targeted primary healthcare for injecting drug users: client characteristics, service utilisation...

8/19/2019 Targeted primary healthcare for injecting drug users: client characteristics, service utilisation and incremental cost, by Dr Md Mofizul Islam

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Targeted primary healthcare forinjecting drug users: client

characteristics, service utilisation

and incremental cost

Md. Mofizul Islam, MSc, MPhil

A thesis submitted in accordance with the


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DECLARATION OF ORIGINALITYI hereby declare that this submission is my own work and to the best of my

knowledge it contains no materials previously published or written by

another person, or substantial proportions of material which have been

accepted for the award of any other degree or diploma at UNSW or any

other educational institution, except where due acknowledgement is made

in the thesis. Any contribution made to the research by others, with whom I

have worked at UNSW or elsewhere, is explicitly acknowledged in the

thesis. I also declare that the intellectual content of this thesis is the product

of my own work, except to the extent that assistance from others in the

project's design and conception or in style, presentation and linguistic

expression is acknowledged.


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ABSTRACTInjecting drug users (IDUs) experience a range of health problems. Access to primary

healthcare (PHC) is nevertheless often limited for this marginalised group. Many seek

care at emergency departments and some require hospital admission due to late

presentation. Consequently in some settings IDU-targeted PHC services were

introduced to offer low-threshold services. However, few such services have undergone

evaluation, and thus limited data are available to inform health service planning.

This thesis overviews IDUs’ barriers to healthcare access (Chapter 2), reviews

operational models of IDU-targeted PHC services (Chapter 3) and, using a case study

approach, evaluates the Redfern Harm Minimisation Clinic (RHMC), a needle and

syringe program (NSP)-based PHC in inner-city Sydney, to determine whether this

service attracts its intended clientele and documents clients’ reasons for presentation

and service utilisation (Chapter 4).

The prevention and management of the hepatitis C virus (HCV), is a key goal of the

RHMC. Chapter 5 examines the patterns of referral uptake and subsequent antiviral


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PHC, and highlight the potential of these services to facilitate reductions in liver disease

burden among IDUs. Adoption of a universal precautionary approach to complement

tailored assessment of health risk behaviours is recommended to reduce social stigma

among this group. It is crucial that services are offered with adequate quality and

quantity with minimum cost and a high throughput is necessary to achieve the latter.

This research has limitations and findings should be interpreted cautiously, particularly

in the context of developing countries. Nevertheless, findings suggest ongoing need for

these services until conventional healthcare facilities evolve to offer acceptable and

accessible environments.


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ACKNOWLEDGEMENTSI thank University of New South Wales for providing me with a University International

Postgraduate Award (UIPA), without which I would not have been able to carry out this

research. I would like to express special debt of gratitude to my supervisors Associate

Professor Carolyn Day, Dr Libby Topp and Professor Kate Conigrave for their valuable

guidance on the research throughout my candidature. It has been a great privilege to learn

from a team of supervisors with versatile qualities, to receive outstanding motivation,

intellectual input and essential guidance throughout the course of my research.

Implementation of a PhD research project, which is unfunded and about contentious public

health intervention, is an extremely difficult task. There were many unforseen barriers

including access to required information and quality and quantity of available data. On a

number of occasions I thought this project was never going to be completed. The

uncertainty prompted me to keep Dr Day busy right from the day one. I am indebted to Dr

Day for her patience and dynamic leadership which kept me moving forward. A substantial

part of the credit goes to Dr Day, who may remember me as one of the most demanding

students.

I was extremely fortunate to have Dr Topp in the supervisory team. Her love and affection


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throughout. I will be delighted if her belief about the potentials of my research in bringing

fortunes for her clinic comes true.

I am grateful to the Drug Health Service of Sydney Local Health District for allowing me to

carry out this research into RHMC, and giving me ancillary support. Very special thanks to

Prof Paul Haber for being supportive throughout my candidature. I thank all the staff

especially Stephen Hayes and Sara Grummett of RHMC, Ms Sarah Hutchinson and Lucia

Evangelista of Drug Health Service at the Royal Prince Alfred Hospital for their support. I

also gratefully acknowledge all the co-authors of papers arising from or supporting this

thesis, especially Dr Angela Dawson and Dr Ingrid van Beek.

