Differences between men and women in substance use: the role of educational level and employment status / Diferencias entre hombres y mujeres en el consumo de sustancias: el rol del nivel educativo y la situación laboral

Objective: To determine differences between men and women in hazardous drinking, heavy cannabis use and hypnosedative use according to educational level and employment status in the economically active population in Spain. Method: Cross-sectional study with data from 2013 Spanish Household Survey on Alcohol and Drugs on individuals aged 25-64 [n=14,113 (women=6,171; men=7,942)]. Dependent variables were hazardous drinking, heavy cannabis use and hypnosedative consumption; the main independent variables were educational level and employment situation. Associations between dependent and independent variables were calculated with Poisson regression models with robust variance. All analyses were stratified by sex. Results: Hazardous drinking and heavy cannabis use were higher in men, while women consumed more hypnosedatives. The lower the educational level, the greater the gender differences in the prevalence of this substances owing to different consumption patterns in men and women. While men with a lower educational level were higher hazardous drinkers [RII=2.57 (95%CI: 1.75-3.78)] and heavy cannabis users [RII=3.03 (95%CI: 1.88-4.89)] compared to higher educational level, in women the prevalence was the same. Women with a lower education level and men with a higher education level had higher hypnosedative consumption. Unemployment was associated with increased heavy cannabis use and hypnosedative use in both women and men and with lower hazardous drinking only in women. Conclusions: There are differences between men and women in the use of psychoactive substances that can be explained by the unequal distribution of substance use in them according to educational level. Unemployment was associated with substance use in both men and women (AU)

Objetivo: Determinar las diferencias entre hombres y mujeres en cuanto a consumo de riesgo de alcohol, de cánnabis y en el consumo de hipnosedantes según el nivel educativo y la situación laboral en la población activa española. Métodos: Estudio transversal con datos de la Encuesta Domiciliaria sobre Alcohol y Drogas en España (2013) de personas de 25-64 años de edad (n=14.113 [mujeres=6.171; hombres=7.942]). Las variables dependientes fueron consumo de riesgo de alcohol, consumo de cánnabis y consumo de hipnosedantes; las principales independientes fueron el nivel de estudios y la situación laboral. Para estimar la asociación entre variables dependientes e independientes se calcularon modelos de regresión de Poisson con varianza robusta. Todos los análisis se estratificaron por sexo. Resultados: Los hombres tenían mayor consumo de riesgo de alcohol y cánnabis, mientras que las mujeres consumían más hipnosedantes. A menor nivel de estudios, mayores diferencias de sexo en el consumo de estas sustancias. Esto fue debido al patrón distinto de mujeres y hombres. Mientras los hombres con un menor nivel de estudios tenían mayor consumo de riesgo de alcohol (RII=2,57; IC95%: 1,75-3,78) y cánnabis (RII=3,03; IC95%: 1,88-4,89), en comparación con los de un mayor nivel de estudios, la prevalencia en las mujeres era la misma. Las mujeres con menor nivel de estudios y los hombres con mayor nivel de estudios consumían más hipnosedantes. La desocupación se asociaba a un mayor consumo de riesgo de cánnabis y de hipnosedantes tanto en las mujeres como en los hombres, y a un menor consumo de riesgo de alcohol solo en las mujeres. Conclusiones: Existen diferencias entre los hombres y las mujeres en el consumo de sustancias psicoactivas. Estas diferencias pueden explicarse por la desigual distribución del consumo de sustancias en ambos sexos según el nivel de estudios. La desocupación se asociaba al consumo de sustancias tanto en los hombres como en las mujeres (AU)

Differences between men and women in substance use: the role of educational level and employment status.

