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February 09, 2007

Interferon alpha therapy for hepatitis C: Treatment completion and response rates among patients with substance use disorders

Interferon alpha therapy for hepatitis C: Treatment completion and response rates among patients with substance use disorders

Background: Individuals with substance use disorders (SUDs) are at increased risk for hepatitis C viral infection (HCV), and few studies have explored their treatment responses empirically. The objective of this study was to assess interferon alpha therapy (IFN) completion and response rates among patients with HCV who had a history of comorbid SUDs. More data is needed to inform treatment strategies and guidelines for these patients. Using a medical record database, information was retrospectively collected on 307,437 veterans seen in the Veterans Integrated Service Network 20 (VISN 20) of the Veterans Healthcare Administration (VHA) between 1998 and 2003. For patients treated with any type of IFN (including regular or pegylated IFN) or combination therapy (IFN and ribavirin) who had a known HCV genotype, IFN completion and response rates were compared among patients with a history of SUD (SUD+ Group) and patients without a history of SUD (SUD- Group). Results: Odds ratio analyses revealed that compared with the SUD- Group, the SUD+ Group was equally likely to complete IFN therapy if they had genotypes 2 and 3 (73.1% vs. 68.0%), and if they had genotypes 1 and 4 (39.5% vs. 39.9%). Within the sample of all patients who began IFN therapy, the SUD- and SUD+ groups were similarly likely to achieve an end of treatment response (genotypes 2 and 3, 52.8% vs. 54.3%; genotypes 1 and 4, 24.5% vs. 24.8%) and a sustained viral response (genotypes 2 and 3, 42.6% vs. 41.1%; genotypes 1 and 4: 16.0% vs. 22.3%). Conclusions: Individuals with and without a history of SUD responded to antiviral therapy for HCV at similar rates. Collectively, these findings suggest that patients who have co-morbid SUD and HCV diagnoses can successfully complete a course of antiviral therapy.


February 08, 2007

Limits of care: What events can you prevent?

Limits of care: What events can you prevent?

Jon E. Grant, JD, MD, MPH


Playing SOCA with drug policy?

Playing SOCA with drug policy?

 

SOCA, the new Serious Organised Crime Agency, launched by Tony Blair with some considerable fanfare in April last year seems to be running into problems even before it's first year is up. At the launch The prime minister told us that from now on life would be "hell" for "criminal Mr Bigs", and the previous Home Secretary announced that he was “sending the organised criminal underworld a clear message: be afraid". (Telegraph comment piece)




Blair launches SOCA, promising 'Hell' for 'Mr Big'


But two reports on Channel Four News last week suggested that any honeymoon period is well and truly over, and that Mr Big may not be quite as afraid as was hoped. So what's it all about and why have things apparently gone pear shaped so quickly? The news reports, which included interviews with disgruntled SOCA staff and various leaked emails, suggested bureaucracy and management issues, low morale and 'loopholes' that meant large numbers of drug seizures were not being followed up, attracting the ire of Police Federation amongst others.

But the problem with SOCA (I am only talking about the drugs side of their work here) is not primarily and internal one of incompetence or organisational strategy. The real problem is because of the terrible truth: the better SOCA do their job, the worse things will get. Supply side drug controls do not and cannot prevent drugs from reaching markets where sufficient demand exists. The best they can achieve is to further inflate drug prices, driving low income problematic users into ever larger volumes of offending to support their habits and attracting ever more violent criminals to control the profits offered up by prohbition. As we shall see, this is no secret to ministers.

SOCA was established last April following a merger of the National Crime Squad, the National Criminal Intelligence Service, and sections of HM Revenue and Customs (HMRC) and the Immigration Service. The new entity has a £400+ million a year budget, and organised crime involvement with the drugs is the most significant focus of their work. According the SOCA website:

Trafficking in heroin and cocaine, particularly crack cocaine, poses the greatest single threat to the UK in terms of the scale of serious organised criminal involvement, the illegal proceeds secured and the overall harm caused.

Home Office estimates put the harm caused by Class A drugs at around £13bn a year. This largely arises from the profits from sales, the crimes addicts commit to fund their habit, and the damage caused to family life and communities, as well as from costs to addicts' health
.

As a brief aside, the above isn't a summary of the information of the SOCA's drug related activities on their website – that's all of it.

Anyway, if the organisation seems to be running into trouble this certainly isn't the fault of its core staff – many of whom, according to the Times, are apparently now trying to leave because of the organisational malaise and a desire to do some real hands on police work. I have met SOCA staff at various conferences and seminars and their professionalism and commitment to tackling organised crime isn't in question.