I thank Dr Topp, A/Professor Day and Professor Lisa Maher for giving me opportunities of

working with the people who inject drugs, and of getting close to those whose healthcare is

the centre point of this thesis. In addition to all the academic stimulation, the material

support I received particularly from Dr Topp, Dr Day and Prof Haber was crucial for me

and my family here in Australia.

During the last three and a half years I learnt many things and experienced many

circumstances which I was unfamiliar with. Undoubtedly these experiences helped me

embrace reality. Doctoral research for a highly motivated overseas student with inherent

t b li f b t li it d l k i ith t ld ff i h i i


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TABLE OF CONTENTSDECLARATION OF ORIGINALITY ......................................................................... II

ABSTRACT ................................................................................................................... III

ACKNOWLEDGEMENTS ............................................................................................ V

TABLE OF CONTENTS ............................................................................................. VII

LIST OF TABLES ....................................................................................................... XIIi

LIST OF FIGURES .....................................................................................................XIV

ABBREVIATIONS ....................................................................................................... XV

CHAPTER 1: INTRODUCTION ................................................................................... 1

CHAPTER 2: . INJECTING DRUG USERS’ COMMON HEALTH PROBLEMS,BARRIERS TO HEALTHCARE ACCESS AND THE CONTEXTOF TARGETED HEALTHCARE ......................................................... 8

2.1 INJECTING DRUG USE AND ASSOCIATED HEALTH PROBLEMS................ 9

2.1.1 PREVALENCE OF INJECTING DRUG USE ........................................................ 9

2.1.2 I NJURIES AND INFECTIONS DIRECTLY RELATED TO INJECTING ................. 10

2.1.3 OTHER INFECTIOUS DISEASES .................................................................... 21


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CHAPTER 3: PRIMARY HEALTHCARE SERVICES THAT TARGET

INJECTING DRUG USERS: A NARRATIVE SYNTHESIS OFLITERATURE ........................................................................................ 46

3.1 METHODS .................................................................................................. 47

3.2 RESULTS .................................................................................................. 52

3.2.1 OPERATIONAL MODELS ............................................................................. 52

3.2.2 ACCESSIBILITY AND ACCEPTABILITY OF IDU-TARGETED PHC ............... 58

3.2.3 IMPACTS ON HEALTH OUTCOMES .............................................................. 64

3.2.4 COST IMPLICATIONS .................................................................................. 66

3.2.5 OPERATIONAL CHALLENGES ..................................................................... 67

3.3 DISCUSSION ............................................................................................... 68

3.3.1 LIMITATIONS .............................................................................................. 72

3.4 CONCLUSION............................................................................................. 74

CHAPTER 4: CLIENT CHARACTERISTICS AND SERVICEUTILISATION OF A LOW-THRESHOLD PRIMARYHEALTHCARE CENTRE BASED AT AN INNER-CITYNEEDLE SYRINGE PROGRAM ...................................................... 76

4 1 METHOD 81


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4.2.5 COMPARISON BETWEEN IDUS ACCESSING RHMC AND BROADER

SAMPLES OF IDUS...................................................................................... 89

4.2.6 MAIN REASONS FOR PRESENTATION.......................................................... 89

4.2.7 SERVICE UPTAKE AND REFERRAL .............................................................. 89

4.2.8 THE ROLE OF RHMC IN PROVIDING OPPORTUNISTIC HEALTHCARE ........ 93

4.3 DISCUSSION ............................................................................................... 98

4.3.1 PATTERNS OF DRUG USE .......................................................................... 100

4.3.2 COMPARISON BETWEEN IDUS ACCESSING RHMC AND ANSPS

PARTICIPANTS .......................................................................................... 100

4.3.3 R EFERRAL UPTAKE .................................................................................. 102

4.3.4 LIMITATIONS ............................................................................................ 104

4.4 CONCLUSION........................................................................................... 105

CHAPTER 5: ROLE OF RHMC IN HEPATITIS C TREATMENTASSESSMENT AND ANTIVIRAL TREATMENTCOMMENCEMENT .......................................................................... 107

5 1 METHOD 108


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5.3.2 CHARACTERISTICS OF TREATMENT INITIATORS ...................................... 122

5.3.3 LIMITATIONS ............................................................................................ 124

5.4 CONCLUSION........................................................................................... 125

CHAPTER 6: THE RELIABILITY OF SENSITIVE INFORMATIONPROVIDED BY INJECTING DRUG USERS IN A CLINICALSETTING OF TARGETED HEALTHCARE: WHATSTRATEGIES TO BE FOLLOWED? ............................................. 127

