Differences in severity of heroin dependence by route of administration: the importance of length of heroin use.

To explore differences in the severity of heroin dependence by route of administration, we interviewed 909 heroin users in three Spanish cities. Dependence was measured with the severity dependence scale (SDS). No major differences in the severity of heroin dependence were detected among users with 5 or more years of heroin use (long-term users), but differences were found among newer users (SDS mean scores, 7.3 in heroin injectors; 7.9 in smokers and 4.6 in sniffers; P = 0.006), especially those with fewer than 3 years of use. Similar differences by route of administration were found when frequency of heroin use (days/month) was considered rather than severity of dependence. However, in the latter case major differences were also found among long-term users. These findings suggest that the route of administration probably influences the rate of progression to dependence but has little influence on the long-run level of dependence. They also help explain some aspects of the transition between routes of heroin administration, which is occurring in different areas.

[Acute respiratory problems and cocaine or heroine smoking]. / Problemas respiratorios agudos y uso de cocaína o heroína por vía pulmonar.

BACKGROUND: To explore if cocaine or heroin smoking was positively associated to acute respiratory complications (ARC). SUBJECTS AND METHODS: We collected data from medical records for 717 cocaine users who were attended in 14 hospital emergency rooms. The association was studied by logistic regression. RESULTS: The most frequent ARC were respiratory infections and complications with chest pain or dyspnea. Cocaine smokers (OR = 3.3; CI 95% = 1.5-6.9) and cocaine sniffers (OR = 2.5; CI 95% = 1.1-5.6) had greater risk of ARC than cocaine injectors. Heroin smokers (OR = 3.5; COI 95% = 1.8-7.0) and heroin sniffers (OR = 2.8; CI 95% = 1.4-5.6) had greater risk of ARC than non heroin users. CONCLUSIONS: These results suggest that cocaine or heroin smoking increases the risk of ARC.

[The persistence of risky conduct for HIV transmission among intravenous drug users in Madrid, Seville, and Valencia. The Working Group of the Médicos del Mundo for the Monitoring of HIV Infection and the Risk Practices of Intravenous Drug Users]. / Persistencia de conductas de riesgo para la transmisión del VIH en inyectores de drogas de Madrid, Sevilla y Valencia. Grupo de Trabajo de Médicos del Mundo para la monitorización de la infección por VIH y las prácticas de riesgo en inyectores de drogas.

OBJECTIVE: To determine the prevalence of HIV infection and risk-taking behavior for infection among intravenous drug users in Madrid, Seville, and Valencia (Spain). To study the main factors associated with such behavior. MATERIAL AND METHODS: Personal interviews were carried out with 821 intravenous drug users recruited in 1994 and 1995 among recent participants in three needle-exchange programs. Subjects were asked about their risk-taking behavior in the 30 days preceding the interview. Bivariate statistical methods and logistical regression techniques were used. RESULTS: In the month before the interview, 13.8% of the subjects in Valencia, 18.1% in Madrid, and 26.9% in Seville used needles that had been used by other people, usually (73-88%) without disinfecting them effectively. Condom use during the reference period was 50% in Seville, 42.5% in Madrid, and 34.2% in Valencia. The prevalence of HIV infection ranged from 30.1% in Seville to 43. 2% in Madrid. Multivariate analysis showed that the factors most closely associated with accepting used needles were: needle sharing (OR = 12.2), residence in Seville (OR = 6.6), and HIV positivity (OR = 4.6). The factors most closely associated with not using condoms systematically were: ignorance of personal HIV serological state (OR = 4.1), needle sharing (OR = 3.7), and HIV negativity (OR = 3.3). CONCLUSIONS: The risk of HIV transmission among intra-venous drug users in Spain is high (infection and risk-taking behavior have a high prevalence), so programs designed to reduce this risk should be increased quickly.

[The prevalence of human immunodeficiency virus infection and the risk behaviors in the heroin addicts of Barcelona, Madrid and Seville: an example of the advantages of centering studies on addicts and not just on intravenous users]. / Prevalencia de infección por el virus de la inmunodeficiencia humana y de conductas de riesgo entre los consumidores de heroína de Barcelona, Madrid y Sevilla: un ejemplo de las ventajas de centrar los estudios en los consumidores y no sólo en los usuarios por vía intravenosa.

