The future of treatment-including addiction treatment-is biotechnological. Depot injections, agonist/antagonist implants, deep brain stimulation, and hapten conjugate vaccines are hailed by researchers and pharmaceutical manufacturers as medicine's best hope to minimize illicit use, to decrease risk of overdose and painful withdrawal, and to prevent diversion of medicines to illicit markets. Marketing and use of new technologies reveal old tensions framing concepts of addiction and its treatment: between medical condition and disorder of the will, between criminal justice and health, and between patient choice and system control. Using the examples of depot naltrexone and implantable and injectable buprenorphine in the U.S., this essay considers the arc of long-acting opioid treatment and implications for the future. These include the rise of Vivitrol courts and "carceral prescription"-where criminal justice systems mandate medicine to lock up brain receptors much as they might lock up people themselves-as well as use of buprenorphine formulations positioned as increasing both patient benefit and provider control. We also consider lessons from debates on long-acting contraceptive technologies such as Norplant and Depo-Provera. While multiple new long-acting formulations are under development, success will be determined less by characteristics of particular formulations and more by whether or not the new technologies are accompanied by a new ethics of addiction treatment that emphasizes therapeutic alliance, concordance over compliance, and a genuine commitment to allowing patients the ability to narrate and be believed in their descriptions of their treatment experiences.

In Ukraine, HIV is concentrated among people who inject drugs (PWID), and opioid agonist therapies (OAT) are the most effective approach to preventing HIV transmission. OAT coverage is well below internationally recommended levels, with OAT provided primarily in specialty addiction treatment clinics. Integrating OAT into primary care settings represents a promising practice for increasing OAT coverage.The study collected data prospectively from the first 50 stable patients transferred from the largest OAT site to 10 primary care clinics in Kiev; patients had negative urine drug tests for the previous six months. Participants completed the BASIS-24—the 24-item Behaviour and Symptom Identification Scale—to assess symptoms of psychiatric and social function across 6 domains: (1) depression and functioning, (2) relationships, (3) self-harm, (4) emotional lability, (5) psychosis, and (6) substance use before transfer and 6 months after transfer from May through November 2019.Participants were on average 36 years old, mostly male (84.0%) and had some employment (64.0%). After six months, some employment increased to 88.0% and BASIS-24 scores significantly improved on four domains: depression (1.09 vs 0.73, p = 0.0005), relationships (2.15 vs 1.7, p < 0.0001), emotional liability (1.30 vs 1.00, p = 0.0209) and substance use (1.23 vs 1.07, p = 0073).Stable OAT patients can be successfully transferred from specialty to primary care clinics without deterioration in mental health symptoms or functioning. Patients transferred to primary care showed significant improvement in their emotional well-being, their substance use, and their employment status.

The 1961 UN Single Convention on Narcotic Drugs 1 UNSingle Convention on Narcotic Drugs, 1961, as amended by the 1972 Protocol amending the Single Convention on Narcotic Drugs. https://www.incb.org/documents/Narcotic-Drugs/1961-Convention/convention_1961_en.pdfDate: 1961 Date accessed: May 31, 2019 Google Scholar proposed to end all non-medical use of cannabis, coca, opium poppy, and their derivatives. In the nearly 60 years since then, global drug use and harm have increased 2 GBD 2016 Alcohol and Drug Use CollaboratorsThe global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. 2018; 5: 987-1012 Summary Full Text Full Text PDF PubMed Scopus (552) Google Scholar despite better scientific understanding of what interventions are effective, as highlighted by a new Lancet Series on drug use. 3 Degenhardt L Grebely J Stone J et al. Global patterns of opioid use and dependence: harms to populations, interventions, and future action. Lancet. 2019; (published online Oct 23)https://doi.org/10.1016/S0140-6736(19)32229-9 Summary Full Text Full Text PDF Scopus (249) Google Scholar , 4 Hall W Stjepanović D Caulkins J et al. Public health implications of legalising the production and sale of cannabis for medicinal and recreational use. Lancet. 2019; (published online Oct 23)https://doi.org/10.1016/S0140-6736(19)31789-1 Summary Full Text Full Text PDF Scopus (148) Google Scholar , 5 Farrell M Martin NK Stockings E et al. Responding to global stimulant use: challenges and opportunities. Lancet. 2019; (published online Oct 23)https://doi.org/10.1016/S0140-6736(19)32230-5 Summary Full Text Full Text PDF Scopus (106) Google Scholar , 6 Peacock A Bruno R Gisev N et al. New psychoactive substances: challenges for drug surveillance, control, and public health responses. Lancet. 2019; (published online Oct 23)https://doi.org/10.1016/S0140-6736(19)32231-7 Summary Full Text Full Text PDF Scopus (111) Google Scholar The global drug problem: change but not progressionReports about drug use make the news headlines these days, whether it be the opioid overdose crisis in the USA or the steep increase in drug overdose deaths in the UK.1,2 In 2017, about 271 million people or 5·5% of the global population aged 15–64 years had used drugs in the previous year and somewhere between 35 million and 72 million people had drug use disorders.3,4 Globally, in 2017, an estimated 585 000 people died and 42 million years of healthy life were lost from use of drugs.3 Around half of these drug-associated deaths were due to untreated hepatitis C infection. Full-Text PDF Global patterns of opioid use and dependence: harms to populations, interventions, and future actionWe summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3–47·9 million) and 109 500 people (105 800–113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes—eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Full-Text PDF Public health implications of legalising the production and sale of cannabis for medicinal and recreational useWe assess the current and describe possible future public health impacts of the legalisation of cannabis production, sale, and use in the Americas. First, we describe global patterns of cannabis use and their most probable adverse health effects. Second, we summarise evidence regarding the effectiveness of cannabinoids for medicinal use and describe approaches that have been used to regulate the use of medicinal cannabis and how these approaches might have affected medicinal and recreational use and harms (eg, road crashes). Full-Text PDF Responding to global stimulant use: challenges and opportunitiesWe did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. Full-Text PDF New psychoactive substances: challenges for drug surveillance, control, and public health responsesThe rapid emergence since the mid-2000s of a large and diverse range of substances originally designed as legal alternatives to more established illicit drugs (pragmatically clustered and termed new psychoactive substances; [NPS]) has challenged traditional approaches to drug monitoring, surveillance, control, and public health responses. In this section of the Series, we describe the emergence of NPS and consider opportunities for strengthening the detection, identification, and responses to future substances of concern. Full-Text PDF