6.1 METHOD .................................................................................................. 130

6.1.1 ELIGIBILITY CRITERIA.............................................................................. 130

6.1.2 PROCEDURE ............................................................................................. 131

6.1.3 CONSENT AND ETHICS ............................................................................. 133

6.1.4 DATA ANALYSIS ....................................................................................... 133

6.2 RESULTS .................................................................................................. 134

6.3 DISCUSSION ............................................................................................. 140

6.3.1 LIMITATIONS ............................................................................................ 143

6.4 CONCLUSION........................................................................................... 144


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CHAPTER 8: GENERAL DISCUSSION ................................................................. 164

8.1 OVERVIEW OF MAIN FINDINGS .............................................................. 164

8.2 ACCESSIBILITY AND ACCEPTABILITY OF TARGETED SERVICES ......... 166

8.3 THE ROLE OF RHMC IN PREVENTION AND REDUCTION OF LIVER

DISEASE ................................................................................................... 170

8.4 UNIVERSAL HEALTH INSURANCE IS IMPORTANT BUT NOT SUFFICIENT

................................................................................................................. 170

8.5 SERVICE UTILISATION IN DIFFERENT SETTINGS .................................. 172

8.6 IMPLICATIONS OF THE FINDINGS AND FUTURE RESEARCH ................. 175

8.7 GENERALISABILITY OF THE RESEARCH ............................................... 178

8.8 LIMITATIONS .......................................................................................... 182

8.9 CONCLUSION........................................................................................... 183

REFERENCES .............................................................................................................. 185

APPENDIX I: PRISMA CHECKLIST ............................................................................ 236

APPENDIX II: RESEARCH PROJECTS UNDERTAKEN AS PART OF THE CANDIDATURE240

APPENDIX III: LIST OF PUBLICATIONS ARISING FROM AND SUPPORTING THIS THESIS

................................................................................................................. 242


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LIST OF TABLES

TABLE 2.1 COMMON HEALTH PROBLEMS ASSOCIATED WITH INJECTING DRUG USE .. 11

TABLE 2.2 COMMON BARRIERS TO ACCESS TO HEALTHCARE BY IDUS ..................... 36

TABLE 3.1 TABLE STATING THE CRITERIA OF LITERATURE SUITABLE FORA NARRATIVE SYNTHESIS .......................................................................... 50

