Tag Archive: Hepatitis C.


On April 3 1924, a group of American congressmen held an official hearing to consider the future of heroin. They took sworn evidence from experts, including the US surgeon general, Rupert Blue, who appeared in person to tell their committee that heroin was poisonous and caused insanity and that it was particularly likely to kill since its toxic dose was only slightly greater than its therapeutic dose.

They heard, too, from specialist doctors, such as Alexander Lambert of New York’s Bellevue hospital, who explained that „the herd instinct is obliterated by heroin, and the herd instincts are the ones which control the moral sense … Heroin makes much quicker the muscular reaction and therefore is used by criminals to inflate them, because they are not only more daring, but their muscular reflexes are quicker.“ Senior police, a prison governor and health officials all added their voices. Dr S Dana Hubbard, of the New York City health department, captured the heart of the evidence: „Heroin addicts spring from sin and crime … Society in general must protect itself from the influence of evil, and there is no greater peril than heroin.“

The congressmen had heard much of this before and now they acted decisively. They resolved to stop the manufacture and use of heroin for any purpose in the United States and to launch a worldwide campaign of prohibition to try to prevent its manufacture or use anywhere in the world. Within two months, their proposal had been passed into law with the unanimous backing of both houses of the US Congress. The war against drugs was born.

To understand this war and to understand the problems of heroin in particular, you need to grasp one core fact. In the words of Professor Arnold Trebach, the veteran specialist in the study of illicit drugs: „Virtually every ‚fact‘ testified to under oath by the medical and criminological experts in 1924 … was unsupported by any sound evidence.“ Indeed, nearly all of it is now directly and entirely contradicted by plentiful research from all over the world. The first casualty of this war was truth and yet, 77 years later, the war continues, more vigorous than ever, arguably the longest-running conflict on earth.

Drugs and fear go hand in hand. The war against drugs is frightening – but not, in reality, for the reasons which are claimed by its generals. The untold truth about this war, which has now sucked in every country in the developed world, is that it creates the very problem which it claims to solve. The entire strategy is a hoax, with the same effect as an air force which bombs its own cities instead of its enemy’s. You have to go back to the trenches of Flanders to find generals who have been so incompetent, so dishonest, so awesomely destructive towards those for whom they claim to care.

The core point is that the death and sickness and moral collapse which are associated with class A drugs are, in truth, generally the result not of the drugs themselves but of the black market on which they are sold as a result of our strategy of prohibition. In comparison, the drugs themselves are safe, and we could turn around the epidemic of illness and death and crime if only we legalised them. However, it is a contemporary heresy to say this, and so the overwhelming evidence of this war’s self-destructive futility is exiled from almost all public debate now, just as it was when those congressmen met.

Take heroin as a single example. And it’s a tough example. In medical terms, it is simply an opiate, technically known as diamorphine, which metabolises into morphine once it enters its user’s body. But, in terms of the war against drugs, it is the most frightening of all enemies. Remember all that those congressmen were told about „the great peril“. Remember the Thatcher government’s multimillion pound campaign under the slogan „Heroin screws you up“. Think of Tony Blair at the 1999 Labour party conference fulminating about the „drug menace“ or of William Hague last year calling for „a stronger, firmer, harder attack on drugs than we have ever seen before“. And now look at the evidence.

Start with the allegation that heroin damages the minds and bodies of those who use it, and consider the biggest study of opiate use ever conducted, on 861 patients at Philadelphia General hospital in the 20s. It concluded that they suffered no physical harm of any kind. Their weight, skin condition and dental health were all unaffected. „There is no evidence of change in the circulatory, hepatic, renal or endocrine functions. When it is considered that some of these subjects had been addicted for at least five years, some of them for as long as 20 years, these negative observations are highly significant.“

Check with Martindale, the standard medical reference book, which records that heroin is used for the control of severe pain in children and adults, including the frail, the elderly and women in labour. It is even injected into premature babies who are recovering from operations. Martindale records no sign of these patients being damaged or morally degraded or becoming criminally deviant or simply insane. It records instead that, so far as harm is concerned, there can be problems with nausea and constipation.

Or go back to the history of „therapeutic addicts“ who became addicted to morphine after operations and who were given a clean supply for as long as their addiction lasted. Enid Bagnold, for example, who wrote the delightful children’s novel, National Velvet, was what our politicians now would call „a junkie“, who was prescribed morphine after a hip operation and then spent 12 years injecting up to 350mg a day. Enid never – as far as history records – mugged a single person or lost her „herd instinct“, but died quietly in bed at the age of 91. Opiate addiction was once so common among soldiers in Europe and the United States who had undergone battlefield surgery that it was known as „the soldiers‘ disease“. They spent years on a legal supply of the drug – and it did them no damage.

We cannot find any medical research from any source which will support the international governmental contention that heroin harms the body or mind of its users. Nor can we find any trace of our government or the American government or any other ever presenting or referring to any credible version of any such research. On the contrary, all of the available research agrees that, so far as harm is concerned, heroin is likely to cause some nausea and possibly severe constipation and that is all. In the words of a 1965 New York study by Dr Richard Brotman: „Medical knowledge has long since laid to rest the myth that opiates observably harm the body.“ Peanut butter, cream and sugar, for example, are all far more likely to damage the health of their users.

Now, move on to the allegation that heroin kills its users. The evidence is clear: you can fatally overdose on heroin. But the evidence is equally clear, that – contrary to the claims of politicians – it is not particularly easy to do so. Opiates tend to suppress breathing, and doctors who prescribe them for pain relief take advantage of this to help patients with lung problems. But the surprising truth is that, in order to use opiates to suppress breathing to the point of death, you have to exceed the normal dose to an extreme degree. Heroin is unusually safe, because – contrary to what those US congressmen were told in 1924 – the gap between a therapeutic dose and a fatal dose is unusually wide.

Listen, for example, to Dr Teresa Tate, who has prescribed heroin and morphine for 25 years, first as a cancer doctor and now as medical adviser to Marie Curie Cancer Care. We asked her to compare heroin with paracetamol, legally available without prescription. She told us: „I think that most doctors would tell you that paracetamol is actually quite a dangerous drug when used in overdose; it has a fixed upper limit for its total dose in 24 hours and if you exceed that, perhaps doubling it, you can certainly put yourself at great risk of liver failure and of death, whereas with diamorphine, should you double the dose that you normally were taking, I think the consequence would be to be sleepy for a while and quite possibly not much more than that and certainly no permanent damage as a result.“ Contrary to the loudly expressed view of so many politicians, this specialist of 25 years‘ experience told us that when heroin is properly used by doctors, it is „a very safe drug“.

Until the American prohibitionists closed him down in the 20s, Dr Willis Butler ran a famous clinic in Shreveport, Louisiana, for old soldiers and others who had become addicted to morphine after operations. Among his patients, he included four doctors, two church ministers, two retired judges, an attorney, an architect, a newspaper editor, a musician from the symphony orchestra, a printer, two glass blowers and the mother of the commissioner of police. None of them showed any ill effect from the years which they spent on Dr Butler’s morphine. None of them died as a result of his prescriptions. And, as Dr Butler later recalled: „I never found one we could give an overdose to, even if we had wanted to. I saw one man take 12 grains intravenously at one time. He stood up and said: ‚There, that’s just fine,‘ and went on about his business.“

Heroin can be highly addictive – which is a very good reason not to start taking it. In extreme doses, it can kill. But the truth which has been trampled under the cavalry of the drug warriors is that, properly prescribed, pure heroin is a benign drug. The late Professor Norman Zinberg, who for years led the study of drug addiction at Harvard Medical School, saw the lies beneath the rhetoric: „To buttress our current programme, official agencies, led originally by the old Federal Bureau of Narcotics, have constructed myth after myth. When pushers in schoolyards, ‚drug progression‘, drugs turning brains to jelly, and other tales of horror are not supported by facts, they postulate and publicise others: ‚drugs affect chromosomes‘; ‚drugs are a contagious disease‘. Officials go on manufacturing myths such as the chromosome scare long after they are disproved on the self-righteous assumption that if they have scared one kid off using drugs, it was worth the lie.“

Take away the lies and the real danger becomes clear – not the drugs, but the black market which has been created directly by the policy of prohibition. If ever there is a war crimes trial to punish the generals who have gloried in this slaughter of the innocent, the culprits should be made to carve out in stone: „There is no drug known to man which becomes safer when its production and distribution are handed over to criminals.“

Heroin, so benign in the hands of doctors, becomes highly dangerous when it is cut by black-market dealers – with paracetamol, drain cleaner, sand, sugar, starch, powdered milk, talcum powder, coffee, brick dust, cement dust, gravy powder, face powder or curry powder. None of these adulterants was ever intended to be injected into human veins. Some of them, such as drain cleaner, are simply toxic and poison their users. Others – sand or brick dust – are carried into tiny capillaries and digital blood vessels where they form clots, cutting off the supply of blood to fingers or toes. Very rapidly, venous gangrene sets in, the tissue starts to die, the fingers or toes go black and then have only one destiny: amputation. Needless suffering – inflicted not by heroin, but by its black-market adulterants.

Street buyers cannot afford to waste any heroin – and for that reason, they start to inject it, because smoking or snorting it is inefficient. The Oxford Handbook of Clinical Medicine records that a large proportion of the illness experienced by black-market heroin addicts is caused by wound infection, septicaemia, and infective endocarditis, all due to unhygienic injection technique. Street users invariably suffer abscesses, some of them of quite terrifying size, from injecting with infected needles or drugs. Those who inject repeatedly into the same veins or arteries will suffer aneurisms – the walls of the artery will weaken and bulge; sometimes they will start to leak blood under the skin; sometimes, these weakened arteries will become infected by a dirty needle and rupture the skin, leaving the user to bleed to death.

