Prevalence of drug use before and during imprisonment in seven European countries (2014-2018).

Substance use is a global phenomenon that is particularly affecting the prison population. This study aimed to describe the prevalence of drug use among people in prison before and during incarceration in seven European countries and to compare it with the prevalence in the general population. Individual data collection was carried out between 2014 and 2018 with a model European Questionnaire on Drug Use among people in prison. A total of 12,918 people living in prison filled in the survey. People in prison report higher level of drug use when compared with the general population and the use of drug inside prison exist, although at lower levels when compared with predetention. Prisons can represent a point of access to engage individuals who use drugs in interventions that address drug use and risk factors related to both drug use and imprisonment.

The impact of the COVID-19 lockdown on drug service provision in European prisons.

PURPOSE: This paper aims to describe the impact of the COVID-19 containment measures on the provision of drug treatment and harm reduction services in European prisons in15 countries during the early phase of the pandemic (March -June 2020). DESIGN/METHODOLOGY/APPROACH: The paper is based on a mixed method research approach that triangulates different data sources, including the results of an on-line survey, the outcome of a focus group and four national case studies. FINDINGS: The emergence of COVID-19 led to a disruption in prison drug markets and resulted in a number of challenges for the drug services provision inside prison. Challenges for health services included the need to maintain the provision of drug-related interventions inside prison, while introducing a range of COVID-19 containment measures. To reduce contacts between people, many countries introduced measures for early release, resulted in around a 10% reduction of the prison population in Europe. Concerns were expressed around reduction of drug-related interventions, including group activities, services by external agencies, interventions in preparation for release and continuity of care. PRACTICAL IMPLICATIONS: Innovations aimed at improving drug service provision included telemedicine, better partnership between security and health staff and an approach to drug treatment more individualised. Future developments must be closely monitored. ORIGINALITY/VALUE: The paper provides a unique and timely overview of the main issues, challenges and initial adaptations implemented for drug services in European prisons in response to the COVID-19 pandemic.

Conocimiento y valoración de las voluntades anticipadas del personal sanitario de unidades de hospitalización a domicilio, oncología médica, hospitales de día y servicios de urgencias / Knowledge and assessment of living wills by health professionals at home hospitalization units, medical oncology departments, daytime hospital services and emergency romos

OBJETIVO: Describir el conocimiento del personal sanitario de servicios implicados en el manejo de enfermos paliativos en situación avanzada, sobre el Documento de Voluntades Anticipadas (DVA) y su Registro Nacional. Conocer cómo valoran su uso y si lo consultan habitualmente. MATERIAL Y MÉTODO: Estudio multicéntrico, transversal descriptivo, mediante cuestionario anónimo cumplimentado por personal médico y de enfermería en tres centros hospitalarios. Se recogieron un total de 160 cuestionarios correspondientes a 58 médicos y 102 enfermeros, pertenecientes a Servicios de Urgencias (SU), Oncología, Unidades de Hospitalización a Domicilio (HaD) y Hospital de Día. El cuestionario constaba de 14 preguntas tipo test de respuesta única, además de las variables demográficas y laborales pertinentes para el estudio. RESULTADOS: Las medias de edad de la muestra fueron de 42 ± 9 años, y la experiencia profesional de 17 ± 9,3 años. El 83,1 % de los encuestados afirmaron conocer el DVA y el 53,7 % que sabrían cumplimentarlo, pero solo un 8,1 % de ellos contestaron correctamente a la pregunta de dónde localizar dicho documento. El 92,5 % de los encuestados no lo consultan nunca. Los dos encuestados que afirmaban consultarlo habitualmente, no supieron localizarlo. CONCLUSIONES: Existe un desconocimiento generalizado del DVA, siendo este independiente tanto de la categoría profesional como de los años de experiencia o del servicio en el que se trabaja. Incluso en los casos que dicen conocerlo, sus respuestas no corroboran tal afirmación