TABLE 3.2 SERVICES PROVIDED, STAFFING AND REPORTED ACCESSIBILITY AND

ACCEPTABILITY OF PRIMARY HEALTHCARE FACILITIES FOR IDUS .......... 55

TABLE 3.3 K EY THEMES ASSOCIATED WITH ACCESSIBILITY, ACCEPTABILITY AND

OPERATIONAL PROBLEMS OF IDU-TARGETED PHC FACILITIES ............... 61

TABLE 4.1 PATTERNS OF SUBSTANCE USE BY CLIENTS OF RHMC IN THE

PRECEDING 12 MONTHS ( N=363) ............................................................... 86

TABLE 4.2 CORRELATES OF ACCESS TO GP SERVICES AMONG 359 RHMC CLIENTS 88

TABLE 4.3 COMPARISON BETWEEN RHMC ATTENDEES AND NSW ANSPS

PARTICIPANTS 2006-2009 ......................................................................... 91


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TABLE 6.2 DEMOGRAPHIC CHARACTERISTICS OF 173 PARTICIPANTS AND

RELATIONSHIP TO DISCORDANCE IN RESPONSES TO SENSITIVE

QUESTIONS ............................................................................................... 135

TABLE 6.3 COMPARISON OF RESPONSES PROVIDED IN ACASI AND FFI

TO BINARY ITEMS ..................................................................................... 138

TABLE 6.4 COMPARISON OF RESPONSES PROVIDED IN ACASI AND FFI

TO NON-BINARY ITEMS ............................................................................ 139

TABLE 7.1 ESTIMATED INCREMENTAL COST OF ADDING A PHC SERVICE TO AN

EXISTING NSP, 2009-10, AU$ (2009) .................................................... 154

TABLE 7.2 CURRENT AND PROJECTED AVERAGE COST PER OCCASION OF SERVICE

PROVIDED BY THE RHMC CLINIC (AU$) ................................................ 156

TABLE 7.3 ESTIMATED COST FOR 2009-10 WITH VARIATION OF RELEVANT

PARAMETERS............................................................................................ 158


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LIST OF FIGURES

FIGURE 3.1 PREFERRED R EPORTING DIAGRAM FOR SYSTEMATIC R EVIEWS AND

META-ANALYSES (PRISMA) SHOWING SELECTION OF

PUBLICATIONS FOR REVIEW ...................................................................... 48

FIGURE 5.1 FLOWCHART OF THE REFERRAL PATHWAYS FOR HCV POSITIVE

CLIENTS AT THE RHMC .......................................................................... 110

FIGURE 5.2 FLOWCHART OF DIAGNOSIS, REFERRAL AND TREATMENT PATHWAYS

FOR ALL CLIENTS...................................................................................... 116

FIGURE 7.1 TREND OF AVERAGE COST PER OCCASION OF SERVICE AS ATTENDANCE

INCREASES UP TO FULL UTILISATION LEVEL ........................................... 158


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ABBREVIATIONS

ACASI Audio Computer-assisted Self-Interviewing

AIDS Acquired Immune Deficiency Syndrome

ALT Alanine Transaminase

ANSPS Australian Needle and Syringe Program Survey

AOR Adjusted Odds Ratios

AU$ Australian Dollar

AVT Antiviral Treatment

BBVIs Blood borne Viral Infections

CDC Centres for Disease Control

CI Confidence Intervals

CNC Clinical Nurse Consultant

DSM Diagnostic and Statistical Manual of Mental DisordersED Emergency Department

EMCDDA European Monitoring Centre for Drugs and Drug Addiction

FFI Face-to-face Interview


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MMT Methadone Maintenance Therapy

MO Medical Officer

MSIC Medically Supervised Injecting Centres

NIDU Non-injecting Drug User

NSP Needle Syringe Program

NSW New South Wales

OST Opioid Substitution Therapy

PCR Polymerase Chain Reaction

PHC Primary Health Care

RHMC Redfern Harm Minimisation Clinic

RN Registered Nurse

RPAH Royal Prince Alfred Hospital

SD Standard Deviation

STI Sexually Transmitted Infections

SVR Sustained Virological Response

TB Tuberculosis

USA United States of America

WHO World Health Organization


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Chapter 1

CHAPTER 1: Introduction

Injecting drug users (IDUs) experience a wide range of health problems (Darke &

Ross, 1997; Stein, 1999; Haber, et al., 2009; Latt, et al., 2009). Although most of

these health problems are preventable and/or treatable in primary healthcare settings,

access to primary healthcare (PHC) is often limited for this marginalised group.

Many seek care at emergency departments (EDs) and some require hospital

admission due to late presentation. Barriers to healthcare, subsequent poor health

outcomes and the considerable costs of emergency treatments have led authorities in

some settings to establish IDU-targeted PHC services, using a number of models.

These are “low-threshold” services and facilitate PHC provision by removing many

of the barriers faced by IDUs when accessing conventional health services. For

instance, unlike conventional settings, low-threshold facilities do not impose

abstinence from drug use as a condition of service access; and clients do not need to

set an appointment or produce identification Services can be provided on a drop in


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Chapter 1

effectiveness of these services, however, may minimise concerns, and favourable

outcomes may help secure necessary funding for maintaining and/or extending these

services.

To understand the context in which targeted services have been implemented, it is

necessary to assess IDUs’ common health problems and barriers to their access to

healthcare and the consequences of late presentation to healthcare. Chapter 2

therefore describes the health problems commonly experienced by IDUs that are

directly and indirectly related to injecting drug use; barriers to accessing

conventional healthcare services experienced by IDUs; and the rationale for the

introduction of targeted primary healthcare.

The specific model of targeted PHC services chosen in a given setting will be

influenced by factors ranging from the socio-demographic characteristics of the

target group to the class, form and availability of their preferred drug(s). Such


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Chapter 1

respect to their impact on health outcomes, cost implications and operational

challenges.

A useful complement to the synthesis of the review would be studying a specific

targeted service. Such an empirical study is likely to provide detailed information on

client characteristics and service utilisation. However, to rigorously evaluate the

effectiveness of such a service using the hierarchy of evidence commonly applied to

health and medical interventions is methodologically challenging (van Beek, 2012).