In the mid 90s, the World Health Organisation estimated that 40% of recent Aids cases internationally had been caused by drug users sharing injecting equipment. The British record on Aids is better because in the late 80s the government quietly broke with its prohibition philosophy and started to provide clean needles. Nevertheless, by June last year, 1,000 black-market drug users in this country had died of Aids which was believed to have been contracted from dirty needles. More needless misery and death.

Far worse, however, is the spread of hepatitis C, which can kill by causing cirrhosis and sometimes cancer in the liver. The official estimate is that 300,000 people in this country are now infected. Dr Tom Waller, who chairs Action on Hepatitis C, says the truth is likely to be much worse. And almost all of these victims are black-market drug users who contracted the disease by sharing dirty injecting equipment. Dr Waller says there is now a „major epidemic“, threatening the lives of „a great many people“. Needlessly.

Street buyers buy blind and so they will overdose accidentally: they have no way of telling how much heroin there is in their deal. Dr Russell Newcombe, senior lecturer in addiction studies at John Moores University in Liverpool, has found the purity of street heroin varying from 20% to 90%. „Users can accidentally take three or four times as much as they are planning to,“ he says. It is peculiarly ironic that governments set out to protect their people from a drug which they claim is dangerous by denying them any of the safeguards and information which they insist must apply to the consumption of drugs which they know to be harmless. (Compare, for example, the mandatory information on the side of a bottle of vitamin C tablets with the information available to a black-market heroin user.)

Street buyers often run short of supplies – and so they mix their drug with anything else they can get their hands on, particularly alcohol. Heroin may be benign, but if you mix it with a bottle of vodka or a handful of sedatives, your breathing is likely to become extremely depressed. Or it may just stop. In any event, whether it is poisonous adulterants or injected infection; whether it is death by accidental overdose or death by polydrug use: it is the black market which lies at the root of the danger. The healthiest route, of course, is not to take the drug at all: but for those who are addicted, prohibition inflicts danger and death. Needlessly. Water would become dangerous if it were banned and handed over to a criminal black market.

The same logic applies to drugs which, unlike heroin, are inherently harmful – such as alcohol, which is implicated in organic damage (liver) and social problems (violence, dangerous driving). American bootleggers brewed their moonshine with adulterants such as methylated spirits, which can cause blindness. (Hence the proliferation of blind blues singers.) And there are documented cases of drinkers during prohibition injecting alcohol, with all of the attendant dangers. (It is instructive to look back on the prohibitionists‘ efforts to justify their war against alcohol with hugely inflated statements of its danger. In his book on the history of drugs, Emperors of Dreams, Mike Jay records the claims that alcohol was an „environmental poison“ which generated cretinism and several otherwise unrecognised syndromes including „blastophoric degeneration“ and „alcoholic diathesis“.)

The risks of consuming LSD and ecstasy are increased enormously by their illegal and unsupervised manufacture. Nobody knows what they are swallowing. Yet, when a Brighton company developed a test to check the purity of ecstasy, the government’s drugs adviser, Keith Hellawell (whose contract has just been suspended), condemned it and warned that the company risked prosecution. It is the same with black-market amphetamines: speed alone may not kill, but speed with a blindfold is highly likely to finish you off.

In the same way, the classic signs of social exclusion among addicts are the product not of their drug but of the illegality of the drug. If addicts fail to work, it is not because heroin has made them work-shy, but because they spend every waking minute of the day hustling. If addicts break the law, it is not because the drug has corrupted their morality, but because they are forced to steal to pay black-market prices. If addicts are thin, it is not because the drug has stripped away their flesh, but because they spend every last cent on their habit and have nothing left for food. Over and over again, it is the black market, which has been created by the politicians, which does the damage.

Keith Hellawell, the man to whom the government turned for advice on drugs, appeared to know none of this. When we interviewed him for a television programme, he insisted that heroin itself was dangerous and then repeatedly dodged requests to come up with any evidence at all to justify his claim. Subsequently, when we offered his department as much time as it would like to find any evidence, it failed to come up with anything at all and passed the question to the Department of Health, which also failed. It is fair to conclude that the government’s former drugs adviser did not know the first thing about heroin.

The confusion between the effect of the drug and the effect of the black market is exacerbated not only because of government policy but also because government statistics completely ignore this distinction, with the result that teams of researchers study drug policy, use compromised statistics and simply recycle the confusion, thus providing politicians with yet more false fuel for their fire. Home Office figures on drug deaths, for example, are hopelessly compromised. Eighteen months ago, the Department of Health, which might have been expected to know better, produced new guidelines for doctors dealing with drug users and recorded the following: „Generally there is a greater prevalence of certain illnesses among the drug misusing population, including viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental disease.“ All of it true of the black market. None of it true of the drug. No attempt to make the distinction.

The black market damages not only drug users but the whole community. Britain looks back at the American prohibition of alcohol in the 20s and shudders at the stupidity of a policy which generated such a catastrophic crimewave. Yet in this country, now, the prohibition of drugs has generated a crime boom of staggering proportions. Research suggests that in England and Wales, a hard core of black-market users is responsible for some £1.5bn worth of burglary, theft and shoplifting each year – they are stealing £3.5m worth of property a day. As a single example, Brighton police told us they estimate that 75% of their property crime is committed by black-market drug users trying to fund their habit. And yet governments refuse to be tough on the cause of this crime: their own prohibition policy.

The global version of this damage was put succinctly by Senator Gomez Hurtado, former Colombian ambassador to France and a high court judge, who told a 1993 conference: „Forget about drug deaths and acquisitive crime, about addiction and Aids. All this pales into insignificance before the prospect facing the liberal societies of the west, like a rabbit in the headlights of an oncoming car. The income of the drug barons is an annual $500,000m, greater than the American defence budget. With this financial muscle they can suborn all the institutions of the state and, if the state resists, with this fortune they can purchase the firepower to outgun it. We are threatened with a return to the dark ages of rule by the gang. If the west relishes the yoke of the tyrant and the bully, current drug policies promote that end.“

Having attacked and maimed and killed the very people they claimed to be protecting; having inflicted a crime wave on the same communities which they said they were defending; having run up a bill which now costs us some £1.7bn a year in this country alone: this war’s generals might yet have some claim to respect if they were able to show that they had succeeded in their original objective of stopping or, at least, of cutting the supply of prohibited drugs. They cannot.

In December 1999, the chief constable of Cleveland police, Barry Shaw, produced a progress report on the 1971 Misuse of Drugs Act, which marked the final arrival of US drugs prohibition in this country: „There is overwhelming evidence to show that the prohibition-based policy in this country since 1971 has not been effective in controlling the availability or use of proscribed drugs. If there is indeed a war against drugs, it is not being won … Illegal drugs are freely available, their price is dropping and their use is growing. It seems fair to say that violation of the law is endemic, and the problem seems to be getting worse despite our best efforts.“

Mr Shaw was able to point to a cascade of evidence to support his view: between 1987 and 1997, there had been a tenfold increase in the seizure of illicit drugs, and yet the supply on the streets was so strong that the price of these drugs had kept dropping; in 1970, only 15% of people had used an illegal drug, but by 1995, 45% had; in 1970, 9,000 people were convicted of a drugs offence but in 1995 94,000 were. The Home Office responded to the chief constable’s report with complete silence: they refused even to acknowledge receiving it. Internal reports from the American Drugs Enforcement Agency confirm the chief constable’s conclusion. (They say Britain now produces so much cannabis that we actually export it to Holland.)

Prohibition has not merely failed to cut the supply of illicit drugs: it has actively spread drug use. The easiest way for new users to fund their habit is to sell drugs and consume the profit; so they go out and find new users to sell to; so it is that when one child in the classroom starts using, others soon join in; one user in the street and neighbours soon follow. Black-market drug use spreads geometrically. The Health Education Authority in 1995 found that 70% of people aged between 11 and 35 had been offered drugs at some time. Pushers push. When Britain began to impose prohibition of heroin, in 1968, there were fewer then 500 heroin addicts in Britain – a few jazz musicians, some poets, some Soho Chinese. Now, the Home Office says there may be as many as 500,000. This is pyramid selling at its most brilliantly effective.

In private, the Home Office’s best defence is that it is so short of reliable intelligence on drugs that nobody can finally prove that the war is lost: we simply don’t know how much heroin or cocaine is imported, or how many people are using it.

Keith Hellawell argued that the 30 years since the Misuse of Drugs Act do not really count, because, until he took over, British governments did not have a real strategy. He told us he was supporting new international tactics (which he could not divulge) and was now seeing figures (which he could not give us) to suggest finally they were going to succeed. This recalls earlier declarations that „We have turned the corner on drug addiction“ (President Nixon, 1973), or „Heroin availability continues to shrink“ (DEA, 1978). In the meantime, world heroin production has tripled in the past decade, cocaine production has doubled and, in the foreign secretary’s Blackburn constituency, police say drug use in the Asian community has soared by 300% in four years.

But the underlying point is even more worrying: once you understand that the real danger comes from the black market and not from the drug, you can see that even if, with some magic formula, the generals started to cut the supply of these drugs, the result would be disastrous. The price of heroin, for example, would start to rise and, since there is no evidence at all that heroin addicts cut their consumption to fit their wallets, they would have to commit more crime to fund their habits. And if the dealers also responded like good entrepreneurs, they would try to keep their prices down by adding even more pollutants to the heroin, thus increasing the health risks to users.

This government has not begun to consider legalisation. No matter the truth about the danger and the death, no matter the truth about the cause of crime, the position is, as Jack Straw put it to the 1997 Labour conference: „We will not decriminalise, legalise or legitimise the use of drugs.“ Why? The obvious answer was offered to us by Paul Flynn, Labour backbencher and staunch opponent of prohibition: „It is being fuelled by politicians who are vote gluttons, who believe that there is popularity and votes to be gained by appearing to be tough on drugs.“

While Keith Hellawell and other prohibitionists are embarrassed by their screaming lack of success, those who want to legalise can point to clear evidence that providing a clean supply of drugs will help with the physical and mental health of users, will cut crime in the community and drain the life out of the black market.

