Publications by authors named "Sarah Larney"

127 Publications

Concordance between self-reported and current hepatitis C virus infection status in a sample of people who inject drugs in Sydney and Canberra, Australia.

Drug Alcohol Rev 2021 Mar 23. Epub 2021 Mar 23.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.

Introduction: Awareness of hepatitis C virus (HCV) status among people who inject drugs is critical to ensure linkage to care and reduce transmission risk. Testing pathways, confusion about results and possible reinfection raise potential for discordance between perceived and actual HCV status among people who inject drugs. We evaluated self-reported and serologically confirmed HCV status concordance among a sample of Australian people who inject drugs.

Methods: Data were collected in May-June 2018 from participants in Canberra and Sydney, Australia, who had injected drugs at least monthly in the past 6 months. Participants completed a structured interview assessing self-reported HCV status and provided a dried blood spot sample for HCV RNA testing.

Results: Of 103 participants, 95% self-reported ever receiving antibody testing, 58% of whom reported having received RNA testing. Seventy-three percent of participants reported never having been told that they had HCV, 18% reported current infection and 9% did not know their current status. According to dried blood spot RNA testing, 20% were currently infected. Over a quarter of the sample (28%, n = 29) did not accurately report their HCV status, half of whom were unaware of a current infection.

Discussion And Conclusions: With over one-quarter of the sample in our study not accurately reporting their current HCV status, our findings reinforce the importance of regular testing for active infection, and the need for improved health literacy on HCV antibody and RNA test results, HCV status post-treatment and reinfection risk.
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http://dx.doi.org/10.1111/dar.13282DOI Listing
March 2021

Concordance between self-reported and current hepatitis C virus infection status in a sample of people who inject drugs in Sydney and Canberra, Australia.

Drug Alcohol Rev 2021 Mar 23. Epub 2021 Mar 23.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.

Introduction: Awareness of hepatitis C virus (HCV) status among people who inject drugs is critical to ensure linkage to care and reduce transmission risk. Testing pathways, confusion about results and possible reinfection raise potential for discordance between perceived and actual HCV status among people who inject drugs. We evaluated self-reported and serologically confirmed HCV status concordance among a sample of Australian people who inject drugs.

Methods: Data were collected in May-June 2018 from participants in Canberra and Sydney, Australia, who had injected drugs at least monthly in the past 6 months. Participants completed a structured interview assessing self-reported HCV status and provided a dried blood spot sample for HCV RNA testing.

Results: Of 103 participants, 95% self-reported ever receiving antibody testing, 58% of whom reported having received RNA testing. Seventy-three percent of participants reported never having been told that they had HCV, 18% reported current infection and 9% did not know their current status. According to dried blood spot RNA testing, 20% were currently infected. Over a quarter of the sample (28%, n = 29) did not accurately report their HCV status, half of whom were unaware of a current infection.

Discussion And Conclusions: With over one-quarter of the sample in our study not accurately reporting their current HCV status, our findings reinforce the importance of regular testing for active infection, and the need for improved health literacy on HCV antibody and RNA test results, HCV status post-treatment and reinfection risk.
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http://dx.doi.org/10.1111/dar.13282DOI Listing
March 2021

A rapid review of the impacts of "Big Events" on risks, harms, and service delivery among people who use drugs: Implications for responding to COVID-19.

Int J Drug Policy 2021 Jan 20:103127. Epub 2021 Jan 20.

Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM), 900 rue Saint-Denis, Montréal, QC H2X 0A9, Canada; Department of Family Medicine and Emergency Medicine, Université de Montréal, 2900 boulevard d'Edouard Montpetit, Montreal, QC H3T 1J4, Canada. Electronic address:

Background: "Big Events" are major disruptions to physical, political, and economic environments that can influence vulnerability to drug-related harms. We reviewed the impacts of Big Events with relevance to the COVID-19 pandemic on drug-related risk and harms and access to drug treatment and harm reduction services.

Methods: We conducted a rapid review of quantitative, qualitative, and mixed methods literature relating to the following Big Events: respiratory infection pandemics, natural disasters, financial crises, and heroin shortages. Included studies reported data on changes to risks, harms, and/or service provisioning for people who use illicit drugs (other than cannabis) in the context of these Big Events. Searches were conducted in PubMed in May 2020, and two reviewers screened studies for inclusion. Peer-reviewed studies published in English or French were included. We used a narrative synthesis approach and mapped risk pathways identified in the literature.

Results: No studies reporting on respiratory infection pandemics were identified. Twelve studies reporting on natural disaster outcomes noted marked disruption to drug markets, increased violence and risk of drug-related harm, and significant barriers to service provision caused by infrastructure damage. Five studies of the 2008 global financial crisis indicated increases in the frequency of drug use and associated harms as incomes and service funding declined. Finally, 17 studies of heroin shortages noted increases in heroin price and adulteration, potentiating drug substitutions and risk behaviors, as well as growing demand for drug treatment.

Conclusion: Current evidence reveals numerous risk pathways and service impacts emanating from Big Events. Risk pathway maps derived from this literature provide groundwork for future research and policy analyses, including in the context of the COVID-19 pandemic. In light of the findings, we recommend responding to the pandemic with legislative and financial support for the flexible delivery of harm reduction services, opioid agonist treatment, and mental health care.
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http://dx.doi.org/10.1016/j.drugpo.2021.103127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816610PMC
January 2021

Retention of opioid agonist treatment prescribers across New South Wales, Australia, 2001-2018: Implications for treatment systems and potential impact on client outcomes.

Drug Alcohol Depend 2021 02 19;219:108464. Epub 2020 Dec 19.

National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia. Electronic address:

Background: There has been much research on the efficacy and effectiveness of opioid agonist treatment (OAT), but less on its implementation and sustainability. A challenge internationally has been recruiting and retaining prescribers. This paper aims to characterise the prescribers in terms of OAT prescribing behaviours.