For instance, a randomised controlled trial (RCT) – the “gold standard” in evaluation

– is often not possible due to ethical and pragmatic concerns (Sanson-Fisher,

Bonevski, Green, & D'Este, 2007). Other evaluation designs such as cluster RCTs or

multiple baseline design require numerous services operating with identical or very

similar models of care and thus substantial funding for their establishment. No such

trials have been conducted to date. Key questions can, however, be answered using a

case-study approach. Firstly, are such services accessed by the target group they are

designed for? Attracting the target group is a fundamental step, and therefore a


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Chapter 1

Standalone targeted PHC services in red-light districts attract clients by their

convenient locations and/or offering light refreshments. Thus it is appropriate to

examine whether such a service ensures situational availability and opportunistic

healthcare.

Although the assessments outlined above do not provide a firm foundation for a

rigorous outcome evaluation, they are necessary first steps in amassing a preliminary

evidence base which can be used in the absence of “hard” evidence, and indeed may

facilitate the development of hard evidence. Consequently a retrospective study of a

targeted PHC, the Redfern Harm Minimisation Clinic (RHMC), an NSP-based PHC

in inner-city Sydney, is presented in Chapter 4. This study examines whether this

targeted service attracts and retains the clients for which it was designed, and

documents clients’ reasons for presentation. The Chapter also documents the

preventative and other healthcare services provided and investigates uptake of

referrals made to other health and social services.


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Chapter 1

(AVT) among IDUs (Grebely et al., 2008). Targeted healthcare services are a

strategically important point of contact for HCV prevention and management. Indeed

in settings such as Australia HCV prevention is a key goal of the NSP services where

targeted PHC services are co-located. Although there are notable exceptions (van

Beek, 2007), the specialised nature of HCV treatment often precludes the provision

of HCV treatment directly through such services. Targeted PHC services

nevertheless play an important role in engaging IDUs and referring them to HCV

treatment facilities. Thus it is important to examine the efforts and achievements of

these services with respect to that goal. Chapter 5 examines the patterns andcorrelates of uptake of referrals made for RHMC clients to a tertiary liver clinic and

subsequent AVT initiation.

Injecting drug use is a highly stigmatised activity (Simmonds & Coomber, 2009).

The chaotic lifestyles often associated with illicit drug use, burden of HCV and other

infectious diseases and related discrimination result in a heightened level of social

ti f IDU Thi ti t t ti l b i t IDU ’ t


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Chapter 1

for reducing this bias, including detection, measurement and adjustment for social

desirability effects, randomised response techniques, self-interviewing methods and

indirect questioning (Nederhof, 1985). However, the degree of social desirability

bias has not been measured in the clinical environment of a targeted PHC setting.

Chapter 6 examines the extent of socially desirable responses reported by IDUs

accessing services from two targeted PHC services by comparing their self-reported

information about drug and sexual risk taking elicited via clinical face-to-face

interview and by audio computer assisted self-interviewing (ACASI) methods.

Cost is a fundamental consideration in any evaluation and crucial to any agency

wishing to introduce new services. Indeed, the long-term sustainability of any

healthcare service is dependent upon the resources required. Although a cost

effectiveness analysis would be the most appropriate tool to evaluate the economic

implications of targeted healthcare services, there are substantial methodological

challenges as different services attract different subgroups of clients. There is

tl i f ti il bl th t f t d PHC i th t


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Chapter 1

Finally, the findings of this research and their public health implications are

discussed in Chapter 8. The limitations of the research, its generalisability to other

settings and further research directions are also outlined.

In summary, this thesis reviews operational models of IDU-targeted PHC services

and, using a case study approach, evaluates the RHMC, an IDU-targeted PHC

service located in inner-city Sydney, in terms of accessibility and acceptability of

these services to the target population, cost implications and operational challenges.

Results have important public health implications for PHC delivery and service

improvement for IDUs, and these implications are discussed for various settings.


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Chapter 2

CHAPTER 2 Injecting drug users’ common health problems, barriers to healthcare access and the context oftargeted healthcare

IDUs are at risk of a wide range of health problems arising from non-sterile injecting

practices, complications of the drug itself or of the lifestyle associated with illicit

drug use and dependence (Darke & Ross, 1997; Haber, Demirkol, Lange, &

Murnion, 2009; Latt, Conigrave, Saunders, Marshall, & Nutt, 2009; Stein, 1999). In

addition to complications of drug injection, unrelated health problems, such as

diabetes, may be neglected due to preoccupation with the drug of dependence.

