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FUTURE RESEARCH IN SUBSTANCE MISUSE AN OVERVIEVW PERSPECTIVE. Michael Farrell PHRN Manchester 20 th October 2006. Political and moral values of the social system . SERVICE Provider AND USER VIEW. Research Evidence. A model for evidence-based clinical decisions (from Haynes et al, 1996).

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Future research in substance misuse an overvievw perspective

FUTURE RESEARCH IN SUBSTANCE MISUSE AN OVERVIEVW PERSPECTIVE

Michael Farrell

PHRN Manchester

20th October 2006


Future research in substance misuse an overvievw perspective

Political and moral values of the social system

SERVICE Provider AND USER VIEW

Research Evidence

A model for evidence-based clinical decisions

(from Haynes et al, 1996)



Hiv prevalence among idus in the eu
HIV prevalence among IDUs in the EU

EMCDDA 2004Notes: Colour indicates midpointsLocal data shown in ()


Hiv in idus in europe
HIV in IDUs in Europe

  • Marked difference between countries and within some countries

    • High prevalence countries (old MS) Italy, Spain, Portugal, followed by France

    • Some high prevalence estimates from new MS (Latvia, Estonia), and worries about others (Poland)

    • Low prevalence countries in both old and new MS including countries with high prevalence IDU

    • Cautious assessment is the long term trend appears to be stable or downwards

      • Some small increases in recent data in some countries or in specific subpopulations

      • Data quality problems so analysis must be made with caution


A note on hcv prevalence in idus
A note on HCV prevalence in IDUs

  • Prevalence estimates higher and more convergent than for HIV

  • Clear need to finding effective prevention strategies

  • Routine disease surveillance sources of limited value

  • Drug injecting principle route of transmission for HCV in Europe


Long term trend in acute drug related deaths 1985 2003
Long term trend in acute drug-related deaths (1985-2003)

300

250

200

Index % (1985=100%)

150

100

50

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003*

100,0

104,5

118,7

136,9

153,7

181,0

216,4

223,5

201,8

212,2

225,4

252,4

230,1

235,6

241,1

255,4

240,1

205,8

194,9

INDEX

EU 15, 1985 to 2003 index year 1985=100


Introduction of mmt nsp 1967 to 2001 eu norway and bulgaria
Introduction of MMT & NSP, 1967 to 2001(EU, Norway and Bulgaria)


Future research in substance misuse an overvievw perspective

450

400

350

300

250

200

150

100

50

0

LU

UK

ES

IE

MT

FR

PT

IT

SI

DK

EU

DE

NL

NO

SE

EL

BE

CZ

LT

FI

HU

BG

LV

PL

RO

+ 4

Estimated number of drug users in substitution treatment in 29 European countries (2003) per 100.000 population aged 15-64


Future research in substance misuse an overvievw perspective

600,000

537,000

500,000

400,000

351,000

265,000

300,000

207,000

200,000

73,400

100,000

0

1993

1995

1997

2000

2003

10-year trend in the number of substitution treatment clients in Europe (EU-15)


Proportion of substitution drugs used in medically assisted treatment in europe 2003

Buprenorphine

Other

20%

1%

Methadone

79%

Proportion of substitution drugs used in medically assisted treatment in Europe, 2003


Prevalence of hiv in injecting drug users some country estimates
Prevalence of HIV in Injecting Drug Users some country estimates

  • European Union, Northern Europe low prevalence, Southern European countries higher prevalence but declining

  • Central and Eastern European countries upward trend, especially Ukraine, Russia,

  • USA and Canada generally stable low levels, outbreak Vancouver British Columbia related to cocaine injecting

  • Australia less than 2%

  • India Manipur Estimated at 50% plus

  • China Yunnan Province 10% to 70% in three years

  • Rapid increase in 31 provinces in China

  • Myanmar 56% IDUs HIV positive in one study

  • Vietnam 63% IDUs


Future research in substance misuse an overvievw perspective

HIV prevalence in injecting drug users estimates

Myanmar

Manipur &

Yunnan

Edinburgh

Ho Chi Minh

City

Lithuania

Bangkok

Odessa

Jakarta


Hiv infection rates in and out of substitution treatment metzger et al 1993
HIV infection rates in and out of substitution treatment estimates(Metzger et al. 1993)

Out %

In %


Drug overdose and mortality
Drug Overdose and Mortality estimates

  • Mean of 5+ non fatal overdoses in heroin using cohorts

  • Mortality 1 to 2%

  • In methadone treatment down to 0.2%

  • Recent Hser 33 year longitudinal study reports over 50% mortality in cohort

  • Suicide completion rates high and significant contributor to overall suicide


The odds of a drug related death in the first week of release
The odds of a drug-related death in the first week of release

among women

  • over 10times greater than that observed at one year (OR 10.6; 95%CI 4.8-22.0)

  • 70 times higher than age matched general population

    among men

  • around 8 times greater than at one year (OR 8.3: 95%CI 5.0-13.3).