Methods: Retrospective cohort study in New South Wales, Australia. Participants were 2199 OAT prescribers between 1 st August 2001-19th September 2018.We examined trends in initiation and cessation of OAT prescribers. Adjusted hazard ratios were calculated to estimate prescriber retention, adjusting for year of initiation, practice type, client load and treatment prescribed.

Results: The rate of prescribers ceasing OAT prescribing has been increasing over time: a prescriber who initiated between 2016-2017 had over four times the risk of cessation compared with one who initiated before 2001, AHR: 4.77; [3.67-6.21]. The highest prescriber cessation rate was in prescribers who had prescribed for shorter time periods. The annual percentage of prescribers who ceased prescribing among those who prescribed for ≤5 years increased from 3% in 2001 to 20 % in 2017. By 2017 more prescribers were discontinuing prescribing than new prescribers were starting. Approximately 87 % (n = 25,167) of OAT clients were under the care of 20 % of OAT prescribers (n = 202); half had been prescribing OAT for 17+ years.

Conclusions: OAT prescribing is increasingly concentrated in a small group of mature prescribers, and new prescribers are not being retained. There is a need to identify and respond to the reasons that contribute to newer prescribers to cease prescribing and put in place strategies to increase retention and broaden the base of doctors involved in such prescribing.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855715PMC
February 2021

Initiation of Medications for Opioid Use Disorder Shortly Before Release From Prison to Promote Treatment Retention: Strong Evidence but Compromised Policy.

J Addict Med 2020 Dec 8. Epub 2020 Dec 8.

Behaviours and Health Risks Program Public Health Discipline Burnet Institute Melbourne, VIC, Australia School of Public Health and Preventive Medicine Monash University Melbourne, VIC, Australia Monash Addition Research Centre Monash University Melbourne, VIC, Australia Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal Quebec, Canada Department of Family Medicine and Emergency Medicine Université de Montréal Canada National Drug and Alcohol Research Centre UNSW Sydney Sydney, NSW, Australia Behaviours and Health Risks Program Public Health Discipline Burnet Institute Melbourne, VIC, Australia Department of Public Health LaTrobe University Victoria, Australia Behaviours and Health Risks Program Public Health Discipline Burnet Institute Melbourne, VIC, Australia Centre for Forensic Behavioural Science Swinburne University of Technology and Forensicare, Alphington, Australia Behaviours and Health Risks Program Public Health Discipline Burnet Institute Melbourne, VIC, Australia St Vincent's Hospital Victoria, Australia Behaviours and Health Risks Program, Public Health Discipline Burnet Institute Melbourne, VIC, Australia School of Public Health and Preventive Medicine Monash University, Melbourne, VIC, Australia.

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http://dx.doi.org/10.1097/ADM.0000000000000788DOI Listing
December 2020

The next wave? Mental health comorbidities and patients with substance use disorders in under-resourced and rural areas.

J Subst Abuse Treat 2021 02 4;121:108189. Epub 2020 Nov 4.

Injury Control Research Center, West Virginia University, United States of America; Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Behavioral Medicine and Psychiatry, West Virginia University, United States of America.

The rapid spread of the coronavirus disease (COVID-19) has impacted the lives of millions around the globe. The COVID-19 pandemic has caused increasing concern among treatment professionals about mental health and risky substance use, especially among those who are struggling with a substance use disorder (SUD). The pandemic's impact on those with an SUD may be heightened in vulnerable communities, such as those living in under-resourced and rural areas. Despite policies loosening restrictions on treatment requirements, unintended mental health consequences may arise among this population. We discuss challenges that under-resourced areas face and propose strategies that may improve outcomes for those seeking treatment for SUDs in these areas.
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http://dx.doi.org/10.1016/j.jsat.2020.108189DOI Listing
February 2021

Association between opioid agonist therapy use and HIV testing uptake among people who have recently injected drugs: a systematic review and meta-analysis.

Addiction 2020 Nov 3. Epub 2020 Nov 3.

Health Protection Research Unit, Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.

Background And Aim: Globally, nearly one in five people who inject drugs (PWID) are living with HIV, and the rate of new HIV infections in PWID is increasing in some settings. Early diagnosis is crucial for effective HIV control. We reviewed the evidence on the association between opioid agonist therapy (OAT) and HIV testing uptake among PWID.

Methods: We conducted a systematic review searching MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials and PsycINFO for studies published from January 2000 to March 2019. Reference lists and conference proceedings were hand-searched. Observational and intervention studies were eligible for inclusion. Risk of bias was assessed using the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tool. Meta-analyses were conducted using random-effects models.

Results: Of 13 373 records identified, 11 studies from Australia, Europe, Malaysia and the United States were included. All studies had at least a serious risk of bias, largely due to confounding and selection bias, making it difficult to draw causal conclusions from the evidence. Ten studies provided data on the association between current OAT use and recent HIV testing. Six showed a positive association, while four provided little evidence of an association: pooled odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.28-2.27. Looking at having ever been on OAT and having ever been HIV tested, seven studies showed a positive association and three showed either weak or no evidence of an association: pooled OR = 3.82, 95% CI = 2.96-4.95.

Conclusions: Opioid agonist therapy may increase uptake of HIV testing among people who inject drugs, providing further evidence that opioid agonist therapy improves the HIV treatment care cascade.
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http://dx.doi.org/10.1111/add.15316DOI Listing
November 2020

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis.

Drug Alcohol Depend 2020 12 12;217:108343. Epub 2020 Oct 12.

National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia.

Background: People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice.

Methods: We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission.

Results: 14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice.

Conclusions: Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736124PMC
December 2020

Hospitalisations for non-fatal overdose among people with a history of opioid dependence in New South Wales, Australia, 2001-2018: Findings from the OATS retrospective cohort study.

Drug Alcohol Depend 2021 01 18;218:108354. Epub 2020 Oct 18.

National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW, 2052, Australia. Electronic address:

Background: To examine, among a cohort of opioid dependent people with a history of opioid agonist treatment (OAT), the frequency and incidence rates of non-fatal overdose (NFOD) hospital separations over time, by age and sex.

