Keep Calm and Carry Naloxone

Recent media reports highlight new research calling for increased access to naloxone as a safe, effective and evidence-based public health strategy.  Distribution of naloxone, often referred to by the brand name Narcan, has been described as a cost-effective method to “cut the death rates from overdose nearly in half” while reducing long-term public health spending on overdose related interventions^1,2.

What is Naloxone?Naloxone is a non-toxic, non-addictive medication that works as an antidote to opioid overdose. Opioids include commonly used drugs such as heroin, oxycontin, and morphine.  Naloxone works to “reverse” an opioid overdose by counter-acting the often fatal depression of respiratory and central nervous systems. If there are no opioids in a person’s system, naloxone has no effect.  Naloxone is administered through injection or nasal spray.

Is Naloxone a new development?Naloxone has been used in clinical settings across Europe, Australia, Canada and the United States for over 40 years.  The World Health Organization has included naloxone on its List of Essential Medicines³ .

Who has access to Naloxone?In some countries, naloxone is available over the counter, but in Canada it is controlled under the Food and Drug Act as a prescription-only medicine.  Naloxone has been available through Edmonton’s Streetworks Program and at Insite in Vancouver.  Take-home and peer-based naloxone access programs are gaining support in a number of areas across the world.

Why is Naloxone access important? According to a 2012 article in the British Columbia Medical Journal, “the current lack of naloxone availability outside primary care, hospital, and ambulance settings limits its lifesaving potential”. The article “seeks to increase physician awareness about the safety, effectiveness, and evidence that increasing access to naloxone saves lives” and describes how access initiatives “can provide an opportunity to engage in meaningful dialogue and empower people who use opioids to take responsibility for themselves and others” ⁴. 

Sources

1. Szalavitz, M. Wider use of antidote could lower overdose deaths by nearly 50%. Retrieved from http://healthland.time.com/2013/02/05/wider-use-of-antidote-could-lower-overdose-deaths-from-by-nearly-50/#ixzz2LZAjnyda

2. Coffin, P., Sullivan, S. (2013). Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Annals of Internal Medicine.  158(1).  Retrieved from http://annals.org/article.aspx?articleid=1487798

3. World Health Organization. Model lists of essential medicines. Retrieved from http://www.who.int/medicines/publications/essentialmedicines/en/index.html

4. Buxton, J. et al. (2012). Increasing access to naloxone in BC to reduce opioid overdose deaths.  BCMJ. 54(5).  Retrieved from http://www.bcmj.org/bc-centre-disease-control/increasing-access-naloxone-bc-reduce-opioid-overdose-deaths

HIV in the World Today

This article was written by AIDS Calgary’s Case Manager.

As some of you may know, this year’s theme in the world of HIV is “Getting to Zero: Zero New HIV Infections, Zero Discrimination and Zero AIDS Related Deaths.” The United Nations (UN) recently published their World’s AIDS Day Report and there have been some great improvements in reducing the rates of HIV. The number of new annual infections has decreased by 21% in the past 15 years, much of this due to advances and accessibility of antiretroviral treatment. The UN estimates that over 700,000 deaths were prevented in 2010 due to the availability of medications and the incident rate of HIV has decreased in 33 countries around the world. Great news indeed!!

While there have been significant improvements in many countries to decrease the transmission and deaths from HIV, there are some areas of the world where this is not the case. Rising rates in Eastern Europe and Central Asia are due to injection drug use and has led to a 250% increase of people living with HIV. It is reported that Russia and Ukraine have contributed to 90% of new infections in the region of Eastern Europe and Central Asia. There are agencies in this area that recognize the value of harm reduction and are working with communities and injection drug users (IDU’s) to decrease the risk of HIV and HEP C transmission.

The Eurasian Harm Reduction Network (EHRN) works in 29 countries and their mission is to “to promote humane, evidence-based harm reduction approaches to drug use, with the aim of improving health and protecting human rights at the individual, community, and societal level.” The EHRN advocates for Opioid Substitution Therapy (OST), such as methadone, as a way to decrease the rates of HIV and HEP C and to improve the lives of some of the most marginalized populations. They estimate that the majority of IDU’s in the regions that they serve are opioid users, though there are still barriers (government and societal) in ensuring that the IDU’s are receiving the treatment they need. The introduction of OST treatment centres has been shown to have a positive impact on reducing the transmission rates in the short amount of time that they have been operational in a number of countries. Unfortunately the benefits of OST are not being seen in Russia as they have not been legalized for use.