The Swiss, for example, in 1997 reported on a three-year experiment in which they had prescribed heroin to 1,146 addicts in 18 locations. They found: „Individual health and social circumstances improved drastically … The improvements in physical health which occurred during treatment with heroin proved to be stable over the course of one and a half years and in some cases continued to increase (in physical terms, this relates especially to general and nutritional status and injection- related skin diseases) … In the psychiatric area, depressive states in particular continued to regress, as well as anxiety states and delusional disorders … The mortality of untreated patients is markedly higher.“ They also reported dramatic improvements in the social stability of the addicts, including a steep fall in crime.

There are equally impressive results from similar projects in Holland and Luxembourg and Naples and, also, in Britain. In Liverpool, during the early 1990s, Dr John Marks used a special Home Office licence to prescribe heroin to addicts. Police reported a 96% reduction in acquisitive crime among a group of addict patients. Deaths from locally acquired HIV infection and drug-related overdoses fell to zero. But, under intense pressure from the government, the project was closed down. In its 10 years‘ work, not one of its patients had died. In the first two years after it was closed, 41 died.

There is room for debate about detail. Should we supply legalised drugs through GPs or specialist clinics or pharmacists? Should we continue to supply opiate substitutes, such as methadone, as well as heroin? Should the supply be entirely free of charge to guarantee the extinction of the black market? How would we use the hundreds of millions of pounds which would be released by the „peace dividend“? But, if we have any compassion for our drug users, if we have any intention of tackling the causes of crime, if we have any honesty left in our body politic, there is no longer any room for debate about the principle. Continue the war against drugs? Just say no.

 

source: http://www.guardian.co.uk/politics/2001/jun/14/drugsandalcohol.socialsciences



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1.1. The provision of foil for the purposes of smoking controlled substances,
generally heroin and crack cocaine, is illegal under section 9A of the Misuse
of Drugs Act 1971. However, some drug services provide foil to heroin users
as a cited harm reduction measure. Evidence has been provided to the
ACMD that some drug intervention agencies supply specialist foil to drug
users to encourage smoking as a safer alternative to the practice of injecting.
The foil generally comes with a specified health warning1.

1.2. In most cases foil is provided in packs, in ready cut sheets. It is noted that,
for the user, kitchen foil is not discreet to carry and is often coated with
vegetable oil that is generally burned off before use.

1.3. The ACMD began its consideration of the issue of the use of foil as a harm
reduction measure in July 2008 after a growing body of evidence of its
potential benefits and also its distribution from drug services.

1.4. Evidence has been presented to the ACMD that the legislation (Section
9A of the Misuse of Drugs Act 1971) is broadly un-enforced; with respect to
drug services providing foil in apparent contravention of the Misuse of Drugs
Act 1971. The ACMD understands that there are various reasons for this: 1) it
is a low policing priority; rather than expend effort collecting evidence and
preparing a file for the Crown Prosecution Service (CPS) they would take a
crime prevention approach and inform those services that were providing foil
that they should stop; 2) it is reported that some forces are ‘supportive’ of the
provision of foil as a harm reduction initiative and have, upon request,
supplied ‘letters of comfort’ which clarifies that they will not produce a report
to the CPS for prosecution.

1.5. According to the Health Protection Agency (2009), there is some
uncertainty about the extent of injecting drug use in the United Kingdom. It
may be as high as 217,000 in England and Wales alone. What is certain is
that people who inject drugs are especially vulnerable to a wide range of
infections. These include viruses such as hepatitis C (HCV) and HIV and also
bacteria such as group A streptococci or Clostridium botulinum. High rates of
mortality and illness arise from these infections so public health and
protective behaviour interventions among injecting drug users (IDU) are
important.

1.6. In its 2009 report The primary prevention of hepatitis C among injecting
drug users, the ACMD estimated that:

1 Details can be found at:
http://www.exchangesupplies.org/needle_exchange_supplies/foil/foil_intro.html

“There are 120,000 to 300,000 (mid estimate 190,000) people that have
been infected with HCV in England and Wales, and about 50,000 in
Scotland. 85% became infected through injecting drug use.”

The report concluded that “Ultimately we need to stop injecting to reduce the
risk of HCV”.

2. Background to the evidence underpinning ACMD’s previous
considerations and recommendations regarding
paraphernalia [under section 9A of the Misuse of Drugs Act
1971]

2.1. The ACMD first considered sterile water for injecting (WFI) in 1991 and
other drug paraphernalia in 1995. The issue was raised again at an ACMD
meeting in November 1998. Concern had been expressed that drugs workers
were putting themselves at risk of prosecution when supplying paraphernalia
in breach of the law.

2.2. A number of reports and studies were discussed at the November 2000
ACMD Technical Committee meeting:

2.2.1. A report by the Royal Pharmaceutical Society of Great Britain
(RPSGB) had recommended that section 9A should be amended to
permit the supply of injecting paraphernalia by pharmacists to drug
misusers.

2.2.2. A report of the Police Foundation’s Inquiry into the Misuse of Drugs
Act 1971 (Police Foundation, 2000) had also recommended that
section 9A should be repealed.

2.2.3. A paper by Sheridan et al. (2000) examined the supply of syringes
and other injecting equipment by needle exchange schemes in
South-East England. The researchers collected data from
approximately 400 community pharmacists and needle exchanges;
the responses had indicated that 83% of needle exchanges supplied
swabs and 6% supplied filters.

2.2.4. Research by Crofts et al. (2000) found detectable levels of hepatitis
C virus on injecting equipment other than needles or syringes – which
suggested that infection could be transferred to syringes (and
individuals) through sharing paraphernalia. The virus had been
detected on 70% of syringes, 67% of swabs, 40% of filters, 25% of
spoons and 33% of water samples.

2.3. The ACMD considered a paper on the supply of drugs paraphernalia at its
meeting in November 2000. The ACMD considered drug paraphernalia and
WFI at its meeting in May 2001 and subsequently the use of filters in May
2003.

2.4. In May 2001, the ACMD made its recommendation to amend the misuse
of drugs legislation to permit the supply of swabs, bowls, spoons, stericups,
citric acid and WFI. In May 2003, the ACMD recommended the inclusion of
generic filters in the legislation. These recommendations were accepted by
government.

3. Current legal position and background

3.1. Section 9A(1) of the Misuse of Drugs Act 1971, below, makes it an offence
to supply any article used for administering a controlled drug unlawfully (i.e.
without a doctor’s prescription).

“A person who supplies or offers to supply any article which may be
used or adapted to be used (whether by itself or in combination with
another article or other articles) in the administration by any person
of a controlled drug to himself or another, believing that the article
(or the article as adapted) is to be so used in circumstances where
the administration is unlawful, is guilty of an offence.”

3.2. Section 9A was inserted in the 1971 Act by the Drug Trafficking Act 1986.
The purpose was to outlaw the supply of cocaine kits (razor blades, foil and
lemon juice) that were being marketed in the mid-1980s. An exception was
made for sterile syringes and needles to permit the supply of clean injecting
equipment to drug users because of their significant harm reducing benefits,
including reducing the spread of HIV, hepatitis B and hepatitis C and other
water and blood-borne diseases.

3.3. The ACMD was previously asked to consider whether the supply of
additional items of paraphernalia should be lawful. (It had become clear that
some pharmacists and drug workers in needle exchanges were supplying
such other items contrary to Section 9A in the belief that they were effective in
reducing the harms associated with injecting drug use). In May 2001, the
ACMD concluded that certain items had significant harm reducing benefits
and recommended that the supply of swabs, utensils for the preparation
(spoons, bowls, cups and dishes), citric acid and ampoules of water for
injection (when supplied in accordance with the Medicines Act 1968) should
be lawful, but only if medical practitioners, pharmacists and persons
employed in the lawful provision of drug treatment services supplied them
and, from 2005 onwards, a supplementary prescriber. Whilst rejecting them in
2001, the ACMD subsequently recommended that the supply of filters should
be lawful in similar circumstances. Cross Government agreement was sought
by the Home Office and changes were made by secondary legislation –
Regulation 6A of the 2001 Regulations – in August 2003. (The ACMD
rejected the inclusion of tourniquets, concluding that the risks outweighed the
benefits). Following evidence that users injecting crack or freebase cocaine
tend to use ascorbic rather than citric acid and following the ACMD’s
recommendation, the 2001 Regulations were further changed in 2005 to
incorporate ascorbic acid.

2 According to the findings of an online survey conducted by the National Needle Exchange
Forum (NNEF) between October and November 2008.

3.4. In accordance with section 9A, the supply of any other article is prohibited
where the supplier believes that it will be “used in circumstances where the
administration [of a controlled drug] is unlawful”, but not otherwise. It is a
matter for the police and the crown prosecution service respectively to assess
what policing priority should be given and whether prosecution is in the public
interest where a drugs worker supplies articles in contravention of section 9A.

3.5. Despite the current legislation 15%2 of UK services have for some time
contravened section 9A by providing foil. Yet there are no cases of a service
being charged with an offence (Pizzey and Hunt, 2008).

3.6. The ACMD considers that any advice provided to ministers regarding
changes in respect of the Misuse of Drugs Act 1971 would need to fulfil two
criteria:

. for there to be evidence that the intervention reduced drug related harm;
and,

. the intervention would not encourage use of illegal drugs, especially
heroin.

