Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Evaluation of the range of safe,
effective and cost effective
interventions aimed at injecting
drug users, primary stimulant users
and prevention of drug related
overdose and death
Authors: S.E Health Protection Team, National Public Health Service
Date: 17/11/09
Version: 0e
Status: Final
Purpose and Summary of Document:
This report provides a review of the international evidence on safe,
effective and cost effective interventions aimed at injecting drug users;
primary stimulant users and interventions aimed at reducing overdose
and drug related deaths
Publication/Distribution:
For publication on Public Health Wales intranet and internet
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Contents
Executive Summary
3
1
Introduction
7
2
Methodology and focus
7
3
Areas of evaluation
8
3.1
Safe, effective and cost effective interventions for injecting
drug users
9
3.1.1
Needle and syringe programs
9
3.1.2
Vending machines (needle / syringe dispensing machines)
12
3.1.3
Drug consumption rooms
15
3.1.4
Provision of harm reduction and safe injecting information
16
3.1.5
Blood borne virus management
17
3.1.6
Provision of injecting related health care
18
3.2
Safe, effective and cost effective interventions to meet the
needs of stimulant users
19
3.2.1
Interventions to meet the needs of stimulant users
19
3.2.2
Substitute prescribing
20
3.2.3
Residential Rehabilitation
20
3.2.4
Contingency Management
20
3.2.5
Psychosocial interventions and brief interventions
21
3.2.6
Provision of equipment used in the consumption of stimulants
22
3.3
Safe, effective and cost effective interventions targeted at
reducing overdose and drug related deaths
23
3.3.1
Provision of education and information relating to overdose
23
3.3.2
Prevention of overdose post-release from prison services
24
3.3.3
Identification and intervention of those at risk of suicide
24
3.3.4
Provision of Naloxone
25
3.3.5
Overdose and stimulant drug use
25
3.3.6
Drug treatment and overdose
25
3.3.7
Overdose and antidepressant and benzodiazepine prescribing
26
3.3.8
Local arrangements between Police and ambulance arrangements
26
3.3.9
Accident and Emergency department follow-up
26
3.3.10
Information dissemination via public health alerts
26
4
References
27
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Executive Summary

The following broad areas for intervention were evaluated:
a) Interventions for injecting drug users (IDUs)
b) Interventions to meet the needs of stimulant users (including cocaine,
crack, amphetamine and methamphetamine)
c) Interventions targeted at reducing overdoses and drug related deaths

This report is not a systematic review; rather it is a pragmatic summary of
peer reviewed evidence. Lack of available peer review evidence does not
necessarily indicate lack of effectiveness of an intervention

The report focuses on interventions with the potential to reduce:
-
blood borne viral (BBV) transmission
-
drug overdose
-
bacterial infections
-
tissue damage due to injections
-
medical complications related to drug use
INTERVENTIONS FOR INJECTING DRUG USERS (IDUS)
Needle and syringe programmes (NSPs)

There is compelling evidence that increasing the availability and
utilisation of sterile injecting equipment by IDUs reduces HIV
substantially

There is no convincing evidence of any major unintended negative
consequences

NSPs are cost effective

NSPs have additional and worthwhile benefits apart from reducing HIV
infection among IDUs

Pharmacies and vending machines increase the availability and
probable utilisation of sterile injecting equipment by IDUs

Vending machines can provide 24 hour availability and improve access
in locations that are difficult to serve

Participation in NSPs reduces injecting risk behaviours in IDUs e.g.
sharing behaviours

Prison based NSPs are feasible and can provide benefits in the
reduction of risk behaviour and transmission of BBVs

There is insufficient evidence to determine the impact of NSPs on
hepatitis C infection in injecting drug users

Bleach and other forms of disinfection are not supported by good
evidence of effectiveness for reducing HIV infection
Drug Consumption Rooms (DCRs) or Safe Injecting Facilities (SIFs)
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users

DCRs may offer a unique and promising way to work with the most
problematic users – to reduce the risk of overdose, improve their health
and lessen the costs to society

DCRs may contribute to a reduced incidence of hepatitis C

Clarification required
establishment of DCRs
regarding
the
legal
issues
around
the
Hepatitis B (HBV) vaccination

HBV vaccination is a key intervention in reducing the direct and indirect
harms associated with injecting drug use

IDUs should be vaccinated against HBV and vaccination should be
prioritised by all substance misuse services including prison health care
services
Provision of harm reduction information and brief behavioural
interventions (BBIs)

There has been no systematic evaluation or review level evidence for
the cost effectiveness of general, unstructured provision of information
on harm reduction and safe injecting however high quality and up to date
information should be provided within the full range of health care setting
where there is contact with potential, current or ex drug users.

BBIs are a potential means to facilitate behaviour change within the area
of substance misuse e.g. in preventing HIV

Evaluations of BBIs as an approach to risk reduction required research
to determine both efficacy and effectiveness

Peer delivered interventions may potentially play a role in risk reduction
however further evaluation is required
Blood borne virus management

Dried blood spot testing as an alternative to venepuncture represents a
highly effective means of diagnosis BBVs amongst current and ex
injecting drug users and can be undertaken with a range of substance
misuse services

Treatment of BBVs in current and ex injecting drug users is effective and
cost-effective (successful outcome of treatment depends on a number of
factors)

Diagnosis of BBVs in ex and current drug users can allow for information
and behavioural lifestyle changes e.g. alcohol consumption that can
have a major impact on disease progression
INTERVENTIONS TO MEET THE NEEDS OF STIMULANT USERS
(INCLUDING COCAINE, CRACK AND AMPHETAMINE
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Evaluation of the Crack Treatment Delivery Model (CTDM) concluded that
appropriate treatment can help reduce high levels of crack use and for those in
treatment there are quantifiable health benefits

Service users placed importance upon fast access to treatment as
appropriateness of the service

Dexamphetamine prescribing may influence drug use and increase
treatment contact and retention.

Drug free psychosocial interventions such as counselling, provided on a
non-residential basis are the most cost effective option for clients with
few complicating problems

There is little understanding of how to prompt initial contact with
treatment services. Once made, rapid intake, proactive reminders and
practical help improve treatment uptake. Empathy and understanding
amongst key workers is important in retention and outcomes

Recognised psychotherapies delivered by professional psychologists
perform no better that well structured drug counselling

Cognitive behavioural approaches have an evidence base to support
them and group therapy may be as effective as individual therapy

Intensive residential rehabilitation may be appropriate for the most
complex cases

Evidence for the effectiveness of residential rehabilitation specific to
stimulant dependence with the UK context is required

Research specific to cocaine-dependent outpatients with depression and
to amphetamine users suggested benefits from Motivational Interviewing

In addition to injection, stimulants may be taken by snorting, smoking
and ingesting orally. A recent review of non-injection drug use and
hepatitis C infection identified gaps in research and concluded that the
causal pathway to infection remained unclear however there is a
theoretical possibility of BBV transmission from sharing crack pipes and
other non injecting equipment. Provision of this equipment improves
engagement
Evaluation of the range of safe, effective and cost effective
interventions targeted at reducing overdoses and drug related
deaths
The primary means to reduce overdose include:

Engendering behaviour change around the risk behaviours that lead to
overdose; this includes education around risks and more broadly, high
standard and appropriately dosed drug treatment that ensures tolerance
to opiates is maintained and that reduces injecting drug use.