OBJECTIVE: To determine differences between men and women in hazardous drinking, heavy cannabis use and hypnosedative use according to educational level and employment status in the economically active population in Spain. METHOD: Cross-sectional study with data from 2013 Spanish Household Survey on Alcohol and Drugs on individuals aged 25-64 [n=14,113 (women=6,171; men=7,942)]. Dependent variables were hazardous drinking, heavy cannabis use and hypnosedative consumption; the main independent variables were educational level and employment situation. Associations between dependent and independent variables were calculated with Poisson regression models with robust variance. All analyses were stratified by sex. RESULTS: Hazardous drinking and heavy cannabis use were higher in men, while women consumed more hypnosedatives. The lower the educational level, the greater the gender differences in the prevalence of this substances owing to different consumption patterns in men and women. While men with a lower educational level were higher hazardous drinkers [RII=2.57 (95%CI: 1.75-3.78)] and heavy cannabis users [RII=3.03 (95%CI: 1.88-4.89)] compared to higher educational level, in women the prevalence was the same. Women with a lower education level and men with a higher education level had higher hypnosedative consumption. Unemployment was associated with increased heavy cannabis use and hypnosedative use in both women and men and with lower hazardous drinking only in women. CONCLUSIONS: There are differences between men and women in the use of psychoactive substances that can be explained by the unequal distribution of substance use in them according to educational level. Unemployment was associated with substance use in both men and women.

Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.

Objective To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment.Design Systematic review and meta-analysis.Data sources Medline, Embase, PsycINFO, and LILACS to September 2016.Study selection Prospective or retrospective cohort studies in people with opioid dependence that reported deaths from all causes or overdose during follow-up periods in and out of opioid substitution treatment with methadone or buprenorphine.Data extraction and synthesis Two independent reviewers performed data extraction and assessed study quality. Mortality rates in and out of treatment were jointly combined across methadone or buprenorphine cohorts by using multivariate random effects meta-analysis.Results There were 19 eligible cohorts, following 122 885 people treated with methadone over 1.3-13.9 years and 15 831 people treated with buprenorphine over 1.1-4.5 years. Pooled all cause mortality rates were 11.3 and 36.1 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 3.20, 95% confidence interval 2.65 to 3.86) and reduced to 4.3 and 9.5 in and out of buprenorphine treatment (2.20, 1.34 to 3.61). In pooled trend analysis, all cause mortality dropped sharply over the first four weeks of methadone treatment and decreased gradually two weeks after leaving treatment. All cause mortality remained stable during induction and remaining time on buprenorphine treatment. Overdose mortality evolved similarly, with pooled overdose mortality rates of 2.6 and 12.7 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 4.80, 2.90 to 7.96) and 1.4 and 4.6 in and out of buprenorphine treatment.Conclusions Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.

Maximal isometric muscle strength values obtained By hand-held dynamometry in children between 6 and 15 years of age.

INTRODUCTION: In this study we aimed to determine the maximal isometric muscle strength of a healthy, normal-weight, pediatric population between 6 and 15 years of age using hand-held dynamometry to establish strength reference values. The secondary objective was determining the relationship between strength and anthropometric parameters. METHODS: Four hundred normal-weight Chilean children, split into 10 age groups, separated by 1-year intervals, were evaluated. Each age group included between 35 and 55 children. RESULTS: The strength values increased with increasing age and weight, with a correlation of 0.83 for age and 0.82 for weight. The results were similar to those reported in previous studies regarding the relationships among strength, age, and anthropometric parameters, but the reported strength differed. CONCLUSIONS: These results provide normal strength parameters for healthy and normal-weight Chilean children between 6 and 15 years of age and highlight the relevance of ethnicity in defining reference values for muscle strength in a pediatric population. Muscle Nerve 55: 16-22, 2017.

Estimating average alcohol consumption in the population using multiple sources: the case of Spain.