In deliberations on drug policy in United Nations fora, a consensus has emerged that drug use and drug dependence should be treated primarily as public health concerns rather than as crimes. But what some member states mean by "public health approach" merits scrutiny. Some governments that espouse treating people who use drugs as "patients, not criminals" still subject them to prison-like detention in the name of drug-dependence treatment or otherwise do not take measures to provide scientifically sound treatment and humane social support to those who need them. Even drug treatment courts, which the U.S. and other countries hold up as examples of a public health approach to drug dependence, can serve rather to tighten the hold of the criminal justice sector on concerns that should be addressed in the health sector. The political popularity of demonisation of drugs and visibly repressive approaches is an obvious challenge to leadership for truly health-oriented drug control. This commentary offers some thoughts for judging whether a public health approach is worthy of the name and cautions drug policy reformers not to rely on facile commitments to health approaches that are largely rhetorical or that mask policies and activities not in keeping with good public health practise.

Drug conventions serve as the cornerstone for domestic drug laws and impose a dual obligation upon states to prevent the misuse of controlled substances while ensuring their adequate availability for medical and scientific purposes. Despite the mandate that these obligations be enforced equally, the dominant paradigm enshrined in the drug conventions is an enforcement-heavy criminal justice response to controlled substances that prohibits and penalizes their misuse. Prioritizing restrictive control is to the detriment of ensuring adequate availability of and access to controlled medicines, thereby violating the rights of people who need them. This paper argues that the drug conventions' prioritization of criminal justice measures-including efforts to prevent non-medical use of controlled substances-undermines access to medicines and infringes upon the right to health and the right to enjoy the benefits of scientific progress. While the effects of criminalization under drug policy limit the right to health in multiple ways, we draw on research and documented examples to highlight the impact of drug control and criminalization on access to medicines. The prioritization and protection of human rights-specifically the right to health and the right to enjoy the benefits of scientific progress-are critical to rebalancing drug policy.

Those researching HIV prevention measures for people who inject drugs (PWID) face a dilemma. Regions where baseline HIV prevalence and onward transmission via injecting is sufficiently high to power HIV prevention trials are also those where repressive laws, policies and practices raise concerns about the ethics of research subject protection. Dawson et al , outlining criteria to address ethical challenges in HIV prevention research among PWID, recommend that all trial participants be offered sterile injecting equipment and urge additional strategies to limit research and background risks.1 In light of ethical questions opened by recent clinical trials involving PWID, including several the authors cite favourably, these cautions are timely. Dawson et al urge weighing of costs and benefits of PWID participation in research trials as an essential part of the ethical calculus. Overdose is a particular risk in any trial that uses abstinence from opioids as a precondition for participation or as an outcome of interest, and a risk that institutional review boards and researchers frequently ignore. Given the increased likelihood of fatal overdose for those who return to injection following a period of abstinence, provision to all trial participants of naloxone—the overdose antidote …

A major UN summit on the world drug problem in 2016 is an opportunity to rethink punitive drug policies that have not succeeded in stemming drug demand or supply and have undermined HIV and HCV responses in many countries. Experiences of some countries demonstrate that treating drug use and minor drug possession in the health rather than the law enforcement sector can dramatically improve access to HIV and HCV services. Alternatives to incarceration for minor drug infractions are particularly important in this regard. The voices of health professionals in national and international debates leading up to this important summit are crucial to making the case for public health-based and human rights-oriented drug policy reform.