No, if there is a problem it is primarily the politics behind the organisation, that casts a shadow over everything it does. The backdrop to the establishment of SOCA is a 10 year drug strategy that, as it approaches its end, has failed in quite spectacular style to achieve its targets on reducing Class A drug supply and use (remember that 50% reduction in class A drug use/availability by 2008?). This failure is combined with a political climate of macho law and order posturing and one-up-manship between the major political parties, characterised by tough talking rhetoric that is heavily dictated by a tabloid agenda.

Drug policy under this Government (and to be fair, previous ones aswell) has been dominated by politics, remaining, for the most part, resolutely un-bothered by rational evidence based policy making. As drug supply, drug use, drug crime, and overall drug harm have continued to rise, the Government, rather than consider a change of approach or progressive policy alternatives, has defaulted to tough talking spin and bluster:

'Tough' new targets are announced as the old ones are missed and quietly retired, usually made as part of an updated strategy, from a newly re-named Drug Strategy Unit/Directorate/Wotsit, after a relocation to a new ministry, or by a tough new 'bruiser' Home Secretary – because obviously that's going to make a massive difference.

'Tough' new legislation is passed, like 2005's ill-thought out Drugs Act, which no-one in the drugs field wanted or asked for (the only welcome clause being the repeal of reforms to section 8 of the MDA, from the Government's previous ill thought out get-tough (sp)initiative). Much of it – like clause 2 of the Drugs Act – is never likely to be commenced because it is frankly a load of rubbish. I use the term advisedly as the biggest Drugs Act nerd on the planet outside of the poor unfortunates at the Home Office who had to draft it.

'Tough' announcements that grab a few headlines but never actually come to fruition because they are impractical, unethical, or occasionally illegal. Consider for example random drug testing in schools (announced in a Tony Blair exclusive interview in the News of the World), or the equally idiotic drugs sniffer dogs in schools, both going the same way (nowhere) as mandatory minimums, three strikes you're out, and all that other disastrous US-style 'war on drugs' nonsense.

'Tough' new appointments are made – The Drug Czar, a tough cop who looks a bit like Jack Palance, modelled on his ass-kickin' US counterpart, who is then unceremoniously dumped a couple of years later - a straw man for a doomed enforcement-led drug strategy he had no hope of salvaging.

And on and on it goes. There's a pattern here. Drug policy has been all about the big announcements, the new stuff – the process. Its all about the future, about turning the corner, about the upcoming breakthrough, about being tough. Its never about the outcomes.

For the simple reason – obvious to anyone not in a sensory deprivation tank for the past decade - that the outcomes are all dreadful.

Worse than dreadful – they are the opposite of what they were supposed to be. Class A drug use, (in particular the problematic kind that we should genuinely be concerned about), has gone up since 1997. A lot – including the crack 'epidemic' that all that toughness manifestly failed to prevent. Drugs are cheaper and more available than they have ever been. By a considerable margin. Attempts to control drug supply are a joke, and a pretty poor return on the £20 billion or so that has been hosed into drug policy enforcement over the past decade. And let us not forget that of the £13 billion a year of drug related harm that SOCA mentions on its otherwise totally un-infomative website, 88% of which is crime costs, and 95% of that being crime committed by addicts to support their habits. ie created by enforcement. ie costs of prohibition.

So come 2002 and Tony Blair is looking down the barrel of a drug policy disaster, a ten year strategy dramatically not doing what is was supposed to, and various groups including the Police Foundation and the Home Affairs Select Committee pointing out this fact very eloquently and publicly. At this point he called upon the top boys from his personal policy think tank – the Number Ten Strategy Unit – and they produced a devastating 114 page analysis of UK drug policy that shows with crystal clarity that supply side enforcement cannot ever work and actually creates huge collateral damage in the form of that £13billion or so a year in crime costs (they actually put it at £16 billion).

The No 10 report (presented to ministers and then supressed until FOI pressure and leaks brought it into the public domain) notes that:

“UK importers and suppliers make enough profit to absorb the modest cost of drug seizures” (p.82)

“The long term decline in the real price of drugs, against a backdrop of rising consumption, indicates that an ample supply of heroin and cocaine has been reaching the UK market”(p.80)

“Despite seizures, real prices for heroin and cocaine in the UK have halved over the last ten years”(p.91)

“Over the past 10-15 years, despite interventions at every point in the supply chain, cocaine and heroin consumption has been rising, prices falling and drugs have continued to reach users. Government interventions against the drug business are a cost of business, rather than a substantive threat to the industry's viability.” (p.94)


The report goes on to demonstrate how this crime will always be created by the underlying economics of the completely deregulated illegal drug market. When increasing numbers of users have to pay street prices grossly inflated by prohibition, the exploding levels of crime described in the report are inevitable:

“The high profitability of the drugs business is derived from a premium for taking on risk, as well as from the willingness of drug users to pay high prices” (p.66)

“profit margins for traffickers can be even higher than those of luxury goods companies” – (cites Gucci as an example) (p.69)


The report then shows that even if supply side interventions (exactly what SOCA are now involved in) were more successful, the result would be increased prices that could force addicts to commit more crime to support their habits.

