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FUTURE RESEARCH IN SUBSTANCE MISUSE AN OVERVIEVW PERSPECTIVE Michael Farrell PHRN Manchester 20th October 2006 Political and moral values of the social system SERVICE Provider AND USER VIEW A model for evidence-based clinical decisions Research Evidence (from Haynes et al, 1996) AIDS cases by transmission group* and year of diagnosis (1987-2003) adjusted for reporting delays, European Union, data reported by 31 December 2003 10000 8000 Injecting 6000 4000 2000 0 1987 1989 1991 1993 1995 1997 1999 2001 2003 Year of diagnosis HBM IDU HC Transmission group not reported NOTE Excluding France, Netherlands (data not available for the w hole period) and Cyprus (no data available) source EuroHIV HIV infections newly diagnosed in injecting drug users in selected EU countries, Russia and Ukraine, by year of report, cases per million population (EUROHIV) 1000 900 Cases per million population 800 700 600 500 400 300 200 100 0 1994 1995 1996 1997 1998 Estonia Latvia Lithuania Portugal Russia Ukraine 1999 2000 2001 2002 2003 Note: no data available from tw o EU countries w ith highest AIDS incidence among IDUs (Spain, Italy) HIV prevalence among IDUs in the EU EMCDDA 2004 Notes: Colour indicates midpoints Local data shown in () HIV in IDUs in Europe Marked difference between countries and within some countries – High prevalence countries (old MS) Italy, Spain, Portugal, followed by France – Some high prevalence estimates from new MS (Latvia, Estonia), and worries about others (Poland) – Low prevalence countries in both old and new MS including countries with high prevalence IDU – Cautious assessment is the long term trend appears to be stable or downwards Some small increases in recent data in some countries or in specific subpopulations Data quality problems so analysis must be made with A note on HCV prevalence in IDUs Prevalence estimates higher and more convergent than for HIV Clear need to finding effective prevention strategies Routine disease surveillance sources of limited value Drug injecting principle route of transmission for HCV in Europe Long term trend in acute drug-related deaths (1985-2003) 300 Index % (1985=100%) 250 200 150 100 50 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003* INDEX 100,0 104,5 118,7 136,9 153,7 181,0 216,4 223,5 201,8 212,2 225,4 252,4 230,1 235,6 241,1 255,4 240,1 205,8 194,9 EU 15, 1985 to 2003 index year 1985=100 Introduction of MMT & NSP, 1967 to 2001 (EU, Norway and Bulgaria) 30 EE NO Cumulative number of countries 25 BE HU LV FR, LT, HU, BU EL 20 BG LV, LT,FI SI PL EL, IE,CZ SK 15 DE SI LU MT 10 ES FR LU, PT DE CZ AT, IT AT IE, PL PT IT NO FI 5 BE, EE DK MT, UK NL, UK DK, NL, SE SE ES 0 1967 1969 1971 1973 1975 1977 1979 1981 Year first publicly funded NSP 1983 1985 1987 1989 1991 1993 Methadone treatment first available 1995 1997 1999 2001 Estimated number of drug users in substitution treatment in 29 European countries (2003) per 100.000 population aged 15-64 450 400 350 300 250 200 150 100 50 0 LU UK ES IE MT FR PT IT SI DK EU DE NL NO SE EL BE CZ LT +4 FI HU BG LV PL RO 10-year trend in the number of substitution treatment clients in Europe (EU-15) 600,000 537,000 500,000 400,000 351,000 265,000 300,000 207,000 200,000 100,000 73,400 0 1993 1995 1997 2000 2003 Proportion of substitution drugs used in medically assisted treatment in Europe, 2003 Buprenorphine 20% Other 1% Methadone 79% Prevalence of HIV in Injecting Drug Users some country estimates European Union, Northern Europe low prevalence, Southern European countries higher prevalence but declining Central and Eastern European countries upward trend, especially Ukraine, Russia, USA and Canada generally stable low