Methods: Retrospective cohort study of people with a history of OAT using state-wide linked New South Wales (NSW) data. The incidence of NFOD hospital separations involving an opioid, sedative, stimulant or alcohol was defined according to the singular or combination of poisoning/toxic effect using ICD-10-AM codes. Crude incidence rates were calculated by gender, age group and calendar year.

Results: There were 31.8 (31.3-32.3) NFOD per 1,000 person-years (PY). Opioid NFOD incidence was higher in women than men: incidence rate ratio (IRR) 1.11 per 1,000PY; 95 %CI: [1.06-1.17]; women had higher sedative NFOD rates than men, IRR 1.27 per 1,000PY [1.21-1.34]. Participants ≤25 years, 26-30yrs, and 31-35yrs had higher incidence of opioid NFOD compared to 46+yrs, with IRRs of: 1.45 per 1,000PY; [1.32-1.59]; 1.20 per 1,000PY; [1.11-1.30] and 1.22 per 1,000PY; [1.13-1.32], respectively. Between 2006-7 and 2016-17, the cohort accounted for 19 % of NSW opioid NFOD episodes, 12 % of sedative, 14 % of stimulant and 5 % of acute alcohol-related NFOD.

Conclusions: Hospital stays due to NFOD are a relatively frequent occurrence among opioid-dependent people. There are clear differences in rates and substances involved by sex, age and over time. Evidence-based interventions that prevent overdose among people who are opioid dependent need to be delivered to scale, including widespread community provision of naloxone.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108354DOI Listing
January 2021

All-Cause and Overdose Mortality Risk Among People Prescribed Opioids: A Systematic Review and Meta-analysis.

Pain Med 2020 12;21(12):3700-3711

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; ‡School of Medicine (Psychology), University of Tasmania, Hobart, Tas, Australia.

Objective: To estimate all-cause and overdose crude mortality rates and standardized mortality ratios among people prescribed opioids for chronic noncancer pain and risk of overdose death in this population relative to people with similar clinical profiles but not prescribed opioids.

Design: Systematic review and meta-analysis.

Methods: Medline, Embase, and PsycINFO were searched in February 2018 and October 2019 for articles published beginning 2009. Due to limitations in published studies, we revised our inclusion criteria to include cohort studies of people prescribed opioids, excluding those studies where people were explicitly prescribed opioids for the treatment of opioid use disorder or acute cancer or palliative pain. We estimated pooled all-cause and overdose crude mortality rates using random effects meta-analysis models. No studies reported standardized mortality ratios or relative risks.

Results: We included 13 cohorts with 6,029,810 participants. The pooled all-cause crude mortality rate, based on 10 cohorts, was 28.8 per 1000 person-years (95% CI = 17.9-46.4), with substantial heterogeneity (I2 = 99.9%). The pooled overdose crude mortality rate, based on six cohorts, was 1.1 per 1000 person-years (95% CI = 0.4-3.4), with substantial heterogeneity (I2 = 99.5%), but indications for opioid prescribing and opioid exposure were poorly ascertained. We were unable to estimate mortality in this population relative to clinically similar populations not prescribed opioids.

Conclusions: Methodological limitations in the identified literature complicate efforts to determine the overdose mortality risk of people prescribed opioids. There is a need for large-scale clinical trials to assess adverse outcomes in opioid prescribing, especially for chronic noncancer pain.
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http://dx.doi.org/10.1093/pm/pnaa214DOI Listing
December 2020

Profile and correlates of injecting-related injuries and diseases among people who inject drugs in Australia.

Drug Alcohol Depend 2020 11 29;216:108267. Epub 2020 Aug 29.

National Drug and Alcohol Research Centre, 22-32 King st. Randwick, University of New South Wales Sydney, Sydney, Australia.

Introduction: People who inject drugs (PWID) commonly experience harms related to their injecting, many of which are consequences of modifiable drug use practices. There is currently a gap in our understanding of how certain injecting-related injuries and diseases (IRID) cluster together, and socio-demographic and drug use characteristics associated with more complex clinical profiles.

Method: Surveys were conducted with 902 Australian PWID in 2019. Participants provided information regarding their drug use, and past month experience of the following IRID: artery injection, nerve damage, skin and soft tissue infection, thrombophlebitis, deep vein thrombosis, endocarditis, septic arthritis, osteomyelitis, and septicaemia. We performed a latent class analysis, grouping participants based on reported IRID and ran a class-weighted regression analysis to determine variables associated with class-membership.

Results: One-third (34 %) of the sample reported any IRID. A 3-class model identified: 1) no IRID (73 %), moderate IRID (21 %), and 3) high IRID (6%) clusters. Re-using one`s own needles was associated with belonging to the high IRID versus moderate IRID class (ARRR = 2.38; 95 % CI = 1.04-5.48). Other factors, including daily injecting and past 6-month mental health problems were associated with belonging to moderate and high IRID classes versus no IRID class.

Conclusion: A meaningful proportion of PWID reported highly complex IRID presentations distinguished by the presence of thrombophlebitis and associated with greater re-use of needles. Increasing needle and syringe coverage remains critical in addressing the harms associated with injecting drug use and expanding the capacity of low-threshold services to address less severe presentations might aid in reducing IRID amongst PWID.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108267DOI Listing
November 2020

All-cause and cause-specific mortality among people with regular or problematic cocaine use: a systematic review and meta-analysis.

Addiction 2021 04 21;116(4):725-742. Epub 2020 Sep 21.

National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, Australia.

Aims: To estimate pooled all-cause and cause-specific mortality risk for people with regular or problematic cocaine use.

Methods: Systematic review and meta-analysis of prospective or retrospective cohort studies or clinical trials (n ≥30) of people with regular or problematic cocaine use with data on all-cause or cause-specific mortality. Of 2808 papers, 28 were eligible and reported on 21 cohorts, with a total 170 019 individuals. Cohorts identified based on acute care for drug poisoning or other severe health presentation were excluded. Title/abstract screening was conducted by one reviewer; a second reviewer independently checked 10% of excluded studies. Two reviewers conducted full-text screening. Data were extracted by one reviewer and checked by a second. A customized review-specific study reporting quality/risk of bias tool was used. Data on crude mortality rates (CMR) and standardized mortality ratios were extracted for both all-cause and cause-specific mortality. Standardized mortality ratios were imputed where not provided by the author using extracted data and information from the Global Burden of Disease Study 2017. Data were pooled using a random-effects model.