Responses and interventions to reduce the mortality rate associated with
overdose once it has occurred e.g. training in resuscitation techniques,
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
local agreements with police to encourage witnesses to call an
ambulance and the provision of naloxone to reverse the effects of opiate
overdose

Information dissemination via public health alerts to significant changes
within drug supply that may influence overdose and to outbreaks of
highly pathogenic bacterial infections.

providing safe environments for drug use by individuals vulnerable to
overdose e.g. via safe injecting facilities

Education around overdose risks, and rapid admission into specialist
drug treatment services for individuals who are likely to relapse into
opiate use upon release from prison

Substance misusers prone to suicide through deliberate overdose tend
to enter treatment. Whilst in treatment the risk is modestly reduced and
dropping out or being thrown out of treatment restores high risk

Engaging drug users in treatment reduces drug related deaths, however
treatment must be high quality and tailored to patient need with careful
consideration of tolerance

A quantitative evaluation of cocaine, crack cocaine and amphetamine
use in relation to drug related death in the UK would provide valuable
evidence in this area

Data on overdose admission to accident and emergency (A&E)
departments show high levels of recidivism amongst vulnerable
individuals. This environment thus presents an opportunity for
intervention, e.g. education and referral to specialist services, for those
vulnerable individuals who are repeatedly overdosing and attending A &
E services
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Introduction
1
The purpose of this report is to provide a succinct review of the international
evidence behind key health care interventions targeted at injecting drug users.
The report will focus on interventions with the potential to reduce:

blood borne viral transmission

drug overdose

bacterial infections

tissue damage due to injections

medical complications related to drug use
The report will not examine the evidence base behind substitution treatment or
psychosocial interventions for opiate substitution treatment. These two central
health interventions targeting injecting drug users have been the subject of
thorough review elsewhere (Gossop et al, 2001; Gossop, 2006; Campbell et al;
2007).
2
Methodology and focus
This report is not a systematic review; rather it is a pragmatic summary of peer
reviewed evidence.
To identify key research and evaluation existing
publications of key UK and international professional bodies were examined to
identify evidence reviews. Publications from World Health Organisation
(WHO), The National Treatment Agency (NTA), the Advisory Council on the
Misuse of Drugs (ACMD), the Scottish Executive, the Department of Health
(DoH), and the National Institute for Health and Clinical Excellence (NICE) were
reviewed. Where such review level evidence was not available peer reviewed
journals were searched using the Medline database.
It should be emphasised that the evaluation of health interventions targeting
injecting drug use faces major methodological challenges that, to date, have
restricted the quality of research evidence. Difficult to access populations, lack
of control groups, lack of studies with sufficient statistical power, poorly defined
outcome measures, lack of robust baseline data and regression to the mean all
contribute in varying degrees to a lack of clarity in effectiveness and cost
effectiveness studies. A lack of evidence should not be considered as
evidence of in-effectiveness; thus biological plausibility and the other Bradford
Hill causal criteria are used by some reviews for interpreting the data (see
WHO, 2004 for a useful summary of these criteria).
This report limits its focus to the areas of intervention listed below, in practice
there is considerable overlap between these interventions, for example
provision of harm reduction material and vending machines are part of needle
and syringe programs (NSP).
It is suggested that this evidence is considered alongside the comprehensive
NTA paper ‘Treating drug misuse problems: evidence of effectiveness’
(Gossop, 2006).
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
3
Safe, effective and cost effective interventions for IDUs
and stimulant users
Areas of evaluation
The following broad areas for intervention were evaluated:
a) Interventions for injecting drug users
b) Interventions to meet the needs of stimulant users (including cocaine, crack,
amphetamine and methamphetamine)
c) Interventions targeted at reducing overdoses and drug related deaths
The degree to which the interventions discussed have been subjected to either
systematic review or to primary research varies greatly. In addition, rigorous
cost-effective appraisals of many of the interventions considered are rare. This
is reflected in the following report and will be addresses in the second stage of
this report process.
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
3.1
Safe, effective and cost effective interventions for IDUs
and stimulant users
Evaluation of the range of safe, effective and cost
effective interventions for injecting drug users
3.1.1 Needle and syringe programs
What are needle and syringe programs?
Needle and syringe programs (NSPs) (also referred to as needle exchange
programs) are programs that, in a range of situations and with different models
of delivery, provide injecting drug users (IDUs) with sterile needles, syringes
and other injecting related paraphernalia including sterile water, one use
cookers, one use filters and citric acid / vitamin C. NSPs also incorporate and
encourage the return and safe disposal of used injecting equipment. In the UK,
NSPs are delivered via community pharmacies, Tier 2 and 3 drug services,
hospital A&E departments and also by specialist mobile, outreach services,
hostels and custody suites.
What are the potential health benefits, and key roles of needle and
syringe programs in community settings?
The potential benefits and key roles of NSP are:

Reducing the transmission of blood borne viruses; in particular HIV,
hepatitis C (HCV) and hepatitis B (HBV)

Reducing the occurrence of soft tissue skin infections around injecting
sites by supporting increased hygiene in injection practices, and the
provision of wound care management

Education of IDUs on the risks of overdose, blood borne viral
transmission, safe injecting practices and associated risks of injection
including venous damage and deep vein thromboses

Provision of vaccinations for hepatitis A, hepatitis B and tetanus

Route for referral of IDUs into drug treatment services

Education and information on sexual health and the provision of
condoms

Education on alternative routes of ingesting illicit drugs including
smoking, and reducing move to injecting