levels, outbreak Vancouver British Columbia related to cocaine injecting Australia less than 2% India Manipur Estimated at 50% plus China Yunnan Province 10% to 70% in three years HIV prevalence in injecting drug users 90 Myanmar 80 HIV prevalence, % 70 Manipur & Yunnan 60 Edinburgh 50 Ho Chi Minh City Bangkok 40 Lithuania Odessa 30 20 10 Jakarta 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 Year 1992 1993 1994 1995 1996 1997 1998 1999 HIV infection rates in and out of substitution treatment (Metzger et al. 1993) 35 36 36 39 39 42 48 49 51 27 21 Out % 13 15 16 17 17 18 18 19 19 20 21 In % ne ths ths ths ths ths ths ths ths ths ths i l se 6 m 2 m 8 m 4 m 0 m 6 m 2 m 8 m 0 m 2 m a 1 1 2 3 3 4 4 6 7 b Drug Overdose and Mortality Mean of 5+ non fatal overdoses in heroin using cohorts Mortality 1 to 2% In methadone treatment down to 0.2% Recent Hser 33 year longitudinal study reports over 50% mortality in cohort Suicide completion rates high and significant contributor to overall suicide Excess mortality ratio Excess mortality ratio for different time periods post-release by cause of death (Singleton, Farrell, Marsden et al 2003) 45 40 35 30 25 20 15 10 5 0 U Drug-related deaths o1 t p 3 6 2 1 2 5 o2 o4 o8 t t t o o o t t t p p p p up up 1u 2u 4u 8u 3 6 1 2 Time since release (w eeks) Not drug-related 2 5 >= l a t To The odds of a drug-related death in the first week of release among women 10 70 over times greater than that observed at one year (OR 10.6; 95%CI 4.8-22.0) times higher than age matched general population among men around 30 8 times greater than at one year (OR 8.3: 95%CI 5.0-13.3). times higher than age matched general population (Singleton, Farrell et al 2003) IN SUMMARY A 8-10 FOLD INCREASED RISK OF MORTALITY IN THE EARLY RELEASE PERIOD Substitution in prisons Estimated that over 30 million imprisoned annually Major risk for blood borne virus spread In most countries where measured between one third and half have drug dependence RCT of methadone in prison (Dolan et al) demonstrates role in reduction of blood borne virus, and general improvement, and post release reduction in mortality for those who continue Rapid expansion in Europe in substitution in prisons Huge challenge for Asia pacific region where insitutional incarceration standard response to opioid dependence Drug Substitution Treatment Strong evidence for the benefits of oral methadone treatment RCTs +++ REASONABLE EFFECT SIZE REDUCES DRUG CRIME .70 REDUCES OPIATE CONSUMPTION .35 REDUCES INJECTING & RISK TAKING 0.22 Now good evidence for buprenorphine and LAAM RCTs ++ (LAAM CURRENTLY UNDER REVIEW) Use of injectable diamorphine and other drugs building evidence base for comparative Gunne & Gronbladh (1981) RCT: Methadone versus no methadone 34 subjects using heroin by injection 17 experimental (methadone) 17 controls (no methadone) Controls not allowed to enter MMT for 2 years Followed up at 2 years and again at 4 years Gunne & Gronbladh (1981): Baseline Experimental Group (methadone) Control group (no methadone) U U U U U U U U U U U U U U U U U U U U U U U U U U U U U U U U U U – ongoing daily heroin Use U Gunne & Gronbladh (1981): 2 years Experimental group (methadone) Control group (no methadone) A A A A U U U A A A A A U U U U A A A A U U U U U U U U U U U D U A – Abstinent U – on-going daily Use D – Deceased D Gunne & Gronbladh (1981): 4 years Experimental Group (methadone) Control group (methadone) Control group (no methadone) A A A A U U U A A A A A A A U U A A A A A A U D U U U A A A D D U A – Abstinent U – on-going daily Use D – Deceased D A 33 year follow-up of narcotic addicts Unknown Dead (Hser et al., 2001) Incarcerated Daily use MMT Occasional use Abstinence 100 22% 2% 6% 7% 4% 80 