Results: The pooled all-cause crude mortality rate was 1.24 per 100 person-years [95% confidence interval (CI) = 0.86, 1.78; n = 16 cohorts], but with considerable heterogeneity (I  = 98.8%). The pooled all-cause standardized mortality ratio (SMR) was 6.13 (95% CI = 4.15, 9.05; n = 16 cohorts). Suicide (SMR = 6.26, 95% CI = 2.84, 13.80), accidental injury (SMR = 6.36, 95% CI = 4.18, 9.68), homicide (SMR = 9.38, 95% CI 3.45-25.48) and AIDS-related mortality (SMR = 23.12, 95% CI = 11.30, 47.31) were all elevated compared with age and sex peers in the general population.

Conclusions: There are elevated rates of mortality among people with regular or problematic cocaine use for traumatic deaths and deaths attributable to infectious disease.
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http://dx.doi.org/10.1111/add.15239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914269PMC
April 2021

Feasibility and acceptability of take-home naloxone for people released from prison in New South Wales, Australia.

Drug Alcohol Rev 2021 Jan 17;40(1):98-108. Epub 2020 Aug 17.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.

Introduction And Aims: To assess the feasibility and acceptability of a take-home naloxone program for people with a history of opioid use released from prison in New South Wales, Australia.

Design And Methods: Cross-sectional interviews with people with a history of opioid use who were recently released from prison (n = 105), and semi-structured interviews with key clinical and operational staff of Justice Health and Forensic Mental Health Network and Corrective Services NSW (n = 9).

Results: Among people with a history of opioid use who had recently left prison, there was very high awareness of the elevated risk of overdose following release from prison (95%) and the potential for naloxone to reverse an opioid overdose (97%). Participants considered that their personal risk of overdose was low, despite ongoing opioid use being common. Participants were largely supportive of take-home naloxone, but the majority (83%) stated that proactively obtaining naloxone would be a low priority for them following release. Key informants were supportive of introducing naloxone training and supply and identified barriers to implementation, including adequate resourcing, identifying the population for training, and developing an appropriate model of training and implementation.

Discussion And Conclusion: There was widespread support for naloxone training in custody and distribution at release among people recently released from prison and key stakeholders in health-care provision and prisons administration. As proactively accessing naloxone is a low priority for patients, naloxone supply at release may be more effective than programs that refer releasees to local pharmacies, but developing a sustainable supply model requires consideration of several barriers.
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http://dx.doi.org/10.1111/dar.13144DOI Listing
January 2021

Injecting risk behaviours amongst people who inject drugs: A global multi-stage systematic review and meta-analysis.

Int J Drug Policy 2020 10 24;84:102866. Epub 2020 Jul 24.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia. Electronic address:

Background: Injecting risk behaviour, such as receptive sharing of injecting equipment and/or re-using one's equipment, is associated with bloodborne virus transmission and infections in people who inject drugs (PWID). We aimed to estimate prevalence and correlates of injecting risk behaviours amongst PWID.

Methods: We conducted a systematic review and meta-analyses to estimate country, regional, and global prevalences of injecting risk behaviours (including sharing or re-using needle/syringe and sharing other injecting equipment). Using meta-regression analyses, we determined associations between study- and country-level characteristics and receptive needle/syringe sharing.

Results: From 61,077 identified papers and reports and 61 studies from expert consutation, evidence on injecting risk behaviours was available for 464 studies from 88 countries. Globally, it is estimated that 17.9% (95%CI: 16.2-19.6%) of PWID engaged in receptive needle/syringe sharing at last injection, 23.9% (95%CI: 21.2-26.5%) in the past month, and 32.8% (95%CI: 28.6-37.0%) in the past 6-12 months. Receptive sharing of other injecting equipment was common. Higher prevalence of receptive needle/syringe sharing in the previous month was associated with samples of PWID with a lower proportion of females, shorter average injecting duration, a higher proportion with ≥daily injecting, and older studies. Countries with lower development index, higher gender inequality and lower NSP coverage had higher proportions reporting receptive needle/syringe sharing.

Conclusions: High levels of injecting risk behaviours were observed amongst PWID globally, although estimates were only available for half of the countries with evidence of injecting drug use. There is a need for better capturing of injecting risk behaviours in these countries to inform implementation of harm reduction services and evaluate potential impacts of interventions to reduce risk.
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http://dx.doi.org/10.1016/j.drugpo.2020.102866DOI Listing
October 2020

What predicts pharmacists' engagement with opioid-outcome screening? Secondary analysis from an implementation study in community pharmacy.

Int J Clin Pharm 2021 Apr 12;43(2):420-429. Epub 2020 Jun 12.

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.

Background Pharmacists have a key role to play in identifying and responding to emerging clinical problems with prescribed opioids. A pilot study in Australia examined the implementation of screening and brief intervention (Routine Opioid Outcome Monitoring [ROOM]) to identify and respond to opioid-related problems in community pharmacies. In this implementation study, the rate of screening varied considerably between pharmacies. Objective The aim of this study was to examine pharmacist characteristics associated with implementation of ROOM. Setting Community pharmacies in Victoria and New South Wales, Australia. Methods We implemented a validated computer-facilitated screening (ROOM), combined with brief intervention for opioid-related problems based on a widely accepted framework for monitoring outcomes. In this analysis, we examined the correlates of ROOM completion for individual pharmacists. Negative binomial regression was used to identify baseline predictors of greater screening, with the number of ROOM screens as the dependent (outcome) variable and pharmacist demographics, knowledge, confidence and comfort responding to prescription opioids problems, and attitudes towards evidence based practice examined as independent (predictor) variables. Main outcome measure Number of screens completed by an individual pharmacist as reported in follow-up surveys by pharmacist. Results Fewer years of practice was associated with a greater number of screenings conducted. On average, each additional decade of practice was associated with a 31% (95% CI 0%, 53%) reduction in the number of screenings undertaken by pharmacists. A multivariable analysis revealed that each additional decade practicing, lower knowledge of naloxone and lower confidence in identifying unmanaged pain were all independently associated with reduced engagement in screening after controlling for other variables. Conclusion Findings from this pilot study identified potential barriers to implementing opioid outcome monitoring. Further studies could test different groups of community pharmacists' experience of different barriers when implementing monitoring outcomes with prescribed opioids, to inform future implementation and clinical practice.
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http://dx.doi.org/10.1007/s11096-020-01074-5DOI Listing
April 2021

Association between opioid agonist therapy and testing, treatment uptake, and treatment outcomes for hepatitis C infection among people who inject drugs: A systematic review and meta-analysis.