This is not to say that there is not work being done in Russia to combat the rising rates of HIV and HEP C; ESVERO is a grassroots organization founded in 2003 and works with IDU’s, activists and service providers to promote change through advocacy, community development and information exchange. Their aim is to promote harm reduction messaging in their country and they offer several training opportunities for outreach workers to increase their knowledge of harm reduction techniques when working with vulnerable populations. In the short amount of time that harm reduction strategies and programs have been implemented in Russia (since 1996), there are now over 70 harm reduction projects throughout the country. Hopefully the next 15 years can see an even larger network of harm reduction programming, as well as access to OST and laws that recognize and support harm reduction methods.

References
http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_WorldAIDSday_report_2011_en.pdf
http://eng.esvero.ru/
http://www.harm-reduction.org/activities.html

Safe Drug Consumption

Since it opened its safe and non-judgmental arms to intravenous drug users in 2003, an air of controversy continues to cloud Vancouver’s Insite facility and programs like it.

Boasting a status of being the first (and only) in North America, Insite describes itself as a health-focused place where individuals can safely inject drugs under the supervision of health care professionals in an effort to avoid death by overdose and the spread of infections, like HIV.

Insite operates under a harm-reduction model with a real-world view on abstinence. Insite is not unlike drug consumption rooms that operate around the world. Although the concept of safe injection and facilities like Insite have been a topic of heated debate in Canada recently, supervised injection sites have been around since the 1970s.

Europe is the front-runner when it comes to utilizing safe injection sites, with four countries currently allowing for such facilities. Outside of those European countries and Canada, Australia is the only other country that provides medically supervised injection sites.

The Netherlands
22 official drug consumption facilities are scattered throughout The Netherlands. Initial sites were established in the 1970s, when drug-use was no longer looked at as deviant, but became accepted as a personal lifestyle. Relaxed laws on drug possession allowed for facilities to open up earlier than most other countries. Facilities often incorporate both smoking and injecting rooms. They also offer services that include: drug-free treatment, medical care, counseling, food, laundry, and showers.

Switzerland
Switzerland’s first supervised injection centre was opened in 1986 when health workers noticed the congregation of injection drug users in public spaces. With 12 Swiss centres now in use, the facilities usually provide a sterile environment and access to medical care and counseling for individuals as well as needles, syringes, spoons, etc. Usually open for seven hours a day, five or six days a week, clients must be at least 16 years old and have a history of injecting before they are allowed to use the centre.

Germany
In 1994 Germany opened its first injecting centre, and currently operates 25 consumption facilities. Employees are mostly social workers, nurses, and medical officers. Clients must be at least 18 years old and adhere to the rules, which include: no violence, no drug-dealing, no sharing of drugs, no injecting of others, no staff assisted injecting, and a 30-minute time limit.

Spain
The most recent European country to incorporate supervised injecting rooms, Spain opened the doors to its first facility in 2000. Spain is home to the only injection facility that is open 24 hours a day.

Although research is limited, evidence suggests the benefits of safe injection sites lie in four important areas: reduced public nuisance, improved access and uptake of health and other welfare services, reduced opioid related overdose risk, and reduced risk of blood-borne virus transmission.

Vancouver’s Insite Program statistics reveal that, on average, the facility sees 491 safe injections daily. The program has had zero overdose fatalities, 2,492 clinical treatment interventions, and 411 admissions to Onsite detoxification. 6,242 referrals were given through Insite to other health and social service facilities, most of which were for detox and addiction treatment.


Resources:
1. Dolan K, Kimber J, Fry C, Fitzgerald J, McDonald D, Trautman F. Harm Reduction Digest 10: Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia. Drug and Alcohol Review (2000) 19, 337-346
2. Hedrich D. European report on drug consumption rooms. European Monitoring Centre for Drugs and Drug Addiction (Feb. 2004) p. 15-23.
3. Vancouver Insite Program, www.supervisedinjection.vch.ca/

This article was submitted by Jess Howat. Jess was a practicum student at AIDS Calgary in March. She is currently working towards a Communication Studies degree between SAIT and the University of Calgary.

