EFFECTIVENESS BANK BULLETIN 1 March 2009: reviews and meta-analyses
EFFECTIVENESS BANK BULLETIN 1 March 2009: reviews and meta-analysesThe entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. The Summary is intended to convey the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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English health advisory body recommends high coverage needle exchange ...
Needle exchange works in prison; bleach second best ...
Methadone maintenance works for prisoners too ...
Heroin maintenance review portrays the practice reality as well as the outcomes ...
Needle and syringe programmes: providing people who inject drugs with injecting equipment.National Institute for Health and Clinical Excellence.
National Institute for Health and Clinical Excellence, 2009.
England's national health advisory body recommends high coverage 24-hour needle exchange plus opiate substitute prescribing and infection treatment to combat not just HIV, but also the hepatitis C epidemic.
Summary These guidelines result from a request by the Department of Health for the National Institute for Health and Clinical Excellence (NICE) to produce public guidance on the optimal provision of needle and syringe programmes for injecting drug users. The guidelines cover adults NICE's Public Health Interventions Advisory Committee has asked NICE to consider producing separate guidance on exchange programmes for young people aged under 18. only. Their remit was to consider what constitutes optimal provision, not whether these programmes should be provided in the first place. NICE's Public Health Interventions Advisory Committee developed these recommendations on the basis of two reviews of the evidence, an economic analysis, expert advice, stakeholder comments and fieldwork, available from NICE's web site.
Particularly significant recommendations include:
• Commissioning bodies should assess the percentage of injections in their areas for which sterile needles and syringes were available, and use this and other information to ensure services meet local need with a view to moving towards over 100% 'coverage' for all local injectors (ie, increasing the number who have more than one sterile needle and syringe available for every injection).
• Commissioning bodies should develop services which offer referral to other harm reduction services, encourage people to stop using drugs or to switch to non-injecting methods (for example, opioid substitution therapy), and address visitors' other health needs.
• They should also not only audit and monitor services to ensure they meet the health needs of injectors, but also address the concerns of the local community.
• The local service mix should include three levels of service providing: 1. injecting equipment either loose or in packs with written harm reduction information; 2. 'pick and mix' injecting equipment plus health promotion advice; 3. level two plus provision of or referral to specialist services (for example, vaccinations, drug treatment and secondary care).
• Commissioning bodies should ensure services offering opioid substitution therapy also make needles and syringes available to their patients.
• Needle exchange services should distribute equipment numbers and type according to need rather than subject to an arbitrary limit.
• They should also provide disposal bins/advice and other injecting equipment, and encourage injectors to switch to other methods of drug use and to attend services which can help them do so.
• Pharmacy-based services in particular should provide information about local agencies offering further support, including opioid substitution clinics.
• Specialist services operating at level 3 (see above) should offer comprehensive harm reduction services including advice on safer injecting practices, assessment of injection site infections, advice on preventing overdoses, help to stop injecting, and referral to opioid substitution clinics.
• They should also offer (or help people to access): opioid substitution; treatment of injection site infections; vaccinations for hepatitis A and B and tetanus; testing and associated counselling for hepatitis B and C and HIV; psychosocial interventions; primary care services (including condoms and general sexual health services, dental care and general health promotion advice); secondary care services (for example, treatment for hepatitis C and HIV); welfare and advocacy services (for example, advice on housing and legal issues).
The NICE committee reached these conclusions partly on the basis of a cost-effectiveness analysis. In estimating benefits this took in to account the potentially important role exchanges can play in bringing people who inject drugs in to contact with a range of services. However, the contribution made by this 'gateway' function was uncertain. Nevertheless the conclusion was that providing clean injecting equipment is cost effective for NHS and personal social services and also for society as a whole.
This work also suggested that while increasing the coverage of syringe distribution and the recruitment rate in to substitute prescribing programmes are sufficient to control HIV, they are not sufficient to reduce the prevalence or incidence of hepatitis C infection. Only multi-faceted interventions including for example these interventions and treatment of hepatitis C infection can achieve substantial decreases in new hepatitis C infections.
Last revised 27 February 2009
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The primary prevention of hepatitis C among injecting drug users REVIEW 2009
Optimal provision of needle and syringe programmes for injecting drug users: a systematic review REVIEW 2010
Hepatitis C is spreading more rapidly than was thought OFFCUT 2005
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
The Patel report: Reducing drug-related crime and rehabilitating offenders DOCUMENT 2010
Harm reduction flood needed to extinguish the hepatitis C epidemic HOT TOPIC 2011
Benefits of concurrent syringe exchange and substance abuse treatment participation STUDY 2011
Needle and syringe programs and bleach in prisons: reviewing the evidence.Betteridge R, Jürgens R., Kerr T.
Canadian HIV/AIDS Legal Network, 2008.
Brief but thoroughly researched review argues that prison needle exchange is among the best ways to contain the potential for rapid spread of HIV infection in prison and possibly too in the community after prisoners are released.