Clin Infect Dis 2020 May 24. Epub 2020 May 24.

The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.

Background: People who inject drugs (PWID) experience barriers to accessing testing and treatment for hepatitis C virus (HCV) infection. Opioid agonist therapy (OAT) may provide an opportunity to improve access to HCV care. This systematic review assessed the association of OAT and HCV testing, treatment, and treatment outcomes among PWID.

Methods: Bibliographic databases and conference presentations were searched for studies assessing the association between OAT and HCV testing, treatment, and treatment outcomes [direct-acting antiviral (DAA) therapy only] among people who inject drugs (in the past year). Meta-analysis was used to pool estimates.

Results: Among 9,877 articles identified, 22 studies conducted in Australia, Europe, North America, and Thailand were eligible and included. Risk of bias was serious in 21 studies and moderate in one study. Current/recent OAT was associated with an increased odds of recent HCV antibody testing [4 studies; odds ratio (OR), 1.80; 95% CI:1.36, 2.39), HCV RNA testing among those who were HCV antibody positive (2 studies; OR, 1.83; 95% CI:1.27, 2.62), and DAA treatment uptake among those who were HCV RNA positive (7 studies; OR 1.53; 95% CI: 1.07, 2.20). There was insufficient evidence of an association between OAT and treatment completion (9 studies) or sustained virologic response following DAA therapy (9 studies).

Conclusions: Opioid agonist therapy can increase linkage to HCV care, including uptake of HCV testing and treatment among PWID. This supports the scale-up of OAT as part of strategies to enhance HCV treatment to further HCV elimination efforts.
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http://dx.doi.org/10.1093/cid/ciaa612DOI Listing
May 2020

Global opioid agonist treatment: a review of clinical practices by country.

Addiction 2020 12 19;115(12):2243-2254. Epub 2020 May 19.

Centre Hospitalier de l'Université de Montréal Research Center, Quebec, Canada.

Aims: We assessed how opioid agonist treatment (OAT) for opioid use disorder (OUD), specifically methadone and buprenorphine, including buprenorphine-naloxone, is delivered in routine clinical practice, with a focus on factors that affect access to and delivery of these services. The aims of this review were to summarize eligibility criteria for entry to OAT, doses in routine clinical practice, access to and eligibility for unsupervised dosing and urine drug screening practices in OAT programs globally.

Methods: We completed searches of PubMed, Embase, and grey literature databases for cross-sectional or observational cohort studies of OAT using either methadone or buprenorphine. Dose data extracted from eligible studies were compared with guidelines provided by WHO.

Results: We found 140 reports from 41 countries that contained data for at least one of the relevant indicators. A diagnosis of opioid dependence or opioid use disorder was the most common eligibility requirement for OAT (13 or 17 countries). Reported mean or median doses for methadone ranged from 16-131 mg whereas range for buprenorphine was 2.5-19 mg. Access to unsupervised dosing under some conditions was reported in 18 of 27 countries. Frequency of regular urine drug screenings (UDS) ranged from several times a week to eight times per year (methadone) or as clinically indicated.

Conclusions: Opioid agonist treatment practices, including doses prescribed, vary greatly both within and across countries. Of particular concern is the persistence of lower dose prescribing practices, in which patients may be prescribed doses below those proven to yield significant clinical benefits.
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http://dx.doi.org/10.1111/add.15087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554123PMC
December 2020

Routine opioid outcome monitoring in community pharmacy: Outcomes from an open-label single-arm implementation-effectiveness pilot study.

Res Social Adm Pharm 2020 12 2;16(12):1694-1701. Epub 2020 Mar 2.

Drug Policy Modelling Program, Social Policy Research Centre, Kensington Campus, University of New South Wales, Sydney, Australia.

Background: In response to rising harms with prescription opioids, recent attention has focused on how to better utilise community pharmacists to monitor outcomes with opioid medicines.

Objective: This pilot aimed to test the implementation of software-facilitated Routine Opioid Outcome Monitoring (ROOM).

Methods: Community pharmacies in Victoria and New South Wales, Australia, were recruited to an open-label single-arm observational implementation-effectiveness pilot study. Pharmacists completed baseline and follow up interviews to measure change in knowledge and confidence following training on, and implementation of ROOM. Paired t-tests compared pre-post scores. Patients that participated were invited to complete a brief evaluation survey. Measures of feasibility and acceptability were collected.

Results: Sixty-four pharmacists from 23 pharmacies were recruited and trained to conduct ROOM. Twenty pharmacies (87%) were able to implement ROOM, with four pharmacies completing the target of 20 screens. Pharmacists completed ROOM with 152 patients in total. Forty-four pharmacists provided baseline and follow-up data which demonstrated significant improvements in confidence identifying and responding to unmanaged pain, depression and opioid dependence. Despite increases, low to moderate confidence for these domains was reported at follow-up. Responses from pharmacists and patients indicated that implementation of ROOM was feasible and acceptable.