BACKGROUND: National estimates on per capita alcohol consumption are provided regularly by various sources and may have validity problems, so corrections are needed for monitoring and assessment purposes. Our objectives were to compare different alcohol availability estimates for Spain, to build the best estimate (actual consumption), characterize its time trend during 2001-2011, and quantify the extent to which other estimates (coverage) approximated actual consumption. METHODS: Estimates were: alcohol availability from the Spanish Tax Agency (Tax Agency availability), World Health Organization (WHO availability) and other international agencies, self-reported purchases from the Spanish Food Consumption Panel, and self-reported consumption from population surveys. Analyses included calculating: between-agency discrepancy in availability, multisource availability (correcting Tax Agency availability by underestimation of wine and cider), actual consumption (adjusting multisource availability by unrecorded alcohol consumption/purchases and alcohol losses), and coverage of selected estimates. Sensitivity analyses were undertaken. Time trends were characterized by joinpoint regression. RESULTS: Between-agency discrepancy in alcohol availability remained high in 2011, mainly because of wine and spirits, although some decrease was observed during the study period. The actual consumption was 9.5 l of pure alcohol/person-year in 2011, decreasing 2.3 % annually, mainly due to wine and spirits. 2011 coverage of WHO availability, Tax Agency availability, self-reported purchases, and self-reported consumption was 99.5, 99.5, 66.3, and 28.0 %, respectively, generally with downward trends (last three estimates, especially self-reported consumption). The multisource availability overestimated actual consumption by 12.3 %, mainly due to tourism imbalance. CONCLUSIONS: Spanish estimates of per capita alcohol consumption show considerable weaknesses. Using uncorrected estimates, especially self-reported consumption, for monitoring or other purposes is misleading. To obtain conservative estimates of alcohol-attributable disease burden or heavy drinking prevalence, self-reported consumption should be shifted upwards by more than 85 % (91 % in 2011) of Tax Agency or WHO availability figures. The weaknesses identified can probably also be found worldwide, thus much empirical work remains to be done to improve estimates of per capita alcohol consumption.

Job Loss, Unemployment and the Incidence of Hazardous Drinking during the Late 2000s Recession in Europe among Adults Aged 50-64 Years.

BACKGROUND: To estimate the incidence of hazardous drinking in middle-aged people during an economic recession and ascertain whether individual job loss and contextual changes in unemployment influence the incidence rate in that period. METHODS: Longitudinal study based on two waves of the SHARE project (Survey of Health, Ageing and Retirement in Europe). Individuals aged 50-64 years from 11 European countries, who were not hazardous drinkers at baseline (n = 7,615), were selected for this study. We estimated the cumulative incidence of hazardous drinking (≥40g and ≥20g of pure alcohol on average in men and women, respectively) between 2006 and 2012. Furthermore, in the statistical analysis, multilevel Poisson regression models with robust variance were fitted and obtained Risk Ratios (RR) and their 95% Confidence Intervals (95%CI). RESULTS: Over a 6-year period, 505 subjects became hazardous drinkers, with cumulative incidence of 6.6 per 100 persons between 2006 and 2012 (95%CI:6.1-7.2). Age [RR = 1.02 (95%CI:1.00-1.04)] and becoming unemployed [RR = 1.55 (95%CI:1.08-2.23)] were independently associated with higher risk of becoming a hazardous drinker. Conversely, having poorer self-perceived health was associated with lower risk of becoming a hazardous drinker [RR = 0.75 (95%CI:0.60-0.95)]. At country-level, an increase in the unemployment rate during the study period [RR = 1.32 (95%CI:1.17-1.50)] and greater increases in the household disposable income [RR = 0.97 (95%CI:0.95-0.99)] were associated with risk of becoming a hazardous drinker. CONCLUSIONS: Job loss among middle-aged individuals during the economic recession was positively associated with becoming a hazardous drinker. Changes in country-level variables were also related to this drinking pattern.

Effect of immigration background and country-of-origin contextual factors on adolescent substance use in Spain.