“There is no evidence to suggest that law enforcement can create such droughts” (p.102
)

[but even if they could…..]

“price increases may even increase overall harm, as determined users commit more crime to fund their habit and more than offset the reduction in crime from lapsed users”(p.99)

John Birt, 'blue skies' thinker and drug policy non-expert, then took that analysis and, in phase two of the Strategy Unit report, tried to come up with some sensible policy responses. Ignoring the analysis that enforcement was counter-productive and creating many of the very problems it was intended to eliminate (presumably because to not ignore it took policy in a direction he found politically unpalatable), he instead devised a repressive programme for shovelling ever greater numbers of drug using offenders into enforced abstinence-based 'treatment' as a way of reducing drug related crime (which formed the basis of the non-sensible Drugs Act 2005).

But no one really thought this was going to be the magic bullet, not even Birt, and besides, treatment isn't much of political crowd pleaser. And so it seemed the stage was set for some more tough new initiatives – yet more process announcements that would delay the reckoning a bit longer. This time though they needed something really big and seriously tough: we obviously needed our very own FBI. And that was what we got, £400million a year's worth, complete with its own futuristic new logo, featuring a big scary cat with mean looking claws striding the globe.




SOCA logo





The Eye of Thundera - Thundercats insignia

So whether SOCA is functioning better or worse than the various agencies it replaces isn't really the point (that really is just a process consideration). If anything the worse they perform the better. But even if SOCA was running like a well oiled military machine, arresting baddies like there was no tommorow (and the 'Mr Bigs' thought the daft thundercats logo was really intimidating), it still wouldn't save them from inevitable failure because however you dress it up, supply enforcement doesn't work, it just makes things worse. Drug seizures, however dramatic, don't stop drugs reaching their markets and arresting violent drug dealing hoodlums and smashing drug crime syndicates just creates a vacancy for the next generation of gangsters, all to keen to make a killing from prohibition. SOCA is an organisation whose drugs brief is set up to fail, and that must be pretty demoralising.


Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City

Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City

Background: Fatal heroin overdose is a significant cause of mortality for injection drug users (IDUs). Many of these deaths are preventable because opiate overdoses can be quickly and safely reversed through the injection of Naloxone [brand name Narcan], a prescription drug used to revive persons who have overdosed on heroin or other opioids. Currently, in several cities in the United States, drug users are being trained in naloxone administration and given naloxone for immediate and successful reversals of opiate overdoses. There has been very little formal description of the challenges faced in the development and implementation of large-scale IDU naloxone administration training and distribution programs and the lessons learned during this process. Methods: During a one year period, over 1,000 participants were trained in SKOOP (Skills and Knowledge on Opiate Prevention) and received a prescription for naloxone by a medical doctor on site at a syringe exchange program (SEP) in New York City. Participants in SKOOP were over the age of 18, current participants of SEPs, and current or former drug users. We present details about program design and lessons learned during the development and implementation of SKOOP. Lessons learned described in the manuscript are collectively articulated by the evaluators and implementers of the project. Results: There were six primary challenges and lessons learned in developing, implementing, and evaluating SKOOP. These include a) political climate surrounding naloxone distribution; b) extant prescription drug laws; c) initial low levels of recruitment into the program; d) development of participant appropriate training methodology; e) challenges in the design of a suitable formal evaluation; and f) evolution of program response to naloxone. Conclusions: Other naloxone distribution programs may anticipate similar challenges to SKOOP and we identify mechanisms to address them. Strategies include being flexible in program planning and implementation, developing evaluation instruments for feasibility and simplicity, and responding to and incorporating feedback from participants.


Excessive Drinking, Not Alcoholism, May Lead To Most Alcohol-Related Problems

Excessive Drinking, Not Alcoholism, May Lead To Most Alcohol-Related Problems

* Many people assume that most people who drink to excess are probably alcoholics. * A recent survey of 4,761 New Mexico adults found that while 16.5 percent drank alcohol in excess of national guidelines, only 1.8 percent met criteria for alcohol dependence. * This suggests that a majority of persons at risk for alcohol-related problems are not alcohol dependent. [click link for full article]


ALCOHOL POLICY: WHO SHOULD SIT AT THE TABLE?

ALCOHOL POLICY: WHO SHOULD SIT AT THE TABLE?

'Moral panic' threat to children of drug addicts

'Moral panic' threat to children of drug addicts

HUNDREDS of children whose parents are drug addicts face the risk of being taken into care because of a "moral panic" over the issue, Scotland's drug and alcohol tsar has warned.


What five cigarettes a day does to your arteries

What five cigarettes a day does to your arteries

A new scan at the University College London is showing the damage that a five-a-day cigarette habit can do to an otherwise healthy person's arteries. Here KATHRYN KNIGHT tries it out