Patterns of substance use and correlates of lifetime and active injection drug use among women in Malaysia

ABSTRACT

Background: While drug use is associated with HIV risk in Southeast Asia, little is known about substance use behaviors among women, including drug injection. Objectives: To describe patterns of substance use among women using alcohol and drugs in Malaysia and identify correlates of lifetime and active drug injection, a risk factor for HIV transmission. Methods: A survey of 103 women who used drugs in the last 12 months assessed drug use history and frequency, including drug injection and drug use during pregnancy, self-reported HIV-status, childhood and adulthood physical and sexual abuse, and access to and utilization of harm reduction services, including needle-syringe exchange programs (NSEP) and opioid agonist maintenance therapy (OAT). Principal component analyses (PCA) were conducted to assess drug use grouping. Results: Amphetamine-type substances (ATS; 82.5%), alcohol (75.7%) and heroin (71.8%) were the most commonly used drugs across the lifetime. Drug injection was reported by 32.0% (n = 33) of participants with 21.4% (n = 22) having injected in the last 30 days. PCA identified two groups of drug users: opioids/benzodiazepines and club drugs. Lifetime drug injection was significantly associated with lower education, homelessness, prior criminal justice involvement, opioid use, polysubstance use, childhood physical and sexual abuse, and being HIV-infected, but not with prior OAT. Conclusion: Women who use drugs in Malaysia report high levels of polysubstance use and injection-related risk behaviors, including sharing of injection equipment and being injected by others. Low OAT utilization suggests the need for improved access to OAT services and other harm reduction measures that prioritize women.     

Psychiatric comorbidity and the persistence of drug use disorders in the United States

Aims DSM‐IV drug use disorders, a major public health problem, are highly comorbid with other psychiatric disorders, but little is known about the role of this comorbidity when studied prospectively in the general population. Our aims were to determine the role of comorbid psychopathology in the 3‐year persistence of drug use disorders. Design and setting Secondary data analysis using waves 1 (2001–02) and 2 (2005–05) of the National Epidemiologic Survey on Alcohol and Related Conditions. Participants Respondents with current DSM‐IV drug use disorder at wave 1 who participated in wave 2 (n = 613). Measurements Alcohol Use Disorders and Associated Disabilities Interview Schedule IV (AUDADIS‐IV) obtained DSM‐IV Axis I and II diagnoses. Persistent drug use disorder was defined as meeting full criteria for any drug use disorder between waves 1 and 2. Findings Drug use disorders persisted in 30.9% of respondents. No Axis I disorders predicted persistence. Antisocial [odds ratio (OR) = 2.75; 95% confidence interval (CI): 1.27–5.99], borderline (OR = 1.91; 95% CI: 1.06–3.45) and schizotypal (OR = 2.77; 95% CI: 1.42–5.39) personality disorders were significant predictors of persistent drug use disorders, controlling for demographics, psychiatric comorbidity, family history, treatment and number of drug use disorders. Deceitfulness and lack of remorse were the strongest antisocial criteria predictors of drug use disorder persistence, identity disturbance and self‐damaging impulsivity were the strongest borderline criteria predictors, and ideas of reference and social anxiety were the strongest schizotypal criteria predictors. Conclusions Antisocial, borderline and schizotypal personality disorders are specific predictors of drug use disorder persistence over a 3‐year period.     

