An approach to heroin use disorder intervention within the South African context: a content analysis study.

BACKGROUND: The field of heroin use disorder intervention has been in transition in South Africa since the outbreak of the heroin epidemic. Yet despite growing evidence of an association between heroin users' use of supplementary intervention services and intervention outcomes, heroin use disorder intervention programmes in South Africa generally fail to meet international research-based intervention standards. METHODS: Semi-structured interviews with ten heroin use disorder specialists were conducted and the interviews were subjected to content analysis. RESULTS AND DISCUSSION: In terms of theory and practice, findings of the study suggest that the field of heroin use disorder intervention in South Africa remains fragmented and transitional. Specifically, limited strategic public health care polices that address the syndromes' complexities have been implemented within the South Africa context. CONCLUSIONS: Although many interventions and procedures have begun to be integrated routinely into heroin use disorder clinical practice within the South African context, comorbidity factors, such as psychiatric illness and HIV/AIDS, need to be more cogently addressed. Pragmatic and evidence-based public health care policies designed to reduce the harmful consequences associated with heroin use still needs to be implemented in the South African context.

Co-morbidity and cannabis use in a mental health trust in South East England.

AIM: The prevalence of co-morbidity (severe mental illness and substance) may be less in rural and semi-rural areas than inner cities. The aims were therefore to measure the prevalence of co-morbidity among patients of attending a mental health service in a semi-rural area South East England. DESIGN AND PARTICIPANTS: Cross-sectional prevalence survey of 1,808 patients with detailed assessments from a representative sample of 373 patients identified as having a combination of severe mental illness and substance misuse. Interviews with key workers were performed using validated methods from the COSMIC study. RESULTS: The response rates equalled or exceeded 90% for the various parts of the study. One-tenth of patients attending the Community Mental Health Teams (CMHTs) reported problematic use of illicit drugs and 17% reported alcohol problems in the past year. 22% of Community Drug and Alcohol Service (CDAS) clients reported a severe mental illness and 46% reported some other form of psychiatric disorder. Of patients with a combined diagnosis of mental illness and substance misuse, cannabis use was 4-fold more common amongst patients attending the CMHT than CDAS (33% vs. 8%) while use of amphetamine was five-fold higher in the CMHT group (10% vs. 2%). Patients with concurrent psychiatric and substance misuse problems represent a similar proportion of the aggregate caseload of both treatment services with observed prevalence amongst the CDAS and CMHT patients with a diagnosis for anxiety disorder (18% vs. 26%), minor depression (42% vs. 32%), personality disorders (32% vs. 36%), histories of self-harm (52% vs. 46%) and violence (33% vs. 30%) respectively. CONCLUSIONS: Co-morbidity is common in clients amongst CMHT and CDAS clients although use of cannabis was significantly more common in CMHT clients than in CDAS clients.

Diamorphine treatment for opiate dependence: putative markers of concomitant heroin misuse.

The supply of substitute opioid medication as a treatment for heroin dependence is now common practice. There is growing international interest in the prescription of injectable diamorphine for subgroups of patients who are unable to stop injecting opiate drugs; in the United Kingdom it is estimated that there are currently 300 patients prescribed diamorphine for this purpose. The detection of illicit heroin misuse (through urinary diamorphine metabolites) is confounded in subjects prescribed diamorphine. We investigated the potential to distinguish between the use of street heroin and pharmaceutical diamorphine through the detection in urine of various opiate alkaloids originating in the opium poppy, Papaver somniferum. Over a 7-week period, 532 clients of an urban substance misuse service provided a total of 1122 urine samples for clinical purposes. Using a novel mixed-mode solid-phase extraction and gas chromatography/mass spectrometry technique, we screened samples for morphine, 6-monoacetylmorphine, codeine, meconine, papaverine, noscapine, thebaine and their metabolites. All urine samples from diamorphine-treated patients were positive for morphine. Of samples from patients receiving other treatments, 30% (95%CI: 27-33%) were positive for morphine, indicating probable street heroin misuse. Of morphine-positive samples, 61% (95%CI: 55-67%), from the "other treatments" group were positive for at least one of codeine, meconine and putative noscapine or papaverine metabolites. This was reduced to 56% (95%CI: 50-62%) when excluding codeine. Only one sample (0.1%) was positive for any one of these putative markers in the absence of morphine, when excluding codeine. These findings show that the detection of urinary noscapine and papaverine metabolites is useful in distinguishing between use of pharmaceutical diamorphine and street heroin. This may be of benefit to promote safer and more effective prescribing of diamorphine in opiate dependency, and as an outcome measure in trials of diamorphine prescribing.