4. Evidence presented to ACMD regarding the use of foil as a
harm reduction intervention

4.1. Two key studies provided evidence of how the provision of foil might reduce
harm among injecting drug misusers in the UK. A published study (Pizzey and
Hunt, 2008), provided an evaluation of results from an intervention in South
West England using foil packs to promote a transition away from heroin
injecting to inhalation. The study analysed data from four needle and syringe
programmes (NSPs) and interviews with injecting drug users (IDUs) in one
NSP. A Turning Point report (Boid and Waldock, 2008) described a trial
scheme entailing the introduction of aluminium foil to Sydney Street needle
exchange and Sharp Action needle exchange in Sheffield.

4.2. The report by Pizzey and Hunt (2008) showed that foil packs were taken
when available (out of 320 attendees, 54% took the foil packs). Over the
period of the evaluation, NSP transactions increased by 32.5% from 1,672 to
2,216.

4.3. The findings from the Pizzey and Hunt (2008) study suggested that
distributing foil packs could be a useful means of engaging needle and
syringe programme (NSP) attendees in discussions about ways of reducing
injecting risks – thereby reducing harms to users and providing a mechanism
of engagement to reduce overall use. It could also reduce injecting in settings
where there was a pre-existing culture of heroin chasing.

4.4. The study called for further research, to evaluate whether the study findings
(Pizzey and Hunt, 2008) could be reproduced in other cultural contexts and
evaluate whether the observed behavioural changes were sustained and led
to reductions in harm including blood-borne infections and overdose.

4.5. The Turning Point report (Boid and Waldock, 2008) details a trial scheme,
with feedback, where foil was provided at both a site based needle exchange
(423 packs provided) and an action van (304 packs provided). Whilst the
feedback received was not analysed it was apparent, from self reported
results, that the provision of foil reduced injecting behaviour and promoted
less risky alternatives.

4.6. The National Needle Exchange Forum (NNEF) undertook an online
questionnaire between October and November 2008, the results of which
were analysed by Liverpool John Moores University. The questionnaire
produced 445 responses from across the UK, these included responses from
managers, commissioners, service users and workers. The results of the
NNEF questionnaire (Chandler et al., 2009) found that 15% of services
provided foil while 67% of services had no provision due to the current legal
status. 92% of respondents felt that foil would help reduce harms and 81%
felt that foil would encourage drug users not to inject. Overall the
questionnaire indicated that respondents were supportive of foil being
supplied through needle exchange programmes. The NNEF recommended
that Aluminium Foil should be added to the current list of exemptions in
Section 9A of the Misuse of Drugs Act. The NNEF further requested a more
detailed assessment and review of Section 9A.

4.7. In February 2009 the Association of Chief Police Officers (ACPO) Drugs
Committee wrote to the ACMD to highlight that ACPO Drugs Committee
members had been aware that, during the last few years, a number of local
service providers had taken part in harm reduction initiatives and had
supplied foil to intravenous drug users in order to encourage a change in their
consumption habits. The ACPO Drugs Committee cited a scheme operating
in Somerset Drug and Alcohol Action Team (DAAT) which had received
prominence following its evaluation in 2008.

4.8. The ACPO Drugs Committee requested clarification of the legislative
framework provided to all parties involved in these schemes so that local
health professionals and police do not expose themselves to breaches of the
law. This is a difficult area since the ACMD is aware that on a local level
individual forces are providing ‘letters of comfort’, where requested, to needle
exchanges and services. These letters do not have any legal standing, but
are a statement that effectively turns a blind eye to the provision of foil by
services.

4.9. Release provided a submission to the ACMD in March 2009 that supported
an amendment to section 9A to include foil in the exempted paraphernalia list.
Release recommended that:

. There should be an immediate review of section 9A and how it
impacted on the development of harm reduction initiatives;

. Consideration to be given to a new system led by medical opinion
whereby those working in this area could dispense equipment if it
could be shown to have an effective impact in reducing harm and/or
acting as a tool for engagement.

4.10. A study by Exley (2008) tested the hypothesis that aluminium foil could be
a significant source of aluminium in users of heroin who were ‘chasing the
dragon’. These experiments used the same ‘batch’ of street heroin. While
there was evidence of an increase in bio-available aluminium from heroin
vaporised off aluminium foil this would not account for the elevated urinary
excretion of aluminium in heroin users. According to a case study aluminium
had been found as a contaminant of heroin; e.g. 42 – 2280 µg aluminium g-1
heroin (Bora et al., 2002). The study also measured the aluminium content of
‘street’ heroin and found; 48.0 . 19.6 µg aluminium g-1 heroin (n=9). In
comparison the aluminium content of tobacco has been found to be; 600-
3700 µg g-1 (Exley et al., 2006) the aluminium content of heroin is generally
too low to account for the high urinary excretion of aluminium from heroin
users.

4.11. A presentation on the Dutch experience (Kools, 2009) provided an
overview of the supply of foil in the Netherlands. The Dutch aim was to
promote a move away from drug administration by injecting towards less risky
methods, a practice known as ‘route transition’. It described autonomous
trends among opiate and stimulant users from injecting towards non-injecting
drug consumption in the early 1990s. This trend in the drug using community
was initially recorded in 1992 and became the basis for a range of health
interventions to promote a shift away from injecting.

4.12. In the Netherlands, the provision of a combination of a full range of health
interventions (Opiate Substitution Therapy – OST), NSPs, consumption
rooms, community outreach, peer support, social marketing etc.) led to
significant individual and public health benefits.

4.13. Currently within the Netherlands foil is available in all needle and

syringe exchange programmes (NSEP) and consumption rooms (CR). It was
highlighted that a success recorded from the intervention had been a
significant reduction of blood-borne viruses (BBVs) (Kools, 2009). In
Amsterdam during the last decade “HIV prevalence had fallen from 8.5 per
cent to virtually zero, and the number of fatal overdoses had also drastically
decreased” (Kools, 2010).

4.14. The ACMD heard that provision of aluminum foil within NSEPs and CR

had not encouraged new users to take up illicit drugs.

4.15. In Scotland, Glasgow Addiction Services have proposed a foil exchange

pilot scheme. This followed encouraging results from a recent service user
evaluation. In October 2009 an anonymous service user questionnaire was
developed and distributed to service users to evaluate the service and
establish their views on foil provision. The key findings regarding foil were that
83% of service users said they would like foil to be offered as part of the
service and 59% said the provision of foil would encourage them to consider
smoking rather than injecting.

5. Consideration of the evidence

5.1. In all studies the benefits ascribed to the use of foil and the aims of
providing the foil were multi faceted. They included:

. To reduce injecting related harms (blood borne viruses, infections, vein
collapse);

. To reduce the risks of overdose;

. To reduce injecting drug use;

. To engage users to discuss options with a view to reduce harms,
injecting and ultimately drug use;

. To reduce drug related litter; and,

. To reduce drug related crime.

5.2. However, from the present studies it is difficult to specifically quantify the
reduction in injecting related harms since studies are not constructed to
measure this. Most of the studies to date have been qualitative in nature and
have been self-reported.

5.3. In the ACMD’s report on the primary prevention of hepatitis C (ACMD,
2009) it was noted that there was only weak evidence for the effectiveness of
many interventions in reducing HCV among IDUs. The key finding was that
there is emerging epidemiological evidence (supported by preliminary studies
in the UK) that the combination of opiate substitution therapy (OST) and NSP
is the most effective way of reducing HCV (and HIV) incidence among active
IDUs (NSP or OST alone may not be sufficient to prevent HCV). Transposing
the findings of the ACMD report (2009) it is likely that the provision of foil
alone, unless a total substitute for injecting behaviour, would not make any
significant impact on the incidence of blood borne viral infections.
Nonetheless, foil provision may have an important role within a programme of
interventions (like other paraphernalia) if it can be used to enforce harm
reduction messages on the dangers of injection.

5.4. The National Institute for Health and Clinical Excellence (NICE) Public
Health Guidance 18 Needle and syringe programmes: providing people who
inject drugs with injecting equipment recognises the importance of NSPs in
providing a gateway for IDUs to commence OST as a mechanism for
reducing harm. In this report is was also noted that from fieldwork findings of
participants who worked at Needle and Syringe Programmes:

‘They were disappointed that the draft guidance did not address the need
to provide foils and crack pipes to help people who inject to stop.’

Treatment guidelines are considered to be an important tool in steering patients to medical treatment. Thisstudy was conducted to analyze guidelines for the treatment of hepatitis C virus (HCV) infection in injectiondrug users (IDUs) in the European Union (EU) countries as a component of treatment access. National and
international databases, expert contacts, professional societies, and health administrations were approachedto acquire guidelines. According to their quality standard, guidelines were divided into expert opinions, semiofficial guidelines, official guidelines, and consensus processes. Recommendations for the treatment ofHCV infection in IDUs vary substantially, from lack of recommendations and outright treatment disapproval to recommendations for treatment under specified circumstances. Recent guidelines that apply qualified processprocedures that include literature research tend to be more permissive.

Qualified guideline processes in each
EU country and subsequently renewed pan-European guidelines are needed.