Conclusions: Pharmacists' confidence in identifying and responding to opioid-related problems significantly increased from baseline to follow up across several domains, however scores indicated that there is still significant scope to further increase confidence in responding to opioid-related problems. ROOM is feasible and acceptable, though more extensive pharmacist training with opportunity to practice skills may assist in developing confidence and skills in this challenging clinical area.
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http://dx.doi.org/10.1016/j.sapharm.2020.02.009DOI Listing
December 2020

Socio-demographic and ecological factors associated with anti-HCV prevalence in people who inject drugs: A systematic review.

Drug Alcohol Depend 2020 04 6;209:107899. Epub 2020 Feb 6.

National Drug and Alcohol Research Centre, UNSW Sydney, 2052, Sydney, NSW, Australia.

Background: The World Health Organization (WHO) aim to eliminate hepatitis C virus (HCV) as a public health threat by 2030. People who inject drugs (PWID) are a key risk group for HCV transmission globally. We explored socio-demographic and ecological variables associated with HCV antibody (anti-HCV) prevalence among samples of PWID.

Methods: We systematically searched for and screened journal articles and online reports published between January 2011 and June 2017. Serologically confirmed anti-HCV prevalence among PWID and other study-level socio-demographic variables were extracted. Country-level ecological indicators were sourced from online databases. We used generalized linear models to investigate associations between anti-HCV prevalence estimates and other study-level and country-level variables.

Results: There were 223 studies from 84 countries contributing 569 estimates of anti-HCV prevalence among PWID. Among study-level indicators, higher levels of anti-HCV prevalence were associated with higher HIV prevalence (B = 0.20; 95 % Confidence Interval [95 %CI] = 0.12, 0.29, p < 0.001) and year of data collection (B=-0.08; 95 %CI=-0.15, -0.02; p = 0.011). At a national level, higher Human Development Index scores (B=4.37; 95 %CI=0.12, 8.63, p = 0.044) were associated with higher levels of anti-HCV in samples.

Implications: Serological surveillance data are increasingly available globally; however, there are still geographical gaps in quantification of HCV prevalence among PWID that must be addressed to inform efforts to achieve HCV elimination. Anti-HCV prevalence was lower in samples of PWID from countries with lower Human Development Index scores, which points to an opportunity to provide targeted intervention and potentially control transmission rates of infection in countries characterized by poor population health, education, and income.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.107899DOI Listing
April 2020

Global systematic review and ecological analysis of HIV in people who inject drugs: National population sizes and factors associated with HIV prevalence.

Int J Drug Policy 2020 03 14;77:102656. Epub 2020 Jan 14.

National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney 2052, NSW Australia.

Background: People who inject drugs (PWID) are at elevated risk of HIV infection. Data on population sizes of PWID living with HIV are needed to inform the implementation of prevention, treatment and care programs. We estimated national population sizes of people who recently (past 12 months) injected drugs living with HIV and evaluated ecological associations with HIV prevalence in PWID.

Methods: We used national data on the prevalence of injecting drug use and of HIV among PWID, derived from systematic reviews, to estimate national population sizes of PWID living with HIV. Uncertainty was estimated using Monte Carlo simulation with 100,000 draws. We extracted data on sample characteristics from studies of HIV prevalence among PWID, and identified national indicators that have been observed or hypothesised to be associated with HIV prevalence in PWID. We used linear regression to evaluate associations between these variables and HIV prevalence in PWID.

Results: Four countries comprised 55% of the estimated global population of PWID living with HIV: Russia (572,500; 95% uncertainty interval (UI) 235,500-1,036,500); Brazil (462,000; 95% UI 283,500-674,500); China (316,500; 95% UI 171,500-493,500), and the United States (195,500; 95% UI 80,000-343,000). Greater anti-HCV prevalence and national income inequality were associated with greater HIV prevalence in PWID.

Conclusion: The countries with the largest populations of PWID living with HIV will need to dramatically scale up prevention, treatment and care interventions to prevent further increases in population size. The association between anti-HCV prevalence and HIV prevalence among PWID corroborates findings that settings with increasing HCV should implement effective interventions to prevent HIV outbreaks. The association between income inequality and HIV among PWID reinforces the need to implement structural interventions alongside targeted individual-level strategies.
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http://dx.doi.org/10.1016/j.drugpo.2019.102656DOI Listing
March 2020

All-Cause and Cause-Specific Mortality Among People Using Extramedical Opioids: A Systematic Review and Meta-analysis.

JAMA Psychiatry 2020 05;77(5):493-502

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia.

Importance: Extramedical opioid use has escalated in recent years. A better understanding of cause-specific mortality in this population is needed to inform comprehensive responses.

Objective: To estimate all-cause and cause-specific crude mortality rates (CMRs) and standardized mortality ratios (SMRs) among people using extramedical opioids, including age- and sex-specific estimates when possible.

Data Sources: For this systematic review and meta-analysis, MEDLINE, PsycINFO, and Embase were searched for studies published from January 1, 2009, to October 3, 2019, and an earlier systematic review on this topic published in 2011.

Study Selection: Cohort studies of people using extramedical opioids and reporting mortality outcomes were screened for inclusion independently by 2 team members.

Data Extraction And Synthesis: Data were extracted by a team member and checked by another team member. Study quality was assessed using a custom set of items that examined risk of bias and quality of reporting. Data were pooled using random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression.

Main Outcomes And Measures: Outcome measures were all-cause and cause-specific CMRs and SMRs among people using extramedical opioids compared with the general population of the same age and sex.

Results: Of 8683 identified studies, 124 were included in this analysis (100 primary studies and 24 studies providing additional data for primary studies). The pooled all-cause CMR, based on 99 cohorts of 1 262 592 people, was 1.6 per 100 person-years (95% CI, 1.4-1.8 per 100 person-years), with substantial heterogeneity (I2 = 99.7%). Heterogeneity was associated with the proportion of the study sample that injected opioids or was living with HIV infection or hepatitis C. The pooled all-cause SMR, based on 43 cohorts, was 10.0 (95% CI, 7.6-13.2). Excess mortality was observed across a range of causes, including overdose, injuries, and infectious and noncommunicable diseases.