Safer Inhalation Kits

“It’s definitely one of the really good services that Safeworks offers.”
– Roseline Carter, Community Strategies Team Leader at AIDS Calgary

Safer inhalation kits are notably one of the most popular supplies handed out by Safeworks, said Roseline Carter. The provision of the kits is an important effort in harm reduction amongst street drug users. With clients often returning on a daily basis to obtain the supplies offered, the effort is certainly not in vain.

Harm reduction amongst crack users with the use of the safer inhalation kits focuses on preventing transmission of infections, including HIV and Hepatitis C, by providing clean paraphernalia for drug consumption. Carter says that since the provision of crack pipes within the last two years, popularity of kits and number of clientele has increased a significant amount.

Safer inhalation kits and supplies have been handed out by Safeworks for five years, but have only had pipes available since November 2008. Safeworks Coordinator, Leegay Jagoe, estimates that 20-40 clean crack pipes are handed out each night from the Safeworks van. The van is the only place where the pipes are accessible; however other supplies are available at all of Safeworks’ site locations which include: the Calgary Drop In Centre, Centre of Hope, Sheldon Chumir Health Centre, and the Safeworks van which operates in the evenings.

“People are more interested in the pipe than anything,” said Jagoe. “We are always promoting mouthpieces with [them], though.”

Safeworks primarily operates as a prevention and education program that works with a target population to reduce harm related to HIV and Hepatitis B and C infection, as well as transmission.

What goes into a safer inhalation kit?

Crack pipes
With regular access to pipes, individuals are less likely to share them. Also, since they are usually made of pyrex glass, they are less likely to break or crack and cut the fingers or lips. They also won’t heat up as quickly as metal pipes or release harmful fumes like make-shift pop can pipes.

Push sticks
Push sticks are usually small, thin wooden sticks that help to prevent finger burns when placing crack cocaine into the end of a pipe.

Filters
Filters, often brass, are simply little screens that can be folded up and placed inside a pipe, to prevent any hot/burning matter from being inhaled by the user.

Mouthpieces
Mouthpieces are made of plastic and are placed over the end of a pipe. They protect smokers from burns, as well as infection through blood transference.

Vaseline
An alternative to chapstick, Vaseline keeps lips from getting dry and cracking or burned.

How can I stay safer when smoking crack?

• Avoid sharing pipes
• Use chapstick or Vaseline on your lips often
• Allow pipes to cool before using
• Use clean pipes and screens
• Use a mouthpiece. Mouthpieces can also be formed from pieces of tape, elastic bands, or anything that keeps lips from touching the pipe directly
• Use condoms or dental dams when giving and/or receiving oral sex

For more information on Safeworks visit: http://www.calgaryhealthregion.ca/programs/harmreduction/safeworks.htm


This article was submitted by Jess Howat. Jess was a practicum student at AIDS Calgary in March. She is currently working towards a Communication Studies degree between SAIT and the University of Calgary.

Smoking crack increases risk of HIV infection

Although intravenous drug use has been known to increase risk of HIV infection for decades, people are only recently beginning to realize the possibility of smoking crack as an independent risk factor.

Infection risk factors
Smoking crack poses the possible risk of infection through the sharing of pipes, however, this risk is considered to be negligible. Smoking crack often produces wounds, sores, or cuts around the mouth, which does allow an entry route for HIV; however, there is no published evidence of HIV transmission specifically through the sharing of crack pipes.1 The heightened likelihood for unprotected sex, particularly oral sex, while smoking crack is thought to contribute to high HIV infection rates in crack users.

Research and studies
Research is often limited and disputed, even though crack use in Canada among injection drug users (IDUs) is known to be widespread.