60 40 48% 20 12% 0 56 N Age 60 64 581 24.5 (3.9) 68 72 76 439 36.8 (5.4) 80 84 88 354 47.6 (5.1) 92 96 242 57.4 (4.0) A 33 year follow-up of narcotic addicts Unknown Dead (Hser et al., 2001) Incarcerated Daily use MMT Occasional use Abstinence 100 22% 2% 6% 7% 4% 80 60 40 48% 20 12% 0 56 N Age 60 64 581 24.5 (3.9) 68 72 76 439 36.8 (5.4) 80 84 88 354 47.6 (5.1) 92 96 242 57.4 (4.0) COMPOSITE SLIDE 3-Year Reincarceration Rates DE TX CA 100 Percent 80 60 40 * 20 0 No Tx Prison Tx * * * Prison+Parole Methadone maintenance for prisoners Location No. MMT Prison Population Rate % NSW Austria Denmark 1000 345 290 8150 6915 3150 12.26 4.9 9.2 France Germany Spain (Bup 879) 157 800 18000 50714 78707 50656 0.3 1.0 35.5 400 180 67065 4985 0.5 3.6 New York Switzerland Source: NSW DCS Inmate Census, UK Home Office, World Prison Population List 4th Ed, US Department of Justice NSW prison methadone program 1986 as a pilot pre release program by Department of Corrective Services (DCS) Criteria 3-6 months prior to release Past or present history of opiate dependence History of returning to injecting and crime on previous releases 3 designated community clinics 1990 those entering custody on MMT were continued Since 1990 12% NSW MMT received in custody NDARC Methadone Study NSW prison methadone maintenance – Randomised control trail of 384 IDUs in 1997 and re-interviewed in 1998 – Heroin use was significantly less for those receiving methadone, as measured by hair analysis. Source: Dolan & Wodak RCT Results MMT HCV incidence % Control 24.3 31.7 Heroin (hair) % 27 42 Heroin (SR) % 33 78 No cases of HIV NDARC Methadone Study Follow up after release from gaol study of above 384 IDUs examining rate of: – Incarceration – Mortality – Hepatitis C Mortality rates (Intent) 1 0.99 0.98 MMT Non MMT 0.97 0.96 0.95 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 HCV incidence (Intent) MMT (N=52) CONTROL (N=56) Cases 14 23 Rate per 100 person 18.3 36.5 10 - 31 23 - 55 years 95% CI Previous rate at 5 months was 24 CI: 7-62 vs 31 CI: 9-81 Source: Dolan, K Re- incarceration up to May 2002 Continuous n=45 NonContinuous p n= 216 Mean total weeks in prison 41 67 .007 (sd) Source: Dolan, K Re- incarceration 1.0 .8 .6 Treatment exposure .4 continuous .2 non continuous 0.0 0 400 Days of follow up 800 1200 1600 Source: Dolan, K Need for upscaling of treatment Urgent need in many regions for concerted effort to expand treatment Discussions and research required on the challenge of upscaling IDTS a major development within English Prisons Major expansion in substitution treatment and psychosocial treatment NEED TO EVALUATE IDTS Implementation assessment Cost Effectiveness Environmental Impact Individual Outcome Impact on Recidivism Impact on Post Release Mortality Research Framework Need pragmatic studies in prison context More longitudinal studies A 10 year mortality outcome study from the National Psychiatric Morbidity Survey Consider a longitudinal Study of Young Offenders and exploration of trajectory of drug histories within the criminal justice system Prisons ideal enviroments for exploration of issues of psychiatric comorbidity and substance use Studies linked to community studies Linking treatment in prison up to the National Drug Treatment Monitoring System Currently Outcomes Monitoring Project Underway, Important to have Prison Treatment Linked into this. Infectious Diseases remain a big threat especially BBVs Conclusions The huge challenge in all settings is to develop a comprehensive range of interventions that are humanitarian, effective and impactful for the all those who require interventions To ensure that ethical and humane treatment is delivered as effectively as possible in all settings