Drug Matrix cell A1: Interventions; Reducing harm
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Drug Treatment Matrix cell A1

Interventions; Reducing harm

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Seminal and key studies on the effectiveness of harm reduction interventions such as needle exchanges.


S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S The study which (seemed to have) validated needle exchange in the UK (1989). Published journal article reported “small but encouraging” extra reductions in the HIV risk behaviour of attendees at pilot exchanges in England and Scotland versus a comparison group, legitimating nationwide expansion. But an Effectiveness Bank critique (2004) reminds us of an unpublicised comparison, which was not encouraging at all. For discussion click here and scroll down to highlighted heading in bite’s Issues section.

S Methadone maintenance protects against HIV infection (1993). Over the 18-month follow-up, 22% of US injectors who had not been on methadone became HIV positive but just 3.5% who had remained in methadone maintenance, a “striking” difference attributed partly to their reduced injecting and sharing of injecting equipment. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

S Methadone treatment saved lives in Sweden (1990). Restrictions on methadone maintenance in Sweden enabled its value to be convincingly demonstrated; when detoxification and drug-free treatment were the alternatives, deaths were about eight times higher. Reviewed with other Swedish studies in The Swedish experience (2000) on p. 6 of linked PDF file. See later confirmatory studies (1 2) from Sweden, and below similar studies from Norway. For discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

K Expand needle exchange and opioid substitute prescribing to contain hepatitis C (2011). Pooled UK data showed that being and staying in methadone maintenance and allied treatments plus adequate access to fresh injecting equipment has prevented many hepatitis C infections. Extrapolating from this data indicated (2012) that to make further substantial progress these interventions must reach not half of UK injectors, but at least 8 in 10. Some of the same authors have collated (2014) studies contradicting previous conclusions that opioid substitute prescribing does not prevent spread of hepatitis C. For discussion click here and scroll down to highlighted heading in bite’s Issues section.

K US randomised trial confirms that methadone maintenance prevents infection infection risk behaviours (2000). Proving methadone maintenance reduces risk of infection has been hampered by the near absence of randomised trials, hence the importance of this US study contrasting continuing maintenance with detoxification. Despite being compensated for by more intensive psychosocial support, when methadone was withdrawn gaps in infection infection risk behaviour and illicit opioid use opened up favouring the maintenance patients. For discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

K Longer on methadone means longer lives for UK heroin patients treated by GPs (2010). GP records suggest opiate users are less likely to die prematurely if substitute prescribing is made available, and that the longer they are in treatment, the greater the life expectancy dividend. This data led to the estimate (2011) that shortening an average nine months of treatment to six would cause 10% more deaths while extending it to 12 would cause 5% fewer. Similar study of specialist services below. For related discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

K English study finds staying in specialist substitute prescribing treatment saves lives (2015). Results suggest that to save the lives of people dependent on heroin or similar drugs, they should be engaged and retained in substitute prescribing programmes like methadone maintenance. Shortly after leaving residential/inpatient care was the highest-risk period. Similar study of primary care patients above and below of opiate users in general whether in treatment or not. For related discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

K Without treatment there might have been 70% more opioid overdose deaths in England (2015). Estimates that across the entire population of problem opiate users in England, between 2008 and 2011 addiction treatment (mainly substitute prescribing) reduced total opioid-related overdose deaths from what would have been 6372 to 3731. Similar study but confined to treatment patients above. For related discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

K Restricted access in Norway exposes substitute prescribing’s lifesaving potential (2008). During their long wait for a slot in Norway’s substitute prescribing programme, five times as many opiate-dependent applicants died due to overdose as did patients in treatment. Similar findings (2013) in respect of drug-related physical complaints. Message is that services should strive to retain ‘problem patients’ in treatment. Similar Swedish studies above. For discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

K Treatment offers shelter from overdose risk (2008) Reports on a large Italian study (2007) which highlighted the protection against overdose deaths afforded by being in treatment, and the danger of leaving with reduced tolerance to opiate drugs but still vulnerable to relapse.

K Training drug users to administer overdose-reversing medication (2008). First large UK follow-up study confirmed the feasibility and to a degree the desired impacts of overdose prevention training featuring the opiate-blocking drug naloxone. However, often naloxone was not used (2009) because drug users were reluctant to carry around the pre-loaded syringes, and naloxone training ‘cascaded’ (2011) to other clinicians and patients at a snail’s pace. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

K Scotland’s pioneering naloxone programme saved lives of released prisoners (2016). In 2011 Scotland became the first country to fund a national policy of distributing the opiate-blocker naloxone to prevent opioid overdose deaths. According to this evaluation it did prevent deaths where this was most likely to be seen – shortly after release from prison. For discussion click here and scroll down to highlighted heading in bite’s Issues section.

K Welsh pilot study leads to national naloxone programme (2012). The evaluation which led to the Welsh national programme to distribute naloxone to opiate users and their associates to curb rising opiate overdose deaths. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

R Overview of drug-related harms to health and how to reduce them (2005). Reviewed expertly and from a UK perspective, panoramic view of international research on the impacts of needle exchange, prescribing and psychosocial interventions on harms including infections and overdose. Focus is on the conclusions reached by United Nations agencies. For discussion click here and scroll down to highlighted heading in bite’s Where should I start? section.

