Responding to illicit drug use in family practice.

PURPOSE OF REVIEW: To examine and analyse recent published research on the impact and management of drug use and related disorders in primary care settings. Emerging trends in drug use and the development of new treatment approaches are making new demands on the primary care sector. RECENT FINDINGS: Most recent publications relate to descriptions of the drugs used and their impact on mental health. The use of cannabis and newer stimulants and 'legal highs' tends to coexist with opiate use, and their physical and mental health sequelae often overlap. Several studies address methadone and buprenorphine prescribing, its efficacy and limitations, and organizational issues in delivery of treatment. Other areas identified in this review are pain control, adverse consequences of drug use including morbidity from infections associated with drug taking and death due to overdose, and longer-term outcomes. Several publications cover management of chronic conditions in an ageing population of drug users with multiple health problems, and others examine the trend toward community instead of specialist care. SUMMARY: A picture is presented of extensive use of psychoactive substances in many communities. This ranges from club drug taking and low level cannabis use to more invasive and self-harming drug taking resulting from the use of opiates and stimulants. Treatment services are challenged with the need to change.

Early life influences on the risk of injecting drug use: case control study based on the Edinburgh Addiction Cohort.

AIMS: To investigate childhood influences on onset of injection drug use. DESIGN: Matched case-control study. SETTING: Edinburgh, Scotland. PARTICIPANTS: A total of 432 individuals presenting at a community health facility with injection drug use and 432 age- and sex-matched non-injecting controls recruited through the same facility. MEASUREMENTS: Main exposures considered were family structure and experience of public care, carer substance use, physical and sexual victimization and conduct problems, all measured at personal interview. The outcome was history of adult injection drug use recorded in medical records corroborated at personal interview. FINDINGS: Compared to two-parent families all other family structures were associated with increased risk of injection drug use, the greatest increased risk being associated with public care. Violence, criminality and financial problems in the family were also associated with increased risk, as were all types of carer substance use. The greatest increased risk was associated with markers of early conduct problems, particularly school exclusion and childhood contact with the criminal justice system. In multivariable analyses the strongest risk factors for later injecting were always having lived with a relative or family friend (not always a parent) and in care/adopted/foster home at any point [odds ratio (OR) = 2.66, 95% confidence interval (CI): 1.02-6.92 and OR = 2.17, 95% CI: 0.91-5.17, respectively], experienced violence from parent or carer (OR = 2.06, 95% CI: 1.26, 3.38) and early evidence of conduct problems [ever excluded from school (OR = 2.73, 95% CI: 1.68, 4.45); childhood criminality (ever arrested by police pre-adult OR = 3.05, 95% CI: 1.90, 4.89, ever been in borstal/young offenders/list D school OR = 4.70, 95% CI: 2.02, 10.94)]. After adjustment for family structure and conduct problems, sexual victimization was associated weakly with injecting onset (OR = 1.29, 95% CI: 0.76-2.19). More than 70% of injection drug use onset appeared attributable to the risk factors identified. CONCLUSIONS: Injection drug use in adults is associated strongly with prior childhood adversity, in particular not living with both parents and early conduct problems. Prevention initiatives should also consider these risk factors.

The Edinburgh Addiction Cohort: recruitment and follow-up of a primary care based sample of injection drug users and non drug-injecting controls.

BACKGROUND: Injection drug use is an important public health problem. Epidemiological understanding of this problem is incomplete as longitudinal studies in the general population are difficult to undertake. In particular little is known about early life risk factors for later drug injection or about the life course of injection once established including the influence of medical and social interventions. METHODS: Individuals thought to be drug injectors were identified through a single primary medical care facility in Edinburgh between 1980 and 2006 and flagged with the General Registry Office. From October 2005 - October 2007, these cases were traced and invited to undergo interview assessment covering early life experience, substance use, health and social histories. Age and sex matched controls for confirmed cases (alive and dead) were later recruited through the same health facility. Controls for living cases completed the same structured interview schedule. Data were also collected on cases and controls through linkage to routine primary care records, death registrations, hospital contact statistics and police and prison records. All interviews were conducted with the knowledge and permission of the current GP. RESULTS: The initial cohort size was 814. At start of follow up 227 had died. Of the remaining 587: 20 had no contact details and 5 had embarked from the UK; 40 declined participation; 38 did not respond to invitations; 14 were excluded by their GP on health or social grounds and 22 had their contact details withheld by administrative authorities. 448 were interviewed of whom 16 denied injection and were excluded. Of 191 dead cases with medical records 4 were excluded as their records contained no evidence of injection. 5 interviewed cases died before follow up was concluded though these individuals were counted as "live" cases. 1 control per case (dead and alive) was recruited. Linkage to Scottish Morbidity Records data (available from 1981 onwards) on general acute inpatient and day cases, mental health inpatient and day cases and cancer was provided by Information Services, NHS Scotland, for all cases interviewed and all dead cases. The Scottish Prison Service provided records for 198 (46%) of cases interviewed, 48 cases not interviewed and 34 (18%) of dead cases. For a sub-sample of 100 interviewees a search of the Lothian and Borders police database was made for official criminal records and 94 had criminal records. Data linkage for controls is ongoing. CONCLUSIONS: Injecting drug users recruited from a community setting can be successfully followed-up through interviews and record linkage. Information from injecting cases is being analysed in terms of injecting patterns and possible influences on these. Comparisons between cases and controls will allow identification of possibly modifiable early life risk factors for drug injection and will also clarify the burden of disease associated with injection and the influence on this of different health and social interventions.