BACKGROUND: The switch from intravenous heroin administration to smoking of heroin might be changed the trends in the prevalence of HIV infection and risk behaviours among Spanish users. SUBJECTS AND METHODS: Cross-sectional study of 909 regular heroin users, recruited within and outside of drug treatment centres. The prevalence of HIV infection and risk behaviours were studied in the whole sample and among injectors. RESULTS: The proportion of heroin users who had ever injected was 86.7% in Barcelona, 71.1% in Madrid and 56.1% in Seville, while the proportion of those who had injected in the last 30 days was 79.7, 35.6 and 29.2%, respectively. The prevalence of HIV infection among users who had ever injected was 46.2% in Barcelona, 39.6% in Madrid and 47.1% in Seville; in the total population of heroin users the prevalence was 40, 31.1 and 28%, respectively. Among current injectors, 10.9% in Barcelona, 13.9% in Madrid and 23.6% in Seville reported they had injected with used syringes in the last 30 days, while the corresponding proportion among the total population of users was 8.7, 4.9 and 6.9%, respectively. Moreover, 19.2% of injectors in Barcelona, 16.7% in Madrid and 16.9% in Seville admitted to injecting drugs which had been diluted in syringes previously used by others in the last 30 days; of this group, over half stated they had not injected with used syringes during that period. CONCLUSIONS: The prevalence of HIV infection and risk behaviours among heroin users differs depending on whether all users or only injectors are considered. This suggests that the transition from injecting to smoking is one of the major factors contributing to the control of the HIV epidemic in Spain. This contribution, which has little to do with regional prevention policies, must be taken into account when comparing their effectiveness.

Cocaine use among heroin users in Spain: the diffusion of crack and cocaine smoking. Spanish Group for the Study on the Route of Administration of Drugs.

STUDY OBJECTIVE: To describe the prevalence and patterns of use of crack and cocaine hydrochloride among heroin users in Spain. To explore if the expansion of heroin smoking is accompanied by a similar phenomenon for cocaine. DESIGN: Cross sectional study in 1995. Face to face interviews using a structured questionnaire. SETTING: Three cities with different prevalences of heroin use by smoking: high (Seville), intermediate (Madrid), and low (Barcelona). PARTICIPANTS: 909 heroin users, 452 in treatment and 457 out of treatment. MAIN RESULTS: Last month prevalence of crack use was 62.3% in Seville, 19.4% in Madrid, and 7.7% in Barcelona. Most users in Madrid (86.5%) and Barcelona (100%) generally prepared their own crack, usually with ammonia as alkali; in Seville most users (69.7%) bought preprocessed crack. The proportion of users who began taking cocaine (crack or cocaine hydrochloride) by smoking has increased progressively since the seventies, rising to 74.1% in Seville, 61.5% in Madrid, and 28% in Barcelona in 1992-1995, with the earliest increase in Seville. The factors associated with crack use were: residence in Seville (odds ratio (OR) = 16.3), cocaine hydrochloride use mainly by smoking (OR = 5.0), by sniffing (OR = 2.7) or by injecting (OR = 2.5), heroin use mainly by smoking (OR = 2.8) and weekly use of cannabis (OR = 1.9). CONCLUSIONS: In Spain smoking cocaine may be progressively diffusing from the south west to the north east, similar to what has happened with smoking heroin, but beginning later in time. The factors associated with smoking cocaine are basically ecological or cultural in nature (characteristics of the available drugs and the main route of heroin administration in each city).

[Emergencies associated with the consumption of designer drugs, hallucinogens and amphetamines treated at 15 Spanish hospitals in 1994. Work Group on the Study of Emergencies due to Psychostimulants]. / Urgencias relacionadas con el consumo de drogas de diseño, alucinógenos y anfetaminas atendidas en quince hospitales españoles durante 1994. Grupo de Trabajo para el Estudio de las Urgencias por Psicoestimulantes.

The clinical records of patients attended at emergency hospitals in fifteen hospitals in Madrid, Valencia and Gran Canaria during 1994 were retrospectively analyzed. Seventy-three emergencies related to the consumption of design drugs, hallucinogens or amphetamines (100 times lower than because of opiates or cocaine) were recorded. Apart from the responsible drug for the emergency visit, in most cases the usual consumption of other substances was mentioned. Acute psychopathological reactions predominated. Three patients were admitted and five were derived to other hospitals; the remaining patients improved and were discharged. The number of emergencies on account of these drugs is relatively low, with a proportion of less than one in 10,000 emergencies attended in these areas and might not radically change if the current predominant consumption pattern is maintained.

