson regression models with robust variance were estimated, obtaining prevalence ratios (PR). Results: Overall, 5.4% of participants reported having been diagnosed with cancer. Prevalence of hazardous drinking in people with cancer was 18% in women and 23% in men. After adjusting for various socioeconomic and health variables, no significant differences were observed between hazardous drinking and type of cancer [PR = 0.99 (95% confidence interval (95% CI) = 0.83-1.17) in people with alcohol-related cancers compared to non-alcohol related cancers] and time since diagnosis [PR = 1.01 (95% CI = 0.82-1.25) in people with a cancer diagnosed >5 years ago compared to those diagnosed ≤5 years ago]. Significant differences were found between hazardous drinking and smoking status and self-perceived health. Conclusion: In total, 20% of people diagnosed with cancer were hazardous drinkers, despite the known relationship between alcohol use and a worse prognosis of the disease and an increased likelihood of recurrence. Short Summary: Overall, 20% of people diagnosed with cancer were hazardous drinkers. There were no significant differences in the prevalence of hazardous drinking depending on the type of cancer (alcohol-related versus non-alcohol related cancers). Highest prevalence of hazardous drinking in people with cancer is found in smokers and people with good self-perceived health. [ABSTRACT FROM AUTHOR]

The objectives were to analyze the knowledge about overdose prevention, the use of naloxone, and the number of fatal overdoses after the implementation of Systematic Training in Overdose Prevention (STOOP) program. We conducted a quasi-experimental study, and held face-to-face interviews before (n = 725) and after (n = 722) implementation of systematic training in two different samples of people who injected opioids attending harm reduction centers. We asked participants to list the main causes of overdose and the main actions that should be taken when witnessing an overdose. We created two dependent variables, the number of (a) correct and (b) incorrect answers. The main independent variable was Study Group: Intervention Group (IG), Comparison Group (CG), Pre-Intervention Group With Sporadic Training in Overdose Prevention (PREIGS), or Pre-Intervention Group Without Training in Overdose Prevention (PREIGW). The relationship between the dependent and independent variables was assessed using a multivariate Poisson regression analysis. Finally, we conducted an interrupted time series analysis of monthly fatal overdoses before and after the implementation of systematic program during the period 2006–2015. Knowledge of overdose prevention increased after implementing systematic training program. Compared to the PREIGW, the IG gave more correct answers (IRR = 1.40;95%CI:1.33–1.47), and fewer incorrect answers (IRR = 0.33;95%CI:0.25–0.44). Forty percent of people who injected opioids who received a naloxone kit had used the kit in response to an overdose they witnessed. These courses increase knowledge of overdose prevention in people who use opioids, give them the necessary skills to use naloxone, and slightly diminish the number of fatal opioid overdoses in the city of Barcelona. [ABSTRACT FROM AUTHOR]

Background: Many risk behaviours in adolescence are socially patterned. However, it is unclear to what extent socioeconomic position (SEP) influences adolescent drinking in various parts of Europe. We examined how alcohol consumption is associated with parental SEP and adolescents' own SEP among students aged 14-17 years.Methods: Cross-sectional data were collected in the 2013 SILNE study. Participants were 8705 students aged 14-17 years from 6 European cities. The dependent variable was weekly binge drinking. Main independent variables were parental SEP (parental education level and family affluence) and adolescents' own SEP (student weekly income and academic achievement). Multilevel Poisson regression models with robust variance and random intercept were fitted to estimate the association between adolescent drinking and SEP.Results: Prevalence of weekly binge drinking was 4.2% (95%CI = 3.8-4.6). Weekly binge drinking was not associated with parental education or family affluence. However, weekly binge drinking was less prevalent in adolescents with high academic achievement than those with low achievement (PR = 0.34; 95%CI = 0.14-0.87), and more prevalent in adolescents with >€50 weekly income compared to those with ≤€5/week (PR = 3.14; 95%CI = 2.23-4.42). These associations were found to vary according to country, but not according to gender or age group.Conclusions: Across the six European cities, adolescent drinking was associated with adolescents' own SEP, but not with parental SEP. Socio-economic inequalities in adolescent drinking seem to stem from adolescents' own situation rather than that of their family. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to estimate the proportion of undiagnosed HIV or Hepatitis C virus (HCV) infection and to assess the risk factors associated with an undiagnosed infection.Methods: A questionnaire was distributed among people who inject drugs (PWID) in harm reduction centres in Catalonia, Spain 2008-2012 (n=2243). Self-report of HIV and HCV was compared to oral fluid tests to calculate the proportion of undiagnosed infection. Associations of undiagnosed HIV and HCV with age, origin, risk and protective factors of infection and services use were calculated using a Poisson regression model with robust variance.Results: The sensitivity of HIV self-report was 78.5% (75.2%-81.5%) and of HCV was 81.2% (79.1%-83.2%), being lower in younger and foreign-born PWID. Specificity for HCV was 55.9% (51.6%-60.1%). PWID who engaged in infection risk behaviors had lower risk of being undiagnosed. Being foreign-born and younger increased the risk of undiagnosed infection. PWID who had not accessed medical care in the last 6months had 1.46 (1.10-1.93) times more risk of undiagnosed HIV and 1.37 (1.11-1.70) times more risk of undiagnosed HCV.Conclusion: Outreach programmes are essential to provide PWID, specially foreign-born and younger PIWD, access to HIV and HCV test. [ABSTRACT FROM AUTHOR]