  • 30 times higher than age matched general population

    (Singleton, Farrell et al 2003)

  • IN SUMMARY A 8-10 FOLD INCREASED RISK OF MORTALITY IN THE EARLY RELEASE PERIOD


Substitution in prisons
Substitution in prisons release

  • Estimated that over 30 million imprisoned annually

  • Major risk for blood borne virus spread

  • In most countries where measured between one third and half have drug dependence

  • RCT of methadone in prison (Dolan et al) demonstrates role in reduction of blood borne virus, and general improvement, and post release reduction in mortality for those who continue

  • Rapid expansion in Europe in substitution in prisons

  • Huge challenge for Asia pacific region where insitutional incarceration standard response to opioid dependence

  • Consistently 90% relapse to heroin use, no studies on mortality


Drug substitution treatment
Drug Substitution Treatment release

  • Strong evidence for the benefits of oral methadone treatment RCTs +++ REASONABLE EFFECT SIZE

  • REDUCES DRUG CRIME .70

  • REDUCES OPIATE CONSUMPTION .35

  • REDUCES INJECTING & RISK TAKING 0.22

  • Now good evidence for buprenorphine and LAAM RCTs ++ (LAAM CURRENTLY UNDER REVIEW)

  • Use of injectable diamorphine and other drugs building evidence base for comparative effectiveness, more dicussion on comparative cost effectiveness.


Gunne gronbladh 1981 rct methadone versus no methadone
Gunne & Gronbladh (1981) RCT: release Methadone versus no methadone

  • 34 subjects using heroin by injection

    • 17 experimental (methadone)

    • 17 controls (no methadone)

  • Controls not allowed to enter MMT for 2 years

  • Followed up at 2 years and again at 4 years





A 33 year follow up of narcotic addicts hser et al 2001
A 33 year follow-up of narcotic addicts release (Hser et al., 2001)

22%

2%

6%

7%

4%

48%

12%

N 581 439 354 242

Age 24.5 (3.9) 36.8 (5.4) 47.6 (5.1) 57.4 (4.0)


A 33 year follow up of narcotic addicts hser et al 20011
A 33 year follow-up of narcotic addicts release (Hser et al., 2001)

22%

2%

6%

7%

4%

48%

12%

N 581 439 354 242

Age 24.5 (3.9) 36.8 (5.4) 47.6 (5.1) 57.4 (4.0)


Composite slide 3 year reincarceration rates
COMPOSITE SLIDE release 3-Year Reincarceration Rates

*

*

*

*


Methadone maintenance for prisoners
Methadone maintenance for prisoners release

Source: NSW DCS Inmate Census, UK Home Office, World Prison Population List 4th Ed, US Department of Justice


Nsw prison methadone program
NSW prison methadone program release

1986 as a pilot pre release program by Department of Corrective Services (DCS)

Criteria

  • 3-6 months prior to release

  • Past or present history of opiate dependence

  • History of returning to injecting and crime on previous releases

  • 3 designated community clinics

    1990 those entering custody on MMT were continued

    Since 1990 12% NSW MMT received in custody


Ndarc methadone study
NDARC Methadone Study release

NSW prison methadone maintenance

  • Randomised control trail of 384 IDUs in 1997 and re-interviewed in 1998

  • Heroin use was significantly less for those receiving methadone, as measured by hair analysis.

Source: Dolan & Wodak


Rct results
RCT Results release

MMT Control

HCV incidence %24.3 31.7

Heroin (hair) %27 42

Heroin (SR) %33 78

No cases of HIV


Ndarc methadone study1
NDARC Methadone Study release

Follow up after release from gaol study of above 384 IDUs examining rate of:

  • Incarceration

  • Mortality

  • Hepatitis C


Mortality rates intent
Mortality rates release (Intent)


Hcv incidence intent
HCV incidence release (Intent)

Source: Dolan, K


Re incarceration up to may 2002
Re- incarceration up to May 2002 release

Source: Dolan, K



Need for upscaling of treatment
Need for upscaling of treatment release

  • Urgent need in many regions for concerted effort to expand treatment

  • Discussions and research required on the challenge of upscaling

  • IDTS a major development within English Prisons

  • Major expansion in substitution treatment and psychosocial treatment


Future research in substance misuse an overvievw perspective

  • NEED TO EVALUATE IDTS release

  • Implementation assessment

  • Cost Effectiveness

  • Environmental Impact

  • Individual Outcome

  • Impact on Recidivism

  • Impact on Post Release Mortality


Research framework
Research Framework release

  • Need pragmatic studies in prison context

  • More longitudinal studies

  • A 10 year mortality outcome study from the National Psychiatric Morbidity Survey

  • Consider a longitudinal Study of Young Offenders and exploration of trajectory of drug histories within the criminal justice system

  • Prisons ideal enviroments for exploration of issues of psychiatric comorbidity and substance use


Future research in substance misuse an overvievw perspective

  • Studies linked to community studies release

  • Linking treatment in prison up to the National Drug Treatment Monitoring System

  • Currently Outcomes Monitoring Project Underway, Important to have Prison Treatment Linked into this.

  • Infectious Diseases remain a big threat especially BBVs


Conclusions
Conclusions release

  • The huge challenge in all settings is to develop a comprehensive range of interventions that are humanitarian, effective and impactful for the all those who require interventions

  • To ensure that ethical and humane treatment is delivered as effectively as possible in all settings