BACKGROUND:Harm reduction is an evidence-based, effective response to HIV transmission and other harms faced by people who inject drugs, and is explicitly supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. In spite of this, people who inject drugs continue to have poor and inequitable access to these services and face widespread stigma and discrimination. In 2013, the Global Fund launched a new funding model-signalling the end of the previous rounds-based model that had operated since its founding in 2002. This study updates previous analyses to assess Global Fund investments in harm reduction interventions for the duration of the rounds-based model, from 2002 to 2014. METHODS:Global Fund HIV and TB/HIV grant documents from 2002 to 2014 were reviewed to identify grants that contained activities for people who inject drugs. Data were collected from detailed grant budgets, and relevant budget lines were recorded and analysed to determine the resources allocated to different interventions that were specifically targeted at people who inject drugs. RESULTS:151 grants for 58 countries, plus one regional proposal, contained activities targeting people who inject drugs-for a total investment of US$ 620 million. Two-thirds of this budgeted amount was for interventions in the "comprehensive package" defined by the United Nations. 91% of the identified amount was for Eastern Europe and Asia. CONCLUSION:This study represents an updated, comprehensive assessment of Global Fund investments in harm reduction from its founding (2002) until the start of the new funding model (2014). It also highlights the overall shortfall of harm reduction funding, with the estimated global need being US$ 2.3 billion for harm reduction in 2015 alone. Using this baseline, the Global Fund must carefully monitor its new funding model and ensure that investments in harm reduction are maintained or scaled-up. There are widespread concerns regarding the withdrawal from middle-income countries where harm reduction remains essential and unfunded through other sources: for example, 15% of the identified investments were for countries which are now ineligible for Global Fund support.

BackgroundPeople who inject drugs (PWID) achieve adherence to and outcomes from hepatitis C virus (HCV) treatment comparable to other patients. Nonetheless, this population has been excluded from treatment by regulation or practice. Approval of safer and more effective oral HCV medicines should offer greater treatment options for PWID, although high medicine prices have led to continued treatment rationing and exclusion in developed countries. In middle-income countries (MICS), treatment is largely unavailable and unaffordable for most PWID.MethodsHuman rights analysis, with its emphasis on the universal and interconnected nature of the economic, social and political spheres, offers a useful framework for HCV treatment reform. Using peer-reviewed and grey literature, as well as community case reports, we discuss barriers to treatment, correlate these barriers to rights violations, and highlight examples of community advocacy to increase treatment for PWID.ResultsStructural drivers of lack of treatment access for PWID include stigma in health settings; drug use status as a criterion for treatment exclusion; requirements for fees or registration by name as a drug user prior to treatment initiation; and incarceration/detention in prisons and rehabilitation centers where treatment is unavailable. High medicine prices force further exclusion of PWID, with cost containment masked as concern about treatment adherence. These barriers correlate to multiple rights violations, including of the rights to privacy; non-discrimination; health; freedom of information; fair trial; and freedom from cruel, inhuman and degrading treatment.ConclusionsNeeded reforms include decriminalization of drug use, possession of drugs and drug injecting equipment; removal of exclusionary or discriminatory treatment protocols; approaches to strengthen links between health providers and increase participation of PWID in treatment design and implementation; and measures to increase transparency in government/pharmaceutical company negotiations and reduce treatment price.