Break the cycle – a route transition intervention aimed at reducing the
initiation of others into injecting
What is the evidence for the effectiveness of needle and syringe
programs?
NSP programs have been recently subjected to three high standard evidence
reviews:
- World Health Organisation evidence for action technical paper (WHO, 2004)
- NICE Needle Syringe Programme appraisal (NICE, 2008a)
- Health Protection Scotland review of evidence (Palmeteer et al, 2008)
The WHO review examined the effectiveness of NSPs in reducing HIV/AIDS
among IDUs. The NICE review, ‘a review of reviews’, looked at reviews of the
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
effectiveness and cost effectiveness of NSPs for IDUs (NICE, 2008a), and an
additional review of the qualitative evidence for NSP. The Scottish review
carried out by Health Protection Scotland, was a ‘review of reviews’ of evidence
for the effectiveness of harm reduction interventions in preventing hepatitis C
transmission among injecting drug users (Palmateer et al, 2008). English
language literature was systematically searched to identify reviews of the
impacts of selected interventions on HCV transmission.
These reviews have focused primarily on the impact of NSP on the
transmission of infectious disease. The evidence presented here is a summary
of the findings within these documents.
What is the evidence for the effectiveness of needle and syringe
programs in reducing HIV/AIDS in injecting drug users?
The NICE review concluded that there was evidence to support the
effectiveness of NSPs in reducing HIV infection among IDUs. There was
evidence from 11 cost effectiveness analyses and one cost benefit analysis
that, in terms of reducing HIV incidence and prevalence among IDUs, NSP are
cost effective.
The WHO review (which was examined within the NICE review of reviews)
looked at evidence for NSP impact on HIV. Applying the Bradford Hill Causal
Criteria (Hill, 1965) (and the additional criteria of cost effectiveness, absence of
negative consequences, unanticipated benefits, feasibility of implementation
and coverage, and special populations) as a framework to evaluate the
effectiveness of needle and syringe programs in reducing HIV/AIDS in injecting
drug users, the review concluded the following:

There is compelling evidence that increasing the availability and
utilisation of sterile injecting equipment by IDUs reduces HIV
substantially

There is no convincing evidence of any major unintended negative
consequences

Needle syringe programs are cost effective

Needle syringe programs have additional and worthwhile benefits apart
from reducing HIV infection among IDUs

Bleach and other forms of disinfection are not supported by good
evidence of effectiveness for reducing HIV infection

Pharmacies and vending machines increase the availability and
probable utilisation of sterile injecting equipment by IDUs (see section
below on further detail regarding vending machines).

Needle and syringe programs on their own are not enough to control HIV
infection among IDUs

Injecting paraphernalia legislation is a barrier to effective HIV control
among IDUs. Note: This conclusion was made within the context of USA
legislation in certain states in the USA
What is the evidence for the effectiveness of needle and syringe
programs in reducing HCV in injecting drug users?
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
The evidence for the effectiveness of NSP (and for other interventions) in
reducing the transmission of HCV is less clear. It is now not possible, for
ethical reasons, to carryout the type of intervention study that could
demonstrate a causal effect of NSP on HCV incidence as NSP are already in
place across the UK. The review level evidence, evaluated by the Scottish
HCV action plan review, is insufficient to conclude that NSP are effective in
reducing HCV incidence (Palmeteer et al, 2008). In addition there is insufficient
evidence to conclude that NSP are cost effective in the prevention of HCV.
In agreement with the Scottish Hepatitis C action plan review, the NICE review
(NICE, 2008a) concluded that, from two systematic reviews that there was
insufficient evidence to determine the impact of NSPs on HCV infection in
IDUs.
What is the evidence for the effectiveness of needle and syringe
programs in reducing injecting risk behaviour?
The NICE review (NICE, 2008a) concluded that there was evidence from one
good quality and five moderate quality systematic reviews and meta-analyses
that participation in NSPs reduces injecting risk behaviours in IDUs, in
particular self reported sharing of needles and syringes, and frequency of
injecting.
The Scottish Hepatitis C Action Plan review (Palmeter et al, 2008) concluded
that there is evidence to suggest that NSP are effective in reducing self
reported reductions in injecting risk behaviour, this relates primarily to
reductions in sharing behaviour.
What is the evidence for needle and syringe programs in prison settings?
With very high rates of incarceration amongst IDUs the role of prisons in
addressing blood borne viral hepatitis is potentially very important. A survey of
eight prisons in England and Wales suggested that hepatitis viruses were
transmitted in the prison context (Weild et al, 2000).
A review of research on prison based syringe exchange programs (operating in
Switzerland, Germany and Spain) indicated that needle and syringe exchange
in prisons is feasible and can provide benefits in the reduction of risk behaviour
and the transmission of blood borne viruses (Dolan et al, 2003). Research in
Scotland has revealed that HCV transmission can occur within the prison
context (Champion et al, 2004). Following an HIV outbreak at HMP Glenochil
in 1993, the Scottish Prison Service introduced several preventative measures
to reduce transmission of blood borne viral transmission; these include bleach
for sterilisation, counselling, detoxification and drug behaviour management
programs (Taylor et al, 1995; Champion et al, 2004).
What is the evidence for the effectiveness of needle and syringe
programs in reducing the occurrence of soft tissue skin infections?
As with blood borne viral transmission there has been no systematic evaluation
of the impact of NSP on injection site infections. With the current distribution of