OBJECTIVE: To describe the knowledge healthcare providers at the units involved in the management of advanced palliatiave care patients have of the advance directives document (ADD). To find out how do they value its use, and whether they check it out regularly. MATERIAL AND METHODS: A multicenter, cross-sectional, descriptive study using an anonymous questionnaire to be completed by doctors and nurses in three hospitals. A total of 160 questionnaires were collected from 58 doctors and 102 nurses working at emergency rooms (ERs), oncology departments, home hospitalization units (HHUs), and day hospital services. Questionnaires included 14 multiple choice questions with only one valid option, and also collected the demographic and labor variables required by the study. RESULTS: Mean age in the sample was 42 ± 9 years, and professional experience was 17 ± 9.3 years. Among responders, 83.1 % claimed knowledge of the ADD, and 53.7 % said they could complete it, but only 8.1 % knew where to find it; 92.5 % of respondents never consult it. The two respondents who claimed they usually checked it out were eventually unable to locate it. CONCLUSIONS: Lack of knowledge about ADDs and their related National Registry is widespread, and occurs regardless of professional category or years of experience. Even in providers who claim awareness of this document the answers provided belie it

Drug supply indicators: Pitfalls and possibilities for improvements to assist comparative analysis.

Interventions to tackle the supply of drugs are seen as standard components of illicit drug policies. Therefore drug market-related administrative data, such as seizures, price, purity and drug-related offending, are used in most countries for policy monitoring and assessment of the drug situation. International agencies, such as the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the UN Office of Drugs and Crime, also monitor and report on the drug situation cross-nationally and therefore seek to collect and make available key data in a uniform manner from the countries they cover. However, these data are not primarily collected for this purpose, which makes interpretation and comparative analysis difficult. Examples of limitations of these data sources include: the extent to which they reflect operational priorities rather than market changes; question marks over the robustness of and consistency in data collection methods, and issues around the timeliness of data availability. Such problems are compounded by cultural, social and contextual differences between countries. Making sense of such data is therefore challenging and extreme care needs to be taken using it. Nevertheless, these data provide an important window on a hidden area, so improving the quality of the data collected and expanding its scope should be a priority for those seeking to understand or monitor drug markets and supply reduction. In addition to highlighting some of the potential pitfalls in using supply indicators for comparative analysis, this paper presents a selection of options for improvements based on the current EMCDDA programme of work to improve their supply-related monitoring and analysis. The conceptual framework developed to steer this work may have wider application. Adopting this approach has the potential to provide a richer picture of drug markets, at both national and international levels, and make it easier to compare data between countries.

Drug affordability-potential tool for comparing illicit drug markets.

BACKGROUND: The importance of illicit drug price data and making appropriate adjustments for purity has been repeatedly highlighted for understanding illicit drug markets. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has been collecting retail price data for a number of drug types alongside drug-specific purity information for over 15 years. While these data are useful for a number of monitoring and analytical purposes, they are not without their limitations and there are circumstances where additional adjustment needs to be considered. This paper reviews some conceptual issues and measurement challenges relevant to the interpretation of price data. It also highlights the issues with between-country comparisons of drug prices and introduces the concept of affordability of drugs, going beyond purity-adjustment to account for varying national economies. METHODS: Based on a 2015 European data set of price and purity data across the heroin and cocaine retail markets, the paper demonstrates a new model for drug market comparative analysis; calculation of drug affordability is achieved by applying to purity-adjusted prices 2015 Price Level Indices (PLI, Eurostat). RESULTS: Available data allowed retail heroin and cocaine market comparison for 27 European countries. The lowest and highest unadjusted prices per gram were observed for heroin: in Estonia, Belgium, Greece and Bulgaria (lowest) and Finland, Ireland, Sweden and Latvia (highest); for cocaine: the Netherlands, Belgium and the United Kingdom (lowest) and Turkey, Finland, Estonia and Romania (highest). The affordability per gram of heroin and cocaine when taking into account adjustment for both purity and economy demonstrates different patterns. CONCLUSION: It is argued that purity-adjusted price alone provides an incomplete comparison of retail price across countries. The proposed new method takes account of the differing economic conditions within European countries, thus providing a more sophisticated tool for cross-national comparisons of retail drug markets in Europe. Future work will need to examine other potential uses of the drug affordability tool. LIMITATIONS: The limitations of this measure reflect primarily the limitations of the constituent data; in addition to issues inherent in collecting accurate data on illicit markets, analysis that relies on data collected from multiple countries is susceptible to discrepancies in data collection practices from country to country.