Conclusions And Relevance: The findings suggest that people using extramedical opioids experience significant excess mortality, much of which is preventable. The range of causes for which excess mortality was observed highlights the multiplicity of risk exposures experienced by this population and the need for comprehensive responses to address these. Better data on cause-specific mortality in this population in several world regions appear to be needed.
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http://dx.doi.org/10.1001/jamapsychiatry.2019.4170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990804PMC
May 2020

All-Cause and Cause-Specific Mortality Among People Using Extramedical Opioids: A Systematic Review and Meta-analysis.

JAMA Psychiatry 2020 05;77(5):493-502

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia.

Importance: Extramedical opioid use has escalated in recent years. A better understanding of cause-specific mortality in this population is needed to inform comprehensive responses.

Objective: To estimate all-cause and cause-specific crude mortality rates (CMRs) and standardized mortality ratios (SMRs) among people using extramedical opioids, including age- and sex-specific estimates when possible.

Data Sources: For this systematic review and meta-analysis, MEDLINE, PsycINFO, and Embase were searched for studies published from January 1, 2009, to October 3, 2019, and an earlier systematic review on this topic published in 2011.

Study Selection: Cohort studies of people using extramedical opioids and reporting mortality outcomes were screened for inclusion independently by 2 team members.

Data Extraction And Synthesis: Data were extracted by a team member and checked by another team member. Study quality was assessed using a custom set of items that examined risk of bias and quality of reporting. Data were pooled using random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression.

Main Outcomes And Measures: Outcome measures were all-cause and cause-specific CMRs and SMRs among people using extramedical opioids compared with the general population of the same age and sex.

Results: Of 8683 identified studies, 124 were included in this analysis (100 primary studies and 24 studies providing additional data for primary studies). The pooled all-cause CMR, based on 99 cohorts of 1 262 592 people, was 1.6 per 100 person-years (95% CI, 1.4-1.8 per 100 person-years), with substantial heterogeneity (I2 = 99.7%). Heterogeneity was associated with the proportion of the study sample that injected opioids or was living with HIV infection or hepatitis C. The pooled all-cause SMR, based on 43 cohorts, was 10.0 (95% CI, 7.6-13.2). Excess mortality was observed across a range of causes, including overdose, injuries, and infectious and noncommunicable diseases.

Conclusions And Relevance: The findings suggest that people using extramedical opioids experience significant excess mortality, much of which is preventable. The range of causes for which excess mortality was observed highlights the multiplicity of risk exposures experienced by this population and the need for comprehensive responses to address these. Better data on cause-specific mortality in this population in several world regions appear to be needed.
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http://dx.doi.org/10.1001/jamapsychiatry.2019.4170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990804PMC
May 2020

Frequency of injecting among people who inject drugs: A systematic review and meta-analysis.

Int J Drug Policy 2020 02 18;76:102619. Epub 2019 Dec 18.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, 2052 New South Wales, Australia.

Background: People who inject drugs (PWID) do so at varying frequencies. More frequent injecting is associated with skin and soft tissue infection, blood borne viruses, and overdose. The aims of this review are to estimate the prevalence of injecting frequency among PWID and compare these estimates to current needle-syringe distribution coverage estimates, and identify socio-demographic and risk characteristics, and harms associated with daily or more injecting.

Methods: We conducted a systematic review of the peer-reviewed and grey literature from 2008 to 2018 and extracted needle-syringe distribution coverage data from a recent systematic review. We generated country-, region-, and global-level estimates of daily or more injecting. We also ran meta-regression analyses to determine associations between daily or more injecting and socio-demographic characteristics, injecting risk behaviour, non-fatal overdose, injection site skin infection, and blood borne virus prevalence.

Results: Our search resulted in 61,077 sources, from which 198 studies were eligible for inclusion in this review. There were 74 countries with estimates for injecting frequency. Globally, we estimated that 68.1% (95%CI 64.5-71.6%) of PWID, equating to approximately 10.5 (95% UI 6.8-15.0) million people, inject daily or more frequently. There was a higher percentage of participants reporting daily or more injecting among samples with shorter injecting careers, more male participants and higher reporting of opioids as their main drug injected. Daily or more injecting was also associated with samples reporting a higher prevalence of HIV and hepatitis C antibody (anti-HCV), non-fatal overdose, and receptive needle sharing in the previous month.

Implications: WHO recently recommended a needle-syringe distribution target of 300 needles per PWID per year which is unlikely to be sufficient for the majority of PWID injecting daily or more who are out of drug treatment.

Funding: The Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, University of New South Wales.
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http://dx.doi.org/10.1016/j.drugpo.2019.102619DOI Listing
February 2020

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia.

Addiction 2020 07 5;115(7):1295-1305. Epub 2020 Feb 5.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia.

Aims: To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia.

Design: Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018.

Setting: Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018.

Measurements: Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance).

Findings: Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), < 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus < 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported 'no problems or concerns' with potential differences in availability, flexibility and location of XR-buprenorphine.

Conclusions: Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment.
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http://dx.doi.org/10.1111/add.14941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292758PMC
July 2020

Associations between national development indicators and the age profile of people who inject drugs: results from a global systematic review and meta-analysis.

Lancet Glob Health 2020 01;8(1):e76-e91

National Addiction Centre, King's College London, London, UK.

Background: Globally, an estimated 15·6 million people inject drugs. We aimed to investigate global variation in the age profile of people who inject drugs (PWID), identify country-level factors associated with age of PWID, and assess the association between injecting drug use (IDU) in young people and rates of injecting and sexual risk behaviours at the country level.

Methods: We derived data from a previously published global systematic review done in April, 2016 (and updated in June, 2017) on the percentage of young PWID, duration of IDU, average age of PWID, average age at IDU initiation, and the percentage of PWID reporting sexual and injecting risk behaviours. We also derived national development indicators from World Bank data. We estimated the percentage of young PWID for each country, using a random-effects meta-analysis (DerSimonian-Laird methodology) and generated pooled regional and global estimates for all indicators of IDU in young people. We used univariable and multivariable generalised linear models to test for associations between the age indicators and country urban population growth, youth unemployment percentage, the percentage of PWID who are female, the percentage of the general population aged 15-24 years, Gini coefficient, opioid substitution therapy coverage (per PWID per year), gross domestic product (GDP) per capita (US$1000), and sexual and injecting risk behaviours.