PURPOSE: The effects of adolescent- and parental-birthplace and country-of-origin contextual factors on substance use among adolescents with recent immigrant background (ARIBs) are poorly understood. We aimed to assess these effects and identify the main mediating factors in Spain. METHODS: Participants were 12,432 ARIBs (≥1 foreign-born parent) and 75,511 autochthonous adolescents from pooled 2006-2010 school surveys. Outcomes were prevalence of use of alcohol, tobacco, cannabis, stimulants and sedative-hypnotics. ARIBs were classified by adolescent birthplace (Spain/abroad), whether they had mixed-parents (one Spanish-born and one foreign-born), and country-of-origin characteristics. Adjusted prevalence ratios (aPRs) and percent change expressing disparities in risk were estimated using Poisson regression with robust variance. RESULTS: Compared to autochthonous adolescents, foreign-born ARIBs without mixed-parents showed significant aPRs <1 for all substances, which generally approached 1 in Spanish-born ARIBs with mixed-parents. The main factors mediating ARIBs' lower risk were less frequent socialization in leisure environments and less association with peers who use such substances. ARIBs' lower risk depended more on country-of-origin characteristics and not having mixed-parents than being foreign-born. Tobacco, cannabis and stimulant use in ARIBs increased with increasing population use of these substances in the country-of-origin. ARIBs from the non-Muslim-regions had a lower risk of using alcohol and higher risk of using sedative-hypnotics than those from the Muslim-region. CONCLUSIONS: Among ARIBs in Spain, parental transmission of norms and values could influence substance use as much as or more than exposure to the Spanish context. Future research should better assess effects of adolescent- and parental-birthplace and country-of-origin contextual factors on substance use.

High hepatitis C virus prevalence and incidence in a community cohort of young heroin injectors in a context of extensive harm reduction programmes.

BACKGROUND: Cohort studies on hepatitis C virus (HCV) among drug injectors are scarcer than studies on HIV. Combined harm reduction interventions (HRIs) can prevent HCV infection. Spain has a medium-high coverage of HRIs. METHODS: 513 young heroin users who injected drugs in the past 12 months (recent injectors) were street-recruited in 2001-2003 and followed until 2006 in three Spanish cities; 137 were anti-HCV seronegative, 77 of whom had ≥1 follow-up visit. Dried blood spots were tested for anti-HCV. HCV incidence and predictors of infection were estimated using Poisson models. RESULTS: At baseline, 73% were anti-HCV positive. Overall incidence (n=77) of HCV seroconversion was 39.8/100 person-years (py) (95% CI 28.7 to 53.8). Excluding non-injectors during follow-up from the analysis (n=57), HCV incidence was 52.9/100 py (95% CI 37.4 to 72.5). Injecting at least weekly (incidence rate ratio (IRR)=5.2 (95% CI 2.5 to 11.1)) and having ≥2 sexual partners (IRR=2.2 (95% CI 1.1 to 4.7)) were independent predictors of HCV seroconversion; drug-injection history <2 years was marginally associated (IRR=2.4 (95% CI 0.9 to 4.7)). HCV incidence may have been underestimated due to differential attrition. CONCLUSIONS: Despite fairly high HRI coverage among Spanish drug injectors, a distressingly high incidence of HCV in a context of high HCV prevalence was found among young heroin injectors.

Potential bias due to outcome-related loss to follow-up in cohort studies on incidence of drug injection: systematic review and meta-analysis.