Objectives:The aim of this study was to assess differences in the prevalence of HIV and HCV infection and associated risk factors between new (injecting for ≤5 years) and long-term injectors and to estimate HIV/HCV incidence among new injectors.Methods:Cross-sectional study among people who inject drugs (PWID) who attended harm reduction centers in Catalonia in 2010–11. Anonymous questionnaires and oral fluid samples were collected. Poisson regression models were applied to determine the association between HIV/HCV infection and risk factors.Results:Of the 761 participants, 21.4% were new injectors. New injectors were younger than long-term injectors (mean age = 31.6 vs. 37.8) and were more likely to be immigrants (59.0% vs. 33.4%). HIV and HCV prevalence was 20.6% and 59.4% among new injectors, and estimated HIV and HCV incidence 8.7 and 25.1 /100 person-years, respectively. Among new injectors, HIV infection was associated with homelessness (PR = 3.10) and reporting a previous sexually transmitted infection (PR = 1.79). Reporting front/backloading (PR = 1.33) and daily injection (PR = 1.35) were risk-factors for HCV infection. For long-term injectors, HIV risk factors were: having shared syringes (PR = 1.85), having injected cocaine (PR = 1.38), reporting front/backloading (PR = 1.30) and ever having been in prison (PR = 2.03).Conclusion:A large proportion of PWID in Catalonia are new injectors, a subgroup with a high level of both sexual and parenteral exposure and a high incidence rate of HIV/ HCV infections. It is important to improve early diagnosis of these infections among this group, in particular among migrants. To identify and address risk factors for homelessness PWID should be a priority. [ABSTRACT FROM PUBLISHER]

Background: The study's aim was to estimate the self-reported prevalence of Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV), and to describe their associated risk factors in a population of users of illicit drugs recruited in Catalonia- Spain, during 2012.Methods: Cross-sectional study. People with illicit drugs use were selected in three different types of healthcare centres. The questionnaire was a piloted, structured ad hoc instrument. An analysis was made to identify factors associated to self-reported HCV, HIV and co-infection. Correlates of reported infections were determined using univariate and multivariate Poisson regression (with robust variance).Results: Among 512 participants, 39.65% self-reported positive serostatus for HCV and 14.84% for HIV, co-infection was reported by 13.48%. Among the 224 injecting drug users (IDUs), 187 (83.48%), 68 (30.36%) and 66 (29.46%) reported being positive for HCV, HIV and co-infection, respectively. A higher proportion of HIV-infected cases was observed among women, (18.33% vs. 13.78% in men). Prevalence of HCV, HIV and co-infection were higher among participants with early onset of drug consumption, long periods of drug injection or who were unemployed. A positive serostatus was self-reported by 21(7.34%) participants who did not report any injection; among them 16 and eight, reported being positive for HCV and HIV, respectively; three reported co-infection. Only two people declared exchanging sex for money. For those that reported a negative test, the median time since the last HIV test was 11.41 months (inter-quartile range (IQR) 4-12) and for the HCV test was 4.5 months (IQR 2-7).Conclusions: Among drug users in Catalonia, HIV, HCV and co-infection prevalence are still a big issue especially among IDUs. Women and drug users who have never injected drugs are groups with a significant risk of infection; this might be related to their high-risk behaviours and to being unaware of their serological status. [ABSTRACT FROM AUTHOR]