Chronic infection with hepatitis C virus (HCV) is considered
to be a major burden, both to those infected
and to the public health system [1]. Besides alcoholism,
chronic HCV infection is the major cause of liver cirrhosis
and end-stage liver disease and the main reason
for liver transplantation [2]. Moreover, chronic HCV
infection is associated with increased rates of depression
and fatigue and leads to impaired quality of life [3, 4].
The future health costs in 10 European Union (EU)
countries for 1 year of drug-related HCV, hepatitis B
virus, and HIV infection were estimated at i1.89 billion,
with HCV accounting for nearly 40% [5]. Within the
EU countries, the prevalence of HCV infection in the
general population is as high as 3%; among injection
drug users (IDUs), the prevalence of HCV infection is
30%–98% [6–8]. The introduction of antiviral com-
bination therapy with ribavirin and pegylated IFN has
led to sustained virological response in 150% of patients;
however, rates depend on the HCV genotype [9,
10]. Nevertheless, treatment of HCV infection in IDUs
is still the subject of controversy. Reasons for withholding
antiviral therapy from IDUs may include the
assumption of poor adherence, fear of adverse effects,
and the risk of reinfection [11]. There is evidence that
IDUs can adhere to medical protocols in the same manner
as do non-IDUs [12], and early pilot studies showed
that antiviral treatment of chronic HCV infection in
IDUs is both safe and effective [13–17]. Rates of reinfection
in IDUs may not necessarily be higher than
in non-IDU populations [18]. Despite these promising
results, IDUs may face barriers when trying to gain
access to treatment for chronic HCV infection. Treatment
guidelines have an increasing effect on the provision
of therapies, because, in times of limited resources,
allocation of even these limited resources
follows, among other considerations, the recommendations
of guidelines. In addition, treatment guidelines
may have an effect on the provision of qualifications
for professionals and on the willingness of sponsors to pay for
treatment and of professionals to provide treatment [19, 20].
This study was undertaken to analyze guidelines for the treatment
of HCV infection as applied in the EU countries with
regard to treatment accessibility for IDUs.

METHODS
Guidelines for the treatment of HCV infection were retrieved
by researching international databases and requesting information
from professional societies and experts. The MEDLINE
database (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) was
used with the keywords “guidelines,” “management,” “guidance,”
and “treatment”—in combination with the terms “hepatitis,”
“hepatitis C,” and “HCV.” The first 200 publications
that were presented for each keyword were considered.
Publications from non-EU countries except for Norway were
not taken into account. Authors of relevant references were
screened for further publications about these topics. Internet
home pages of international and national professional societies
in the areas of addiction medicine, gastroenterology, and
hepatology were screened for guidelines and experts. Experts,
as identified by the European Monitoring Centre for Drugs and
Drug Addiction (http://www.emcdda.eu.int) and the Centre for
Interdisciplinary Addiction Research of the University of
Hamburg (http://www.zis-hamburg.de), were asked to provide
both guidelines and expert contacts in their country. In addition,
we contacted experts and/or institutions discovered via
the European Society for the Study of the Liver (EASL; http:
//www.easl.ch), European Network for HIV/AIDS and Hepatitis
Prevention in Prisons, and European Information Network
on Drugs and Drug Addiction (http://www.emcdda.eu
.int/index.cfm?fuseactionppublic.Content&nNodeIDp403&s
LanguageISOpEN). To assess quality levels, guidelines were
divided into consensus papers, official guidelines, semiofficial
guidelines, and expert opinions. To qualify as a consensus paper,
guidelines had to follow, at least partially, recommendations
for development in the areas “scope and purpose,” “stakeholder
involvement,” “rigor of development,” “clarity of presentation,”
“applicability,” and “editorial independence,” as suggested by
the Appraisal of Guidelines Research and Evaluation collaboration
[21]. To qualify as official guidelines, guidelines had to
be authored by a professional organization; to qualify as semiofficial
guidelines, the authorship of at least 3 experts on the
topic was required. Recommendations by single experts on the
topic were rated as expert opinions.

RESULTS
The results of this research are presented by country, guideline
quality level, and content analysis.
EU. The latest consensus paper of the EASL was published
in 1999. It states that “Active intravenous drug users should
not be treated due to the risk of reinfection. In addition, compliance
with treatment is poor in patients in whom alcoholism
has not been interrupted and in whom drug addiction continues”
[22, p. 958].

Austria. The Austrian Society of Gastroenterology and Hepatology
published in 1998 official guidelines for the treatment
of viral hepatitis. This publication states, “For persons actively
injecting drugs and/or drinking alcohol antiviral treatment is
absolutely contraindicated. Patients after successful detoxification
and/or patients in methadone maintenance therapy may
receive antiviral treatment” [23, p. 25]. A group of 7 authors
who are specialists in addiction medicine published guidelines
for treatment of chronic hepatitis C in drug users in Austria
from the point of view of addiction medicine, which was categorized
as semiofficial guidelines [24]. These authors indicate
that patients are eligible for treatment after at least 6 months
of abstinence or, in case of substitution treatment, without
additional drug use or, in case of drug use, no injection drug
use or intoxication and few psychosocial deficits. Patients definitely
not eligible for treatment are characterized by periodically
or continuously uncontrolled drug use or by injection
drug use without applying safer-use criteria. Patients undergoing
substitution treatment who follow safer-use criteria when
injecting intravenously or IDUs who follow safer-use criteria
are possibly eligible for treatment. Recently, Ferenci [25] published
his expert opinion, which is largely in concordance with
the 1998 recommendations of the Austrian Society for Gastroenterology
and Hepatology.

Belgium. The Steering Committee of the Belgian Association
for the Study of the Liver published official guidelines
[26]; however, these guidelines lack recommendations for patients
with drug-related problems. A group of 4 authors published
guidelines categorized as semiofficial, which stated that
“…current studies support that the anti-HCV therapy of
IVDUs [IDUs] should be the same as in other HCV-infected
patients” but excluded certain IDUs by saying that “Patients
with uncontrolled active intravenous drug use are not candidates
for medical treatment due to lack of compliance and a
high risk of re-infection” [27, p. 99].

Denmark. One expert opinion was acquired in Denmark.
It was reported that most Danish treatment centers adhere to
the EASL consensus report. “[Being an] IDU is not a reason
for exclusion and certainly substitution treatment is not. Most
centres would however not treat IDUs actively injecting” (B.
P. Christensen, personal communication).

Finland. Two semiofficial guidelines were acquired for Finland.
In the guidelines from the year 2002 it is assumed that
IDUs “…even if drug dependence does not exist any longer,
cannot profit from therapy” [28, p. 1261]. The other guidelines,
published in 2003, states that “…long-term intravenous
consumption…represents a clear contra-indication of therapy…”
[29, p. 525].

France. The French consensus paper states that “occasional
intravenous drug use by an otherwise stabilized patient does
not contraindicate treatment” [30, p. 306]. Expert opinions and
literature research constituted an integral component of the
consensus process. An expert mapped out that a nonstabilized
IDU with ongoing drug use must not be treated [31]; on behalf
of the bibliographic group, a case-by-case decision was recommended
[32].

Germany. One official guidelines and 2 semiofficial guidelines
exist. The author of the official guidelines is the German
Society of Digestive and Metabolic Diseases. This publication
states that “an interferon-based therapy should not be initiated
in active drug and/or alcohol users. Drug users should be abstinent
before initiation of interferon-based therapy for at least
twelve months, alcoholics for at least six months. No consensus
exists as to treatment of patients in methadone maintenance
programs” [33, p. 981]. Semiofficial guidelines authored by the
president of the German Society of Addiction Medicine recommends
postponing treatment in cases of !12 months of
abstinence in drug users or in cases of substantial alcohol intake
[34]. A second semiofficial guidelines was authored by 8 experts
on the topic under the auspices of the German Ministry of
Health and the Robert Koch Institute. This publication recommends
treatment of IDUs within a methadone maintenance
program, restricts treatment of IDUs after detoxification to
specialized centers, and recommends treatment of abstinent
IDUs in general in close collaboration with experts in addiction
medicine (U. Marcus, Ministry of Health and Social Security,
personal communication).

Greece. No data were acquired.

Ireland. No data were acquired.

Italy. An expert on the topic stated that there are no specific
guidelines for the treatment of HCV infection in IDUs (G.
Rezza, personal communication). Guidelines of the Italian Association
for the Study of the Liver will be published soon (M.
Strazzabosco, personal communication).

Luxembourg. No data were acquired.

The Netherlands. According to an expert opinion, treatment
for HCV infection is offered to IDUs within a special
treatment program [35], although inclusion criteria remain
unclear.

Norway. According to guidelines classified as semiofficial,
“Patients addicted to alcohol should not be treated. The same
applies to those addicted to other substances, although heroin
addicted sometimes are successfully treated. Drug addicts
treated with methadone are in exceptional cases also treated
with IFN and ribavirin. Until now, six months abstinence before
initiating HCV-therapy has been required” [36, p. 927].

Portugal. No data could be acquired.

Spain. Two official guidelines, authored by the Spanish
College of Hospital Pharmacists and the Society of Primary
Care Physicians, respectively, do not address the problem of
treatment for HCV infection in IDUs [37, 38]. Two semiofficial
guidelines, each authored by a group of 6 experts, do not consider
injection drug use as a treatment contraindication [39,
40]. An expert opinion promoted by the Spanish Association
for the Study of the Liver (http://www.aeeh.org) does not specifically
address the topic of treatment of HCV among IDUs.

On this Web page, consensus papers of the National Institutes
of Health [41] and the EASL [22] are also presented. Therefore,
the official position of this professional society remains unclear.
In the autonomous region of Catalonia, official guidelines published
by the Department of Health and Social Security [42]
considers injection drug use a contraindication for the treatment
of HCV infection.

Sweden. Official guidelines authored by 19 experts considers
“ongoing or recent drug or alcohol abuse” a contraindication
for treatment [43]. The official guidelines of the Swedish
Medical Products Agency considers “ongoing or recent drug
use” a relative contraindication for treatment [44].

United Kingdom. The official guidelines of the Royal College
of Physicians of London and the British Society of Gastroenterology
states that “current IVDUs should not be treated
although in selected cases ex-IVDUs taking regular oral methadone
may be considered for treatment” [45, p. i7]. The official
guidelines of the National Institute for Clinical Excellence states
that “treatment of people who continue to use drugs intravenously
is often not indicated due to the high probability of
reinfection, presumed likelihood of relatively high levels of noncompliance
and the possibility of drug interactions. Cessation
of intravenous drug use before starting antiviral treatment is
therefore important. Combination therapy is not contra-indicated
for former intravenous drug users whose drug use has
been stabilized on oral methadone or other products such as
buprenorphine” [46].