AIMS: A systematic review and meta-analysis were conducted to synthesize results from cohort studies on initiation into drug injection among vulnerable populations, to quantify heterogeneity in the estimated incidence rates of drug injection and to identify potential sources of heterogeneity and bias. METHODS: MEDLINE, EMBASE, PsycINFO and LILACS were searched for relevant studies published between 1980 and 2012. Investigators independently reviewed studies for inclusion, retrieved information on baseline population characteristics and follow-up features and assessed study quality. Study-specific incidence rates of drug injection were calculated as the number of new injectors divided by the person-years at risk. The I(2) statistic was used to quantify heterogeneity in incidence rates across studies, and random-effects meta-regression models were used to identify determinants of heterogeneity and bias. RESULTS: Nine cohorts totalling 1843 participants met the inclusion criteria, with individual sample sizes of 70-415 participants and follow-up lengths of 6 months-3.4 years. The incidence of drug injection varied widely, from 2.1 to 24.2 cases per 100 person-years. The strong between-study heterogeneity (I(2) = 90%, P<0.001) was reduced significantly after accounting for the different follow-up lengths (I(2) = 17%, P = 0.30), with a 57% (95% confidence interval 46-66%) decrease in the pooled incidence of drug injection per 1-year increase in average follow-up. CONCLUSIONS: The incidence of drug injection decreases sharply with increasing follow-up length in cohort studies on drug injection initiation. Low retention rates and potential for downward selection bias in cohort studies on drug injection initiation are caused primarily by greater loss to follow-up among individuals at higher risk of starting injection, compared with other participants.

An example of the usefulness of joinpoint trend analysis for assessing changes in traffic safety policies.

AIM: To show the usefulness of joinpoint trend analysis for assessing changes in traffic safety policies. METHODS: Trends in driver death rates from traffic injury stratified by alcohol involvement in Spain during 2001-2011 were characterized with joinpoint regression to observe how changes in these rates match in time with the implementation of traffic regulations and interventions. RESULTS: Both alcohol-related (blood alcohol concentration >0.3g/l) and non-alcohol-related rates decreased similarly (10-11% annually) during 2001-2011, although the former showed an earlier (2003 joinpoint) acceleration of the downward trend than the latter (2006 joinpoint); both joinpoints matched in time with relevant road safety interventions. CONCLUSIONS: These results, which are consistent with results from previous analytical studies, show that joinpoint trend analysis, although not valid for causal inference, is useful for assessing changes in traffic safety policies. This methodology can be easily extended to other risk factors, such as excessive speeding or not wearing a seat belt.

[Research methods on alcohol-related harm in the population]. / Métodos de investigación sobre daños en la población relacionados con el alcohol.

The aim of this paper is to describe the available methods to quantify the main health and social harms related to alcohol consumption in the population and to provide recommendations to improve research on these issues. Methods using individual and aggregate level data for the study of the relationship between alcohol consumption and related harms are taken into account, highlighting their strengths and weaknesses. Methodological aspects to quantify the magnitude and trends of alcohol-related and alcohol-attributable mortality, including alcohol dependence, acute intoxication, injury, violent behavior, disease burden and social costs are widely considered. There are often discrepancies between the study results mainly due to the difficulty of adequately measuring alcohol consumption and its relationship to health conditions. In the future we must strengthen research on the effect of drinking patterns and context in chronic diseases using appropriate controls, clarify the relationship of alcohol use disorders and other mental disorders , improve the measurement of alcohol intoxication when acute problems occurs, periodically quantify the disease burden and social costs attributable to alcohol (using country- specific attributable fractions) and develop valid and comparable methods and indicators for monitoring alcohol-related harm.

Métodos de investigación sobre daños en la población relacionados con el alcohol / Research methods on alcohol related harm in the population

El objetivo de este trabajo es describir los principales métodos disponibles para cuantificar los danos sociales y sanitarios relacionados con el alcohol en la población y hacer recomendaciones para mejorar la investigación sobre estos aspectos. Se consideran los métodos para estudiar la naturaleza de la relación entre el consumo de alcohol y los danos a partir de datos individuales y agregados, señalando sus ventajas y limitaciones. Se describen los métodos para cuantificar la magnitud y las tendencias de los danos relacionados con alcohol en la población, incluyendo dependencia, intoxicación aguda, lesiones o conductas violentas, mortalidad, carga de enfermedad y costes sociales atribuibles. A menudo hay discrepancias entre los resultados de los estudios por la dificultad para medir adecuadamente el consumo y su relación con las condiciones de salud. Hay que potenciar la investigación sobre el efecto de patrones y contexto de consumo en las enfermedades crónicas utilizando grupos control adecuados, aclarar la relación de la dependencia alcohólica con otros trastornos mentales, mejorar la medida del grado de intoxicación alcohólica cuando se producen otros problemas agudos, cuantificar periodicamente la carga de enfermedad y los costes atribuibles a alcohol (usando fracciones atribuibles específicas de país) y desarrollar métodos e indicadores validos y comparables para monitorizar los danos relacionados con alcohol (AU)