Background: To estimate the incidence of hazardous drinking in middle-aged people during an economic recession and ascertain whether individual job loss and contextual changes in unemployment influence the incidence rate in that period. Methods: Longitudinal study based on two waves of the SHARE project (Survey of Health, Ageing and Retirement in Europe). Individuals aged 50–64 years from 11 European countries, who were not hazardous drinkers at baseline (n = 7,615), were selected for this study. We estimated the cumulative incidence of hazardous drinking (≥40g and ≥20g of pure alcohol on average in men and women, respectively) between 2006 and 2012. Furthermore, in the statistical analysis, multilevel Poisson regression models with robust variance were fitted and obtained Risk Ratios (RR) and their 95% Confidence Intervals (95%CI). Results: Over a 6-year period, 505 subjects became hazardous drinkers, with cumulative incidence of 6.6 per 100 persons between 2006 and 2012 (95%CI:6.1–7.2). Age [RR = 1.02 (95%CI:1.00–1.04)] and becoming unemployed [RR = 1.55 (95%CI:1.08–2.23)] were independently associated with higher risk of becoming a hazardous drinker. Conversely, having poorer self-perceived health was associated with lower risk of becoming a hazardous drinker [RR = 0.75 (95%CI:0.60–0.95)]. At country-level, an increase in the unemployment rate during the study period [RR = 1.32 (95%CI:1.17–1.50)] and greater increases in the household disposable income [RR = 0.97 (95%CI:0.95–0.99)] were associated with risk of becoming a hazardous drinker. Conclusions: Job loss among middle-aged individuals during the economic recession was positively associated with becoming a hazardous drinker. Changes in country-level variables were also related to this drinking pattern. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to estimate the lethality of opioid overdose among young heroin users.Methods: A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models.Results: The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5).Conclusions: Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to estimate the magnitude of gender differences in hazardous drinking among middle-aged people and to analyse whether these differences are associated with contextual factors, such as public policies or socioeconomic factors. Methods: Cross-sectional design. The study population included 50- to 64-year-old residents of 16 European countries who participated in the Survey of Health, Ageing and Retirement in Europe project conducted in 2010-12 (n = 26 017). We estimated gender differences in hazardous drinking in each country. To determine whether different social context or women's empowerment variables were associated with gender differences in hazardous drinking, we fitted multilevel Poisson regression models adjusted for various individual and country-level variables, which yielded prevalence ratios and their 95% confidence intervals (95% CI). Results: Prevalence of hazardous drinking was significantly higher in men than women [30.2% (95% CI: 29.1-31.4%) and 18.6% (95% CI: 17.7-19.4%), respectively] in most countries, although the extent of these differences varied between countries. Among individuals aged 50-64 years in Europe, risk of becoming a hazardous drinker was 1.69 times higher (95% CI: 1.45-1.97) in men, after controlling for individual and country-level variables. We also found that lower values of the gender empowerment measure and higher unemployment rates were associated with higher gender differences in hazardous drinking. Conclusion: Countries with the greatest gender differences in hazardous drinking were those with the most restrictions on women's behaviour, and the greatest gender inequalities in daily life. Lower gender differences in hazardous drinking seem to be related to higher consumption among women. [ABSTRACT FROM AUTHOR]

Background The goal of this study was to estimate excess death due to external causes among 18- to 64-year-olds with alcohol use disorder (AUD) who were treated at public outpatient treatment centers, and the time elapsed from treatment initiation to death. Methods We conducted a retrospective longitudinal study among 7,012 outpatients aged 18 to 64 years who began treatment for AUD between 1997 and 2007. Deaths due to external causes (intentional and unintentional injuries) were monitored until the end of 2008. Person-years (PY) of follow-up and crude mortality rates (CMRs) were calculated for all study variables, for each sex, and for 2 age groups (18 to 34 and 35 to 64 years). Standardized mortality ratios (SMRs) were estimated by age group and sex. Survival was analyzed using the Kaplan-Meier method and Cox regression. Results We recorded 114 deaths due to external causes. The CMR was 2.7 per 1,000 PY (95% confidence interval [CI]: 2.2 to 3.2), with significant gender differences only among younger individuals (CMR for males = 3.9 per 1,000 PY [95% CI: 2.2 to 5.5] and CMR for females = 2.8 per 1,000 PY [95% CI: 0.1 to 5.6]). Unintentional injury was the most common cause of death ( n = 65), of which acute poisoning ( n = 25; 38.5%) and traffic accidents ( n = 15; 23.1%) were the most prevalent. Suicide accounted for 91.8% ( n = 49) of deaths from intentional injuries. The excess of mortality between the AUD group and the general population (SMR) was 9.5 higher than in the general population (95% CI: 7.9 to 11.4), with significant differences between genders (SMR = 6.1 [95% CI: 4.9 to 7.5] in males and SMR = 20.4 [95% CI: 13.9 to 29.9] in females). Approximately 35% of deaths among individuals aged <35 years and 60% among women occurred within a year of initiating treatment. Conclusions This study highlights the importance of excess of mortality among people with AUD and patients' vulnerability during the initial years of treatment. Preventing premature deaths due to external causes among women and younger patients with AUD is a priority. [ABSTRACT FROM AUTHOR]

Aims To analyse the association between alcohol advertising restrictions and the prevalence of hazardous drinking among people aged 50-64 years in 16 European countries, taking into account both individual and contextual-level factors (alcohol taxation, availability, etc.). Design Cross-sectional study based on SHARE project surveys. Setting and Participants A total of 27 773 subjects, aged 50-64 years, from 16 European countries who participated in wave 4 of the SHARE ( Survey of Health, Ageing and Retirement in Europe) project. Measurements We estimated the prevalence of hazardous drinking (through adaptation of the SHARE questions to the scheme used by the Alcohol Use Disorders Identification Test Consumption ( AUDIT- C) for each country. To determine whether the degree of advertising restrictions was associated with prevalence of hazardous drinking, we fitted robust variance multi-level Poisson models, adjusting for various individual and contextual variables. Prevalence ratios ( PR) and their 95% confidence intervals (95% CI) were obtained. Findings The observed prevalence of hazardous drinking was 24.1%, varying by sex and country. Countries with greater advertising restrictions had lower prevalence of hazardous drinking: 30.6% (95% CI = 29.3-31.8) in countries with no restrictions, 20.3% (95% CI = 19.3-21.2) in countries with some restrictions and 14.4% (95% CI = 11.9-16.8) in those with greatest restrictions. The PR found (with respect to countries with greatest restrictions) were 1.36 (95% CI = 0.90-2.06) for countries with some restrictions and 1.95 (95% CI = 1.31-2.91) for those with no advertising restrictions. Conclusions The extent of advertising restrictions in European countries is associated inversely with prevalence of hazardous drinking in people aged 50-64 years. [ABSTRACT FROM AUTHOR]