Khat use and monitoring drug use in Europe: the current situation and issues for the future.

AIM OF THE STUDY: To review the information available on the use of khat (Catha edulis) in the EU, and to assess the future use of this drug and related substances. MATERIAL AND METHODS: Khat is not controlled by international law and it has not been systematically included in the list of illicit drugs monitored in the EU. The current principal source of information on khat use in Europe is the early-warning system set up to monitor new and emerging drugs. Further information was obtained from official national reports to the EMCDDA and from the scientific literature. RESULTS: Across Europe, the use of khat is low. Khat use is limited to countries with immigrant communities from countries where khat use is common (such as Ethiopia, Somalia and Kenya). Information on the prevalence of khat use in the general population is scarce. Data on seizures provide an insight on the situation, though these may be difficult to interpret. The most recent estimates suggest that Europe accounts for about 40% of the khat seized worldwide. CONCLUSION: The shortage of data on the use and patterns of use of khat in Europe does not allow an evaluation of the needs for health and social interventions in communities in which the drug is used. But seizures of the plant are increasing in the EU, and more synthetic derivatives of the pharmacologically active ingredients of the plant (cathine and cathinone) are appearing on the market. Some of these, like mephedrone, have significant potential for future diffusion, and are likely to play a greater role on the European drug scene of the future.

Use of supervised injection facilities and injection risk behaviours among young drug injectors.

AIMS: To study the use of supervised injection facilities (SIFs) as a predictor of safer injecting practices. DESIGN: Cross-sectional study conducted with face-to-face interview using a structured questionnaire with computer-assisted personal interviewing. Dried blood spot samples were collected for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) antibody testing. SETTING: All participants were street-recruited by chain referral methods in Madrid and Barcelona. PARTICIPANTS: A total of 249 young heroin drug injectors recruited by the ITINERE cohort study in two Spanish cities with SIFs. MEASUREMENTS: The main outcome measures were self-reported injecting behaviours and SIFs attendance. RESULTS: SIF users were more marginalized socially than non-users. They were also more often regular injectors (weekly or more versus sporadic) [odds ratio (OR) = 4.9, 95% confidence interval (CI): 2.7-8.8], speedball users (OR = 2.5, 95% CI: 1.5-4.3) and anti-HCV-positive (OR = 3.1, 95% CI: 1.4-7.1). In the logistic regression analysis, using SIFs was associated independently with not borrowing used syringes (OR = 3.3, 95% CI: 1.4-7.7). However, no significant association was found between SIF use and not sharing injection equipment indirectly (OR = 1.1, 95% CI: 0.5-2.2). CONCLUSIONS: SIFs attract highly disadvantaged drug injectors who engage none the less in less borrowing of used syringes than non-users of these facilities. The risks of indirect sharing should be emphasized when counselling SIF attendees.

Access to sterile syringes among young drug injectors in Madrid and Barcelona and its association with risk behaviour.

BACKGROUND AND OBJECTIVE: To evaluate access to sterile syringes and its association with injection risk behaviour in Madrid and Barcelona. MATERIALS AND METHODS: Cross-sectional community study by computer-assisted personal interview in 465 young heroin injectors between 2001 and 2003. RESULTS: Some 4.2% had not obtained any free sterile syringes in the previous 12 months. In Madrid 32.1% had obtained all their sterile syringes free of charge (ASSF), versus 44.6% in Barcelona (p<0.01). Not sharing (not using syringes used by someone else and not front/backloading) was associated with obtaining ASSF (OR=1.69) and with sporadic injection (OR=1.83). Not reusing one's own syringes was associated with the same two variables (OR=4.02 and OR=2.50, respectively). CONCLUSIONS: Access to sterile syringes is very high in Madrid and Barcelona, although the two cities have different approaches. The acquisition of all syringes free of charge should be facilitated, especially among frequent injectors.