However, despite this high need, for a variety of reasons IDUs are reluctant to access

conventional health and social services (Day, Ross, et al., 2003; French, McGeary,

Chitwood, & McCoy, 2000; Morrison, Elliott, & Gruer, 1997). Many IDUs,

particularly younger people, dislike being identified as drug users (Islam, Stern,


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Chapter 2

emergency departments (ED) and hospitals consequently creates additional pressure

on limited healthcare budgets (French et al., 2000).

To better understand this phenomenon this chapter describes: i) the health problems

IDUs may experience that are directly and indirectly related to injecting drug use; ii)

the barriers to accessing conventional healthcare services experienced by IDUs; and

iii) the rationale for the introduction of targeted PHC services.

2.1 Injecting drug use and associated health

problems

2.1.1 Prevalence of injecting drug use

Injecting drug use is well established throughout the world and appears to be

emerging in many countries where it has previously been unreported (UNAIDS,

2009). By 2008, injecting drug use had been reported in 148 countries and territories


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Chapter 2

2.1.2 Injuries and infections directly related to injecting

Injecting-related injuries

IDUs suffer high levels of morbidity and mortality arising from injecting practices

(both sterile and non-sterile); complications of the drug itself or of the lifestyle

associated with illicit drug use and dependence (Table 2.1); and/or unrelated health

problems that may be neglected due to a preoccupation with drug use (Latt et al.,

2009). Injecting is the most harmful route of illicit drug administration. Indeed, poor

injecting practices can lead to a number of injuries. Repeated injecting at the same

site, injecting with a barbed or blunt needle, injecting without having venous access

or inadvertent arterial injection are practices which potentially cause injury (Dwyer

et al., 2009; Salmon et al., 2009; Topp, Iversen, Conroy, Salmon, & Maher, 2008).

However, most of the studies investigating this issue are of cross-sectional design,

and rely on self-reported information from the IDUs (Hope, 2010). Repeated

injecting into the same site may cause local ischemia or necrosis and the tissue may


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Chapter 2

Table 2.1 Common health problems associated with injecting drug use

Injuries and infections directly related to injecting

Injecting-related injuries • Bruising

• Scarring

• Swelling and inflammation including urticaria

• Venous injury

• Arterial injury

• Ulcers

Injecting-related infections andcomplications

• Cellulitis and abscess

• Thrombophlebitis

• Bacteraemia and septicaemia

• Musculoskeletal infections

• Endovascular complications•

-

Blood-borne virus • Viral hepatitis (hepatitis B and C)

• HIV/AIDS

Other infectious diseases

Sexually transmitted infections • Sexually transmitted infections

Respiratory infections • Respiratory tract infections

• Tuberculosis (TB)


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Chapter 2

Injecting-related infections and complications

There are numerous injecting-related infections, but few clinically validated studies

of such infections (Binswanger, Kral, Bluthenthal, Rybold, & Edlin, 2000; Lloyd-

Smith et al., 2008). Cellulitis and skin abscesses are common injecting-related

infections and often co-occur (Stein, 1999; World Health Organization, 2009).

Microbiological studies of soft tissue infections (Orangio et al., 1983) have

demonstrated that infections in IDUs are acquired mainly either from their

commensal flora or from organisms contaminating the drugs, drug adulterants, or

paraphernalia. In a study of a small sample of IDUs opportunistically recruited from

EDs in a New York hospital, Orangio et al (1984) found that 29 of the 38 IDUs

tested were infected with various organisms. Beta haemolytic streptococci and

staphylococcus aureus represented almost half of the pathogens isolated. Individuals

who inject for several years are at risk of developing chronic and recurrent abscesses

that may be related to colonisation with an abscess-inducing subspecies of a common

skin bacterium (Staphylococcus aureus) (World Health Organization, 2009). If


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Chapter 2

commonly, local extension of a skin or soft-tissue infection. These infections may be

indolent, and the only symptom may be pain without fever (Chandrasekar & Narula,

1986; Sapico & Montgomerie, 1980). Musculoskeletal infections may be

polymicrobial or anaerobic, especially if the injecting site, equipment, and/or drugs

are contaminated with saliva (Gordon & Lowy, 2005). This may occur when a drug

designed for oral administration such as methadone or sublingual administration

such as buprenorphine, is secreted in the mouth and subsequently injected.