Aim To determine predictors of changes in amount of cocaine use among regular users outside treatment services. Design Longitudinal study-we estimated the proportion of subjects who increased or decreased cocaine use and assessed possible predictors related to these changes among a street-recruited cohort of young regular cocaine users ( RCU). Setting Three Spanish cities: Barcelona, Madrid and Seville Participants A total of 720 RCU aged 18-30 years not regularly using heroin were recruited in the community during 2004-06 (Itinere Project). Follow-up interviews ( n = 501) were carried out at 12-24 months. Measurements The average amount of cocaine used weekly was calculated taking into account the number of days of use and the usual quantity (g/day). A multinomial logistic regression approach was used to investigate the association between changes in amount of cocaine use (i.e. difference exceeded 33.3% of baseline level) after 12-24 months, and baseline socio-demographic characteristics, nightlife, patterns of cocaine use and use of alcohol and other psychoactive drugs. Findings Cocaine use baseline average level was 2.14 g/week [95% confidence interval ( CI) = 2.02-2.42]. It decreased in 71.5% of subjects and increased in 14.1%. In multinomial analysis, negative associations were found between decreasing cocaine use and high levels of alcohol consumption and using an increasing number of psychoactive drugs. Moreover, low education level, having used cocaine frequently in houses and reporting cocaine binges were associated with increasing cocaine use. Conclusions A street-recruited cohort of cocaine users in Spain showed a significant reduction in cocaine use over a period of 12-24 months. High consumption of alcohol and increasing use of other psychoactive drugs decreased the probability of reducing cocaine use. [ABSTRACT FROM AUTHOR]

Abstract: We assessed mortality risk factors and excess mortality compared to the general population in two Spanish sub-cohorts of 8,825 cocaine and heroin users (CHUs) and 11,905 only cocaine users (OCUs) aged 15–49 admitted to drug treatment. Heroin use (among all cocaine users), no-regular employment and drug injection (among CHUs and OCUs), daily cocaine use and previous drug treatment (among CUs), and death before 2005 and >10years of heroin use (among CHUs) were clearly associated with higher mortality in Cox regression. Excess mortality was assessed by the directly standardized mortality rate ratio, which was higher in CHUs (14.3; 95% CI: 12.6–16.2) than CUs (5.1; 95% CI: 4.3–6.0) and in women than men, especially among OCUs (8.6; 95% CI: 7.5–10.0 vs. 3.5; 95% CI: 3.3–3.8); it decreased with age among CHUs, but did not decrease overall during 1997–2008. OCUs excess mortality was considerable and showed no signs of decline, suggesting the need for improved treatment and prevention interventions. [Copyright &y& Elsevier]

Aims This study estimates life-time incidence trends of cannabis and cocaine use over 38 years from general population surveys of drug use ( GPSDU) in Spain, taking into account changes of population age structure. Design Periodic cross-sectional studies. Setting Eight biennial GPSDU from 1995 to 2009 in Spain. Participants Interviewees aged 15-64 years who reported age of first ever cannabis and/or cocaine use between 10 and 64 years between 1971 and 2008. Measurements Estimates of raw and standardized incidences were calculated as a weighted mean of the incidences from all surveys. Standardization was conducted to take into account changes of population age structure. Incidence trends were extracted applying weighted cubic smoothing splines to incidence estimates. Findings For both substances, estimated raw incidence trends increased up until 2000 (rates of 11.5 ± 0.7 and 3.6 ± 0.5 per 1000, respectively, for cannabis and cocaine), and then decreased significantly (in 2008, 9.6 ± 1.2 and 2.7 ± 0.6, respectively). In contrast, standardized rates exhibit a steadily increasing trend up to 2000 (9.0 ± 0.6 and 2.8 ± 0.4), followed by a statistically non-significant increasing trend afterwards (in 2008, 9.5 ± 1.2 and 2.8 ± 0.6). The largest increases of incidence were observed in both male and female subjects aged 15-19 years. Conclusions Using data from Spanish general population surveys of drug use, an apparently decreasing trend of raw incidence rates in both cannabis and cocaine use from 2000 became non-decreasing trends when these rates were standardized. First experiences of cannabis and cocaine use in Spain occur mainly in younger ages (15-19 years). [ABSTRACT FROM AUTHOR]