Future VirologyVol. 8, No. 2 EditorialFree AccessViral transmission linked to injecting illicit drugs: finding the best medicineJoanne Csete & Daniel WolfeJoanne Csete* Author for correspondenceGlobal Drug Policy Program, Open Society Foundation, Millbank Tower, 21–24 Millbank, London SW1P 4QP, UK. . & Daniel WolfeInternational Harm Reduction Development Program, Open Society Foundation, 400 W. 59 Street, New York, NY 10019, USAPublished Online:14 Feb 2013https://doi.org/10.2217/fvl.12.128AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: criminal justicehepatitis CHIVhuman rightspoliceprisonIn many of the countries with the largest number of hepatitis C cases – including China, Russia and the USA – the majority of HCV transmission is due to contaminated injection equipment [1]. Almost one third of new HIV infections outside sub-Saharan Africa, and a growing percentage of those in parts of Africa, are linked to unsafe injection [2]. With the devastating epidemics of sexually transmitted HIV in Africa well past their peak growth rates, the fastest-growing HIV epidemics in the world are those linked to drug injection [101].One of the most important determinants of the course of HIV and hepatitis C epidemics and the management of these conditions among people who inject drugs may be the way drug users are treated by police and criminal justice systems. The harms of repressive policing and incarceration as impediments to prevention, treatment, care and support services for people susceptible to injection-linked viruses must be better understood and addressed. Health professionals should be an important voice in advocating law enforcement and criminal justice policies and practices that do not impede access to healthcare and do not violate the rights of people who use drugs.Since the first major UN General Assembly session on HIV in 2001, the community of nations has been committed to increasing access to HIV-prevention services for people who inject drugs, including programs that provide sterile injection equipment and, for people who inject opiates, sustained treatment with medicines such as methadone and buprenorphine, as well as access to other drug-dependence treatment [102]. In spite of this commitment, these services, along with treatment for HIV and HCV, remain inaccessible to the vast majority of people who use illicit drugs in most countries outside the global north, in addition to some parts of the northern countries too [3].The problem here is not ignorance of effective interventions or even, in most cases, cost. Sterile syringe programs and many forms of outpatient treatment of drug dependency, including methadone maintenance, can be provided on a relatively small budget, and their effectiveness has been extensively studied. Rather, policy-makers are failing to address the pernicious depth and breadth of the HIV and HCV risks faced by people who inject illicit drugs, including those linked to criminalization of drug use and possession. It is time to broaden and correct the public health notion of HIV and HCV risks to reflect the reality of the lives of people who inject drugs.The harms of repressive drug policing and incarceration seem to be too little understood or too easily dismissed by policy-makers as determinants of HIV and HCV risk. A vast body of largely qualitative literature attests to the many ways in which harsh laws and repressive policing add to health-related injection risks [4,5]. Paraphernalia laws discourage people from carrying clean syringes and may encourage syringe sharing. Police targeting drug users at syringe programs or treatment facilities to fill arrest quotas can lead people to eschew use of life-saving services. Crackdowns can cause people to inject in remote locations far from health services, or can even lead people who smoke or inhale drugs to inject because the effect is quicker. In one of the few quantitative studies of these phenomena, Strathdee et al. estimated that as many as 29% of new HIV infections could be averted among people who inject drugs in Odessa, Ukraine if police beatings did not traumatize them and impede their use of health services [6].Police forces usually state that their goal is to focus their efforts on major drug kingpins, but minor drug sellers and people whose only 'crime' is drug use are much easier to capture. Once in custody, people who are dependent on drugs are highly vulnerable to police abuse, including being interrogated or coerced into confessions when they are in a state of drug withdrawal [7,8]. A UN official has said that this practice is a form of torture [103].In countries with the harshest drug laws, people who inject drugs are likely to be in pretrial detention or prison at some time in their lives. Being in state custody may be the most important nonmedical determinant of HIV and hepatitis C risk in many countries. Stuckler et al. demonstrated that the rates of incarceration in Eastern Europe and Central Asia are highly correlated with the prevalence of TB and multidrug-resistant TB in the general population [9]. We do not have a similar analysis for HIV or HCV, but it is clear that the risks are high and prevention services few. A number of studies demonstrate the importance of incarceration in interrupting antiretroviral therapy or methadone treatment, and a recent study confirms that incarceration-related interruptions can lead to HIV treatment failure even in people whose viral load was stabilized [8,10].The paucity of HIV and HCV prevention services and effective treatment for drug dependence in prison and remand facilities is a glaring public health problem. People who use illicit drugs are over-represented in detention facilities worldwide. Interior Ministries undo with one hand what Ministries of Health do with the other. Countries should not expect to control their HIV and hepatitis C epidemics without controlling the risks faced by people in the custody of the state and at the mercy of the police.The reality that drug injection takes place in detention facilities is often denied by those in power. Taking a more honest approach, countries such as Switzerland and Spain have virtually eliminated new HIV and HCV transmission in prison by ensuring ready access to clean injection equipment for prisoners [11]. Such measures are not limited to European countries, with Moldova and Kyrgyzstan also implementing needle and syringe programs in prison [11]. This measure also protects guards, who no longer face the risk of being pricked by a contaminated syringe when searching cells or doing pat-downs.Indeed, countries that have made low-threshold or easy-access harm-reduction and addiction-treatment services a priority have had enormous success in reducing HIV and hepatitis C among people who inject drugs. It is a public health crisis that in so many other countries these measures are not even considered. There are, for example, at least 37 countries that offer methadone in the community, but not in prison or pretrial detention [12], or in which possession of sterile injection equipment can be used as grounds for arrest. The political pressure to be 'tough on drugs' makes it easy for politicians to demonize people who use drugs as a social evil and to portray services for them as a waste of public resources. The narrative of 'personal responsibility' and the perpetuation of the idea of drug dependence as moral weakness or a character flaw allow political leaders to espouse bad policies with impunity.In many countries, health professionals may be the only hope for directing policy and program decision-making towards approaches to HIV and HCV that address the risks of policing and incarceration. They can be effective advocates for alternatives to arrest and incarceration for minor drug infractions, and for the expansion of effective health and social services that provide such alternatives. They can promote good-quality, comprehensive HIV and HCV prevention and treatment for people in state custody. Medical and nursing associations and leaders in the field should also work to ensure that health professionals in prisons and remand facilities are able to pursue the best clinical and public health practices in their work without their health judgments being overruled in the name of security.Research on the epidemiological importance of policing and incarceration in HIV and HCV risk and the course of viral epidemics – and conversely, on the positive health impacts of alternatives to incarceration and zero tolerance policies – would be welcome. Some political leaders will not be swayed by any amount of evidence on the urgent need for prevention and treatment services for people who inject drugs, but understanding the full range of risks may help some of those in power to see a reduction in repression as being part of the best medicine for HCV and HIV.Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.Papers of special note have been highlighted as: ▪▪ of considerable interestReferences1 Nelson PK, Mathers BM, Cowie B et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet378(9791),571–583 (2011).Crossref, Medline, Google Scholar2 Strathdee SA, Stockman JK. Epidemiology of HIV among injecting and non-injecting drug users: current trends and implications for interventions. Curr. HIV/AIDS Rep.7(2),99–106 (2010).Crossref, Medline, Google Scholar3 Joint United Nations Programme on HIV/AIDS. Chapter 3. In: UNAIDS Report on the Global AIDS Epidemic 2010. UNAIDS, Geneva, Switzerland (2010).Google Scholar4 Jürgens R, Csete J, Amon JJ, Baral S, Beyrer C. People who use drugs, HIV and human rights. Lancet376(9739),475–485 (2010).▪▪ Summary of a large body of qualitative literature, much of it gathered by human rights organizations, showing how human rights violations undermine access to healthcare for people who use drugs.Crossref, Medline, Google Scholar5 Wolfe D, Cohen J. Human rights and HIV prevention, treatment and care for people who inject drugs: key principles and research needs. J. Acquir. Immune Defic. Syndr.55(Suppl. 1),S56–S62 (2010).Crossref, Medline, Google Scholar6 Strathdee SA, Hallett TB, Bobrova N et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet376(9737),268–284 (2010).▪▪ Notable effort to quantify the impact of police repression with respect to averting HIV transmission.Crossref, Medline, Google Scholar7 Csete J, Cohen J. Health benefits of legal services for criminalized populations: the case of people who use drugs, sex workers and sexual and gender minorities. J. Law Med. Ethics38(4),816–831 (2010).Crossref, Medline, Google Scholar8 Carrieri P, Wolfe D, Roux P. Reconcept-ualizing research on treatment outcomes for criminalized groups. J. Acquir. Immune Defic. Syndr.59(4),329–330 (2012).Crossref, Medline, Google Scholar9 Stuckler D, Basu S, McKee M, King L. Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countries. Proc. Natl Acad. Sci. USA105(36),13280–13285 (2008).▪▪ Insightful consideration of the importance of the statistical relationship between mass incarceration, fueled by harsh drug laws, and the course of TB epidemics.Crossref, Medline, CAS, Google Scholar10 Milloy M-J, Kerr T, Buxton J et al. Social and environmental predictors of plasma HIV RNA rebound among injection drug users treated with antiretroviral therapy. J. Acquir. Immune Defic. Syndr.59(4),393–399 (2012).Crossref, Medline, Google Scholar11 Lines R, Jürgens R, Betteridge G, Stöver H. Taking action to reduce injecting drug-related harms in prisons: the evidence of effectiveness of prison needle exchange in six countries. Intl J. Prisoner Health1(1),49–64 (2005).▪▪ Summary of evaluations of prison-based sterile syringe programs – a neglected intervention – with respect to HIV transmission in six countries.Crossref, Google Scholar12 Larney S, Dolan K. A literature review of international implementation of opioid substitution treatment in prisons: equivalence of care? Eur. Addict. Res.15(2),107–112 (2009).Crossref, Medline, Google Scholar101 World Health Organization European Regional Office. European Action Plan for HIV/AIDS 2012–2015. Copenhagen: World Health Organization. www.euro.who.int/__data/assets/pdf_file/0011/153875/e95953.pdf (Accessed 29 October 2012)Google Scholar102 United Nations General Assembly. Declaration of commitment on HIV/AIDS. UN doc. no. A/RES/S-26/2 (2001). www.un.org/ga/aids/docs/aress262.pdf (Accessed 29 October 2012)Google Scholar103 Nowak M, Open Society Foundation. Treated with Cruelty: Abuses in the Name of Drug Rehabilitation. Introduction. www.opensocietyfoundations.org/sites/default/files/treatedwithcruelty.pdf (Accessed 29 October 2012)Google ScholarFiguresReferencesRelatedDetailsCited ByHuman rights and access to hepatitis C treatment for people who inject drugsInternational Journal of Drug Policy, Vol. 26, No. 11 Vol. 8, No. 2 STAY CONNECTED Metrics History Published online 14 February 2013 Published in print February 2013 Information© Future Medicine LtdKeywordscriminal justicehepatitis CHIVhuman rightspoliceprisonFinancial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download