A nine-year Vancouver study, started in 1996, found that daily crack users were four times more likely to become infected with HIV than those who rarely or never smoked. From this, researchers concluded crack smoking as a means of transmission.2

An American study interviewed 153 crack smokers. Of this, 80 per cent reported burns on their lips, 11 per cent reported cuts, 66 per cent shared pipes, and 62 per cent gave oral sex. All such situations, especially combined, are known to allow for extremely high-risk opportunities for infection.3

Another Canadian study, based in Ontario, found that 63 per cent of IDUs reported smoking crack, often due to the drug’s affordability and availability. The 2007 report also noted a lessened amount of injection use when safer inhalation kits were available. With the high-risk group less likely to share pipes and/or needles, infection risk significantly lowered.4

Canadian harm reduction efforts
Some Canadian cities, including Calgary, Toronto, Montreal, Vancouver and Edmonton, currently allow for the provision of safer inhalation kits, or crack kits, to individuals in an effort to reduce the spread of HIV through crack use. Such kits usually include pipes, filters, mouth pieces, push sticks, lip balm and sometime disinfectant.

Safe inhalation rooms
Injection sites, like Vancouver’s Insite, are already in use in an effort to stop the spread of HIV through needle-sharing. Many harm reduction advocates would like to see the same system employed for crack users.

Safe inhalation rooms would provide a safe environment for crack use under the supervision of health professionals. Ultimately, and not unlike injection sites, they would function as a public health-care facility, where individuals would have access to nurses, addiction counsellors, and support workers. Not only would the risks involved with using the drug be reduced, but people would have immediate access to help should they need it.


References:
1. Canadian AIDS Society. HIV Transmission: Guidelines for Assessing Risk (2005), pg 31.
2. DoBeck K MPP, Kerr T PhD, Li K PhD, Fischer B PhD, Buxton J MD, Montaner J MD, Wood E MD PhD. Smoking of crack cocaine as a risk factor among people who use injection drugs. October 2009. Canadian Medical Association Journal
3. Safer Crack Use Coalition of Toronto (SCUC). Fact Sheet: Health Issues Affecting Crack Smokers. www.canadianharmreduction.com.
4. Leonard L, DeRubies E, Pelude L, Medd E, Birkett N, Seto J. Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking reserouces are distributed. University of Ottawa. February 2007. International Journal of Drug Policy


This article was submitted by Jess Howat. Jess was a practicum student at AIDS Calgary in March. She is currently working towards a Communication Studies degree between SAIT and the University of Calgary.

The devastating toll of syringe reuse

About This Talk
Reuse of syringes, all too common in under-funded clinics, kills 1.3 million each year. Marc Koska clues us in to this devastating global problem with facts, photos and hidden-camera footage. He shares his solution: a low-cost syringe that can't be used twice. Watch his video here:

http://www.ted.com/talks/marc_koska_the_devastating_toll_of_syringe_reuse.html

About Marc Koska
Marc Koska wants to improve health care in the developing world by re-designing dangerous medical tools -- and offering education to practitioners in under-funded clinics. Full bio and more links

HIV and Addiction

People use alcohol or other recreational drugs for a variety of reasons. Not all people who use substances have concerns about their use, experience negative outcomes, or want to cut down/quit. For some people, the use of substances may be causing problems in their lives and they may consider harm reduction strategies, cutting down or quitting altogether.

Substance use and addiction can be a potential factor when we consider HIV transmission and living with HIV/AIDS. “Research findings clearly show that the use of alcohol and other substances of abuse is a factor in the spread of HIV and can complicate the long-term health outcomes of HIV-positive individuals.” (National Institute on Alcohol Abuse and Alcoholism, 2002). Substance use and addiction can be a factor in HIV transmission as it may impact decision making. This can make it more difficult to use clean needles when doing injection drugs or to negotiate condom use when having sex.

When thinking about substance use and addiction for people living with HIV/AIDS, Canadian AIDS Treatment Information Exchange notes the following: “Ecstasy and crystal meth (“Tina”) may reach dangerously high levels in the blood in combination with a PI {protease inhibiter} such as ritonavir (Norvir). They may also cause lasting damage to important chemicals in the brain, leaving users vulnerable to conditions such as untreatable depression. Some anti-HIV drugs such as nevirapine (Viramune) and efavirenz (Sustiva) may lower blood levels of heroin or methadone in the body, possibly causing involuntary withdrawal. Some other drugs may raise blood levels of these recreational drugs, which may cause a dangerous overdose.” (CATIE, nd.)

