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Preventing Medical Complications of Injection Drug Use

Preventing Medical Complications of Injection Drug Use. Keith Heinzerling, MD, MPH UCLA Seminars in Addiction Psychiatry Course August 11, 2005. Public Heath Burden of Blood-borne Viral Infections. Human immunodeficiency virus (HIV): 850,000 to 950,000 Americans infected

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Preventing Medical Complications of Injection Drug Use

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  1. Preventing Medical Complications of Injection Drug Use Keith Heinzerling, MD, MPH UCLA Seminars in Addiction Psychiatry Course August 11, 2005

  2. Public Heath Burden of Blood-borne Viral Infections • Human immunodeficiency virus (HIV): • 850,000 to 950,000 Americans infected • 180,000 to 280,000 unaware of infection • Hepatitis C virus (HCV): • 4 million Americans infected • Leading reason for liver transplant • HIV-HCV co-infection: higher mortality

  3. Injection Drug Use: Important Source of Transmission • Sharing of contaminated drug injection equipment by injection drug users (IDUs) has resulted in: • 25% of cumulative AIDS cases before 2000 (CDC, 2003) • 20% of new HIV/AIDS diagnoses in 2000 (CDC, 2004) • 68% of HCV infections (Alter, 2002)

  4. Prevalence of HIV and HCV Among IDUs is High • HIV seroprevalence among IDUs: • 2% to 30% (Monterroso, 2000) • HCV seroprevalence among IDUs: • 66% to 93% in methadone patients • 27% to 41% in IDUs under age 30 • Average time to HCV seroconversion for IDUs is 3.4 years (Hagan, 2004)

  5. Soft Tissue Infections (STIs): Common Among IDUs • Prevalence (Binswanger, 2000): • 68% (lifetime), 32% (current) • Risk factors (Murphy, 2001): • Syringe reuse, Skin popping, Speedball • San Francisco General (CDC, 2001): • $10 million for inpatient and ER care • California, 2000 (Heinzerling, 2005): • 4,152 hospital discharges for STIs

  6. Preventing Complications WithGood Injection Hygiene: www.cleanneedlesnow.org Courtesy of Kristen Ochoa

  7. Use Sterile Water and a Clean “Cooker” to Dissolve Drugs

  8. Use Sterile “Cottons” to Filter Drugs

  9. Find a Good Vein

  10. Find a SAFE Vein

  11. Missing or “Booting” Can Cause Abscesses or Cellulitis

  12. Sharing Cookers, Cottons, Water is More Common than Syringe Sharing (Source of HCV?)

  13. Increased HIV/HCV Risk: “Backloading”

  14. Being Injected by Others: Frequent Syringe Sharing and Exposure to Blood

  15. Syringe Exchange Programs: Sterile Syringes, Injection Equipment, and Health Services for IDUs

  16. History of Syringe Exchange Programs (SEP): • 1984: First SEP in Amsterdam • 1988: First US SEP in Tacoma, WA • 1999: Surgeon General’s SEP Report • 2000: SEPs “legal” in California • 2002: 148 SEPs in 32 states exchanged 25 million syringes; “Bridge to Services for IDUs”- HIV testing at 72%, HCV testing at 43%, HBV vaccination at 36% • 2005: 30 SEPs in California, 7 SEPs in Los Angeles- services available 6 days a week

  17. SEPs: Reduced Risk Behaviors for HIV and Abscesses but Maybe Not for HCV • HIV: Meta-analysis (Ksobiech, 2003) • 47 studies from 1988-2001 • SEP use significantly associated with lower syringe sharing, lending, and borrowing • STIs (Bluthenthal, 2004) • Syringe reuse lower for SEPs without caps on number of syringes exchanged • Effectiveness for HCV Unclear (Thorpe, 2005) • SEP use associated with reductions in syringe sharing but not sharing of cookers

  18. Comprehensive approach is needed: • Sterile syringes and condoms • Injection and sexual risk reduction counseling • Screening for HIV, HBV, HCV, STDs • Substance abuse treatment

  19. Unmet Need for Recommended Preventive Health Services Among Syringe Exchange Program Clients in California KG Heinzerling, NM Flynn, AH Kral, RL Anderson, ML Gilbert, A Scott, SM Asch, RN Bluthenthal CDC R06/CCR918667 UCLA / VA RWJ Clinical Scholars Program

  20. Research Questions • Are SEP clients receiving recommended preventive services from any source? • What percent of preventive services are received from SEPs? • What is the availability of HIV and HCV testing on-site at SEPs?

  21. Research Questions • What factors are associated with receipt of HIV and HCV testing by SEP clients? • SEP on-site testing, use of primary care or drug treatment? • What is the frequency of health care linkages among SEPs with different availability of on-site HIV/HCV testing?

  22. Methods- Sample • Programs: • 23 SEPs throughout California • Two-thirds of California SEPs in 2003 • Clients: • Approximately 25 clients per SEP recruited by SEP staff from March to September 2003 • 560 current injection drug users with at least one SEP visit in the last 30 days

  23. Methods- Data Collection • SEP Directors were interviewed about: • Availability of on-site HIV and HCV testing • SEP structural and organizational characteristics • SEP Clients were interviewed about: • Demographics, medical history, risk behavior • Receipt of preventive services- past 6 months

  24. Results: SEPs in Sample

  25. SEP Client Characteristics

  26. Percent of Eligible Clients Who Received Each Service and Source of Care Percent of Eligible Clients Who Received Service

  27. Availability of SEP On-site Testing Services

  28. Percent of Clients Who Received HIV and HCV Testing by Availability of SEP On-Site Testing Services HIV Test p=0.002 HCV Test p=0.008 Percent of Eligible Clients Who Received Testing

  29. Percent of Clients Who Received HIV and HCV Testing by Use of Primary Care HIV Test p=0.84 HCV Test p=0.12 Percent of Eligible Clients Who Received Testing

  30. Percent of Clients Who Received HIV and HCV Testing by Use of Drug Treatment HIV Test p=0.10 HCV Test p=0.72 Percent of Eligible Clients Who Received Testing

  31. Logistic Regression Model Predicting Receipt of HIV Testing

  32. Logistic Regression Model Predicting Receipt of HCV Testing

  33. SEP-Health Care Linkages and On-site Testing Availability

  34. Limitations • Convenience sample limited to IDUs using SEPs • Self-reports of utilization • Observational design

  35. Conclusions • SEPs are often the only source of preventive care for their IDU clients • Primary care providers and drug treatment programs miss opportunities to test SEP clients for HIV and HCV

  36. Conclusions • Availability of on-site HIV and HCV testing may be increased by formation of structural or organizational links between SEPs and health care providers • Should drug treatment programs provide needle exchange?

  37. Other Available Interventions • Pharmacy syringe sales: • Purchase up to 10 syringes without a prescription, disposal and prevention info available from pharmacist • Approved by Los Angeles County Supervisors June 2005, implementation by October 2005 • Supervised Injection facilities: • First in North America: Vancouver in 2003 • Decreases in injecting in public and publicly discarded syringes 12 weeks after facility opened (Wood E, 2004) • Pilot supervised smoking facility underway

  38. Acknowledgements • Staff and Clients of California Syringe Exchange Programs • UCLA / VA RWJ Clinical Scholars Program • CDC R06/CCR918667 • RAND, UC San Francisco, UC Davis • Urban Health Study

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