Drug use in rural China: a preliminary investigation in Hunan Province

Aims To compare characteristics and illicit drug abuse patterns among drug abusers in rural and urban areas of Hunan Province, China. Measurements and design Data collected by public security bureau on newly registered drug abusers between 2005 and 2008 in five urban and five rural areas (n = 1639) were extracted anonymously and analyzed. Setting and participants All newly registered drug users in urban (n = 812) and rural (n = 827) areas of Hunan Province were included. Findings Drug users from the rural areas were younger [31 (6.6) versus 34 (8.0) years, P < 0.001], with a higher proportion of males (86% versus 82%, P < 0.05) or married (34% versus 27%, P < 0.01). Rural drug users reported an earlier onset of drug use [27 (5.9) versus 30 (7.9) years old, P < 0.001], were more likely to report heroin as their primary drug of abuse (53% versus 47%, P < 0.001) and had a lower prevalence of criminal activities (19% versus 31%, P < 0.001). Rural drug users were less likely to report needle sharing (1.8% versus 4.3%, P < 0.01), less likely to report being human immunodeficiency virus positive (0.8% versus 2.6%, P < 0.01) and less likely to report prior drug treatment participation (2.8% versus 6.8%, P < 0.001). Conclusions Drug abuse is a substantial problem in both urban and rural areas in China. The very low proportion of newly registered drug users reporting any prior drug abuse treatment points to the importance of expanding substance abuse treatments, especially in rural areas where treatment penetration is even lower than in urban areas.     

Outcomes for older trauma patients in the emergency department screening positive for alcohol,cocaine, or marijuana use

Background: Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients. Objectives: To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older. Methods: This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80?mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens. Results: 21?320 patients were included in the alcohol analysis and 17?077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p?0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative. Conclusion: Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.     

Development and initial validation of a brief screener for focused HIV prevention efforts

Objectives

The public health response to the spread of HIV relies on behavioural changes, especially reductions in sexual and drug‐use‐related transmission risk behaviours (TRBs). While understanding the factors that dispose people towards risky behaviours is important scientifically, it can be difficult to distil the many predictors of sexual risk behaviours into a useful clinical tool for focused prevention efforts. Our goal was to evaluate the extent to which known predictors of sexual TRBs (self‐efficacy, treatment optimism, engagement with medical care, awareness of risky behaviours, substance use, and relevant behavioural and socio‐demographic characteristics) combined with additional attitude‐related assessments to identify those who had engaged in recent sexual TRBs and may therefore be at risk of additional TRBs.

Methods

In this study, we analysed data on beliefs and behaviours related to sex, substance use, HIV prevention and other relevant factors for 280 patients at a publicly funded HIV/AIDS clinic in Seattle. All participants completed a baseline audio computer‐assisted self interview (ACASI) as part of a larger trial focused on reducing TRBs.

Results

Our multivariate model yielded three screening questions that could prove effective in identifying HIV‐positive patients in need of focused prevention resources.

Conclusions

The resulting screener holds promise as a brief and easily deployed tool that can be used by providers regardless of access to ACASI technology. Additional validation is needed and longitudinal evaluation is currently in progress.

     

Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons

OBJECTIVE: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use. DESIGN: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996. MEASUREMENTS: Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART. RESULTS: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08). CONCLUSIONS: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.     

Gender moderates the influence of psychosocial factors and drug use on HAART adherence in the context of HIV and childhood sexual abuse

This study aimed to examine gender moderation within a stress and coping model of HIV medication adherence in adults with a history of childhood sexual abuse (CSA). Sequelae of CSA, including negative coping, psychological distress, and drug use, interfere with adherence to highly active antiretroviral treatment (HAART). These obstacles to adherence are likely moderated by gender. Gender may particularly influence the mediational effect of drug use on adherence. Participants included 206 adults living with HIV/AIDS and CSA. Categorical/continuous variable methodology in a structural equation modeling framework was used to test a multigroup model with women and men. Gender significantly moderated several effects in the model. For women, the effect of psychological distress on HAART adherence was mediated by drug use and the effect of drug use on viral load was mediated by HAART adherence. Among men, drug use did not significantly impact adherence. Since gender appears to moderate the effect of drug use on medication adherence, it is particularly important to address drug use within the context of HIV disease management in women with a history of CSA. Further, interventions to increase HAART adherence should take trauma history, gender, and drug abuse into account when assessing efficacy.     

Pneumothorax in drug abusers: a complication of internal jugular venous injections

We report the cases of six patients who suffered pneumothorax following admitted drug injection into the internal jugular vein area. One was treated in the hospital with observation and serial roentgenograms, two were treated with chest tube thoracostomy, and three left the emergency department against medical advice and were lost to follow up. As increasing numbers of parenteral addicts turn to central venous injection sites, this complication is likely to become more common.     