ObjectiveIn 2010 the international HIV/AIDS community called on countries to take action to prevent HIV transmission among people who inject drugs (PWID). To set a baseline we proposed an “accountability matrix”, focusing upon six countries accounting for half of the global population of PWID: China, Malaysia, Russia, Ukraine, Vietnam and the USA. Two years on, we review progress.DesignWe searched peer-reviewed literature, conducted online searches, and contacted experts for ‘grey’ literature. We limited searches to documents published since December 2009 and used decision rules endorsed in earlier reviews.ResultsPolicy shifts are increasing coverage of key interventions for PWID in China, Malaysia, Vietnam and Ukraine. Increases in PWID receiving antiretroviral treatment (ART) and opioid substitution treatment (OST) in both Vietnam and China, and a shift in Malaysia from a punitive law enforcement approach to evidence-based treatment are promising developments. The USA and Russia have had no advances on PWID access to needle and syringe programmes (NSP), OST or ART. There have also been policy setbacks in these countries, with Russia reaffirming its stance against OST and closing down access to information on methadone, and the USA reinstituting its Congressional ban on Federal funding for NSPs.ConclusionsPrevention of HIV infection and access to HIV treatment for PWID is possible. Whether countries with concentrated epidemics among PWID will meet goals of achieving universal access and eliminating new HIV infections remains unknown. As long as law enforcement responses counter public health responses, health-seeking behaviour and health service delivery will be limited.