R Opiate substitute treatment cuts HIV infection rate (2005). Pooled results from nine studies from across the world offer “strong evidence” that opiate substitution treatment has been associated with a 54% reduction in the risk of HIV infection. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

R Psychosocial programmes not the way to reduce HIV risk (Cochrane review, 2010). Found no evidence that multiple training/information sessions were any more effective than minimal educational interventions at preventing behaviour which risks HIV infection among injectors or cocaine users. Findings similar (2012) in respect of hepatitis C.

R Preventing drug-related disease spread in prisons (2009). Free source at time of writing. Having been in prison has repeatedly been associated with increased risk of infection. Review concludes that needle and syringe programmes and opioid substitute prescribing reduce infection infection risk behaviours in prisons without adversely affecting the health of staff or prisoners. Role of substitute prescribing confirmed by another review (2010).

R WHO finds “compelling evidence” for needle and syringe programmes’ anti-HIV impact (World Health Organization, 2004). But the WHO-commissioned experts also concluded while necessary these programmes are not sufficient; also needed are education, treatment (especially substitute prescribing) and community development. Findings also published in two journal articles (1 2). For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

R Needle exchange faces the challenge of hepatitis C (2003 and 2004). Four-part series from Drug and Alcohol Findings documents the difficulty needle exchanges have had in controlling spread of hepatitis C and identifies promising practice ingredients. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

R Needle exchanges will prevent more infections by switching to low dead space syringes/needles (2013). Simulation model suggests that switching injectors from high to low dead space syringes/needles which retain much less fluid can prevent or reverse injection-related HIV epidemics. English study (2017) found low dead space equipment acceptable to injectors but may need to be introduced gradually. Laboratory study (2017) suggests that to prevent spread of hepatitis C, exchanges should focus on needles and syringes rather than other injecting equipment.

R Feasibility and effects of naloxone distribution programmes (2014). Free source at time of writing. Because lives are at stake no randomised trials were found by this systematic review, but across 19 studies naloxone was administered 1949 times, generally with a 100% survival rate. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

R Anti-overdose strategies (Scottish Government, 2008). Wide-ranging review including responding appropriately in an emergency, naloxone, ambulance protocols, local collaborations, and information campaigns. Includes fresh data from surveys and interviews in Scotland with drug users and their families and police and emergency services.

R Safe consumption rooms reduce risk of drug-related harm and promote treatment entry (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA], 2017). European Union’s drug misuse centre reviews three decades of experience and research from Europe and elsewhere on centres where illicit drugs can be used under the supervision of trained staff, facilities increasingly being considered in the UK.

G NICE endorses needle and syringe programmes (National Institute for Health and Care Excellence [NICE], 2014). UK’s official health advisory body finds needle exchange “an effective way to reduce many of the risks associated with injecting drugs” though there was “insufficient evidence” in relation to hepatitis C. Recommends expansion so every injector has more sterile equipment than they need for every injection. See also related quality standards (NICE, 2012). For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

G WHO “strongly recommends” needle exchange and maintenance prescribing to combat HIV (World Health Organization, 2014). Consolidates WHO guidance on HIV prevention, diagnosis, treatment and care for key populations including prisoners and people who inject drugs. Strongly advocates universal access of injectors to needle exchange and of dependent opioid users to indefinite, high dose methadone and buprenorphine maintenance.

G UK government’s advisers call for investment in substitute prescribing to reduce overdose deaths ([UK] Advisory Council on the Misuse of Drugs, 2016). UK’s official drugs policy advisory body concludes that an ageing population of heroin users in poor health has contributed to recent increases in drug-related deaths, and that to hold down the increases government must maintain investment in substitute prescribing. For related discussion click here and scroll down to highlighted heading in bite’s Highlighted study section.

G WHO says better access to naloxone will save lives (World Health Organization, 2014). WHO judges that “Increased access to naloxone for people likely to witness an overdose could significantly reduce the high numbers of opioid overdose deaths” and makes corresponding recommendations, but also stresses that naloxone provision “does not address the underlying causes of opioid overdose”. For discussion click here and scroll down to highlighted heading in bite’s Where should I start? section, or here for related discussion in Issues section.

G Increase availability of overdose-reversing drug ([UK] Advisory Council on the Misuse of Drugs, 2012). UK’s official drugs policy advisory body recommends that the opiate-blocker naloxone and related training be made more widely and easily available to drug users and their associates to prevent opioid overdose deaths. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

G Scottish Drugs Forum naloxone web site. Offers resources, advice, guidance, information and news on programmes featuring the drug naloxone which reverses opiate overdose. Being reconstructed at time of writing. For related discussion click here and scroll down to highlighted heading in bite’s Issues section.

G Best practice in drug misuse interventions including harm reduction (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA], accessed 2017). Web-based guidance from the EU’s drug policy and practice evidence centre, offering several fact sheets related to harm reduction.

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