Findings: In the original systematic review, data on age of PWID was reported in 741 studies across 93 countries. Globally, 25·3% (95% uncertainty interval [UI] 19·6-31·8) of PWID were aged 25 years or younger. The highest percentage of young PWID resided in eastern Europe (43·4%, 95% UI 39·4-47·4), and the lowest percentage resided in the Middle East and north Africa (6·9%, 5·1-8·8). At the country level, in multivariable analysis higher GDP was associated with longer median injecting duration (0·11 years per $1000 GDP increase, 95% CI 0·04-0·18; p=0·002), and older median age of PWID (0·13 years per $1000 increase, 0·06-0·20; p<0·0001). Urban population growth was associated with higher age at IDU initiation (1·40 years per annual percentage change, 0·41-2·40). No associations were identified between indicators of IDU in young people and youth unemployment, Gini coefficient, or opioid substitution therapy coverage provision at the country level. No associations were identified between injecting and sexual risk behaviours and age of PWID.

Interpretation: Variation in the age profile of PWID was associated with GDP and urbanisation. Regions with the highest prevalence of young PWID (aged ≤25 years) had low coverage of interventions to prevent the spread of blood-borne viruses. Data quality highlights the need for improvements in monitoring of PWID populations.

Funding: Australian National Drug and Alcohol Research Centre, Australian National Health and Medical Research Council, Open Society Foundation, WHO, the Global Fund, UNAIDS, National Institute for Health Research Health Protection Research Unit for Evaluation of Interventions, Wellcome Trust.
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http://dx.doi.org/10.1016/S2214-109X(19)30462-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7024964PMC
January 2020

Use of alcohol swabs to clean injecting sites among people who regularly inject drugs in Australia.

Drug Alcohol Rev 2020 01 11;39(1):83-92. Epub 2019 Dec 11.

National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.

Introduction And Aims: Cleaning drug injection sites with alcohol swabs prior to injecting reduces risk of abscesses and other skin and soft tissue infections (SSTI). Better understanding of swabbing behaviours can inform interventions to improve injecting hygiene. We aimed to determine the socio-demographic, drug use and injecting risk exposure correlates of swabbing prior to injecting and reasons for not swabbing.

Design And Methods: The Illicit Drug Reporting System recruited participants who had injected drugs at least monthly in the past six months in June-July 2017 from all Australian capital cities via needle and syringe programs and word-of-mouth. A structured interview was used to collect information on drug use and related behaviour, as well as swabbing practices. Logistic regression was used to identify factors associated with not swabbing at last injection.

Results: Of 853 respondents, one-quarter (26%) reported that they did not swab prior to their last injection. In adjusted analyses, crystal methamphetamine as the last drug injected, past month receptive or distributive syringe sharing, and past month re-use of one's own needle were significantly associated with not swabbing at last injection. Among participants who did not swab at last injection, swabbing was frequently considered unnecessary and a small number disliked using alcohol swabs.

Discussion And Conclusions: Efforts are needed to increase awareness of the importance of injecting hygiene in preventing SSTI. Interventions to increase swabbing should be included as part of a wider package of injecting hygiene education, particularly in light of associations with receptive and/or distributive syringe sharing.
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http://dx.doi.org/10.1111/dar.13006DOI Listing
January 2020

Prevalence of Injecting Drug Use and Coverage of Interventions to Prevent HIV and Hepatitis C Virus Infection Among People Who Inject Drugs in Canada.

Am J Public Health 2020 01 14;110(1):45-50. Epub 2019 Nov 14.

Brendan Jacka, Stine Hoj, and Julie Bruneau are with Research Center of the Centre Hospitalier de l'Université de Montréal, Montréal, Quebec. Canada. Sarah Larney and Louisa Degenhardt are with National Drug and Alcohol Research Centre, UNSW Sydney, NSW, Australia. Naveed Janjua and Mel Krajden are with British Columbia Centres for Disease Control, Vancouver, British Columbia, Canada. Jason Grebely is with The Kirby Institute, UNSW Sydney.

To determine the number of people who inject drugs (PWID) in Canada and the annual coverage of opioid agonist treatment (OAT) and needle-and-syringe provision for PWID. We estimated the number of PWID in 11 of 13 Canadian provinces and territories in 2011 by using indirect multiplier methods based on provincial and territorial methadone recipient totals and proportion of surveyed PWID receiving methadone. We modeled annual increases for 2011 to 2016 on Quebec and British Columbia longitudinal data. We calculated needle-and-syringe coverage (World Health Organization [WHO] recommendation: ≥ 200 per PWID) and OAT coverage (WHO recommendation: ≥ 40 per 100 PWID) per province and territory annually. An estimated 130 000 individuals in Canada (0.55%) injected drugs in 2011, increasing to 171 900 individuals (0.70%) in 2016. Needle-and-syringe coverage increased from 193 to 291 per PWID, and OAT coverage increased from 55 to 66 per 100 PWID over the study period. While the number of PWID increased between 2011 and 2016, OAT coverage remained high, and needle-and-syringe coverage generally improved over time. These data will inform public health surveillance, service planning, and resource allocation, and assist monitoring of treatment and harm-reduction coverage outcomes.
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http://dx.doi.org/10.2105/AJPH.2019.305379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893337PMC
January 2020

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis.

Addiction 2020 06 10;115(6):1011-1023. Epub 2020 Feb 10.

National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aims: To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

Design: Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

Setting And Participants: People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

Measurements: Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

Findings: Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

Conclusions: People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.
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http://dx.doi.org/10.1111/add.14892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210080PMC
June 2020

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis.

Addiction 2020 06 10;115(6):1011-1023. Epub 2020 Feb 10.

National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aims: To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

Design: Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

Setting And Participants: People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

Measurements: Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

Findings: Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

Conclusions: People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.
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http://dx.doi.org/10.1111/add.14892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210080PMC
June 2020