The aim of this paper is to describe the available methods to quantify the main health and social harms related to alcohol consumption in the population and to provide recommendations to improve research on these issues. Methods using individual and aggregate level data for the study of the relationship between alcohol consumption and related harms are taken into account, highlighting their strengths and weaknesses. Methodological aspects to quantify the magnitude and trends of alcohol-related and alcohol- attributable mortality, including alcohol dependence, acute intoxication, injury, violent behavior, disease burden and social costs are widely considered. There are often discrepancies between the study results mainly due to the difficulty of adequately measuring alcohol consumption and its relationship to health conditions. In the future we must strengthen research on the effect of drinking patterns and context in chronic diseases using appropriate controls, clarify the relationship of alcohol use disorders and other mental disorders , improve the measurement of alcohol intoxication when acute problems occurs, periodically quantify the disease burden and social costs attributable to alcohol (using country- specific attributable fractions) and develop valid and comparable methods and indicators for monitoring alcohol-related harm (AU)

Mortality risk factors and excess mortality in a cohort of cocaine users admitted to drug treatment in Spain.

We assessed mortality risk factors and excess mortality compared to the general population in two Spanish sub-cohorts of 8,825 cocaine and heroin users (CHUs) and 11,905 only cocaine users (OCUs) aged 15-49 admitted to drug treatment. Heroin use (among all cocaine users), no-regular employment and drug injection (among CHUs and OCUs), daily cocaine use and previous drug treatment (among CUs), and death before 2005 and >10 years of heroin use (among CHUs) were clearly associated with higher mortality in Cox regression. Excess mortality was assessed by the directly standardized mortality rate ratio, which was higher in CHUs (14.3; 95% CI: 12.6-16.2) than CUs (5.1; 95% CI: 4.3-6.0) and in women than men, especially among OCUs (8.6; 95% CI: 7.5-10.0 vs. 3.5; 95% CI: 3.3-3.8); it decreased with age among CHUs, but did not decrease overall during 1997-2008. OCUs excess mortality was considerable and showed no signs of decline, suggesting the need for improved treatment and prevention interventions.

Non-fatal opioid overdose and major depression among street-recruited young heroin users.

BACKGROUND/AIMS: Non-fatal opioid overdose (NFOO) and major depression (MD) are highly prevalent in heroin users. Many risk factors are known for NFOO, but studies in non-clinical samples on its relationship with MD are lacking. We aimed to examine this relationship in a street-recruited sample, controlling for potential well-known confounders. METHODS: A cross-sectional study in 452 heroin users street-recruited by chain referral methods in three Spanish cities. Eligibility criteria were: age≤30 years, heroin use at least 12 days in the last year and at least once in the last 3 months. Depression was assessed using the Composite International Diagnostic Interview. A precise definition of NFOO was used. Adjusted odds ratios (AORs) for the NFOO predictors were obtained by logistic regression. RESULTS: The prevalence of NFOO and MD in the last 12 months was 9.1 and 23.2%, respectively. After adjusting for potential confounders, NFOO and MD were significantly associated (AOR 2.2; 95% CI 1.01-4.74). Other associated factors were imprisonment (AOR 4.1; 95% CI 1.4-12.1), drug injection (AOR 6.7; 95% CI 2.4-18.4) and regular use of tranquillisers/sleeping pills (AOR 2.9; 95% CI 1.16-7). CONCLUSIONS: Drug and mental health treatment facilities should consider the relationship between MD and NFOO when contacting and treating heroin users. Imprisonment, drug injection and use of tranquillisers/sleeping pills are also risk factors for NFOO.