Endovascular infections, including infective endocarditis, septic thrombophlebitis,

mycotic aneurysms, and sepsis, are among the most serious complications of

injecting drug use (Gordon & Lowy, 2005; World Health Organization, 2009).

Some injecting-related problems are associated with the use of certain drug types and

preparation. Injection of pharmaceutical preparations such as methadone syrup and

temazepam gel capsules is associated with abscess, fistulas, venous thrombosis and

high rates of digital and limb amputation (Aitken & Higgs, 2002; Jensen &


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Chapter 2

abscesses and cellulitis, which a case-control study conducted in San Francisco

found to be three times higher for those who used this combination than those who

did not (Murphy et al., 2001).

Drug adulterants can also potentially cause complications. The association between

black-tar heroin and clostridial infections is an example of infections related to

adulterants. Black-tar heroin becomes contaminated with spores when mixed with

adulterants (e.g., methamphetamine or strychnine) or diluted (“cut”) with substances

such as dextrose or dyed paper. Although black-tar heroin is typically heated in

water before use, clostridial spores survive boiling and may even begin to germinate

(Passaro, Werner, McGee, Mac Kenzie, & Vugia, 1998; Werner, Passaro, McGee,

Schechter, & Vugia, 2000). Intravenous use of black-tar heroin causes venous

sclerosis and promotes the practice of “skin popping” (subcutaneous or

intramuscular injection) with the loss of usable veins (Gordon & Lowy, 2005).


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Chapter 2

al., 2009). These particles will cause great harm if injected into the bloodstream.

Injecting the contents of filters can cause irritation of lining and/or blockage of veins

through the introduction of particulate matter. Adding too little water to the solution

to be injected can create a thick “sludge” that damages the vein by entering under

high pressure. Although finer bore needles are recommended to reduce vein damage,

they can cause damage by increasing the pressure under which fluid and particulate

matter enter the vein.

The form of heroin traditionally available in Australia was the soluble white form

originating from the Golden Triangle region of South East Asia (Maher, Swift, &

Dawson, 2001). Since 2001 heroin has been less pure with increasing reports of

“brown” heroin (Stafford & Burns, 2010), which is understood to be heroin in its

alkaline form (Australian Crime Commission, 2012; Day, Topp, et al., 2003). In

many settings outside Australia, street heroin tends to be mostly brown and is sold in

poorly soluble alkaline form (King, 1997). An acid is often added to alkaline heroin


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Chapter 2

fortunately relatively rare complications and published literature is mostly based on

case studies.

Blood-borne viral infections

Sharing of contaminated injecting equipment is a major risk factor for the acquisition

of blood-borne viral infections (BBVIs), notably the HCV, the hepatitis B virus

(HBV) and the human immunodeficiency virus (HIV). Among IDUs, sharing of

contaminated equipment is the primary mode of BBVIs (Crofts & Aitken, 1997;

Stimson, Jarlais, & Ball, 1998), although HIV (Degenhardt et al., 2010) and HBV

(Alter, 2003) can also be acquired through unprotected sexual contact. Chronic

infection with these viruses is associated with substantial morbidity and premature

death; the development of Acquired Immune Deficiency Syndrome (AIDS) among

HIV-infected persons (Marmor, Des Jarlais, Friedman, Lyden, & el-Sadr, 1984); and

serious liver disease including cirrhosis and hepatocellular carcinoma among HCV

and HBV-infected persons (Walshe & Wolff, 1952). Although no licensed vaccines

against HIV and HCV are currently available, a safe, affordable and effective


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Chapter 2

with a range of between 0.8 and 6.6 million (UNAIDS, 2009). HIV infection among

IDUs has been reported in 120 countries. In a further 20 countries where injecting is

known to occur, no reports of HIV among IDUs are available; and in eight countries

HIV has not been detected or is less than 0.01 percent. Given that IDUs in many

developing countries are highly marginalised with limited access to healthcare, these

figures are likely to be underestimates.