More free syringes, fewer drug injectors in the case of Spain.

International policy on the prevention of HIV and other health problems among drug users should be guided by scientific evidence. However, it has frequently been argued that Needle Exchange Programs (NEPs) have negative effects such as facilitation of injection of illicit drugs, without providing evidence to support this hypothesis. Since the early 1980s Spain has experienced a severe HIV epidemic among drug injectors. A delayed but comprehensive implementation of harm reduction programs has taken place since the early 1990s. This paper assesses trends between 1991 and 2004, both in the number of sterile syringes exchanged or delivered by NEPs or other programs to improve injectors' access to sterile injection material, and in the number of injectors admitted to first treatment for heroin or cocaine dependence, as a proxy for trends in the number of new drug injectors in Spain. The results show increased access to sterile syringes and a sharp decrease in the number of new drug injectors, suggesting that NEPs have not promoted drug injection. A positive overall transition from injecting to smoking was also observed in the most frequent route of heroin or cocaine administration.

[Estimating mortality attributed to illegal drug use in Spain]. / Estimación de la mortalidad atribuible al consumo de drogas ilegales en España.

BACKGROUND AND OBJECTIVE: The impact of illegal drug consumption on general mortality in Spain is unknown. We aimed to quantify this impact for the period 1994-2000. SUBJECTS AND METHOD: Number of directly drug-related deaths from HIV among injecting drug users as well as others -- both taken from the General Mortality Register (GMR). Next, corrections were made, multiplying the aforementioned figures by the percentage of injecting drug users in the AIDS register in the first case, and by the underestimation index in the second. This index was calculated comparing the GMR with the specific drug-related register in certain areas. RESULTS: In Spain, mortality from illegal drug use fell from 22.7 per 100,000 inhabitants, aged 15-49 years (16.4% of all deaths) in 1996 to 8.9/100,000 in 2000 (7.8% of all deaths), meaning a 58% decrease in general mortality. In 2000, drug-related deaths surpassed AIDS mortality in the group of men aged 15-49 years. CONCLUSIONS: Illegal drug use continues to be an important cause of death among young people in Spain. Overdose is the most likely primary cause of death in drug consumers.

[Prevalence of indirect sharing of drug-injecting paraphernalia in Galicia, Madrid, Seville and Valencia [Spain]]. / Prevalencia de prácticas indirectas de compartir material para inyectarse drogas en Galicia, Madrid, Sevilla y Valencia.

OBJECTIVES: To study drug-injecting practices, particularly indirect sharing of injecting paraphernalia (ISIP), and sexual risk behavior. METHODS: We performed a cross-sectional study of 1638 users of needle exchange programs (NEPs). Different types of ISIP were studied: taking diluted drugs in a syringe used by others, placing the needle in a recipient with other used needles, and reusing cleaning liquid previously used by others. RESULTS: The prevalence of injecting with syringes already used by others was 16% in Galicia, 4.7% in Madrid, 17.6% in Seville and 13.2% in Valencia (p < 0.001). With geographical variations, other types of ISIP (Galicia: 32.4%; Madrid: 28.5%; Seville: 42.6%; Valencia: 27.4% -p < 0.001-) were more frequent than injecting with syringes already used by others (Galicia: 32.4%; Madrid: 28.5%; Seville: 42.6%; Valencia: 27.4% -p < 0.001-). The percentage not injecting with syringes used by others but performing ISIP was 21.7%, 25.3%, 28.2% and 18.1% (p < 0.01) respectively. In all geographical areas, sexual risk practices were more prevalent with steady sex partners (68.6%, 72.0%, 77.8%, 72.8% [NS]) than with casual partners (36.6%, 40.9%, 37.9%, 23.9% [NS]). Among injectors with a stable partner, 81.3% in Galicia, 75.9% in Madrid, 86.1% in Seville and 79.7% in Valencia reported that his/her serological status was negative for HIV or was unknown (p < 0.001). CONCLUSIONS: ISIP is more prevalent than injection with syringes already used by others. For a substantial percentage of injectors, ISIP is the only risk practice. ISIP and the low use of condoms, particularly with steady partners, could be a contributory factor to the spread of HIV, hepatitis C virus, and hepatitis B virus infection.