Summary Substantial scientific evidence has shown that needle and syringe distribution programmes in the community are the most effective intervention available to prevent HIV transmission associated with injecting drug use. As well, needle and syringe distribution programmes have been associated with increases in access to care and treatment and substantial cost savings, and have not led to increased levels of risk behaviour among visitors or increased drug use by people who inject drugs.
There is also an important and growing body of evidence demonstrating the success of prison-based needle and syringe distribution programmes. Since the early 1990s, the number of such programmes has steadily grown. There are now in excess of 60 programmes in nine countries. While existing quantitative evaluations have some limitations, overall evaluations have been highly and consistently favourable. Needle and syringe distribution programmes in prison have been associated with substantial reductions in needle and syringe sharing, and there have been no recorded cases of HIV infection among participating prisoners. Additional benefits include reductions in overdose incidents and deaths, increased referral to drug treatment, increased awareness of infections transmission and risk behaviours, and a reduction in injection site abscesses. None of the projected adverse consequences have been found. In particular, there have been no incidents in which programme syringes or needles were used as weapons, drug use has been stable or has decreased, and there has been no increase in injecting drug use among prisoners. In general, needle and syringe distribution programmes have been accepted by prison staff, including staff initially opposed.
Bleach programmes to help prisoners decontaminate used injecting equipment should be available in prisons without needle and syringe distribution programmes, and also in prisons which have as a complement to these programmes. However, because of bleach’s limited effectiveness, bleach programmes can only be regarded as a second-line strategy and cannot replace needle and syringe distribution programmes.
From a public health perspective, piloting and rapidly expanding needle and syringe distribution programmes is a priority for responding to the dual epidemics of injecting drug use and HIV infection among prisoners. Outbreaks of HIV infection among prisoners in the former Soviet Union have been documented. Given the evidence of entrenched epidemics of injecting drug use and HIV infection in prisons in many countries in Eastern Europe and the former Soviet Union, it is clear that further inaction on the part of prison officials will result in increased morbidity, including HIV infection, and mortality among people who inject drugs in prison. Moreover, the failure to implement needle and syringe distribution programmes could result in spread of HIV infection among the prison population as a whole, and could potentially lead to generalised epidemics in communities into which prisoners are released. Such further spread of HIV would lead not only to greater suffering for affected individuals and their families, but also would result in substantial, avoidable health care costs.
Last revised 27 February 2009
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Optimal provision of needle and syringe programmes for injecting drug users: a systematic review REVIEW 2010
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Hepatitis C is spreading more rapidly than was thought OFFCUT 2005
Opioid substitution therapy in prisons: reviewing the evidence REVIEW 2008
First randomised trial finds methadone helps prisoners control drug use and infection risk STUDY 2004
The Patel report: Reducing drug-related crime and rehabilitating offenders DOCUMENT 2010
Female crack smokers respond well to standard HIV risk-reduction sessions STUDY 2004
The primary prevention of hepatitis C among injecting drug users REVIEW 2009
Opioid substitution therapy in prisons: reviewing the evidence.Betteridge R, Jürgens R., Kerr T.
Canadian HIV/AIDS Legal Network, 2008.
Brief but thoroughly researched review commends prison methadone programmes as causing no substantial problems while improving the climate in prison, reducing drug use and infection risk behaviours, and improving post-release treatment uptake and recidivism rates.
Summary Within prisons the prevalence of injecting and HIV infection, combined with the high turnover of the prison population, create the potential for efficient and widespread transmission of infectious diseases and other drug-related harms. However, prisons also present opportunities for the treatment of drug dependence and the prevention of disease transmission among a substantial number of disadvantaged individuals. Most of the 15 ‘old’ European Union (EU) member states and several newer member states have prison-based methadone maintenance programmes. These also exist in other countries including Australia, Canada, the USA, Iran, and Indonesia. Several prison systems in Eastern Europe and the former Soviet Union have initiated methadone maintenance programmes or are planning to do so. This trend follows recommendations from the World Health Organization and other UN agencies.
A wealth of scientific evidence has shown that methadone maintenance is the most effective intervention available for the treatment of opiate dependence, associated with reductions in risk behaviour, illicit drug use, crime, sex work, unemployment, mortality, and HIV transmission. Methadone maintenance has been found to be more effective than detoxification programmes in promoting treatment retention and abstinence from illicit drug use.
Evaluations of prison-based methadone maintenance programmes have been highly and consistently favourable. Such programmes have been associated with substantial declines in HIV risk behaviour (eg, sharing syringes), decreased levels of drug use and participation in the prison-based drug trade, and increased participation in drug treatment following release from prison. The available evidence also suggests that methadone maintenance programmes have a positive effect on criminal recidivism and re-incarceration. Finally, studies have shown that methadone maintenance has a positive effect on the prison environment. Although concerns have often been raised initially about security, violent behaviour, and diversion of methadone, these problems have not emerged or have been successfully addressed once programmes were established.