The reliability and validity of the Severity of Dependence Scale for detecting cannabis dependence in psychosis

AIMS: To determine the reliability and validity of the Severity of Dependence Scale (SDS) for detecting cannabis dependence in a large sample of in-patients with a schizophrenia spectrum disorder. DESIGN: Cross-sectional study. PARTICIPANTS: Participants were 153 in-patients with a schizophrenia spectrum disorder in Brisbane, Australia. MEASUREMENTS: Participants were administered the SDS for cannabis dependence in the past 12 months. The presence of Diagnostic and Statistical Manual Version-IV (DSM-IV) cannabis dependence in the previous 12 months was assessed using the Comprehensive International Diagnostic Interview (CIDI). FINDINGS: The SDS had high levels of internal consistency and strong construct and concurrent validity. Individuals with a score of >or = 2 on the SDS were nearly 30 times more likely to have DSM-IV cannabis dependence. The SDS was the strongest predictor of DSM-IV cannabis dependence after controlling for other predictor variables. CONCLUSIONS: The SDS is a brief, valid and reliable screen for cannabis dependence among people with psychosis.     

Urbanization and hospital admission rates for alcohol and drug abuse: a follow-up study of 4.5 million women and men in Sweden

AIMS: This study analyses whether the level of urbanization is associated with hospital admissions for alcohol and drug abuse, after adjustment for individual demographic and socio-economic characteristics. DESIGN: Follow-up study from 31 December 1996 to 31 December 1999. SETTING: Sweden. PARTICIPANTS: The entire Swedish population aged 25-64 yeras, in total 4.5 million women and men. MEASUREMENTS: Hospital admission rates for alcohol abuse (12,812 events) and drug abuse (6459 events). Level of urbanization was defined by population density and divided into quintiles. Cox proportional hazard models were used to analyse the data. FINDINGS: The results showed an apparent gradient for both women and men; with increasing level of urbanization the hospital admission rates for alcohol abuse and drug abuse increased sharply. After adjustment for age, marital status, education and immigrant status, the hazard ratios for hospital admission for alcohol abuse were 1.76 [confidence interval (CI) = 1.58-1.96] for women and 1.71 (CI = 1.60-1.82) for men in the most densely populated areas (quintile 5). For drug abuse the corresponding hazard ratios were 1.89 (CI = 1.67-2.15) for women and 2.38 (CI = 2.12-2.67) for men. CONCLUSIONS: A high level of urbanization was associated with increased hospital admission rates for alcohol abuse and drug abuse. The level of urbanization should be considered in the distribution of resources for prevention and treatment of alcohol and drug abuse.     

The use of record linkage to examine illicit drug use in pregnancy

AIMS: To examine the obstetric and perinatal outcomes for women with a drug-related hospital admission during pregnancy. DESIGN: Antenatal and birth admissions to New South Wales (NSW) hospitals from the NSW Inpatient Statistics Collection were linked to birth information from the NSW Midwives Data Collection over a 5-year period (1998-2002). MEASUREMENTS: Birth admissions were flagged as positive for drug use where a birth admission or any pregnancy admission for that birth involved an opioid, cannabis or stimulant-related International Classification of Diseases version 10 Australian modification (ICD-10AM) code. FINDINGS: A total of 416 834 live births were analysed over a 5-year period (1998-2002). Of these, 1974 pregnancies had an opioid ICD-10AM diagnosis recorded, 552 a stimulant-related ICD-10AM and 2172 a cannabis ICD-10AM diagnosis. Births in each of the drug groups were to women who were younger, had a higher number of previous pregnancies, were indigenous, smoked heavily and were not privately insured. These women also presented later in their pregnancy to antenatal services and were more likely to arrive at hospital unbooked. Neonates born to women in each of the drug groups were more likely to be premature and were admitted to neonatal intensive care and special care nursery more often, with neonates born to women in the opioid group admitted most often. CONCLUSIONS: Linked population level administrative data is a powerful method for examining the maternal and neonatal outcomes associated with the use of specific illicit drugs during pregnancy.     