Background: Opioid dependent patients have legal problems, driving violations and accidents more frequently than the general population. We have hypothesized that those patients currently driving may have better legal outcomes than those who do not possess a valid driving license. With this aim we have analyzed the information gathered in the PROTEUS study regarding the legal and driving statuses and assessed the possible association between them. The PROTEUS study was an observational, cross-sectional, descriptive, multicenter nationwide representative study, conducted in Spanish healthcare centers for opioid dependent patients.Findings: The driving and legal statuses of a population of opioid dependent patients ≥ 18 years and enrolled in Opioid Agonist Therapy treatment centers in Spain, were assessed using a short specific questionnaire and the EuropASI questionnaire to highlight distinct individual clinical needs. 621 patients were evaluable (84% men, 24.5% active workers). 321 patients (52%) drove on a regular basis. Nineteen percent of patients had some problem with the criminal justice system. There was a significant difference (p = 0.0433) in status, according to the criminal justice system, between patients who drove on a regular basis and those who did not, with a higher percentage of patients with non-pending charges among usual drivers.Conclusions: Regular drivers showed fewer legal problems than non-regular drivers, with the exception of those related to driving (driving violations and drunk driving). Driving is a good prognostic factor for the social integration of the patients and policies should be implemented to enable these patients to drive safely under medical authorization. The legal description will be useful to assess treatment efficacy. [ABSTRACT FROM AUTHOR]

Abstract: Background: Published studies indicate that primary cocaine users (PCUs) have a mortality rate 4–8 times higher than their age–sex peers in the general population. Most PCUs are primary intranasal cocaine users, never-injectors and never-opioid users (PICUNINOs) and are usually underrepresented in cohort mortality studies. The aim is to estimate excess mortality in all PCUs and in the subgroups of never-opioid users and PICUNINOs in Spain. Methods: 714 PCUs aged 18–30 were street-recruited in 2004–2006 in Spain and followed until 2010 to ascertain vital status. Drug use was self-reported at baseline and 1–2years later. Mortality was compared with that of the general population using standardized mortality ratios (SMRs). Results: SMRs were 4.7 (95% CI: 2.4–9.0), 2.5 (95%CI: 0.8–7.8) and 3.1 (95% CI: 1.0–9.6), respectively, among all participants, never-opioid users and PICUNINOS when using only baseline data on drug use, and 1.2 (95% CI: 0.2–8.5) and 1.4 (95% CI: 0.2–9.9) among the latter two subgroups, when using baseline plus follow-up data. Conclusion: Short-term mortality in young Spanish PCUs is 5 times higher than in the general population. This excess mortality may largely be explained by a history of opioid use or the risk of starting such use. [Copyright &y& Elsevier]

Abstract: Background: Heroin users who do not inject constitute a large pool of drug users with a potentially important impact on public health. We aimed to estimate the incidence of hepatitis C virus (HCV) among heroin users who had never injected (NIDUS) at baseline, and the effect of starting injecting during follow-up, other percutaneous exposures, sharing snorting paraphernalia, cocaine/crack use, and risky sexual behaviour on HCV-seroconversion. Methods: Prospective cohort of 305 HCV-negative NIDUs at baseline, aged 18–30 and street-recruited in three Spanish cities in 2001–2003. Computer-assisted personal interviews were conducted and dried blood-spot samples were collected. Bivariate and multivariable Poisson models were used. Results: Among the 305 never-injectors who were HCV-negative at baseline, 197 (64.6%) were followed-up and 21 seroconverted [HCV-incidence rate=5.8/100 person-years at risk (pyar) (95% CI: 3.6–8.9)]. HCV incidence in new-injectors was 28.4/100pyar [(95% CI, 14.7–49.7) vs. 2.8/100pyar (95% CI, 1.3–5.4)] among NIDUs. Of the risk exposures considered, starting injecting was the only predictor of HCV-seroconversion [adjusted relative risk=10.1, 95% CI: 3.8–26.7]. Conclusion: The HCV-seroconversion rate was 10 times higher among new-injectors than never-injectors. No predictors other than starting injecting were found for HCV-seroconversion. Harm reduction interventions to prevent HCV infection should include prevention of drug injection. [Copyright &y& Elsevier]

