Search

Background: Men who have sex with men who ever injected drugs (ever MSM-IDU) carry a high hepatitis C virus (HCV) burden. We estimated whether current HCV testing and treatment in San Francisco can achieve the 2030 WHO HCV elimination target on HCV incidence among ever MSM-IDU.Methods: A dynamic HCV/HIV transmission model among MSM was calibrated to San Francisco data, including HCV antibody (15.5%, 2011) and HIV prevalence (32.8%, 2017) among ever MSM-IDU. MSM had high HCV testing (79%-86% ever tested, 2011-2019) and diagnosed MSM had high HCV treatment (65% ever treated, 2018). Following COVID-19-related lockdowns, HCV testing and treatment decreased by 59%.Results: Among all MSM, 43% of incident HCV infections in 2022 were IDU-related. Among ever MSM-IDU in 2015, HCV incidence was 1.2/100 person-years (95%CrI: 0.8–1.6). Assuming COVID-19-related declines in HCV testing/treatment persist until 2030, HCV incidence among ever MSM-IDU will decrease by 84.9% (72.3%-90.8%) over 2015-2030. This decline is largely attributed to HCV testing and treatment (75.8%; 66.7%-89.5%). Slightly greater decreases in HCV incidence (94%-95%) are projected if COVID-19-disruptions recover by 2025 or 2022.Conclusion: We estimate that HCV incidence will decline by >80% over 2015-2030 among ever MSM-IDU in San Francisco, achieving the WHO target.

BackgroundIn many countries, the average age of people who use illicit opioids, such as heroin, is increasing. This has been suggested to be a reason for increasing numbers of opioid-related deaths seen in surveillance data. We aimed to describe causes of death among people who use illicit opioids in England, how causes of death have changed over time, and how they change with age.MethodsIn this matched cohort study, we studied patients in the Clinical Practice Research Datalink with recorded illicit opioid use (defined as aged 18–64 years, with prescriptions or clinical observations that indicate use of illicit opioids) in England between Jan 1, 2001, and Oct 30, 2018. We also included a comparison group, matched (1:3) for age, sex, and general practice with no records of illicit opioid use before cohort entry. Dates and causes of death were obtained from the UK Office for National Statistics. The cohort exit date was the earliest of date of death or Oct 30, 2018. We described rates of death and calculated cause-specific standardised mortality ratios. We used Poisson regression to estimate associations between age, calendar year, and cause-specific death.FindingsWe collected data for 106 789 participants with a history of illicit opioid use, with a median follow-up of 8·7 years (IQR 4·3–13·5), and 320 367 matched controls with a median follow-up of 9·5 years (5·0–14·4). 13 209 (12·4%) of 106 789 participants in the exposed cohort had died, with a standardised mortality ratio of 7·72 (95% CI 7·47–7·97). The most common causes of death were drug poisoning (4375 [33·1%] of 13 209), liver disease (1272 [9·6%]), chronic obstructive pulmonary disease (COPD; 681 [5·2%]), and suicide (645 [4·9%]). Participants with a history of illicit opioid use had higher mortality rates than the comparison group for all causes of death analysed, with highest standardised mortality ratios being seen for viral hepatitis (103·5 [95% CI 61·7–242·6]), HIV (16·7 [9·5–34·9]), and COPD (14·8 [12·6–17·6]). In the exposed cohort, at age 20 years, the rate of fatal drug poisonings was 271 (95% CI 230–313) per 100 000 person-years, accounting for 59·9% of deaths at this age, whereas the mortality rate due to non-communicable diseases was 31 (16–45) per 100 000 person-years, accounting for 6·8% of deaths at this age. Deaths due to non-communicable diseases increased more rapidly with age (1155 [95% CI 880–1431] deaths per 100 000 person-years at age 50 years; accounting for 52·0% of deaths at this age) than did deaths due to drug poisoning (507 (95% CI 452–562) per 100 000 person-years at age 50 years; accounting for 22·8% of deaths at this age). Mirroring national surveillance data, the rate of fatal drug poisonings in the exposed cohort increased from 345 (95% CI 299–391) deaths per 100 000 person-years in 2010–12 to 534 (468–600) per 100 000 person-years in 2016–18; an increase of 55%, a trend that was not explained by ageing of participants.InterpretationPeople who use illicit opioids have excess risk of death across all major causes of death we analysed. Our findings suggest that population ageing is unlikely to explain the increasing number of fatal drug poisonings seen in surveillance data, but is associated with many more deaths due to non-communicable diseases.FundingNational Institute for Health Research.