Scotland. The official guidelines of the Scottish Executive
states that “treatment is not recommended for drug users who
continue to inject, where drug interactions, compliance and the
possibility of reinfection are issues. This will need to be assessed
on a case-by-case basis” [47, p. 7]. Table 1 encapsulates the
findings described above.

CONCLUSION
This study was conducted to provide an overview on the guidelines
for treatment of chronic HCV infection in IDUs. Because
of the disabling potential of HCV infection and its high prevalence
among IDUs, it is considered to be a major burden to
both the public and the individual. Treatment guidelines have
an effect of allocation of resources and provision of therapy in
terms of finances, qualification, and outreach. Therefore
ment access is influenced by guidelines. Treatment guidelines
allowing for or even recommending treatment of a specific
disease can facilitate access to treatment [19, 20].

Data were gathered in Austria, Belgium, Denmark, Finland,
France, Germany, Italy, The Netherlands, Norway, Spain including
Catalonia, Sweden, and the United Kingdom (including
Scotland). Contacts were established in Greece, Ireland, Luxembourg,
and Portugal as well, but data quality and sources
remain unclear yet and are therefore not considered. According
to their quality level, guidelines were categorized into expert
opinions, semiofficial guidelines, official guidelines, and consensus
papers (table 1). Taking into account only guidelines
with the highest level, the EU and French guidelines met criteria
of consensus papers; in Austria, Belgium, Germany, Spain (including
the autonomous region of Catalonia), Sweden, and the
United Kingdom (including Scotland), guidelines met the criteria
of official guidelines; semiofficial guidelines were found
for Finland and Norway; and expert opinions were retrieved
in Denmark (P. Christensen, personal communication), Italy
(M. Strazzabosco and G. Rezza, personal communications), and
The Netherlands [22, 23, 26, 28, 29, 30, 33, 36, 41–43, 45–47].

Treatment of HCV infection in active IDUs is allowed under
specific circumstances according to the French consensus;
methadone maintenance was regarded as a treatment requirement
by the official guidelines of Austria and the United Kingdom
and the expert opinion from Finland (M. Fa¨rkkila¨ and
H. Nuutinen, personal communication) [23, 30, 45, 46]. Abstinence
was a pretreatment prerequisite in the EU consensus,
in the official guidelines of Germany, Sweden, Scotland, and
Catalonia, in the semiofficial guidelines of Finland and Norway,
and in the expert opinion of Denmark (P. B. Christensen, personal
communication) [22, 28, 29, 33, 36, 42, 43, 47]. Treatment
recommendations were lacking in the official guidelines from
Belgium and Spain as well as in the expert opinion from Italy
(M. Strazzabosco and G. Rezza, personal communications) [26,
41].

Treatment recommendations remain unclear in the expert
opinion from The Netherlands [35]. Publication dates of guidelines
vary from 1997 to 2003 and therefore cannot consider
the evidence published thereafter. Besides mentioned guidelines
which qualify for the highest level of quality in the respective
country, additional and more recent guidelines with a lower
level of quality exist in Austria, Belgium, Germany, and Spain.
Two of these guidelines [25, 34] are as restrictive as and 5 are
more permissive than the older and higher-level guidelines in
the respective country (U. Marcus, personal communication)
[24, 27, 39, 40]. Overall, treatment guidelines qualifying for a
higher quality level and/or published more recently are more
likely to allow for treatment of IDUs under specific conditions
and/or under methadone maintenance therapy (U. Marcus,
personal communication) [24, 27, 30, 39, 40]. First clinical
studies showing that treatment of HCV infection in IDUs is as
safe and effective as in non-IDUs [13–17] and that rates of
reinfection are not necessarily higher than in non-IDU populations
[18] may have contributed to this process. Generally,
it is desirable to implement a structured high-quality guideline
process in each country to improve acceptance. An update of
the EU consensus [22] would be helpful in establishing widely
accepted state-of-the-art guidelines. The problem of HCV infection
in IDUs is recognized in most EU countries. Guidelines
represent 1 component in enabling access to treatment, accompaniment
by implementation of outreach programs, qualification
of professionals, and adequate funding.

Full File, Source, links and more information in the attachment

HepatitisCVirusInfection

Researchers at the University of Pennsylvania have demonstrated that morphine withdrawal complicates hepatitis C by suppressing IFN-alpha-mediated immunity and enhancing virus replication. The paper by Wang et al., �Morphine withdrawal enhances hepatitis C virus (HCV) replicon expression,� appears in the November issue of The American Journal of Pathology and is accompanied by a commentary.

Hepatitis C virus (HCV) is common among intravenous drug users, with 70 to 80% of abusers infected in the United States. This high association has peaked interest in determining the effects of drug abuse, specifically opiates, on progression of the disease. The discovery of such an association would impact treatment of both HCV infection and drug abuse.

Dr. Wen-Zhe Ho has been interested in such interplay for some time. His laboratory has previously shown using cell culture that morphine enhances virus replication and inhibits IFN-alpha (a natural anti-viral factor produced by immune, as well as host cells, and the only one approved in recombinant form for treating HCV infection). To further these results, his lab has used a cell model system to determine the consequences of morphine withdrawal, which is a common recurring event in opioid users.

Chuan-Qing Wang and colleagues examined the effects of morphine withdrawal (MW) on HCV-infected cultured liver cells by exposing cells to the drug for four days followed by its removal. They also assessed the effects of using naloxone, to block the opioid receptors, in conjunction with drug removal, i.e. precipitated morphine withdrawal (PW). To measure HCV replication, they used a virus-like �replicon� that mimics the events that occur in liver cells and expression of viral RNA and proteins that HCV uses. Although the replicon does not produce the infectious virus, the HCV replicon system represents the best available system for examining the impact of opiates on HCV at the time of their research study.

Similar to their previous results, the authors found that MW and PW increased levels of HCV replicon RNA and protein expression. In addition, both withdrawal scenarios inhibited IFN-alpha expression in liver cells in the presence or absence of HCV replicon. Since IFN-alpha is a critical self-defense mechanism utilized by liver cells to fight off viral infection, including HIV, this study suggests that morphine withdrawal weakens host cell immunity and provides a favorable environment for HCV growth in the liver.

The authors extended their study by examining the mechanism behind these observations. MW and PW inactivated the IFN-alpha promoter (the switch for making IFN-alpha) by directly inhibiting its activator, interferon regulatory factor-7 (IRF-7), and this effect was more pronounced in HCV replicon-containing cells. Finally, the ability of IFN-alpha treatment to block HCV replicon expression (85%) fell following MW (60%) and PW (50%). This finding, in conjunction with the earlier report by the same group, provides an explanation to the question of why so many HCV-infected patients fail to respond to IFN-alpha treatment.

Although the clinical relevance of this study remains to be determined, these data showing that withdrawal promotes HCV expression by suppressing anti-HCV factor (IFN-alpha) production by liver cells suggests that �opioid abuse may contribute to the chronicity of HCV infection and promote HCV disease progression.� The study also underscores the necessity of future clinical and epidemiological studies to define the role of opiate abuse in promoting HCV disease.

These results suggest that opioid abusers experiencing periods of drug abuse, followed by periods of withdrawal (due to lack of supplies) may lead to immunocompromised liver. These findings further support the need for methadone maintenance treatment as an additional benefit for opioid abusers.

Research was supported by National Institute on Drug Abuse, National Institutes of Health.

This work involved collaborators at Joseph Stokes, Jr. Research Institute at The Children’s Hospital of Philadelphia; The Center for Studies of Addiction, University of Pennsylvania School of Medicine; and The Children’s Hospital of Fudan University, Shanghai, China.

Wang C-Q, Li Y, Douglas SD, Wang X, Metzger DS, Zhang T, Ho W-Z: Morphine withdrawal enhances hepatitis C virus (HCV) replicon expression. Am J Pathol 2005, 167:1333-1340

The American Journal of Pathology, the official journal of the American Society for Investigative Pathology (ASIP), seeks to publish high-quality original papers on the cellular and molecular mechanisms of disease. The editors accept manuscripts which report important findings on disease pathogenesis or basic biological mechanisms that relate to disease, without preference for a specific method of analysis. High priority is given to studies on human disease and relevant experimental models using cellular, molecular, biological, animal, chemical and immunological approaches in conjunction with morphology.

ntravenous (IV) drug users who abuse morphine, then withdraw from it later, may be unknowingly complicating the beneficial effects of their hepatitis C treatment or giving their hepatitis infection an unwanted boost. That’s the conclusion of a study by researchers at Children’s Hospital of Philadelphia, the University of Pennsylvania and in China.1 The findings are published in the November issue of the American Journal of Pathology.
Detrimental Effects of Morphine Withdrawal
Quitting morphine in this population of hepatitis C patients may suppress the benefits of interferon-alfa in the body and enhance the replication of the virus, the study investigators led by Wen-Zhe Ho, MD, a research associate professor in the division of Immunologic and Infectious Diseases at Children’s Hospital of Philadelphia, reported.
According to the study investigators, hepatitis C infection is common among IV drug users; up to 90 percent of such users are infected with HCV in the United States, and one-fifth to one-half have chronic infection.2 The high numbers of these patients with the disease has prompted medical researchers to study the effects of drug abuse, especially the use of opiates, on HCV progression.
„In the case of HCV infection, there is little information about whether drug abuse, such as heroin, enhances HCV replication and promotes HCV disease progression,“ wrote Ho and his team. „This lack of knowledge about the impact of opioid abuse on HCV disease is a major barrier to fundamental understanding of HCV-related morbidity and mortality among intravenous drug users and to the development of new therapeutic approaches for HCV infection.“
The scientists theorized that illicit drugs might be able to detrimentally alter the immune response against the viral infection in some way. Other studies, they pointed out, showed that these drugs have the ability to block the production of beneficial interferons in the body that normally fight the virus.