Milloy et al make1 a key contribution in understanding the role of 2 environmental factors, involvement in the sex trade and incarceration, in undermining antiretroviral therapy (ART) success among people who use drugs (PWUD). Consistent with previous results,2 the authors also show that receiving methadone treatment during ART significantly improves long-term virological response to ART for those who are opiate dependent. The detrimental effects of criminalization of vulnerable groups on HIV incidence and access to HIV prevention and treatment3,4 are widely acknowledged. The effects of such environmental factors on the continuity of HIV treatment have been less apparent. To date, the most commonly documented environmental barriers to ART effectiveness are those connected to interruptions of supply of antiretroviral treatment (stock outs) and characteristics related to models of HIV treatment delivery.5 Although incarceration as a cause of interruption of ART or methadone treatment has been previously documented,6,7 this study confirms the link between incarceration and ART failure in virologically stabilized patients. Illicit drug use per se was not associated with viral rebound in this study, a finding that requires widening the analytical frame beyond the usual focus on individual behavior and biological markers to the broader causes of ART interruptions and treatment failure among PWUD. For sex workers who use drugs, violence by clients and police harassment are known to be risk factors for HIV acquisition and nonadherence to ART,8–10 with law enforcement crackdowns moving at-risk individuals to hidden or dangerous locations and undermining daily routines critical to antiretroviral treatment intake. The negative effects of violence by police and clients of sex workers may be mutually reinforcing: an earlier Vancouver study showed those sex workers who had experienced violence at the hands of the police to be 3 times more likely to experience client-perpetrated violence and twice as likely to experience client-perpetrated rape.11 In a recent study among injecting drug users in Odessa, Ukraine, police beatings were associated with sharply increased risk of HIV acquisition.4 This study by Milloy et al reminds us that police practices may also be tied to failures of HIV treatment. Incarceration represents a major "biographic split" in the lives of people living with HIV to the detriment of those on antiretroviral therapy. Reduced access to ART11 and forced "treatment interruption"12 are frequent for individuals living in countries where vulnerable groups are criminalized.12,13 Even for those prisoners who eventually receive treatment, length of treatment interruptions may increase prisoner risk of developing antiretroviral resistance.14 With condoms unavailable in many penal settings, coinfection with sexually transmitted diseases may also increase HIV viral load,15 contributing to virological rebound in this population. A common public health strategy is to recast hazard ratios in terms of attributable risk: that is, the fraction of events preventable by eliminating the exposure in question. In this study, the results show that the point and interval estimate of the hazard ratio is 1.83 (1.33–2.52) for recent incarceration. In other words, the attributable fraction for individuals exposed to recent incarceration is 40.0 (17.2–56.8) (estimate provided by Milloy et al for this editorial). This means that among the recently incarcerated IDUs, 40% of cases where viral load rebounded would be eliminated through an approach other than incarceration. If the lower bound of the interval is used, elimination of incarceration might at least have averted around one-fourth of viral rebounds. Analysis of attributable benefit is also possible, with methadone treatment in this study preventing as many as approximately one-fifth of cases of virological rebound. These are findings with major economic and policy implications. The need for more effective and cost-effective approaches is particularly acute in the many countries where PWUD are imprisoned for drug use or possession of drugs for personal use even in the absence of any other crime and in an economic climate where budget difficulties sharply constrain HIV treatment. Overall incidence of viral rebound in this study (approximately 13% per year) is comparable to that reported among injecting drug users by Mocroft et al,16 where viral load rebounded after initial suppression in approximately 9% of patients. These findings by Milloy et al, however, suggest new directions for the interpretation of such percentages and underscore the importance of reexamination of multicohort analyses that have focused primarily on whether individuals used drugs and other individual determinants of HIV treatment outcomes. Share of PWUD incarcerated and experiences of police violence or harassment are only 2 of what should be a robust set of indicators used to characterize policy and health system elements critical to positive HIV treatment outcomes among PWUD. Others might include availability or lack thereof of opiate substitution treatment at HIV and tuberculosis treatment centers, police harassment of methadone or buprenorphine patients and providers, collateral fees required to access either ART or opiate substitution treatment, and presence of policies that implicitly or explicitly ban ART or tuberculosis treatment for those unable or unwilling to abstain from illicit drug use. It is indeed time to start a new ART era, one in which research becomes more helpful in identifying structural and policy changes needed to help health staff and patients achieve optimal HIV treatment. This study by Milloy et al gives us an important lesson about how such research can be done.