Importance: Mortality among people with opioid dependence is higher than the general population and a global health burden. Opioid agonist treatment (OAT) is an effective treatment for opioid dependence, however, there has not yet been a systematic review on the relationship between OAT and specific causes of mortality. Objective: To estimate the impact of time in OAT on all-cause and cause-specific mortality. We also examine risk during time periods of treatment, by setting (community and incarceration) and by participant characteristics.Data Sources: We searched Embase, MEDLINE, and PsycINFO through January 2020; clinical trial registries, and previous Cochrane reviews.Study Selection: All observational studies that collected data on all-cause or cause-specific mortality among people with opioid dependence in and out-of-OAT were included. Randomised controlled trials (RCTs) were also included. Data Extraction and Synthesis: We followed GATHER, PRISMA, and MOOSE guidelines. Data on study, participant and treatment characteristics were extracted; person-years, and all-cause and cause-specific mortality. Crude mortality rates and rate ratios (RRs) were pooled using random-effects meta-analyses. Main Outcomes: All-cause and cause-specific mortality, overall; by methadone, buprenorphine; setting, and time-period. Results: 15 eligible RCTs, N=3,852 participants; 36 primary cohort studies, N=749,634. Cohort studies found all-cause mortality during OAT more than halved compared to time out-of-OAT (RR=0.47; 95%CI 0.42-0.53). This relationship was consistent by gender, age, location, HIV, or HCV status, and people who inject. Associations were not different for methadone (RR=0.47; 95%CI 0.41-0.54) versus buprenorphine (RR=0.34; 95%CI 0.26-0.45). There was lower risk of drug-related, suicide, alcohol-related, cancer, and cardiovascular mortality during OAT. In the first four weeks of methadone, all-cause mortality and drug-related poisoning was almost double that in the remainder of OAT (not so for buprenorphine). It was six-times higher in the four weeks following OAT cessation, remaining double the rate for the remainder of time out-of-OAT. OAT is strongly associated with a lower risk fo mortality when incarcerated and after release from incarceration, particularly suicide and overdose.Discussion: OAT is associated with a reduction in multiple causes of death. Nonetheless, access remains limited, and coverage too low. Work to improve access globally is likely to have important population-level benefits.

Poor quality urban environments substantially increase non-communicable disease. Responsibility for associated decision-making is dispersed across multiple agents and systems: fast growing urban authorities are the primary gatekeepers of new development and change in the UK, yet the driving forces are remote private sector interests supported by a political economy focused on short-termism and consumption-based growth. Economic valuation of externalities is widely thought to be fundamental, yet evidence on how to value and integrate it into urban development decision-making is limited, and it forms only a part of the decision-making landscape. Researchers must find new ways of integrating socio-environmental costs at numerous key leverage points across multiple complex systems. This mixed-methods study comprises of six highly integrated work packages. It aims to develop and test a multi-action intervention in two urban areas: one on large-scale mixed-use development, the other on major transport. The core intervention is the co-production with key stakeholders through interviews, workshops, and participatory action research, of three areas of evidence: economic valuations of changed health outcomes; community-led media on health inequalities; and routes to potential impact mapped through co-production with key decision-makers, advisors and the lay public. This will be achieved by: mapping system of actors and processes involved in each case study; developing, testing and refining the combined intervention; evaluating the extent to which policy and practice changes amongst our target users, and the likelihood of impact on non-communicable diseases (NCDs) downstream. The integration of such diverse disciplines and sectors presents multiple practical/operational issues. The programme is testing new approaches to research, notably with regards practitioner-researcher integration and transdisciplinary research co-leadership. Other critical risks relate to urban development timescales, uncertainties in upstream-downstream causality, and the demonstration of impact.