Morphine’s Effect on Hepatitis C Studied Previously
In a previous study, Ho and his colleagues found that morphine boosted the virus‘ growth and interfered with interferon alfa in a collection of liver cells.3 Interferon alfa is the basis for the pegylated interferon that people with hepatitis C take as medication for the disease today in combination with the antiviral oral drug, ribavirin.4 Also produced naturally in the body, interferon is an antiviral factor produced by certain cells.
The follow-up to that laboratory-based study was the latest research aimed at determining how withdrawing from morphine might affect the course of the disease. „Physical dependence on morphine is characterized by the occurrence of an abstinence or withdrawal syndrome on termination of the drug,“ wrote Ho and his fellow investigators. These abstinence syndromes also can occur during the use of an opioid antagonist such as naloxone (Narcan), a drug that reverses the effects of narcotics, the researchers explained. Thus, they also tested the effect of naloxone-induced morphine withdrawal for the study.
Ho and his team exposed a group of liver cells kept in culture to morphine for four days, then removed it. The scientists also used a model that mimicked the events that occur in liver cells when genetic material (HCV RNA) and proteins used by the hepatitis C virus to create infection are present. This allowed the researchers to mimic the replication patterns of the virus without actually using an infectious virus.
Effects of Morphine Withdrawal
Similar to what they found in their previous study,3 Ho and his colleagues learned that removing morphine boosted levels of HCV RNA (the genetic material used by the virus) and hepatitis C viral protein in the cells. This, in essence, indicates that the viral infection is spreading. However, 72 hours after morphine was removed, HCV RNA levels decreased, suggesting there was only a temporary surge.
Withdrawing the morphine also blocked interferon-alfa production in the liver cells compared to cells in which morphine was not withdrawn. Since interferon-alfa is a critical self-defense mechanism used by liver cells to fight off attacks by the hepatitis C virus or HIV, the findings suggest that drug abusers who quit using morphine can weaken their immune system’s ability to defend the body against an HCV infection, and provides a favorable environment for hepatitis C viral growth in the liver.
Underlying Causes Studied
Next, Ho’s group wanted to understand why removing morphine created such a beneficial environment for the hepatitis C virus. They learned that removing morphine from liver cells blocked the production of interferon-alfa by, in turn, suppressing its activator, interferon regulatory factor-7 (IRF-7). The team also found that the ability of interferon-alfa to block HCV replication (or the model of HCV in this case) fell by nearly two-thirds.
The same detrimental effect of morphine removal also occurred in relation to manmade interferon alfa. This manmade, or recombinant, form is similar to the interferon medication used for people with hepatitis C today. When synthetic interferon was added to the cell lines, they demonstrated a strong ability to fight off the hepatitis virus. However, when morphine was withdrawn from the cells, the anti-HCV ability of interferon-alfa „was significantly diminished,“ Ho and his colleagues wrote.
These results were observed when morphine was directly withdrawn or indirectly removed by using naloxone, they reported, and even to a greater extent in the latter case.
„Collectively, these new observations in conjunction with our earlier findings support the notion that opioid abuse is a co-factor that promotes HCV replication,“ wrote Ho and his colleagues.
The researchers point out that the clinical relevance of this study remains to be determined, but the findings suggest that „opioid abuse may contribute to the chronicity of HCV infection and promote HCV disease progression.“
They recommend both clinical and epidemiological studies be launched to better define the rule of drug abuse in the context of HCV infection. In the meantime, they say drug abusers who use such opioids as morphine, followed by periods of withdrawal due to lack of supplies, may be doing much more harm to their livers.
„Our findings provide a plausible interpretation of the high failure rate of interferon-alfa therapy in intravenous drug users,“ the investigators concluded. „The identification of mechanism(s) involved in morphine’s action on the anti-HCV effect of interferon-alfa has the potential to improve interferon-alfa-based treatment for HCV-infected IV drug users.“
Study Reaction
In an accompanying editorial,5 Kevin Moore, PhD, and Geoff Dusheiko, MD, both professors of Hepatology at Royal Free and University College Medical School in London, write that the findings suggest that IV drug abusers or those receiving opioid substitutes like methadone, and who are infected with HCV, may have more difficulty clearing the virus.
„Until recently, there were no data on the effects of opiates on HCV replication or the development of liver injury and fibrosis, one of the earliest features of progression to cirrhosis,“ wrote Moore and Dusheiko.
„The growing implication from these and other studies is that continued opiate abuse leads to enhanced viral replication, liver injury, and … fibrosis. Further studies are required to determine whether these effects occur in humans, as well,“ they wrote.

World Hepatitis Day: Will CA Allow Pharmacists to Save Lives and Money through Syringes?

California is one of only three states in the U.S. that still prohibits pharmacists from selling a syringe without a prescription from a physician.

May 19th marks World Hepatitis Awareness Day – a great opportunity for California to take action to help prevent liver cancer and liver disease caused by hepatitis C and B. We ask you to join us in supporting Senate Bill 1029 to ensure all Californians have access to an essential and common-sense component of an effective hepatitis prevention strategy: the ability to purchase sterile syringes in a pharmacy.

Hepatitis C, which is commonly transmitted when syringes are shared, can lead to liver disease, cirrhosis, liver cancer, and premature death. While treatment for hepatitis C is partially effective, it is expensive and for some patients debilitating. Even with treatment, some remain chronically infected.

Long after a person has stopped using drugs, living with chronic hepatitis C can lead to other health problems, to disability, to job loss, and even homelessness. Thirty percent of people living with HIV are co-infected with hepatitis C. Hepatitis C is now one of the leading causes of death for people with HIV/AIDS in San Francisco. Hospitalizations for hepatitis C cost the California taxpayers over $1.5 billion in 2007 alone.

While all forms of hepatitis can cause severe health problems and even death, there is no vaccine for hepatitis C. The only way to prevent it is to ensure that people have the information and resources they need to avoid transmitting it.

Yet California is one of only three states in the U.S. that still prohibits pharmacists from selling a syringe without a prescription from a physician. Most states amended their laws in light of evidence that limited accesses to sterile syringes led drug users to share used ones, and that sharing syringes transmits HIV and hepatitis B and C.

The sharing of used syringes is the most common cause of new hepatitis C infections in the state and the second most common cause of HIV infection. We know from the research that pharmacy sales are a cost-effective way to combat the spread of hepatitis C and HIV without contributing to increased drug use, drug injection, crime or unsafe discard of syringes.

That is why Senate Bill 1029 is needed. It would expand the current pilot program, scheduled to end this year, to allow any pharmacy in the state to sell up to 30 syringes to individuals if the pharmacist so desires. Study after study has shown that increasing access to sterile syringes is the best way to prevent syringe sharing. By preventing HIV and hepatitis C, it is an efficient and cost-effective means of saving public dollars, and more importantly, lives. There is no cost to taxpayers through this plan, as the cost of prevention falls to the individual who purchases the syringes.

As people concerned with the health and well-being of all Californians, we ask you to stand with us in support of SB 1029. The California Department of Public Health, the Federal Centers for Disease Control & Prevention, the World Health Organization, and all leading health policy research organizations agree – safe and legal syringe access through pharmacies is a key component to the prevention of hepatitis C and HIV.
Leland Y. Yee, Ph.D. (D-San Francisco) is a California state Senator. Barry Zevin MD, is a physician specialist with the, Tom Waddell Health Center, San Francisco Department of Public Health, and assistant clinical professor at UCSF School of Medicine.

source: http://www.alternet.org/health/14690…rough_syringes

Hepatitis C can lie low for years until it wreaks havoc with your liver

WHO’S AT RISK
Hepatitis C is a disease of the liver; there are five hepatitis viruses, and this one has one of the highest rates of progression to chronic disease. “Hepatitis C is a viral infection that causes inflammation of the liver that can lead to increased scar tissue and eventually to cirrhosis,” says Kim-Schluger. “About 4 million Americans are infected with hepatitis C — 1.6% of the population.”

Hepatitis C is a blood-borne disease whose underlying virus was only isolated in 1989. “If you look the number new infections through the decades, a large percentage of patients were infected before 1992, when we developed a good test for hepatitis C,” says Kim-Schluger. “Infection rates dropped precipitously after that.” Because the blood supply wasn’t being reliably screened for hepatitis C until 1992, many americans were infected as the result of blood transfusions.

The two groups at highest risk of the disease are people who received transfusions before 1992 and IV drug users. Other groups at risk are people who have used intranasal cocaine, hemodialysis patients, and health-care workers who are pricked by needles. The virus can also be sexually transmitted. “The risk increases with high-risk behaviors like multiple partners,” says Kim-Schluger. “It’s a low risk, but it’s not zero.”

SIGNS AND SYMPTOMS:
For many patients, the diagnosis of hepatitis C comes without warning signs. “The tricky thing is that the majority of people are asymptomatic, or only have vague symptoms like feeling fatigued,” says Kim-Schluger. “So it is up to the doctor to ask about the risk factors and then screen people who are at risk.”

Up to about 15% of people infected by the hepatitis C virus are able to clear it from their bodies spontaneously. “The other 85% will continue to have virus within their blood,” says Kim-Schluger. “Of that group, about 20% of will develop cirrhosis and 1% to 5% will develop liver cancer related to cirrhosis.” With an infected population of 4 million, these percentages indicate that there will be hundreds of thousands of cases of severe liver disease caused by hepatitis C in the next 10 to 20 years.

Hepatitis C usually has a long latency period, during which the virus lies dormant. “The delay between infection and end-stage liver disease varies a lot, depending on factors like when you were infected and your gender,” says Kim. “It’s usually about 30 years from infection to cirrhosis.” Using alcohol and marijuana shortens this lag. The disease also progresses faster in people who are older than 40 when they get infected. Premenopausal women are slightly protected by estrogen, which may slow fibrosis, the growth of damaging scar tissue in the liver.

