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Background and aimsThe individual-level effectiveness of opioid agonist treatment (OAT) in reducing mortality is well established but there is less evidence on population-level benefits. We use modeling informed with linked data from the OAT program in New South Wales (NSW), Australia, to estimate the impact of OAT provision in community and prison on mortality and the impact of eliminating excess mortality during OAT initiation/discontinuation.DesignDynamic modeling.Setting and participantsA cohort of 49,359 individuals who ever received OAT in NSW from 2001-2018.MeasurementsReceipt of OAT was represented through five stages: (i) first month on OAT, (ii) short (1-9 months) and (iii) longer (9+ months) duration on OAT, (iv) first month following OAT discontinuation and (v) rest of time following OAT discontinuation. Incarceration was represented as four strata (i) never or not incarcerated in the past year, (ii) currently incarcerated, (iii) released from prison within the past month and (iv) released from prison 1-12 months ago. The model incorporated elevated mortality post-release from prison, and OAT impact on reducing mortality and incarceration.FindingsAmong the cohort, mortality was 0.9 per 100 person-years, OAT coverage and retention remained high (>50%, 1.74 years/episode). Over 2001-2020, we estimate OAT provision reduced overdose and other cause mortality among the cohort by 53% [95% credible interval: 49%-56%] and 27% [22%-30%], respectively. We estimate 1.2 deaths averted and 9.7 life-years gained per 100 person-years on OAT. Prison OAT with post-release OAT-linkage accounted for 12% [11%-13%] of all deaths averted by the OAT program, primarily through preventing deaths in the first month post-release. Preventing elevated mortality during OAT initiation and discontinuation could have averted up to 1.4% [1%-2%] and 3% [2%-5%] of deaths, respectively.ConclusionThe community and prison opioid agonist treatment program in New South Wales, Australia appears to have substantially reduced population-level overdose and all-cause mortality in the past 20 years, partially due to high retention.

Abstract Background Injecting drug use is a key risk factor, for several infections of public health importance, especially hepatitis B (HBV) and hepatitis C (HCV). In England and Wales, where less than 1% of the population are likely to be injecting drug users (IDUs), approximately 38% of laboratory reports of HBV, and 95% of HCV reports are attributed to injecting drug use. Methods Voluntary unlinked anonymous surveys have been performed on IDUs in contact with specialist agencies throughout England and Wales. Since 1990 more than 20,000 saliva samples from current IDUs have been tested for markers of infection for HBV, HCV testing has been included since 1998. The analysis here considers those IDUs tested for HBV and HCV (n = 5,682) from 1998–2003. This study derives maximum likelihood estimates of the force of infection (the rate at which susceptible IDUs acquire infection) for HBV and HCV in the IDU population and their trends over time and injecting career length. The presence of individual heterogeneity of risk behaviour and background HBV prevalence due to routes of transmission other than injecting are also considered. Results For both HBV and HCV, IDUs are at greatest risk from infection in their first year of injecting (Forces of infection in new initiates 1999–2003: HBV = 0.1076 95% C.I: 0.0840–0.1327 HCV = 0.1608 95% C.I: 0.1314–0.1942) compared to experienced IDUs (Force of infection in experienced IDUs 1999–2003: HBV = 0.0353 95% C.I: 0.0198–0.0596, HCV = 0.0526 95% C.I: 0.0310–0.0863) although independently of this there is evidence of heterogeneity of risk behaviour with a small number of IDUs at increased risk of infection. No trends in the FOI over time were detected. There was only limited evidence of background HBV infection due to factors other than injecting. Conclusion The models highlight the need to increase interventions that target new initiates to injecting to reduce the transmission of blood-borne viruses. Although from the evidence here, identification of those individuals that engage in heightened at-risk behaviour may also help in planning effective interventions. The data and methods described here may provide a baseline for monitoring the success of public health interventions.

New direct-acting antivirals have the potential to transform the hepatitis C (HCV) treatment landscape, with rates of sustained viral response in excess of 90%. As these new agents are expensive, an important question is whether to focus on minimizing the consequences of severe liver disease, or reducing transmission via 'treatment as prevention'. A back-calculation model was used to estimate the impact of treatment of mild, moderate and compensated cirrhosis on incident cases of HCV-related end-stage liver disease/hepatocellular carcinoma (ESLD/HCC). In addition, a dynamic model was used to determine the impact on incidence and prevalence of chronic infection in people who inject drugs (PWID), the main risk group in England. Treating 3500 cirrhotics per year was predicted to reduce ESLD/HCC incidence from 1100 (95% CrI 970-1240) cases per year in 2015 to 630 (95% CrI 530-770) in 2020, around half that currently expected, although treating moderate-stage disease will also be needed to sustain this reduction. Treating mild-stage PWID was required to make a substantial impact on transmission: with 2500 treated per year, chronic prevalence/annual incidence in PWID was reduced from 34%/4.8% in 2015 to 11%/1.4% in 2030. There was little overlap between the two goals: treating mild stage had virtually no impact on ESLD/HCC within 15 years, but the long timescale of liver disease means relatively few PWID reach cirrhosis before cessation of injecting. Strategies focussing on treating advanced disease have the potential for dramatic reductions in severe morbidity, but virtually no preventative impact.