Substance addiction can also potentially impact HAART Adherence. One study found that “current {substance} users were significantly less likely to be adherent than former, or never users” (Hicks PL, et al, 2007). Other sources indicate that substance addiction may impact HIV disease progression. NIDA reported that “Drug abuse and addiction can also worsen the progression of HIV and its consequences, especially in the brain. In animal studies, methamphetamine increased HIV viral replication; in human methamphetamine abusers, HIV caused greater neuronal injury and cognitive impairment compared with nondrug users”. (2005). “Heavy alcohol consumption has a negative impact on the CD4 cell count in HIV-infected persons not receiving ART. In addition to the known deleterious effects of alcohol on ART adherence, these findings suggest that avoiding heavy alcohol consumption in patients not on ART may have a beneficial effect on HIV disease progression.” (Samet, JH, et al, 2008)

AIDS Calgary is committed to a harm reduction and human rights based approach in service delivery. We accept that abstinence from risk behavior (such as substance use) may not be desired or possible in some life circumstances. We value individual rights to self determination and recognize that not everyone wants to cut down or quit using substances. There are harm reduction strategies that can keep you safer while still using. This could include not sharing needles or pipes, finding out more about recreational drug interactions, talking with a support person about your own goals, health information and education, replacement therapy such as methadone, and so on.

If you are living with HIV you can connect with a Case Manager at AIDS Calgary to talk about a variety of options, including harm reduction strategies, counseling and support. AADAC (Alberta Alcohol and Drug Abuse Commission) can also provide information, counseling and residential or outpatient addiction treatment programs. For more information see: http://www.aadac.com/default.asp or the 24-hour AADAC Help Line 1-866-332-2322

It is important to consult with knowledgeable pharmacist/physician for current information and strategies on minimizing drug interactions.

Sources
Canadian AIDS Treatment Information Exchange (CATIE). (nd) Recreational Drugs and HIV. Retrieved March 24, 2009 from http://www.catie.ca/treatmentFAQ_e.nsf/c3f8add81db5bbbb85257188005be34b/89705028c888b02185256f0f0056c9a0!OpenDocument

Hicks PL, Mulvey KP, Chander G, Fleishman JA, Josephs JS, Korthuis PT, Hellinger J, Gaist P, Gebo KA; HIV Research Network. (2007) The Impact Of Illicit Drug Use And Substance Abuse Treatment On Adherence To HAART. AIDS Care. 2007 Oct;19(9):1134-40. Retrieved March 24, 2009 from http://www.ncbi.nlm.nih.gov/pubmed/18058397

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2002). Alcohol Alert #57. Retrieved March 24, 2009 from http://pubs.niaaa.nih.gov/publications/aa57.htm

Samet JH, Cheng DM, Libman H, Nunes DP, Alperen JK, Saitz R. (2007). Alcohol Consumption and HIV Disease Progression. J Acquir Immune Defic Syndr. 2007 October 1; 46(2): 194–199. Retrieved March 24, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2247363

Drug Use and Human Rights

Human rights and people who use illegal drugs. It is uncommon for many people to link human rights and people who use drugs together in the same sentence. We live in a world that has a poor history of identifying that people who do drugs also deserve to have their basic human rights recognized, respected, and restored.

To better understand the context of human rights in the life of a person who uses drugs, consider the process of undergoing surgery at your local hospital. The surgery is an invasive and painful procedure. You are given the same amount of pain management medication as the person next to you, who has never used drugs in their life. Unfortunately, what works for a person who has never used drugs before is not the same as what works for a person who has been using drugs for 20 years. This situation is an unfortunate example of a human rights violation that happens all the time.

Do we find it acceptable to say that a person can handle the pain? Or that a person won’t mind the pain? Or even that a person might deserve the pain? Human beings generally respond negatively to pain and a person who has gone through an experience such as this one would be extremely hesitant to access necessary health care services in the future.

Most of us take advantage of our basic human right to quality health care. And that’s the way it should be. We should be able to just assume that we will always have access to essential and high quality health care. We shouldn’t be afraid to go into a doctor’s office or a clinic or a hospital. We shouldn’t worry that the standards of our health care might be different than the standards for the person in the next bed over.

Standards of health care are a complex subject under a great deal of ongoing debate in Canada. This is a specific example provided to illustrate a very simple point.

Above all else, we should be recognizing that people who use drugs are just that, people. People who deserve their basic human rights as much as you or I.