Pacemaker lead thrombo-endocarditis in an intravenous drug abuser

We report a 30-year-old male intravenous drug abuser presenting with persistent pacemaker lead thrombosis with superimposed pacemaker lead endocarditis. He underwent urgent surgery, but expired due to refractory sepsis. This case confirms that patients with pacemakers are at risk of developing pacemaker lead thrombosis. In addition, they are at high risk of developing pacemaker lead endocarditis if additional risk factors for endocarditis are present. We believe this case report is unusual on account of pacemaker lead thrombosis as well as endocarditis occurring in a patient with history of intravenous drug abuse. Whether pacemaker patients with multiple leads need to be on long-term antiplatelet or anticoagulation therapy necessitates further studies.     

Revisiting drug progression: long-range effects of early tobacco use

AIMS: Drug progression models have been a cornerstone of scientific and public policy discussions for decades. These models have been criticized for their lack of causal mechanisms leading to drug dependence. Future research should focus on identification of pathways and covariates. This study re-examines tobacco use onset and progression to drug dependence in a multi-ethnic sample followed longitudinally from early to late adolescence (1990 to 1998-2000). METHODS: Data were collected in schools (n = 1208) during early adolescence (mean age 11.07), and subsequently face-to-face interviews were conducted at late adolescence (mean age 20.01). FINDINGS: Results indicated ethnic differences in rates and progression of tobacco use, with African Americans and foreign-born Latinos having larger proportions of abstainers and lower rates of persistent use. Most early adolescent smokers progressed to regular use. The odds of progression to marijuana abuse or dependence by later adolescence were highest (O.R. = 4.9) among persistent smokers, but not significant for foreign-born Latinos. The odds of progression to drug abuse or dependence were also highest (O.R. = 6.4) for persistent smokers, but not significant for African Americans. CONCLUSIONS: Implications for research on pathways and mechanisms of progression are discussed. Prevention programs may interrupt drug progression if they delay onset of tobacco use until mid-adolescence. Preventing targeted marketing efforts by the tobacco industry, regulating and enforcing tobacco control laws and pricing cigarettes at cost levels that adolescents find prohibitive are effective supplements to traditional behavior change interventions.     

In search for geroprotectors: in silico screening and in vitro validation of signalome-level mimetics of young healthy state

Populations in developed nations throughout the world are rapidly aging, and the search for geroprotectors, or anti-aging interventions, has never been more important. Yet while hundreds of geroprotectors have extended lifespan in animal models, none have yet been approved for widespread use in humans. GeroScope is a computational tool that can aid prediction of novel geroprotectors from existing human gene expression data. GeroScope maps expression differences between samples from young and old subjects to aging-related signaling pathways, then profiles pathway activation strength (PAS) for each condition. Known substances are then screened and ranked for those most likely to target differential pathways and mimic the young signalome. Here we used GeroScope and shortlisted ten substances, all of which have lifespan-extending effects in animal models, and tested 6 of them for geroprotective effects in senescent human fibroblast cultures. PD-98059, a highly selective MEK1 inhibitor, showed both life-prolonging and rejuvenating effects. Natural compounds like N-acetyl-L-cysteine, Myricetin and Epigallocatechin gallate also improved several senescence-associated properties and were further investigated with pathway analysis. This work not only highlights several potential geroprotectors for further study, but also serves as a proof-of-concept for GeroScope, Oncofinder and other PAS-based methods in streamlining drug prediction, repurposing and personalized medicine.     

Methylene chloride inhalation: an unusual form of drug abuse

Methylene chloride is a chlorinated hydrocarbon used widely in home and industry. Its intentional abuse has not been reported previously. We describe the case of a 14-year-old boy who presented with lethargy, nausea, and chills six hours after the intentional inhalation of a household product containing methylene chloride. The patient's elevated carboxyhemoglobin level responded well to 100% oxygen therapy. The pathophysiology and treatment of methylene chloride are discussed.