Aims: To corroborate protective effects of a range of drug treatment modalities against overdose mortality risk. Design & Methods: Nested case-control study, with incidence density sampling, selecting controls retrospectively at each case event. Cases and controls came from a sub-cohort of opioid dependent patients (N=4,444) from two Italian regions (Lazio and Piedmont). From 1998 to 2005, there were 91 overdose deaths (cases) matched to 352 controls. The primary outcome was overdose mortality and the primary exposure was drug treatment: opioid agonist treatment (OAT), opioid detoxification, residential community, psychosocial, and other pharmacological treatment. Conditional logistic regression models generated intervention effects comparing mortality risk in and out of treatment, adjusting for confounding variables. Results: Overall, drug treatment reduced overdose mortality risk by 80% (adjusted odds ratio [AOR]: 0.18, 95%CI: 0.10-0.33, p

For over a decade, pandemics have been on the UK National Risk Register as both the likeliest and most severe of threats. Non-infectious ‘lifestyle’ diseases were already crippling our healthcare services and our economy. COVID-19 has exposed two critical vulnerabilities: firstly, the UK’s failure to adequately assess and communicate the severity of non-communicable disease; secondly, the health inequalities across our society, due not least to the poor quality of our urban environments. This suggests a potentially disastrous lack of preventative action and risk management more generally, notably with regards to the existential risks from the climate and ecological crises.

Importance Cannabis use is consistently linked to poorer mental health outcomes, and there is evidence that use of higher-potency cannabis increases these risks. To date, no studies have described the association between cannabis potency and concurrent mental health in a general population sample or addressed confounding using longitudinal data.Objective To explore the association between cannabis potency and substance use and mental health outcomes, accounting for preceding mental health and frequency of cannabis use.Design, Setting, and Participants This cohort study used data from the Avon Longitudinal Study of Parents and Children, a UK birth cohort of participants born between April 1, 1991, and December 31, 1992. Present data on outcomes and exposures were collected between June 2015 and October 2017 from 1087 participants at 24 years of age who reported recent cannabis use.Exposures Self-reported type of cannabis most commonly used in the past year, coded to a binary exposure of use of high-potency cannabis or lower-potency cannabis.Main Outcomes and Measures Outcomes were reported frequency of cannabis use, reported cannabis use problems, recent use of other illicit drugs, tobacco dependence, alcohol use disorder, depression, generalized anxiety disorder, and psychotic-like experiences. The study used secondary data; consequently, the hypotheses were formulated after data collection.Results Past-year cannabis use was reported by 1087 participants (580 women; mean [SD] age at onset of cannabis use, 16.7 [3.0] years). Of these, 141 participants (13.0%) reported the use of high-potency cannabis. Use of high-potency cannabis was associated with increased frequency of cannabis use (adjusted odds ratio [AOR], 4.38; 95% CI, 2.89-6.63), cannabis problems (AOR, 4.08; 95% CI, 1.41-11.81), and increased likelihood of anxiety disorder (AOR, 1.92; 95% CI, 1.11-3.32). Adjustment for frequency of cannabis use attenuated the association with psychotic experiences (AOR 1.29; 95% CI, 0.67-2.50), tobacco dependence (AOR, 1.42; 95% CI, 0.89-2.27), and other illicit drug use (AOR, 1.29; 95% CI, 0.77-2.17). There was no evidence of association between the use of high-potency cannabis and alcohol use disorder or depression.Conclusions and Relevance To our knowledge, this study provides the first general population evidence suggesting that the use of high-potency cannabis is associated with mental health and addiction. Limiting the availability of high-potency cannabis may be associated with a reduction in the number of individuals who develop cannabis use disorders, the prevention of cannabis use from escalating to a regular behavior, and a reduction in the risk of mental health disorders.