From a public health perspective, initiating and rapidly expanding methadone maintenance programmes is a priority for responding to the dual epidemics of injection drug use and HIV infection among prisoners. Given the evidence of entrenched epidemics of injection drug use and HIV infection in prisons in many countries in Eastern Europe and the former Soviet Union, it is clear that inaction on the part of prison officials will result in increased morbidity and mortality among drug dependent prisoners. Moreover, the failure to implement methadone maintenance could result in further spread of HIV infection among prisoners who inject drugs and the prison population as a whole, and could potentially lead to generalised epidemics in communities into which prisoners are released. Such further spread of HIV would lead not only to greater suffering for affected individuals and their families, but also would result in substantial, avoidable health care costs.
Last revised 27 February 2009
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First randomised trial finds methadone helps prisoners control drug use and infection risk STUDY 2004
Substitution treatment of injecting opioid users for prevention of HIV infection REVIEW 2008
Continuity vital after prison treatment STUDY 2005
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
The Patel report: Reducing drug-related crime and rehabilitating offenders DOCUMENT 2010
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Optimal provision of needle and syringe programmes for injecting drug users: a systematic review REVIEW 2010
Needle and syringe programs and bleach in prisons: reviewing the evidence REVIEW 2008
Initiating methadone prescribing in prison promotes its continuation on release STUDY 2006
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Can heroin maintenance help Baltimore? What Baltimore can learn from the experience of other countries.Reuter P.
Baltimore: The Abell Foundation, 2009.
Though intended for Baltimore this review will be of great value for administrations everywhere considering heroin prescribing programmes. It is particularly useful for its accessible style and hands-on portrayal of existing programmes.
Summary The review analysed heroin maintenance programs in Switzerland, the Netherlands, Germany and Vancouver, describing in detail how they operate in practice and the clinics' ambience as well as evaluation results. The latter have, the review found, all been positive. Retention in treatment has been high and drop-out has often been into other treatment modalities. Reductions in crime and improvements in health and social functioning are somewhat, but not greatly, better would be expected of a good methadone programme. However, patients in heroin assisted treatment Heroin normally supplements other medications such as methadone and is accompanied by psychosocial therapy and other forms of support. have a record of repeated failure on methadone, so crude comparison may be misleading. It is difficult to find any evidence that heroin prescribing has caused additional harms either to users or to the broader population. There is no indication that heroin has leaked from the facilities on to the black market. Though it is difficult to develop a research design that would assess this, no one has claimed that the availability of heroin programmes has led to an increase in the number of people experimenting with heroin.
The operation of such programmes has not led to a loss of public support at any site where they have been tried. In November 2008 a referendum on continuing heroin maintenance in Switzerland resulted in a favourable vote of more than two-thirds. While there are initial local complaints about the client population, these seem to fade fairly rapidly. These complaints also do not appear to be any more serious than those surrounding a methadone clinic.
One concern is that heroin assisted treatment is substantially more expensive than methadone maintenance. That has been the experience in both Switzerland and the Netherlands. Costs were much higher not because of the cost of heroin itself, but primarily because of associated programme costs. However, studies in both countries found that the additional benefits outweighed the additional costs. For example, adding the social costs to the costs of provision of services, a patient in treatment for a given period of time in the heroin arm of the Dutch trials cost 37,000 Euros compared to 50,000 Euros for the methadone arm of the trial. Reductions in crime were a large part of the gains, as was true in the Swiss studies. This comparison points to a chronic problem of substance abuse treatment funding; expenditures are borne by the health care sector, while benefits are primarily reaped by the criminal justice sector and the community.
Heroin assisted therapy is clearly a supplement to methadone maintenance rather than a substitute for it. Nowhere where it has been available has it attracted a substantial share of heroin users who seek treatment; 10% is a high estimate of the potential share of treatment slots that might be occupied by heroin assisted treatment patients.
In respect of Baltimore, the question for the community is: Is the undertaking worth the effort for such a small share of clients? At best there is a case only for an experiment. Population differences require caution. The potential for gain, however, is substantial. Even in the aging heroin addict population, there are many who are heavily involved in crime and return frequently to the criminal justice system. Their continued involvement in street markets imposes a large burden on the community in the form of civil disorder that helps keep investment and jobs out. If heroin maintenance could remove 10% of Baltimore's most troubled heroin addicts from the streets, the result could be substantial reductions in crime and various other problems that greatly trouble the city. That is enough to make a debate on the matter worthwhile.
Last revised 27 February 2009
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Role Reversal FINDINGS REVIEW 2003
Heroin-assisted treatment in Switzerland: a case study in policy change STUDY 2009
NTA guidance on heroin prescribing OFFCUT 2003
Prescription of heroin for the management of heroin dependence: current status REVIEW 2009
Heroin maintenance for chronic heroin-dependent individuals REVIEW 2010
First large-scale randomised trial boosts case for heroin prescribing STUDY 2003
Ever controversial: prescribing opiates to opiate addicts HOT TOPIC 2010
The Andalusian trial on heroin-assisted treatment: a 2 year follow-up STUDY 2010