Cannabis is the most widely produced and consumed illicit psychoactive substance worldwide. Occasional cannabis use can progress to frequent use, abuse and dependence with all known adverse physical, psychological and social consequences. Individual differences in cannabis initiation are heritable (40-48%). The International Cannabis Consortium was established with the aim to identify genetic risk variants of cannabis use. We conducted a meta-analysis of genome-wide association data of 13 cohorts (N=32 330) and four replication samples (N=5627). In addition, we performed a gene-based test of association, estimated single-nucleotide polymorphism (SNP)-based heritability and explored the genetic correlation between lifetime cannabis use and cigarette use using LD score regression. No individual SNPs reached genome-wide significance. Nonetheless, gene-based tests identified four genes significantly associated with lifetime cannabis use: NCAM1, CADM2, SCOC and KCNT2. Previous studies reported associations of NCAM1 with cigarette smoking and other substance use, and those of CADM2 with body mass index, processing speed and autism disorders, which are phenotypes previously reported to be associated with cannabis use. Furthermore, we showed that, combined across the genome, all common SNPs explained 13-20% (P

Hepatitis C virus (HCV) antiviral treatment for people who inject drugs (PWID) could prevent onwards transmission and reduce chronic prevalence. We assessed current PWID treatment rates in seven UK settings and projected the potential impact of current and scaled-up treatment on HCV chronic prevalence. Data on number of PWID treated and sustained viral response rates (SVR) were collected from seven UK settings: Bristol (37-48% HCV chronic prevalence among PWID), East London (37-48%), Manchester (48-56%), Nottingham (37-44%), Plymouth (30-37%), Dundee (20-27%) and North Wales (27-33%). A model of HCV transmission among PWID projected the 10-year impact of (i) current treatment rates and SVR (ii) scale-up with interferon-free direct acting antivirals (IFN-free DAAs) with 90% SVR. Treatment rates varied from

This paper describes the results of an assessment of benefits from an Intelligent Transportation Systems (ITS) architecture, based on the National ITS Architecture Development program. Benefits of the architecture include those typically attributed to systems engineering and integration. The architecture provides a common framework so that, in planning and implementing systems, state and local agencies can be assured that ITS products and services are compatible and inter-operable with other ITS products and services. More directly, three beneficial features of the national architecture can be identified: 1) a framework for system integration; 2) common data and functions; and, 3) open interface standards.

This document focuses on a Field Operational Test (FOT) to develop an integrated information system for transit and traffic management and for traveler information that relies on Global Positioning System (GPS) equipped buses as probe vehicles. The document provides the evaluation plan for the FOT. The plan covers three principal elements: 1) Institutional, TMC Operator and Bus Operator, 2) Public Knowledge and Perceptions, and 3) System performance. The document provides an overall evaluation framework that describes how the evaluation elements will assess project objectives. In addition, for each element, the plan provides goals and objectives, data collection methods, data analysis methods, resources, schedule and deliverables.

In this paper, the authors formulate an evaluation taxonomy to identify a broad range of factors that would be important for a comprehensive assessment of congestion pricing. The evaluation taxonomy consists of three dimensions: road pricing strategies, impacted groups and impacts. The paper also includes a literature review of previous research in road pricing, especially regarding modeling tools and methods for conducting evaluation.

Outdoor practitioners widely embed reflective practice (RP) into the delivery of experiential education, but its contribution to their continued professional development remains under developed; by default, claims of its worth to the experiential education, they deliver must be approached with caution. Although the value of RP has been established in other domains, undergraduates on vocational outdoor leadership courses, in common with many other students, find engaging with RP problematic. This might be attributable in part to a focus on practicality and "doing rather than thinking" but also to obstacles encountered in their work experience where data are captured for later critical analysis. This paper sets out to establish the barriers to RP experienced by undergraduates during one season's summer employment. Data were gathered from focus groups, externally checked by two critical friends and subjected to interpretative phenomenological analysis. Extracts from reflective journals were used to illustrate the emergent themes. The results highlighted several commonly perceived barriers to RP in the outdoor workplace and have been used as discussion points in class to help students understand the nature of work in the outdoor sector and to identify and develop appropriate coping strategies.