Reasons for selecting an initial route of heroin administration and for subsequent transitions during a severe HIV epidemic.

AIM: To identify the most important reasons for selecting a particular route of heroin administration and for subsequent transitions during a period of epidemic HIV transmission. To study temporal trends in these reasons. DESIGN: Cross-sectional survey. PARTICIPANTS: Nine hundred heroin users in three Spanish cities: 305 in Seville, 297 in Madrid and 298 in Barcelona. MEASUREMENTS: A separate analysis was made of the reasons for five types of behaviour: (a) selecting injection as the initial usual route of heroin administration (URHA); (b) changing the URHA to injection; (c) never having injected drugs; (d) selecting the smoked or sniffed route as the initial URHA; and (e) changing the URHA to a non-injected route. Subjects were invited to evaluate the importance of each reason included in a closed list. Spontaneously self-perceived reasons were also explored in an open-ended question for each of the five types of behaviour studied. FINDINGS: The primary reason selected for each type of behaviour was: (a) pressure of the social environment; (b) belief that injection is a more efficient route than smoking or sniffing heroin; (c) concern about health consequences (especially fears of HIV and overdose), and fear of blood or of sticking a needle into one's veins; (d), pressure of the social environment and (e) concern about health consequences and vein problems. For women, having a sexual partner who injected heroin played a decisive role in initiating or changing to injection. Few people spontaneously mentioned market conditions for purchasing heroin as an important reason for any behaviour, nor did many mention risk of overdose as reasons for (c) or (d). CONCLUSIONS: These findings should be considered when designing interventions aimed at preventing initiation of injecting or facilitating the transition to non-injected routes.

Factors associated with non-fatal heroin overdose: assessing the effect of frequency and route of heroin administration.

AIMS: To examine risk factors associated with non-fatal heroin overdose, particularly frequency and route of heroin administration. DESIGN: Data from cross-sectional surveys were analysed as a case-control and as a case cross-over design. SETTING AND PARTICIPANTS: 2556 subjects treated for heroin dependence in 164 outpatient facilities in Spain. MEASUREMENTS: Prevalence of overdose involving emergency care in the 12 months before treatment admission. CASE CONTROL DESIGN: Odds ratio (OR) adjusted by logistic regression. CASE-CROSSOVER DESIGN: Estimated relative risk (RR) of transient risk of injecting heroin. FINDINGS: The prevalence of overdose was 10%. In the case control analysis the cumulative risk of overdose increased as the frequency of heroin use decreased. However, among daily heroin users this risk increased as the frequency of heroin injection rose, with an OR of 6.0 (95% CI: 3.9-9.6) for daily injectors versus non-injectors. Sniffers had a higher risk than smokers among non-daily users, but not among daily users. Other factors associated with increased risk of overdose were: tranquilizers, alcohol or cocaine use, living in certain regions and being long-term HIV+ 0. In the case-crossover analysis, the RR for injecting heroin versus using other routes immediately before overdose was 15.9 (95% CI: 9.5-26.6), and was much higher for non-daily heroin users than for daily users. CONCLUSIONS: These findings suggest that the rapid entry of a large quantity of heroin into the blood (as occurs when injecting) involves a high risk of overdose, especially when the heroin tolerance level is low (as occurs in sporadic users).