Abstract: Background: Opioid overdose risk reduction behaviours include some preventive behaviours to avoid overdoses (PB) and others to avoid death after overdose, such as never using heroin while alone (NUA). Few studies have examined the prevalence and predictors of these behaviours. Aim: To establish the prevalence and predictors of PBs and NUA among heroin users, both injectors and non-injectors, in three Spanish cities. Methods: 516 injecting and 475 non-injecting heroin users aged 18–30 were street-recruited in 2001–2003 and interviewed by face-to-face computer-assisted interview. PBs and NUA in the last 12 months were explored using open-ended and precoded questions, respectively. Specific predictors for three PB categories were investigated: control of route of drug administration, control of quantity or type of heroin used, and control of co-use of other drugs. Bivariate and logistic regression methods were used. Results: Overall, the most prevalent PBs were: using a stable and not excessive amount of heroin (12.7%), injecting or using the whole heroin dose slowly or dividing it into smaller doses (12.4%), reducing or stopping heroin injection (8.3%), and not mixing heroin with tranquillisers (5.1%). Most PBs were significantly more prevalent among injectors than non-injectors. No one mentioned reducing the amount of heroin after an abstinence period. Some 36.2% had NUA. In multiple regression analysis, knowledge of risk factors for opioid overdose was a predictor of specific PBs, although this was not always the case. Use of syringe exchange programmes was a predictor of PB among injectors. However, attending methadone maintenance treatment (MMT) or other drug-dependence treatment was not a predictor of any opioid overdose reduction behaviour. Only ever having witnessed or experienced an overdose predicted PB in both injectors and non-injectors. Conclusions: The proportion of heroin users with opioid overdose risk reduction behaviours is very low. Additional specific measures to prevent overdose are needed, as well as increased emphasis on reducing the risk of overdose in programmes to prevent HIV and other blood-borne infections in heroin injectors. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the effect of methadone maintenance treatment (MMT) on cocaine use and cocaine injection among heroin users. Methods: Generalized estimating equations (GEE) were used to examine the association between MMT enrollment (0, <12, ≥12 months) and changes in frequency of cocaine use or injection in two consecutive follow-up visits among heroin users in the Itinere cohort, and to determine whether these changes were independent of equivalent changes in heroin use or injection. Seven multivariate models were constructed, one for each outcome variable on drug use changes. Results: Of the 992 participants recruited in 2001–2003, 628 (63.3%) had at least one follow-up visit. Of these, 55.8% were enrolled in MMT at baseline and an additional 23.2% initiated MMT during follow-up. In multivariate GEE, changes significantly and positively associated with MMT enrollment were: less cocaine use [MMT<12 months (OR=1.70, 95% CI=1.17–2.48)] and less cocaine injection [MMT≥12 months (OR=2.98, 95% CI=1.51–5.89)]. Being on MMT≥12 months was negatively associated with more cocaine use (OR=0.62, 95% CI=0.38–0.99) and with more cocaine injection (OR=0.52, 95% CI=0.28–0.98). When equivalent changes in heroin were used as a covariate, the MMT effect on less cocaine use was hardly modified (OR=1.69, 95% CI=1.07–2.65), and the effect on changes in cocaine injection disappeared. Conclusion: MMT enrollment is a protective factor against both cocaine use and injection among heroin users. The effect of MMT on cocaine injection appears to be mediated by heroin injection, whereas its effect on cocaine use is more direct. [Copyright &y& Elsevier]

Aims: Our aim was to further assess the Severity of Dependence Scale (SDS) validity and to identify the cut-off score for a DSM-IV diagnosis of heroin and cocaine dependence through a cross-sectional survey in Barcelona, Spain. Methods: The Psychiatric Research Interview for Substance and Mental Disorders (PRISM) was used as the gold standard. 146 young (18–30 years old) heroin users were recruited from outside the healthcare context, 135 of whom were also current cocaine users. SDS scores were correlated to quantity, frequency and length of drug use. Results: The SDS cut-off point at which there was optimal discrimination of a DSM-IV diagnosis presence was found to be 3 (i.e., a score of 3 or more) for heroin dependence and 4 for cocaine dependence. Conclusions: The study gives further support to SDS dimensional properties and to its validity for rapid assessment of current heroin and cocaine dependence. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This study examined the relationship between the personality profile of a sample of cocaine users and the presence of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnoses and the severity of substance use. A total of 120 participants (46 women, mean age: 23.8 years) from nonclinical settings in Barcelona, Spain, 2003-2006, were assessed using the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) and the Temperament and Character Inventory-Revised version (TCI-R). Most of the participants had completed more than primary education, nearly half of them were employed, one third lived with parents, and near a quarter had some criminal record. Snorting was the main route of cocaine administration. They were using a mean of 1.82 substances. Cocaine users with low Self-Directedness, low Cooperativeness, and high Self-Transcendence scores in the TCI-R, with high severity of substance use and psychiatric comorbidity, would be suggestive of a possible specific phenotype. The limitations and implications of the study are discussed. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this qualitative study is to investigate young people''s perceptions, in Barcelona, Spain, about the evolution, magnitude, causes and determinants of traffic crashes, to describe their opinions on road safety regulations, and to explore their suggestions and proposals. Interviews were conducted with 43 key informants and 12 focus groups involving 98 participants. Discussion guides were designed to get insight on perceptions of relevance and trends in road traffic injuries, determinants of these, regulations and enforcement, as well as to gather their own ideas for reducing traffic injuries. Young people are aware that traffic injuries are a relevant and increasingly serious problem. The main determinants identified are: driving under the influence of drugs and alcohol, fatigue, night driving, unsafe infrastructures, age of drivers and lack of public transport alternatives. Young people admit that fines, speed cameras and alcohol breath testing reduce risky driving. They prefer community work to fines. They have a poor image of public administrations in charge of prevention of traffic injuries. They demand information on traffic regulations and politicians’ decisions, and a considerable increase in weekend and night time public transport. Effectiveness of interventions to reduce traffic injuries can be improved by taking the recipients’ perceptions into account. [Copyright &y& Elsevier]