NSP in the UK such an evaluation is unlikely.
What is the evidence for the effectiveness of needle and syringe
programs as sources of education on overdose, blood borne viral
transmission, safe injecting practices and associated risk of injections?
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
NSPs should provide, in addition to clean injecting equipment; education on
overdose, blood borne viral transmission, safe injecting practices and
associated risk of injections. The NTA review of NSP in England in 2005
(Abdulrahim et al, 2006) reported that the majority of Drug Action Team (DATs)
had at least one specialist NSP that provided face to face harm reduction
advice, and referral to structured treatment. However around a half did not
provide a service offering HCV or HBV testing (Abdulrahim et al, 2006). A pilot
needle exchange data collection project, undertaken by NPHS in 2008,
established that harm reduction information was routinely provided in the
voluntary and statutory sector needle exchange services but to a far less extent
in community pharmacy based outlets (NPHS, 2009). There is no research
evidence to inform the effectiveness of these educational interventions as
provided by NSP on blood borne viral transmission or other injection related
infections.
What is the evidence for the effectiveness of needle and syringe
programs in the provision of hepatitis B vaccination?
The effectiveness of HBV vaccination is well established. Recommendations for
its use and target groups are covered in Immunisation against infectious
disease (Department of Health 2006). It is clear that NSP can facilitate HBV
vaccination, however the contribution of NSP to HBV vaccination has not be
subject to systematic review in Wales. The NTA review of NSP in England in
2005 (Abdulrahim et al, 2006) reported wide variation in the provision of onsite
HBV immunisation.
What is the evidence for the effectiveness of needle and syringe
programs in as a route for referral of IDUs into drug treatment services?
It is rational to assume that NSP can provide a route for referral of IDUs into
drug treatment services. The extent to which this occurs is unclear in the UK.
NSPs are provided within pharmacy settings and also within drug treatment
service settings. The pilot needle exchange data collection project (NPHS,
2009) established that signposting to specialist drug services occurred regularly
in the voluntary and statutory sector needle exchange services but to a far less
extent in community pharmacy based outlets.
3.1.2 Vending machines (Needle / syringe dispensing machines)
What are needle and syringe dispensing machines?
Needle / syringe dispensing machines (NDM) have been used since 1988 as
an established part of the blood borne virus prevention in injecting drug user
populations (Leicht, 1993). Syringe vending machines are NDMs where the
contents are sold.
The definition of NDM is broader and includes machines
with free or token accessed dispensing. NDM are designed to provide 24 hour
access to sterile injecting equipment (needles and syringes) and safe disposal
of used equipment. There are a number of countries within Europe utilising
NDM alongside more traditional needle exchange programmes. Outside of
Europe NDM have been used in Australia (115 machines) and New Zealand (4
machines) (Islam et al, 2007). All forms of sterile injecting equipment
distribution have the potential to increase the amount of discarded needles and
syringes, however, drug related litter prevention is addressed by the placing of
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
a disposal bin in the close vicinity of the vending machine. There is currently a
vending machine in operation in Southampton.
What are the potential health benefits of needle and syringe dispensing
machines?
NDM are designed to support, not replace, existing pharmacy or drug service
based needle exchanges services. NDM are designed for use by all injecting
individuals including those who do not, or will not, access pharmacy or drug
service based needle exchange services. The reasons for this may include:
young age; being responsible for children, early on in injecting career;
unwillingness to identify themselves as part of an injecting community, inject
infrequently; fear of breach of confidentiality by needle exchange staff. NDM
can also provide sterile injecting equipment in locations where it is not feasible
to provide pharmacy or drug service needle exchange provision.
What is the evidence for the effectiveness of needle and syringe
dispensing machines?
Measuring the impact of NDM on the transmission of blood borne viruses is, for
logistic and ethical reasons, unlikely to be achieved in the short term. NDM are
generally introduced as part of a package of interventions (e.g. pharmacy
based needle exchange, methadone programs etc) aimed at reducing drug
related harm. Disease incidence studies with sufficient power to measure the
impact of interventions on the transmission of blood borne viruses amongst
drug injectors are by nature large and thus costly. Separating out the effects of
individual components of an intervention and controlling for confounding effects
in studies of disease incidence is a major challenge. The majority of published
research on the efficacy of NDM is therefore limited to evaluations of temporal
and spatial levels of use, perceptions of NDM, potential problems e.g. safe
disposal of used equipment associated with NDM, and cost effectiveness.
Two key review documents have examined the evidence base for NDM; In
2004 a World Health Organisation Evidence for Action Technical Paper
addressed NDM within a wider appraisal of the effectiveness of sterile needle
and syringe programming in reducing HIV/AIDS among injecting drug users
(WHO, 2004) and Islam and Conigrave (2007) examined the advantages and
disadvantages of syringe vending machines in light of available evidence.
The WHO report (WHO, 2004) examined the wider effectiveness of the sale of
needles and syringes from pharmacies and vending machines in preventing
HIV infection among IDUs. The report examined nine studies that looked at
the effect of pharmacy sales and syringe vending machines on risk outcomes
and HIV sero-prevalence among IDUs and concluded that there was sufficient
evidence to fulfil:








strength of association
replication of findings
specificity of association
temporal sequence
biological plausibility
coherence of evidence
reasoning by analogy
cost effectiveness
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales




Safe, effective and cost effective interventions for IDUs
and stimulant users
absence of negative consequences
feasibility of implementation
expansion and coverage
special populations
However there was insufficient evidence to fulfil:
 biological gradient
 experimental evidence
 unanticipated benefits
No indeterminate or negative studies were identified for either pharmacy sales
or vending machines. Whilst the application of the criteria was to the wider
effectiveness of the sale of needles and syringes from pharmacies and vending
machines the report identified that:
a) syringe vending machines can provide 24 hour availability and improve
access in locations that are difficult to serve
b) the introduction of vending machines in an open prison in Hamburg resulted
in a significant reduction in needle sharing
c) no evidence was found that increased pharmacy sales or vending machines
have caused non-IDUs to become users
d) primary users of vending machines were more likely to be younger, less
likely to be in drug maintenance treatment and less likely to share needles
and syringes (Obadia et al, 1999).
The literature and international experience of syringe vending machines was
reviewed by Islam and Conigrave (2007). This review identified a number of
advantages and disadvantages associated with this intervention. The
advantages cited were:
a) Off peak and increased after-hour access to sterile injecting equipment that
matches patterns of drug use and availability
b) Increasing geographic reach; reducing the distance between IDU and sterile
equipment
c) Access in areas where it is not possible to establish staffed outlets
d) Non-stigmatised access to sterile equipment and access for individuals who
do not wish to be ‘seen as IDUs’
e) Anonymity, privacy and confidentiality
Machines have also been used within prisons in Germany and Switzerland.
Research from France reported that users of machines reported less sharing of
syringes in the previous six months than users of pharmacies, and a little more
than users of staffed needle exchanges (Moatti et al, 2001). However machine
users reported reduced sharing of paraphernalia compared to pharmacy users.
(Note: without randomised control trials such data is, due to potential
confounding, difficult to interpret).
The main disadvantage cited by the review was that vending machines keep
injecting drug users away from important health contact. This lack of contact
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
potentially deprives injectors of information, education and communication.
Staffed exchanges can be the first point of contact for health services with
some injectors facilitating access into treatment and for the most vulnerable
contact with primary health care. This issue may be overcome if distribution of
tokens for the vending machines is facilitated by substance misuse or health
services.
What evidence exists for the cost effectiveness of needle and syringe
dispensing machines?
There is no evidence to inform estimates of the cost effectiveness of vending
machines.
The potential impact of needle and syringe exchange is limited by the access
and attractiveness of these services to potential clients; vending machines can
increase this access to a broader range of IDUs and extend the time when
sterile equipment is available. They can offer anonymous and confidential
provision. Vending machines however do not offer contact between IDU and
health staff. They potentially have a role to supplement NSP provision in
specific circumstances but should not replace NSP. NDM could provide clean
equipment to steroid injectors; steroid use is on the increase in Wales, many
steroid users do not wish to access drug services and exchanges aimed at
opiate and stimulant injectors. Any NDM should be accompanied by tamper
proof needle and syringe disposal facilities. Realistic objectives should be set
for the evaluation of any NDM introduced in Wales.
3.1.3 Drug consumption rooms
What are drug consumption rooms?
Drug consumption rooms (DCRs, also known as supervised injecting rooms or
medically supervised injecting centres) are legally sanctioned facilities that
allow injecting drug users to self-administer illicit drugs in an environment that
can support a reduction in the risk of blood borne viral transmission, injection
site infections, drug overdose and public order concerns. These facilities have
trained medical personnel present at all times to supervise, but physically not
assist, injectors. There were, as of 2006, approximately 65 DCRs in operation
in eight countries around the world but there are none in the UK. An
independent working group, set up by the Joseph Rowntree Foundation,
examined the evidence for the development of DCRs in the UK. The group
concluded that DCRs offered ‘a unique and promising way to work with the
most problematic users – to reduce the risk of overdose, improve their health
and lessen the costs to society…’ and recommended the piloting and
evaluation of DCRs in the UK (Independent Working Group, 2006). Guidance
on standards for the establishment and operation of DCRs in the UK has
recently been published outlining and addressing the legal issues (Hunt, 2008).
A review of the evidence of primary prevention interventions for HCV among
IDUs found only one evaluation of a DCR that studied anti-HCV seroconversion as an outcome. Overall the review concluded that it was plausible
that DCR could contribute to a reduced incidence of HCV (Wright and
Tompkins, 2006).
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
3.1.4 Provision of harm reduction and safe injecting information
What information on harm reduction and safe injecting is offered and
what formats have been evaluated?
Information on harm reduction and safe injecting is currently offered in a range
of settings across Wales. The manner in which this information is provided,
both verbal, written or visual (DVD/film) will vary across the country from
general provision of information to structured intervention. To our knowledge
the impact of this information upon disease transmission, risk behaviour or
client knowledge has not been systematically evaluated. Despite these
limitations, high quality and up to date information should be provided within the
full range of health care settings where there is contact with potential, current or
ex drug users. There is no review level evidence for the cost effectiveness of
the general, unstructured provision of information on harm reduction and safe
injecting.
Brief behavioural interventions (BBIs) are a potential means to facilitate
behaviour change within the area of substance misuse. BBIs have been shown
to have a role in preventing HIV (Fishbein, 2000). A recent study from Australia
compared a BBI for reducing hepatitis C risk practices among injecting drug
users to a standardised educational intervention (Tucker et al, 2004). The
study reported that both the intervention and control group reported significant
reductions in risk behaviour however the brief intervention did not show
evidence of being more effective.
The range of interventions that can be considered as BBI is extensive; likewise
the potential targets for intervention, for example reduction of risk behaviour,
reduction of viral transmission, reduction in injecting frequency etc. Evaluations
of BBI as an approach to risk reduction require research to determine both
efficacy and effectiveness.
Peer delivered interventions can potentially play a role in risk reduction (Aitken
et al, 2002). However further evaluation is needed on how such interventions
can best be delivered to reduce disease incidence.
Hepatitis B vaccination is a key intervention in reducing the direct and indirect
harms associated with injecting drug use. Recommendations for its use and
target groups are covered in Immunisation against infectious disease (DoH,
2006). Injecting drug users should be vaccinated against HBV and vaccination
should be prioritised by all substance misuse services including prison health
care services. Evidence from NPHS research with injecting drug users in
Wales indicated that of a sample of 700 current IDUs, 71% had been in prison
on at least one occasion and that the majority of IDUs had received HBV
vaccination within the prison setting (NPHS, 2006). In addition research from
Scotland demonstrated the potential increase in uptake of HBV vaccination that
can be achieved with a prison based vaccine program; with prison vaccination
contributing significantly to coverage measured in community settings
(Hutchinson et al, 2004).
3.1.5 Blood borne virus management
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
The management of chronic hepatitis B, hepatitis C and HIV should be carried
out by specialist clinicians (gastroenterologists, hepatologists and infectious
disease specialists) and primary care. Guidelines for treatment of chronic HBV
infection have been issued by the NICE. NICE has made recommendations for
the use of adefovir dipivoxil and peginterferon alfa-2a to treat chronic hepatitis
B (NICE, 2006b). These recommendations do not apply to people who are also
infected with hepatitis C or D, or HIV. More recently Entecavir has been
approved for treatment of Hepatitis B (NICE, 2008b). The effectiveness of HBV
vaccination is also well established for HBV prevention in those infected with
hepatitis C and HIV
NICE guidelines support the use of combination therapy for treatment of HCV
positive individuals with mild, moderate or severe liver disease, patients may
require ongoing support throughout the treatment process (NICE, 2006a).
Changes in lifestyle, in particular in relation to alcohol consumption can have a