In The Lancet, Evgeny Krupitsky and colleagues 1 Krupitsky E Nunes EV Ling W Illeperuma A Gastfriend DR Silverman BL Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011; (published online April 28.)https://doi.org/10.1016/S0140-6736(11)60358-9 Summary Full Text Full Text PDF Scopus (406) Google Scholar report on the use of injectable naltrexone for treatment of opioid dependence. Their report comes some months after the US Food and Drug Administration (FDA) approved use of the preparation for opioid-dependent patients on the basis of the same findings. The study by Krupitsky and colleagues suggests the strong potential of a once-monthly, extended-release formulation of injectable naltrexone for opioid addiction—the median proportion of weeks of confirmed abstinence was 90·0% in the depot naltrexone group compared with 35·0% in the placebo group (treatment effect 55% [95% CI 15·9–76·1], p=0·0002). The study is also striking, however, for the questions it raises about the FDA's approval processes and clinical trial ethics. Factors requiring scrutiny include paucity of efficacy data, adequacy of risk assessment (particularly of overdose risk in treatment dropouts), and the questionable ethics of a placebo-controlled trial when an accepted standard of treatment exists. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trialXR-NTX represents a new treatment option that is distinct from opioid agonist maintenance treatment. XR-NTX in conjunction with psychosocial treatment might improve acceptance of opioid dependence pharmacotherapy and provide a useful treatment option for many patients. Full-Text PDF

We review evidence for effectiveness, cost-effectiveness, and coverage of antiretroviral therapy (ART) for injecting drug users (IDUs) infected with HIV, with particular attention to low-income and middle-income countries. In these countries, nearly half (47%) of all IDUs infected with HIV are in five nations—China, Vietnam, Russia, Ukraine, and Malaysia. In all five countries, IDU access to ART is disproportionately low, and systemic and structural obstacles restrict treatment access. IDUs are 67% of cumulative HIV cases in these countries, but only 25% of those receiving ART. Integration of ART with opioid substitution and tuberculosis treatment, increased peer engagement in treatment delivery, and reform of harmful policies—including police use of drug-user registries, detention of drug users in centres offering no evidence-based treatment, and imprisonment for possession of drugs for personal use—are needed to improve ART coverage of IDUs.