Background: To evaluate the prevalence of hepatitis B virus (HBV) and associated factors in 949 heroin users (HU): injectors (IHUs) and non-injectors (NIHUs). Methods: Cross-sectional study; structured questionnaire administered by computer-assisted personal interviewing and audio computer-assisted self-interviewing; dry blood samples analysed for the hepatitis B core antigen and hepatitis B surface antigen; bivariate analysis and logistic regression. Results: The prevalence of infection was significantly higher in IHUs (22.5%) than in NIHUs (7.4%) in the three cities. In the logistic analysis of male IHUs, infection was found to be associated with living in Seville, age over 25, foreign nationality, having had a sexual partner who traded sex, hepatitis C virus infection, and having injected for more than 5 years. In female IHUs, HBV infection was associated with age over 25, having injected as the first main route of administration, and having begun to inject before 18 years of age. In NIHUs, the associated factors were female gender, foreign nationality and having been tattooed. In young IHUs, the prevalence of HBV infection remains four times higher than in the general population of the same age group. Conclusion: The vaccination strategy urgently needs to be reinforced and redesigned to achieve acceptable control of the HBV infection in the most vulnerable groups, with special attention to immigrants. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: The prevalence of vaccination against hepatitis B virus (HBV), factors associated with vaccination, and missed opportunities for vaccination were assessed among 949 street-recruited young injecting heroin users (IHUs) and noninjecting HUs (NIHUs). A cross-sectional study was carried out in Madrid, Barcelona, and Seville. Face-to-face interviews were held using a structured questionnaire with computer-assisted personal interviewing. Dried blood spot samples were tested for anti-HBV core antigen and HBV surface antigen. Bivariate and logistic regression analyses were performed. The prevalence of HBV vaccination was 21.7%, with significant differences among the cities (13.3% in Madrid, 18.4% in Seville, and 33.2% in Barcelona) and between IHUs (23.8%) and NIHUs (17.9%). In the logistic regression analysis, living in Barcelona and being aged 25 years or younger were associated with HBV vaccination in IHUs and NIHUs; in IHUs, vaccination was also associated with living in the street or in institutions for most of the last 12 months. Practically all those susceptible to HBV infection had missed at least one opportunity for vaccination, and most of them had missed such an opportunity in the last year. The proportion of vaccinated HUs remains very low despite efforts to set up harm reduction programs. New and more active strategies must be incorporated in these programs. [Copyright &y& Elsevier]

Aims To examine the psychiatric status of young cocaine users using a validated instrument for the evaluation of psychiatric comorbidity, emphasizing the distinction between independent and induced psychiatric conditions. Design Cross-sectional study. Setting Barcelona, Spain. Participants A cohort of 139 young (18–30 years) adult current regular cocaine users. Measurements The Psychiatric Research Interview for Substance and Mental Disorders (PRISM-IV, which produces diagnoses according to DSM-IV criteria, including Axis II antisocial and borderline personality disorders). Findings Nearly 42.5% of the subjects presented psychiatric comorbidity. The most common Axis I diagnoses were mood disorders (26.6%) and anxiety disorders (13%). Increasing age, having ever received treatment for drug use and freebase cocaine use were associated with substance-induced disorders diagnoses relative to primary Axis I disorders. Conclusions This study has shown a relatively high prevalence of psychiatric comorbidity in cocaine users recruited in non-clinical settings. Future studies examining potential differential factors associated with primary versus substance-induced disorders are necessary to optimize the implementation of more suitable approaching programmes for young regular cocaine users. [ABSTRACT FROM AUTHOR]