Has health in Spain been declining since the economic crisis?

BACKGROUND: The economic recession starting in 2008 may be having negative effects on health. PURPOSE: We aimed to identify and characterise changes in trends in 15 health indicators in Spain during the recession. METHODS: Joinpoint regression and average annual percent change (AAPC) were used to compare trends. RESULTS: Premature mortality rates from several causes of death, except from cancer, showed statistically significant downward trends during the recession, as did poor self-reported health. HIV incidence was stable. No indicator declined significantly more slowly during the recession than in the preceding 4-year period, and two declined significantly faster. CONCLUSION: Health in Spain has continued to improve during the first four years of the economic recession at a rate equal to or higher than in previous years.

Trends of heroin use and heroin injection epidemics in Europe: findings from the EMCDDA treatment demand indicator (TDI).

We estimate trends and geographical differences in the heroin epidemic in the European Union plus Croatia and Turkey by analyzing aggregated data on first heroin treatment admissions (cases) during 2000-2009. In 2005-2009 the proportion of drug injectors was higher in Central and Eastern European countries (CEECs) than in Western European countries (WECs), whereas the opposite occurred with mean age at first heroin use and first treatment. During this period, the number of cases, cases per center, and proportion of injectors in WECs declined, whereas mean age at first treatment and first heroin use increased. The opposite occurred in Turkey, except for proportion of injectors, while trends were less clear in the other CEECs. In the 7 WECs with data, trends in 2000-2005 and 2005-2009 were similar. This suggests that the number of recent-onset heroin users and heroin injectors may have declined some years before the study period, especially in WECs.

Mortality in a cohort of young primary cocaine users: controlling the effect of the riskiest drug-use behaviors.

BACKGROUND: Published studies indicate that primary cocaine users (PCUs) have a mortality rate 4-8 times higher than their age-sex peers in the general population. Most PCUs are primary intranasal cocaine users, never-injectors and never-opioid users (PICUNINOs) and are usually underrepresented in cohort mortality studies. The aim is to estimate excess mortality in all PCUs and in the subgroups of never-opioid users and PICUNINOs in Spain. METHODS: 714 PCUs aged 18-30 were street-recruited in 2004-2006 in Spain and followed until 2010 to ascertain vital status. Drug use was self-reported at baseline and 1-2years later. Mortality was compared with that of the general population using standardized mortality ratios (SMRs). RESULTS: SMRs were 4.7 (95% CI: 2.4-9.0), 2.5 (95%CI: 0.8-7.8) and 3.1 (95% CI: 1.0-9.6), respectively, among all participants, never-opioid users and PICUNINOS when using only baseline data on drug use, and 1.2 (95% CI: 0.2-8.5) and 1.4 (95% CI: 0.2-9.9) among the latter two subgroups, when using baseline plus follow-up data. CONCLUSION: Short-term mortality in young Spanish PCUs is 5 times higher than in the general population. This excess mortality may largely be explained by a history of opioid use or the risk of starting such use.

HCV seroconversion among never-injecting heroin users at baseline: no predictors identified other than starting injection.