The practice of flashblood, injecting the blood of other heroin users to relieve withdrawal symptoms documented by McCurdy et al. (June 2010) 1, underscores not only the risk of human immunodeficiency virus (HIV) transmission among injecting drug users in East Africa, but also the urgent need for effective opiate substitution treatment. Tanzania is alone in the region in its initiation of methadone treatment for opiate dependence, but the targets for this pilot effort remain far below estimates of need 2. Despite widespread needle sharing and HIV transmission among injecting drug users (IDUs) on the coast and in Nairobi, the Kenyan National Campaign Against Drugs Abuse Authority (NACADA) has raised concerns that needle exchange contradicts official government policy of ‘total abstinence and a drug free lifestyle’, and noted publicly that the ‘benefits of methadone are far outweighed by the risks’ and that Kenya is ‘not in a position to handle methadone substitution therapy’3. Sterile syringe programs remain unavailable anywhere in Africa except Mauritius 4. The US President's Emergency Plan for AIDS Relief (PEPFAR) is legally required to collect data on IDUs assisted by its programs [5, p. 38], and the United States no longer bans federal support for needle exchange programs. Nonetheless, PEPFAR—which supports the Tanzanian methadone pilot—has yet to fund harm reduction measures such as needle exchange and methadone treatment that have been rigorously demonstrated to be effective in HIV prevention 6. Qualitative research of the kind proposed by McCurdy and colleagues on those factors, including flashblood, that increase the vulnerability of women IDUs is indeed important. Similar analysis of the political and structural dynamics shaping the risk environment in East Africa may be equally critical if the aim is removing barriers to effective HIV prevention and treatment. None.

Efforts to provide HIV prevention, treatment, and care to injecting drug users (IDU) are shaped by tensions between approaches that regard IDU as criminals and those regarding drug-dependent individuals as patients deserving treatment and human rights. Advocates for IDU health and human rights find common cause in urging greater attention to legal frameworks, the effects of police abuses, and the need for protections for particularly vulnerable populations including women and those in state custody. Arbitrary detention of drug users, and conditions of pretrial detention, offer examples of how HIV prevention and treatment are adversely impacted by human rights abuse. National commitments to universal access to prevention and treatment for injecting drug users, and the recognition that users of illicit substances do not forfeit their entitlement to health services or human dignity, offer a clear point of convergence for advocates for health and rights, and suggest directions for reform to increase availability of sterile injection equipment, opiate substitution treatment, and antiretroviral therapy. For IDU, protection of rights has particular urgency if universal access to HIV prevention and treatment is to become an achievable reality.

The future of treatment—including addiction treatment—is biotechnological. Depot injections, agonist/antagonist implants, deep brain stimulation, and hapten conjugate vaccines are hailed by researchers and pharmaceutical manufacturers as medicine's best hope to minimize illicit use, to decrease risk of overdose and painful withdrawal, and to prevent diversion of medicines to illicit markets. Marketing and use of new technologies reveal old tensions framing concepts of addiction and its treatment: between medical condition and disorder of the will, between criminal justice and health, and between patient choice and system control. Using the examples of depot naltrexone and implantable and injectable buprenorphine in the U.S., this essay considers the arc of long-acting opioid treatment and implications for the future. These include the rise of Vivitrol courts and “carceral prescription”—where criminal justice systems mandate medicine to lock up brain receptors much as they might lock up people themselves—as well as use of buprenorphine formulations positioned as increasing both patient benefit and provider control. We also consider lessons from debates on long-acting contraceptive technologies such as Norplant and Depo-Provera. While multiple new long-acting formulations are under development, success will be determined less by characteristics of particular formulations and more by whether or not the new technologies are accompanied by a new ethics of addiction treatment that emphasizes therapeutic alliance, concordance over compliance, and a genuine commitment to allowing patients the ability to narrate and be believed in their descriptions of their treatment experiences.

The US President's Emergency Plan for AIDS Relief (PEPFAR) is credited with provision of antiretroviral therapy to 2·1 million people with HIV, almost all of whom live in sub-Saharan Africa, and has spent more than US$18 billion on the continent. 1 US President's Emergency Plan for AIDS Relief (PEPFAR)Celebrating life: latest PEPFAR results. http://www.pepfar.gov/documents/organization/115411.pdfDate: 2008 Google Scholar The achievements of this programme have, unfortunately, not reached thousands of injecting drug users in PEPFAR countries in Africa, many of whom have HIV.