major impact on disease progression.
Treatment of acute infection is in the UK relatively uncommon, acute infections
are largely asymptomatic and with current levels of diagnostic infections many
acute infections will be missed. With improvements in diagnosis of infection,
possible with the adoption of dried blood spot testing across Wales it is likely
that more acute infections may be detected. A recent review of treatment of
acute HCV infection (Wiegand et al, 2008) concluded that acute HCV can be
successfully treated and highlighted the need for further research into this
important area.
HIV treatment can be managed by Highly Active Anti Retroviral Treatment
(HAART) within specialist clinical settings.
Diagnostic testing is an essential step on the pathway to treatment. Research
in South Wales showed that testing rates amongst IDUs was low (NPHS, 2006)
A pilot study in North West Wales has demonstrated the effectiveness of dried
blood spot testing as an alternative to venepuncture testing amongst IDUs
(DBS is much easier among individuals with poor vein access) (Craine et al,
2008). In the study there was an approximately seven fold increase in testing
by DBS when compared to venepuncture testing in the previous year.
Recent research from Ireland reported that structured clinical guidance for GPs
increased screening for HCV (Cullen et al 2006). There is little evidence in the
UK for the effectiveness or otherwise for awareness raising among those who
may have in the past put themselves at risk of blood borne viral hepatitis
infection. However, a recent Health Technology Assessment (Castelnuovo et
al, 2006) concluded that:
a) Case finding for hepatitis C in former injecting drug users is likely to be
considered cost-effective by NHS commissioners
b) Improvements in treatment would improve cost effectiveness
c) Case finding is likely to be most effective when targeted at people with more
advanced HCV disease
Screening for HCV in the prison setting is possible, however early evaluation of
a screening project in HMP Dartmoor reported low uptake of screening and a
high attrition rate through the screening process (Horne et al, 2004). Research
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
into optimising both screening of prisoners and subsequent follow-up of
infected individuals is urgently needed.
Screening of pregnant women is routinely undertaken for HIV and HBV
however testing for HCV is currently by consent.
3.1.6 Provision of injecting related health care; bacterial infections, vein
damage and deep vein thromboses
Injecting drug use carries with it the risk of blood borne viral transmission via
sharing of contaminated equipment as addressed in previous sections, and
problems associated with bacterial infections, vein damage and deep vein
thromboses (DVTs). Wound care for bacterial infections may be addressed,
depending on the severity of the problem, within a range of health care settings
ranging from acute hospital settings for severe manifestations through to clinics
within drug services for more straight forward cases. DVTs will require
attention within acute hospital settings. The extent to which drug services can
address the problems associated with injecting will reflect the clinical resources
available to services. Services must however be able to spot serious problems
and rapidly refer individuals to specialist services for treatment.
We are aware of no systematic evaluation of interventions aimed at bacterial
infections, vein damage and deep vein thromboses within a UK context.
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
3.2 Assess the range of safe, effective and cost effective
interventions to meet the needs of stimulant users (including
cocaine, crack, amphetamine and methamphetamine)
3.2.1 Interventions to meet the needs of stimulant users
What interventions are indicated for the treatment of stimulant users?
There is only limited research data on the efficacy of treatment interventions for
the treatment of stimulant users. Nonetheless drug services are faced
increasingly with the challenge of providing treatment for stimulant use amongst
individuals both with and without opiate dependency.
Crack use: The most detailed evaluation currently available to guide the
treatment of crack cocaine use in the UK context is the NTA and DoH National
Evaluation of Crack Cocaine Treatment and Outcomes (NECTOS) study
(Weaver et al, 2007). This study drew on the experiences of services providing
specialist interventions for crack cocaine use in the UK. This evaluation
concluded that specialist crack treatment services are relatively new and do not
have an established evidence base. The report identified a need to implement
and evaluate promising interventions that are appropriate to crack and
stimulant use in the context of opiate substitution therapy. In the absence of a
wide research evidence base the development of specialist services should
continue on the basis of emerging best practice.
A further recent study evaluated the implementation of the Crack Treatment
Delivery Model (CTDM) across 11 cities and 13 services in England (Arnull et
al, 2007). This model was developed by the NTA as part of the response to the
National Crack Action Plan (NTA, 2002). The model was designed in line with
NTA models of care and Drug and Alcohol National Standards (DANOS). The
CTDM aimed to disseminate best practice in the engagement, retention and
treatment of crack users and involved; training for managers and staff; a
manual of practice materials; guidance about service specifications; other
frameworks for service delivery; two days consultancy support for each site.
The study concluded that:
a) Services adapted existing resources to their needs
b) Staff who adopted and adapted materials were most positive about the pilot
c) Managers and stakeholders were less engaged
d) The appropriateness of the service was important to users (particularly
women and those from BME groups)
e) Service users placed importance upon fast access to treatment
The implications of the findings were that appropriate treatment can help
reduce high levels of crack use and for those in treatment there are quantifiable
health benefits. The CDTM is elaborated in detail within the evaluation report
(Arnull et al, 2007). The NTA produce a resource pack for treatment providers
on treating crack and cocaine use (NTA, 2003).
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
3.2.2 Substitute prescribing
Substitute prescribing for stimulant, primarily amphetamine, use is a
contentious procedure (Gossop, 2006a); limited evidence exists as to its
effectiveness. Research has suggested that dexamphetamine prescribing may
influence drug use and increase treatment contact and retention (McBride et al,
1997; Shearer et al, 2001). It has been suggested that treatment should be
time limited and restricted to heavy and problematic primary stimulant users
(Flemming, 1998). Although amphetamine prescribing occurs, research is
needed to robustly evaluate its effectiveness.
3.2.3 Residential Rehabilitation
One USA study reported limited evidence for the impact of residential programs
on crack users who had no pressing reason to enter residential as opposed to
non-residential rehabilitation (e.g. lacked housing). The study found that
intensive day programs matched outcomes from residential rehabilitation at a
potentially lower cost (Greenwood, 2001). In addition, there is some evidence
to suggests benefits from residential rehabilitation in the treatment of cocaine
dependence (Hubbard et al, 1997). Evidence for the effectiveness of
residential rehabilitation specific to stimulant dependence within the UK context
is required.
3.2.4 Contingency management
Contingency management (CM) interventions offer tangible reinforcements to
individuals in treatment for substance misuse who abstain from using drugs or
who meet other objectively determined goals (Sindelar et al, 2007). One
example of CM is the provision of vouchers for retail goods given in return for
the production of drug-free urine samples. The majority of research on CM has
been carried out in the USA, the roll of CM in the UK drug treatment context
has not been subjected to the same degree of attention.
Recent research from the USA suggests that CM treatment is associated with a
reduction in HIV risk behaviour, especially injecting risk behaviour in cocaine
using patients on methadone maintenance treatment (Hanson et al, 2008). The
primary beneficial effects reported were apparent three months after CM
ended. Similarly, recent research suggests CM that may be beneficially in the
treatment of methamphetamine, however CM should be a component of a
wider treatment package and not a treatment offered alone (Roll, 2007). There
is no trial level evaluation for the impact of CM on amphetamine use.
In evaluating the impact of CM on stimulant use there are a number of variables
that may impact on the effectiveness, and cost effectiveness, (Sindelar, 2007;
Petry et al, 2004), with the magnitude of the reinforcement influencing the
outcome (Higgins et al, 2007a). A meta-analysis of CM for treatment of
substance misuse disorders carried out in 2006 (Prendergast et al, 2006)
concluded that CM was among the more effective approaches in promoting
abstinence during the treatment of substance use disorders. CM was seen to
improve the ability of clients to remain abstinent thus improving use of other
clinical interventions.
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Note: A text book examining in detail contingency management (Contingency
Management in Substance Misuse Treatment) has been recently published
(Higgins et al, 2007b). In addition Contingency management has been
reviewed by Gossop (2006).
3.2.5 Psychosocial interventions and brief interventions
In a review of evidence of effective treatment for cocaine and crack
dependence, the NTA (2002) concluded that:

Drug free psychosocial interventions such as counselling, provided on a
non-residential basis are the most cost effective option for clients with
few complicating problems

There is little understanding of how to prompt initial contact with
treatment services. Once made, rapid intake, proactive reminders and
practical help improve treatment uptake. Empathy and understanding
amongst key workers is important in retention and outcomes

Recognised psychotherapies delivered by professional psychologists
perform no better that well structured drug counselling

Cognitive behavioural approaches have an evidence base to support
them and group therapy may be as effective as individual therapy

Intensive residential rehabilitation may be appropriate for the most
complex cases
The range of psychosocial interventions and brief interventions summarised
below are reviewed in greater detail in the NTA publication ‘Treating drug
misuse problems: evidence of effectiveness’ (Gossop, 2006) from which much
of this summary on psychosocial interventions is drawn. Methodologically
conducting research on psychosocial interventions can be challenging;
interventions may have more than one component and may be provided
alongside other treatments (e.g. substitution treatments) it may also be difficult
to control for the quality of the intervention and skills of practitioners providing
interventions.
Motivational Interviewing (MI): Research has suggested that MI can be
beneficial within the context of drug use; a recent meta-analysis found that MI
frequently improved outcomes both as a stand alone treatment and as an
adjunct to other treatment (Hettema et al, 2005). However improved outcomes
were not consistently seen and effectiveness was variable. Research specific
to cocaine-dependent outpatients with depression and to amphetamine users
suggested benefits from MI (Daley et al, 1998; Baker et al, 2001)
Cue exposure: Evidence for the effectiveness of cue exposure treatments for
drug dependence is lacking (Conklin and Tiffany, 2002; Gossop, 2006).
Relapse prevention: Relapse prevention (RP) aims to prevent lapses into
drug use after abstinence using a range of techniques that include cognitive
and behavioural interventions. A review of controlled trials concluded that there
is some support for relapse prevention in the treatment of drug dependence
(Carroll, 1996). Outcomes may be influenced by participant preference and by
underlying psychological distress of patients (Brown, 2002). A study comparing
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
group vs. individual treatments in outcomes amongst cocaine dependent
patients reported no difference between the groups with improvements in
addiction severity, craving and coping behaviours reported for both individual
and group treatments, however RP was no more effective than other active
treatments (Schmitz, 1997; Gossop, 2006).
12 step programs: 12 step programs as used by narcotics anonymous and
alcoholics anonymous within the context of group treatment are based on an
abstinence model.
There has been little systematic evaluation of the
effectiveness of 12 step treatments. However existing research suggests that
such approaches may be effective for cocaine dependence (Weiss et al, 2005).
Brief interventions: Recent research from Australia has reported benefits in
terms of amphetamine abstinence after brief cognitive behavioural intervention
with regular amphetamine users (Baker, 2001). Evidence for the effectiveness
of brief cognitive behavioural interventions specific to stimulant dependence
within the UK context is needed.
Acupuncture: A systematic review concluded that there is no evidence to
support the use of acupuncture to treat cocaine dependence (Mills et al, 2005).
3.2.6 Provision of equipment used in the consumption of stimulants
The provision of safe injecting equipment for the injection of stimulants is
supported by the evidence presented in section 3.1 on NSP. However in
addition to injection, stimulants may be taken by snorting, smoking and
ingesting orally. A recent review of non-injection drug use and hepatitis C
infection identified gaps in research and concluded that the causal pathway to
infection remained unclear (Scheinmann et al, 2007).
Preliminary research has demonstrated the presence of HCV viral RNA on a
used crack pipe collected from one of 51 street collected crack pipes, indicating
the theoretical possibility of HCV transmission from crack pipes (Fisher, 2008).
Providing crack users with pipes to prevent HCV transmission has been
suggested, however we know of no robust evaluation of the intervention in
terms of reduction of the risk of blood borne viral transmission. Similarly the
virological plausibility of intranasal transmission has been suggested by the
finding that blood and HCV RNA present in the nasal secretions and drugsniffing implements of HCV-infected intranasal drug users recruited in New
York City (Aaron et al, 2008). The epidemiological significance of these
findings remains unknown.
Provision of equipment for the consumption of stimulants is not backed up by
robust research evidence on the impact of the intervention on disease
transmission. However, arguably such interventions may improve engagement
in services. Properly evaluated studies with clearly defined outcome measures
are required.
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
3.3 Evaluation of the range of safe, effective and cost
effective interventions targeted at reducing overdoses and
drug related deaths
The interventions discussed below require multi-agency partnership and joint
working practices to be effectively addressed and the challenges sit beyond the
boundaries of any one organisation. For more detailed analysis of these issues
readers are directed to a very thorough and recent review of the literature on
reducing drug users’ risk of overdose produced by the Scottish Government
which highlights recommendations to reduce drug related death (Rome et al,
2008).
Reduction in overdose death: The primary cause of illicit drug use related
overdose death in the UK is due to respiratory suppression in heroin (or other
opiate) overdose.
This may be in combination with alcohol and
benzodiazepines. Risk of overdose is increased amongst individuals with
reduced or low tolerance to opiates, e.g. after a period of detoxification due to
rehabilitation or imprisonment, and patients in the first few weeks of methadone
substitution (Strang, 2006). The UK Advisory Council on the Misuse of Drugs
(ACMD) published a report drawing on international evidence and highlighting
the increase in drug related death seen in the UK (ACMD, 2000). The report
concludes that the primary means to reduce overdose are:

Engendering behaviour change around the risk behaviours that lead to
overdose; this includes education around risks and more broadly, high
standard and appropriately dosed drug treatment that ensures tolerance
to opiates is maintained and that reduces injecting drug use.

Responses and interventions to reduce the mortality rate associated with
overdose once it has occurred; such as education around the
appropriate responses when an overdose is witnessed, training in
resuscitation techniques, local agreements with police to encourage
witnesses to call an ambulance and, potentially the provision of naloxone
to reverse the effects of opiate overdose.

Information dissemination via public health alerts to significant changes
within drug supply that may influence overdose and to outbreaks of
highly pathogenic bacterial infections.