The transition from injecting to smoking heroin in three Spanish cities. The Spanish Group for the Study of the Route of Heroin Administration.

AIMS: To measure the current prevalence of different routes of heroin administration among users and to describe the most frequent patterns in the evolution of the main route from the time of first use to the present and their implications for the control of the HIV epidemic. DESIGN: Cross-sectional study. Face-to-face interviews using a structured questionnaire. SETTING AND PARTICIPANTS: Nine hundred and nine regular heroin users from Madrid, Barcelona and Seville (about 300 per city), half of them recruited in treatment centres and the other half out of treatment. MEASUREMENTS: Socio-demographic characteristics, current and historical behaviours related to route of administration. FINDINGS: Before 1980 injection was the first main route of heroin administration for most users in Barcelona and Madrid; in Seville smoking already predominated, although 40% of users began by injecting. Sniffing subsequently became predominant in Barcelona, while smoking became the predominant first route in Madrid and Seville (smoking has been the only first route in Seville since 1991). The prevalence of injection as the main route of administration during the last 30 days was 77.3% in Barcelona, 24.3% in Madrid and 23.9% in Seville; smoking predominated in the latter two cities. The factors most strongly associated with injection as the preferred route were city of recruitment and having a partner who injected. Some 73% of those who stopped injecting in their last change of route stated that the results of their HIV test or fear of becoming infected had been important in making this decision. CONCLUSIONS: The change from injecting to smoking will greatly facilitate the control of HIV infection in Spain. However, the main causal factor does not appear to be the perception of HIV risk, but rather other, ecological factors (cultural or market-related). The absence of these factors in some areas may impede the spread of smoking.

Temporal and geographic variations in the characteristics of heroin seized in Spain and their relation with the route of administration. Spanish Group for the Study of the Purity of Seized Drugs.

We studied the evolution of the purity and other characteristics of heroin seized in 17 Spanish provinces (especially seizures presumed to be street drugs) and explored their relation with the prevalence and recent changes in intravenous use. We found great variability in purity within and between provinces: in provinces with large cities the purity is similar to or greater than that detected elsewhere in Europe, in others it is less than 30 percent, and on the island of Mallorca it is over 60 percent. Purity has increased in recent years. The heroin in circulation is predominantly brown in all of Spain except on the Mediterranean coast. The principal adulterants detected are caffeine, paracetamol and piracetam; phenobarbital and procaine have disappeared. In provinces where white heroin is in circulation, most heroin users in treatment use the intravenous route; in provinces where brown heroin predominates, the proportion of chasers increases with increasing purity of heroin (correlation coefficient = 0.6). The disappearance of white heroin has paralleled the spread of the phenomenon of chasing.

Opiates or cocaine: mortality from acute reactions in six major Spanish cities. State Information System on Drug Abuse (SEIT) Working Group.

STUDY OBJECTIVE: To describe temporal and geographical variations in mortality from acute reactions to opiates or cocaine and the demographic and toxicological characteristics of persons who died from these in major Spanish cities between 1983 and 1991. DESIGN: Descriptive study. Data were obtained retrospectively from pathologists' reports. SETTING: Cities of Madrid, Barcelona, Valencia, Seville, Zaragoza, and Bilbao. SUBJECTS: Deaths from acute reactions to opiates or cocaine were defined as those in which pathologists' reports did not indicate any other cause of death and in which evidence was found of recent consumption of these drugs. MAIN RESULTS: The mortality rate from acute reactions to opiate/cocaine per 100,000 population in the six cities as a whole rose from 1.2 in 1983 to 8.2 in 1991. Average annual rates for the whole period ranged from 1.7 in Seville to 4.9 in Barcelona. The male/female rates ratio was 5.9:1. The mean age of persons who died rose from 25.1 years in 1983 to 28 years in 1991. In more than 90% of the cases in whom toxicological tests were undertaken opiates were detected, and the proportion in which benzodiazepines or cocaine were detected increased during the period studied. CONCLUSIONS: Between 1983 and 1991 mortality from acute reactions to opiates/cocaine rose dramatically in major Spanish cities and significant differences in mortality between cities were found. Deaths were concentrated among men and young people. Acute drug reactions became one of the leading causes of death in persons 15-39 years of age, representing 11.1% of mortality from all causes in 1988 for this age group. Future studies should examine the relationship between the temporal and geographical variations in this type of mortality and various personal, environmental and social factors.