BACKGROUND: Heroin users who do not inject constitute a large pool of drug users with a potentially important impact on public health. We aimed to estimate the incidence of hepatitis C virus (HCV) among heroin users who had never injected (NIDUS) at baseline, and the effect of starting injecting during follow-up, other percutaneous exposures, sharing snorting paraphernalia, cocaine/crack use, and risky sexual behaviour on HCV-seroconversion. METHODS: Prospective cohort of 305 HCV-negative NIDUs at baseline, aged 18-30 and street-recruited in three Spanish cities in 2001-2003. Computer-assisted personal interviews were conducted and dried blood-spot samples were collected. Bivariate and multivariable Poisson models were used. RESULTS: Among the 305 never-injectors who were HCV-negative at baseline, 197 (64.6%) were followed-up and 21 seroconverted [HCV-incidence rate=5.8/100 person-years at risk (pyar) (95% CI: 3.6-8.9)]. HCV incidence in new-injectors was 28.4/100 pyar [(95% CI, 14.7-49.7) vs. 2.8/100 pyar (95% CI, 1.3-5.4)] among NIDUs. Of the risk exposures considered, starting injecting was the only predictor of HCV-seroconversion [adjusted relative risk=10.1, 95% CI: 3.8-26.7]. CONCLUSION: The HCV-seroconversion rate was 10 times higher among new-injectors than never-injectors. No predictors other than starting injecting were found for HCV-seroconversion. Harm reduction interventions to prevent HCV infection should include prevention of drug injection.

Association between cannabis use and non-traffic injuries.

BACKGROUND: This study aimed to assess the association between cannabis use and unintended non-fatal injuries other than those caused by road crashes. METHODS: Cross-sectional data were collected from a nationwide sample of 27,934 subjects surveyed in 2005 in Spain: 14,699 persons aged 15-34 years and 13,235 aged 35-64 years. Logistic regression was used to obtain odds ratios (OR) between patterns of cannabis use and frequency of non-traffic injuries, adjusted for sociodemographic factors and for the use of alcohol, tobacco and other drugs. RESULTS: Cannabis use in the last 12 months was associated with a higher frequency of injuries (OR=1.4; 95% CI: 1.2-1.7). The OR in older adults (35-64 year age group) was 1.8 and 1.3 in younger people (15-34 year age group). The strongest associations found were between weekly use of cannabis and injuries from knocks and bumps (OR=5.1; 95% CI 2.9-8.9) and those occurring outside work (OR=3.0; 95% CI 1.8-4.9) in the older adult population. CONCLUSION: Although our analysis did not control for behavioural factors, cannabis use is independently associated with an increased frequency of non-traffic injuries, especially in the older adult population. These associations emphasise the need to carry out longitudinal studies addressing the causal links between cannabis use and unintended injuries.

Harm reduction interventions for drug injectors or heroin users in Spain: expanding coverage as the storm abates.

AIMS: To show the utility of analysing time trends of need and coverage of needle-exchange programmes (NEPs) and opioid substitution treatment (OST) to assess harm reduction policies targeting drug injectors or heroin users. DESIGN: Multiple methods applied to secondary data. SETTING: Spain. PARTICIPANTS: Thousands of drug injectors or heroin users included in administrative registers, surveys and published studies during 1987-2010. MEASUREMENTS: Coverage for the general population was calculated as the ratio between interventions provided (obtained directly from the sources) and interventions needed (estimated by multiple methods), and as the difference between the two. Timeliness was estimated by time elapsed between year of highest need and year in which coverage reached a reference level. FINDINGS: In 2010 NEPs provided 138 syringes per drug injector [95% confidence interval (CI) 100-223], covering 25.7% (95% CI 18.3-43.3) of their need. OST coverage was 60.3% (95% CI 44.3-94.2). Syringe and OST provision increased between 1991 and 2001 and then declined. Syringe and OST coverage also increased substantially during this period and then stabilized, due mainly to decreases in drug injection or heroin use. Medium-level coverage for both syringes and OST was not achieved until 2000, 8 years after the peak in need (1992). CONCLUSIONS: In Spain, the expansion of harm reduction interventions was greatly delayed, although the concomitant decrease in heroin and injecting drug use led to reasonable coverage after 2000. A longitudinal measurement of need and coverage provides insight into the timeliness and potential population impact of interventions, enabling better assessment of their adequacy.