Potentially by providing safe environments for drug use by individuals
vulnerable to overdose for example via safe injecting facilities (see
section on drug consumption rooms above).
3.3.1 Provision of education and information relating to overdose
Education for drug users targeting overdose can influence both self
preservation and mutual preservation (Best et al, 2001). The DoH have
provided detailed guidance for drug action teams in England on providing
resuscitation training for drug users (Gillies, 2002). This guidance highlights
the importance of targeting all drug users, but especially those at most risk of
overdose. These include people leaving prison, detoxification or residential
rehabilitation, homeless people and those not in contact with mainstream
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
services. In addition poly drug users and homeless users are at increased risk
and long term users may become complacent about the risks. Individuals on
opiate substitution should also be targeted. Health care staff with contact with
drug users should also be trained. The guidance recommends that in each
area at least 12 sessions a year should be held. The aim of training should
provide participants with the necessary basic knowledge and skills to respond
effectively, appropriately and confidently to a drugs overdose.
Encouraging witnesses to stay with the casualty until medical help arrives is
important; remaining with a casualty may help prevent choking or provide
sensory stimulation influencing the progression of the overdose (Best et al,
2002). Administration of CPR has been associated with improved clinical
outcomes in overdose (Dietze et al, 2002). Such interventions are more likely
when witnesses have received information on how to prevent or revive a
casualty (Pollini, 2006).
A number of areas in the UK have engaged in projects addressing overdose
risk: The Scottish Government has funded a critical incidents national training
officer to provide initiatives directed at overdose; in Greater Manchester the
North West Ambulance Service has been involved in training (Rome et al,
2008), in Merseyside a multi-component campaign using social marketing to
reduce overdose was commissioned by local police, ambulance, the NHS and
DAATs. The project ‘Lifeguard: Act Fast Save a Life’ involved local capacity
building, a mass media campaign and training for professionals and drug users
(HIT, 2009)
3.3.2 Prevention of overdose post-release from prison services
Drug users leaving prison services are at an elevated risk of overdose due to
relapse to opiate use following a loss of tolerance (Darke et al, 1996; Seaman
et al, 1998; Neale, 2000). The period immediately following release provides
an opportunity for interventions to reduce risk. Education around overdose
risks, and rapid admission into specialist drug treatment services for individuals
who are likely to relapse into opiate use upon release is important. This
requires substantial resources and proactive communication between prisonbased health care, CARAT services and drug misuse services in the
community to meet the scale of need presented by opiate users in Wales.
3.3.3 Identification and intervention of those at risk of suicide via
overdose
Deliberate overdoses among heroin users are difficult to distinguish from
accidents (Farrell et al, 1996). Among drug using populations the prevalence of
underlying mental health problems and feeling of hopelessness that may be
associated with overdose (ACMD, 2000; Farrell et al, 1998; Best et al, 2001).
Best and colleagues reviewed a range of evidence on non-accidental overdose
and concluded that substance misusers prone to suicide tend to enter
treatment, whilst in treatment the risk is modestly reduced and that dropping out
or being thrown out of treatment restores high risk (Best et al, 2001).
3.3.4 Provision of Naloxone
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
There have been calls, from leading researchers and clinicians in the UK, to roll
out and evaluate the impact of the provision of ‘take home’ naloxone for opiate
users on opiate overdose death (Strang, 2006). Naloxone is a safe and
effective opiate antagonist that rapidly reverses the respiratory suppression of
heroin overdose.
Early anecdotal evidence from the USA suggests that naloxone offers a
potential benefit in risk reduction relating to opiate overdose (Strang, 2006).
Whilst there is a persuasive argument for making naloxone widely available and
‘take home’ there has from some quarters been a call for caution (Ashworth,
2006). Recent UK research has provided support for the provision of overdose
training and ‘take home’ naloxone (Strang et al, 2008). The research
concluded that overdose management training, which included ‘take home’
naloxone, may reduce drug related deaths. Further research is urgently
needed to evaluate the impact of a widespread roll out of this intervention.
Several ‘take home’ naloxone pilots have taken place in England and in
Scotland (Rome et al, 2008); initial results from a Lanarkshire pilot and a
Glasgow pilot show naloxone has been appropriately used. In England, Salford
DAT, Wiltshire DAAT and North West Ambulance Service have been involved
in trials. Formal evaluation of these trials is to our knowledge yet to be
published. Naloxone demonstration trials are to be undertaken in Wales from
April 2009. There is a planned trial funded by the Medical Research Council to
examine the effectiveness of providing naloxone on release from prison to
prevent heroin-related overdose; the trial should start in late 2008.
3.3.5 Overdose and stimulant drug use
The epidemiology of drug related death due to stimulant use is poorly
described. There has been a suggestion that cocaine use by injecting drug
users may be associated with an increased risk of non-fatal opioid overdose
although a causal link has not been demonstrated (Oliver et al, 2007; Taylor et
al, 1996; Ochoa et al, 2003). A quantitative evaluation of cocaine, crack
cocaine and amphetamine use in relation to drug related death in the UK would
provide valuable evidence in this area.
3.3.6 Drug treatment and overdose
The role of opiate substitution treatment in reducing drug related death is well
established (Ward et al, 1999). Substitution treatment can prevent the loss of
tolerance to opiates within patients who are likely to relapse into opiate use
after periods of reduced tolerance. Engaging drug users in treatment saves
lives, however treatment must be high quality and tailored to patient need with
careful consideration of tolerance. Drug treatment has been addressed
elsewhere in detail (Gossop, 2006).
3.3.7 Overdose and antidepressant and benzodiazepine prescribing
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
Public Health Wales
Safe, effective and cost effective interventions for IDUs
and stimulant users
Opiate users who are prescribed benzodiapines are at elevated risk of
overdose due to the respiratory depressive effects of both substances (Best et
al, 2001) and as such caution and patient education is required.
Antidepressant prescribing, in particular tricyclic antidepressants, may influence
risk of fatal opiate overdose (Best et al, 2001; Darke et al, 2000).
3.3.8 Local arrangements between police and ambulance arrangements
Concerns of police involvement in overdose related to illicit drugs may be in
certain instances a disincentive to the calling of an ambulance to a drug
overdose (Tobin et al, 2005). In response to this problem some UK police
forces areas have been involved in developing protocols regarding police
attendance at overdose incidence. For example the Greater Manchester Police
in 2002 implemented what has been termed the ‘Manchester Protocol’ for the
attendance of police at overdose. The Greater Manchester Police supported
the Greater Manchester Ambulance Service in their policy of not notifying the
police of potential drug overdose incidents unless there were exceptional
circumstances. This policy was designed to reduce the number of drug related
deaths by encouraging overdose casualties to access emergency treatment
without fear of police attendance (Chief Constable’s Order, 2002/04). Where
fatalities occur, all drug related deaths are subject to a Coroner’s inquest and
must be fully investigated (GMP, 2003). Likewise, Nottinghamshire Police and
the East Midlands Ambulance Service and local DAATs have set up
arrangements, similar protocols have been established in Kirklees,
Leicestershire, and Avon and Somerset (Rome et al, 2008). These schemes
have to our knowledge yet to be formally evaluated.
3.3.9 Accident and Emergency department follow-up
Data on overdose admission to accident and emergency department show high
levels of recidivism amongst vulnerable individuals (Best et al, 2001; Ryan,
2000; Ghodse et al, 1986). This environment thus presents an opportunity for
intervention, for example education and referral to specialist services, for those
vulnerable individuals who are repeatedly overdosing and attending A & E
services. WAG are currently commissioning research in Wales on near misses
or non-fatal overdoses including a literature review and meta-analysis of such
interventions
3.3.10 Information dissemination via public health alerts
Providing accurate, rapid and well-disseminated information to at-risk
populations in relation to changes in drug composition that are likely to impact
upon overdose risk is vital in reducing overdose and outbreaks of highly
pathogenic bacterial infections. A greater understanding is needed of how best
messages concerning drug composition should be provided (Rome et al, 2008).
Author: Noel Craine, Josie Smith
Date: 17/11/09
Status: Final
National Public Health Service for Wales
Safe, effective and cost effective interventions for
IDUs and stimulant users
References
Abdulrahim D et al. (2006). Findings of a survey of needle exchanges in England. London:
National Treatment Agency. Available at:
http://www.nta.nhs.uk/publications/documents/nta_nes1_needle_exchange_survey.pdf
[Accessed 13th Feb 2009]
Advisory Council on the Misuse of Drugs. (2000). Reducing drug related deaths. London:
The Stationery Office; 2000
Aitken CK, Kerger M and Crofts N. (2002). Peer-delivered hepatitis C testing and counselling:
a means of improving the health of injecting drug users. Drug Alcohol Rev 21: pp.33-37
Ashworth AJ. (2006). Emergency naloxone for heroin overdose: beware of naloxone's other
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