Patients do start to show symptoms when they reach end-stage liver disease. “By this time, there is often bleeding in the esophagus or the stomach,” says Kim. “That has to do with the scar tissue causing increased pressure and causing portal hypertension” — high blood pressure in the portal vein, which serves the liver. Often, fluid builds up in the abdomen, and the liver stops clearing the toxins it can ordinarily remove.

TRADITIONAL TREATMENT
Hepatitis C isn’t treated until it becomes chronic, which means the body hasn’t cleared the virus on its own. “The first line of treatment is a combination of drug therapies,” says Kim. “Pegylated interferon is an injection that you get once a week, and ribavirin is a drug that you take every day.” Depending on the genetic makeup, or genotype, of the virus you have, the therapy lasts six to 12 months. right now, the success rate for these antiviral treatments is about 50%. “If the treatment is successful, it gets rid of the virus,” says Kim. “but it’s difficult treatment, and there are many side effects.”

Patients have three types of responses to the therapy. “Responders clear the virus, and nonresponders don’t clear it at all,” says Kim. “Relapsers clear the virus during therapy, but afterward it comes back.”

For patients whose hepatitis C progresses to cirrhosis and then end-stage liver disease, a transplant is the sole remaining option. “The only way to survive end-stage liver disease is a transplant, and the overall transplant survival rate after one year is 85%,” says Kim. “Unfortunately, the virus doesn’t go away after transplant, so there are issues of recurrent disease after transplant.” Beyond liver transplant, “the next step would be a cure, and I am hopeful that there will be a cure during our lifetime,” says Kim.

RESEARCH BREAKTHROUGHS:
Doctors are continually improving the treatments available for hepatitis C so they can bring relief to a higher percentage of patients. “There are new protease and polymerase inhibitors coming out in the near future, as soon as 2011-2012,” says Kim. “You have to use this therapy in conjunction with the interferon and ribavirin, but then it increases the response rate from 50% to 70%.”

QUESTIONS FOR YOUR DOCTOR:
If you’re diagnosed and need therapy, the key question to ask is, “What can I expect in terms of side effects?” Some of the best medications can cause psychiatric side effects, so it’s essential to talk to your doctor about your psychiatric history and any other medications or herbal supplements you’re taking. Another good question is, “What genotype of hepatitis do I have, and how does

that affect the outcome of therapy?” Your options will depend on which genotype you have.

WHAT YOU CAN DO
Get screened.
I
f you have risk factors for hepatitis C, find out if you have the infection.

source: http://www.nydailynews.com/lifestyle…er.html?page=1

Introduction:
The hepatitis C virus (HCV) is one of the leading known causes of liver disease in the
United States. It is a common cause of cirrhosis and hepatocellular carcinoma (HCC) as well as
the most common reason for liver transplantation. At least 4 million people in this country are
believed to have been infected with HCV. Following the identification of hepatitis A and
hepatitis B, this disorder was categorized in 1974 as “non-A, non-B hepatitis.” In 1989, the
hepatitis C virus was identified and found to account for the majority of those patients with non-
A, non-B hepatitis. In March 1997, the National Institutes of Health (NIH) held a Consensus
Development Conference regarding management and treatment of HCV.

This led to an important, widely distributed NIH Consensus Statement that, for several years, defined the
standard of care. Now 5 years later, knowledge of hepatitis C has increased dramatically, leading
to the need to reexamine the approaches to management and treatment. This conference was
2
convened with the aim of reviewing the most recent developments regarding management,
treatment options, and the widening spectrum of potential candidates for treatment and of
updating the 1997 Consensus Statement.
This NIH Consensus Development Conference on Management of Hepatitis C: 2002 was
held June 10–12, 2002. The primary sponsors of this meeting were the National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK) and the Office of Medical Applications
of Research (OMAR) of the NIH. The cosponsors were the National Institute of Child Health
and Human Development (NICHD); the National Cancer Institute (NCI); the National Center for
Complementary and Alternative Medicine (NCCAM); the National Institute on Alcohol Abuse
and Alcoholism (NIAAA); the National Institute on Drug Abuse (NIDA); the National Institute
of Allergy and Infectious Diseases (NIAID); the National Heart, Lung, and Blood Institute
(NHLBI); the Centers for Medicare & Medicaid Services (CMS); the Centers for Disease
Control and Prevention (CDC); the U.S. Food and Drug Administration (FDA); and the
U.S. Department of Veterans Affairs (VA).

The Agency for Healthcare Research and Quality (AHRQ) provided support to the NIH
Consensus Development Conference on Management of Hepatitis C: 2002 through its Evidencebased
Practice Center program. Under contract to the AHRQ, the Johns Hopkins University
Evidence-based Practice Center developed the systematic review and analysis that served as a
reference for discussion at the Conference.

This two-and-a-half-day conference examined the current state of knowledge regarding
the management of hepatitis C and identified directions for future research. During the first dayand-
a-half of the conference, experts presented the latest hepatitis C research findings to an
3 independent non-Federal Consensus Development Panel. After weighing this scientific evidence,
the panel drafted a statement, addressing the following key questions:
• What is the natural history of hepatitis C?
• What is the most appropriate approach to diagnose and monitor patients?
• What is the most effective therapy for hepatitis C?
• Which patients with hepatitis C should be treated?
• What recommendations can be made to patients to prevent transmission of
hepatitis C?
• What are the most important areas for future research?

Read the full statement:

NIH_HCV_Cons_2002Final

Introduction:

Hepatitis C, Substance Use,
and Dependence

Illicit drug and alcohol abuse and dependence are problems
of major medical importance in the United States, leading
to high rates of morbidity and mortality from end-stage
liver disease. The prevalence of illicit drug use in the United
States, as estimated by the National Survey on Drug Use
and Health in 2002, stands at 19.5 million Americans above
the age of 12; half of Americans aged 12 or older (51.0%)
reported being current drinkers of alcohol, an estimated
120 million people [1•].

Salient illicit drug use and practices
are presented in Table 1. The Centers for Disease Control
has estimated that 60% of all new cases of hepatitis C are
related to injection drug use [2]. Injection drug practices
include the use of heroin, cocaine, methamphetamine, and
prescription opioids (Table 1).

It has been estimated that
there are at least 800,000 untreated injection-heroin users
[3]. However, the population of opioid-drug users may be
grossly undercounted, because some surveys have found up
to three times more illicit drug users in particular regions
than commonly estimated [4].
Drug addiction is a chronic, relapsing neurophysiologic
disease resulting from the prolonged neurologic
effects of drugs. The neurochemical abnormalities resulting
from chronic use, such as opioids, underlie many of the
observed physical and behavioral aspects of addiction
(Table 1). The brain abnormalities associated with addiction
are wide ranging, complex, and long lasting [5,6].

They can involve genetically abnormal brain signaling
pathways, social factors, psychological conditioning or
stress, and result in cravings leading to a predisposition to
relapse even months or years after drug use cessation.
Recent studies have identified risk factors for the transition
to injection drug use that include the following: emerging
drug practices, differential characteristics of opiate injectors
versus inhalers, and patient-related factors that predict
entry into substance abuse treatment [7•,8].

The importance
of limiting individuals from progressing to injection
drug use can be vividly seen from data comparing the
hepatitis C incidence between injection and noninjection
drug users [9]. This longitudinal surveillance study in
New York City showed an annual incidence rate of
hepatitis C in young noninjection drug users of 0.4 per 100
person-years compared with 35.9 per 100 person-years in
injection drug users (IDUs).

Thus, delaying or preventing
the transition to injection drug use can have a significant
health benefit by reducing the risk of comorbid conditions
associated with substance abuse and addiction.

read the full file here: 002_HP04-3-1-05

Executive Summary_ _______________________________________________________________ 5
Introduction_______________________________________________________________________ 7
Methodology_____________________________________________________________________ 10
Summaries of Published Studies
Evaluating Insite: Why and How
Reasons for evaluating Insite_______________________________________________________________ 13
How Insite is studied_ ____________________________________________________________________14
Early Results
Attendance, drug use patterns and referrals__________________________________________________ 15
Who Uses Insite?
Characteristics of Insite users_ _____________________________________________________________ 17
Frequent Insite users_ ____________________________________________________________________18
Hepatitis C infection among Insite users_____________________________________________________19
HIV prevalence among Insite users__________________________________________________________21
Younger Insite users______________________________________________________________________22
Does Insite Promote Drug Use?
A before and after study_ _________________________________________________________________ 23
Insite and initiation of injection drug use_____________________________________________________25
Insite and Addiction Treatment
Insite users and detox____________________________________________________________________26
Detox before and after Insite_______________________________________________________________ 27
Impact on Crime and Public Disorder
Insite’s impact on drug-related crime________________________________________________________29
Insite’s impact on public order______________________________________________________________30
Insite and Overdose Prevention
Drug overdoses at Insite_ _________________________________________________________________ 31
Are there more overdoses now because of Insite?_____________________________________________ 33
Insite’s impact on overdose risk____________________________________________________________34
Overdose deaths prevented by Insite________________________________________________________ 35
Impact on High-Risk Behaviour
Insite’s effect on syringe sharing____________________________________________________________ 37
Characteristics of Insite users who share syringes _ ____________________________________________38
Reduced syringe sharing and HIV prevention _________________________________________________39
Insite’s effect on condom use_ _____________________________________________________________40
Safer injecting education at Insite__________________________________________________________41
Insite’s effect on safer injecting practices_____________________________________________________43
Women benefitting from safer injecting education at Insite_____________________________________44
Insite users’ perspectives on safer injecting education at Insite___________________________________45

Read more about Canada:insite_report-eng