Objective: To study socioeconomic inequalities in AIDS mortality in Barcelona, Spain, during the periods 1991–6 (before highly active antiretroviral therapy (HAART)) and 1997–2001 (post-HAART) taking into account individual as well as community effects of socioeconomic level. Design: Cross-sectional design. Setting: Barcelona, Spain. Participants: All residents aged ⩾20 years. All AIDS-related deaths occurring between 1991 and 2001 were studied. The individual variables analysed were age, sex, educational level, neighbourhood of residence and HIV transmission group. Male unemployment was used as the community-level indicator of neighbourhood deprivation. Multilevel Poisson regression models were fitted to estimate the relationship between AIDS mortality and the individual- and community-level variables. Results: At the individual level, AIDS mortality relative risks (RR) were higher among intravenous drug users (IDUs) with lower educational level in both periods. For the younger population, the RR of AIDS-related mortality associated with having little education compared with having a primary education or more was 4.7 (95% CI 3.6 to 6.1) in men and 5.2 (95% CI 3.6 to 7.7) in women in the pre-HAART period, and 4.7 (95% CI 2.7 to 8.1) in men and 4.5 (95% CI 1.4 to 14.1) in women in the post-HAART period. At the community level, an area effect in AIDS mortality was found, which was more important in neighbourhoods having high deprivation in both periods, although the effect was most important in the post-HAART period. Conclusions: This study has shown inequalities in AIDS mortality in terms of both individual variables and a community-level variable in the pre-HAART as well as in the post-HAART period. These socioeconomic inequalities of AIDS mortality must be considered when prevention and treatment strategies are implemented. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to determine whether socioeconomic AIDS mortality inequalities before and after the introduction of highly active antiretroviral therapy (HAART) have increased or decreased in a Spanish city where HAART is free. Methods: The study used a trend design, including all Barcelona residents older than 19 years of age. All AIDS deaths, which occurred among these residents between 1991 and 2001 were included. The variables studied were age, sex, socioeconomic (SES) group and HIV transmission group. AIDS age-standardized mortality rates for each year were estimated. Poisson regression models were fitted to obtain the relative risk (RR) of AIDS death for each socioeconomic group with respect to the reference group. Results: AIDS mortality increased up until 1995 and subsequently decreased due to the introduction of HAART. The increase in AIDS mortality was greater in the lowest SES group, which had higher rates and a RR of dying larger than that of the highest SES group, fact that remained fairly stable over the whole period. A similar pattern was observed in intravenous drug users. In the homosexual transmission group, rates for the lowest SES group were higher for the whole period and increased until 1996, while rates for the other SES groups were lower and decreased over the entire period. Conclusions: The fact that inequalities in AIDS mortality by SES group remained fairly stable for the whole period suggests that perhaps access to HAART, or adherence, is lower than desirable, in people of lower SES groups. These results ought to be taken into account when implementing treatment and prevention strategies. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate changes in the prevalence of HIV infection among young heroin users in three Spanish cities, and their association with harm reduction programmes (HRPs). Methods: Two cross sectional studies. The 1995 study included 596 users; half were street recruited and half were recruited at drug treatment centres. The 2001–03 study included 981 street recruited users. Face to face interviews were conducted using a structured questionnaire. Samples for HIV testing (saliva in 1995 and dried blood spot in 2001–03) were collected. Results: The proportion who had ever injected (IDUs) decreased in all three cities. HIV prevalence in IDUs decreased by half in Barcelona (44.1% to 20.8%) and Seville (44.2% to 22.2%), but remained constant in Madrid (36.8% and 34.9%). This difference was attributable to a decrease in HIV prevalence in long term IDUs in Barcelona and Seville, but not in Madrid. The crude odds ratio for HIV prevalence in Madrid compared with Barcelona in long term IDUs was 2.3 (95%Cl 1.4 to 3.7), increasing to 3.1 (95%Cl 1.5 to 6.2) after adjusting for sociodemographic and risk factors. HIV prevalence in short term IDUs was similar in all cities. In 1992 Barcelona already had 20 heroin users in methadone maintenance programmes (MMPs) per 10 000 population aged 15–49 years; Seville reached this rate in 1994, and Madrid, not until 1998. Conclusions: The prevalence of HIV infection did not decrease in long term injectors in Madrid. The delayed implementation of HRPs, especially MMPs, may be the most plausible hypothesis. This finding should shed light on decision making in countries in a similar epidemiological and sociological situation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although some studies have described the epidemiology of infection with HIV or hepatitis B and C in young users in Spain – one of the European countries with the highest prevalences – there are no studies of the prevalence of HTLV infection and the most important associated factors. Objectives: To evaluate the prevalence and main determinants of HTLV-1 and HTLV-2 infection in young heroin users (including both injection (IDUs) and non-injection drug users (NIDUs)) recruited outside health care services in three of Spain''s principal cities. Study design: Cross-sectional cohort study. All participants (981) were street-recruited by chain referral procedures between April 2001 and December 2003. Face-to-face interviews were conducted using a structured questionnaire and dried blood spot samples were collected for serological testing. Results: No sample was positive for HTLV-1 and 27 samples were positive for HTLV-2; all of these were found only in Spanish IDUs in the cities of Madrid (17, 6.2%) and Barcelona (10, 3.5%). The only two factors significantly associated with HTLV infection in the logistic regression analysis were HIV infection (OR 5.7; 95% CI 2.2–14.8) and having injected in the last 30 days (OR 6.5; 95% CI 1.4–29.8). Having been in prison (OR 2.4; 95% CI 0.9–6.4) and HCV infection (OR 3.8; 95% CI 0.5–30.7), which were strongly and significantly associated in the bivariate analysis, were no longer significant in the logistic analysis. Almost the same variables were selected in the tree analysis, in which subjects could be classified into three groups: high prevalence (28.5%, HIV+ and HBV+ who had injected in the last 30 days), medium prevalence (17.8%) and low (<3%) or zero prevalence (HIV−, HCV− and HBV−). Conclusions: HTLV-1 was not detected among young Spanish heroin users. HTLV-2 was not found in NIDUs (perhaps due to the low rate of sexual transmission); it was found only in IDUs from Madrid and Barcelona, but not in those from Seville. Its prevalence is very low and the main correlates of infection were HIV infection and injection as the usual route of heroin administration. [Copyright &y& Elsevier]

The author discusses the prohibition of alcohol advertising in Europe. Topics discussed include the impact of alcohol in an individual's social and physical welbeing, the level of alcohol consumption among college students who are engaged in sports, and the adverse effects of alcohol in society and health.