The prevalence of HIV among IDUs varies dramatically between and also within

countries. In Australia, annual cross-sectional sero-prevalence studies among

attendees of sentinel NSP sites performed between 1995-2009 indicate an aggregated

prevalence of HIV antibody of little more than one percent (Topp, Day, Iversen,

Wand, & Maher, 2011). Although rates of new HIV infections among IDUs have

been falling overall globally, HIV prevalence is increasing in such low-prevalence

countries as Bangladesh, Pakistan (where injecting drug use is the predominant mode

of HIV transmission), and the Philippines (UNAIDS, 2010), although this estimation

i li it d b th f t th t th d t ll t d i l f b Th


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Chapter 2

but it remains a disease management tool rather than a cure. Although a number of

candidate vaccines for HIV are at different stages in clinical trials (Spearman, 2006),

a safe and effective vaccine is unlikely to be available in the near future due to

genetic diversity and mutability of HIV-1, the structural features of the viral

envelope glycoprotein, and the presence of carbohydrate moieties that shield

potential epitopes from antibodies (Kwong, Mascola, & Nabel, 2012).

IDUs are one of the main subpopulations affected by HIV/AIDS, but are less likely

to receive HAART than other groups (Aceijas et al., 2006; Wolfe, 2007), even in

those countries with relatively good treatment access for the general population

(Celentano et al., 2001; van Asten et al., 2003). Those IDUs who do receive HAART

usually commence it at more advanced stages of infection (Kohli et al., 2005).

Canadian and US studies have shown that in the late 1990s, when HAART was

widely available free of charge in those countries, only 27 and 14 percent of eligible

IDUs respectively received this treatment (Celentano et al., 1998; Strathdee et al.,


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An international systematic review estimated 67 percent (range 60-80 %) of IDUs

are infected with HCV ( Nelson et al., 2011). Like many other developed countries,

injecting drug use is the primary route of HCV infections in Australia. In 2010, the

Australian NSP survey (ANSPS) found 53 percent of participants were HCV

antibody positive (Iversen, Topp, & Maher, 2011). Incidence has been more varied,

with a range from 5.3 to 44.1 per 100 person years, because of differences in study

methodologies, baseline prevalence of HCV infection and socio-demographic

characteristics and risk-behaviour profiles of participants. Most recently Maher and

colleagues (2007) reported an incidence of 45.8 (95% CI 35.6, 58.8) per 100 person

years.

About 80 percent of individuals exposed to HCV develop chronic infection (Te &

Jensen, 2010), and 3 to 11 percent of people with chronic HCV infection will

develop liver cirrhosis within 20 years (Dore, Freeman, Law, & Kaldor, 2002), with

associated risks of liver failure and hepatocellular carcinoma (Limberg, 2004). In


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antigen (HBsAg) positive in 2010, with an IDU population-weighted global

prevalence of 8.4 percent (Nelson et al., 2011). The largest populations of blood-

borne virus infected IDUs by region are East Asia and Southeast Asia (0.3 million,

range 0.1–0.7) and Eastern Europe (0.3 million, range 0.1–0.5 million) (Nelson et al.,

2011). Selective vaccination programs against HBV among this group are

characterised by low uptake and difficulty reaching the most at-risk individuals (Day

et al., 2010). Nonetheless, in Australia, rates of newly acquired HBV notification

declined from 2.3 per 100 000 of the population in 2001 to 1.5 per 100 000 in 2006

(NCHECR, 2007). Notwithstanding this decrease, IDUs remain among those at

highest risk of contracting HBV infection (Francois, Hallauer, & Van Damme,

2002). Although vaccination against HBV was added to the infant immunisation

schedule in Australia in 2000, this is not expected to reduce population prevalence

until 2030 (Tawk et al., 2006) and targeted vaccination for IDUs will continue to be

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and 4.0 times higher than among those with HBV mono-infection (Amin et al.,

2006).

2.1.3 Other infectious diseases

Sexually transmitted infections

An increasing body of empirical research suggests that individuals who use alcohol

and other illicit drugs are more likely to have multiple sex partners, more

unprotected sex, and a higher prevalence of HIV and sexually transmitted infections

(STIs) than non-drug users (Booth, Watters, & Chitwood, 1993; Chitwood &

Comerford, 1990; Leigh, 1990; Leigh & Stall, 1993; Logan, Cole, & Leukefeld,

2003; Maranda, Han, & Rainone, 2004; Poulin et al., 2001; Ross, Gold, Wodak, &

Miller, 1991; Ross, Hwang, Zack, Bull, & Williams, 2002; Taylor, Fulop, & Green,

1999). The mechanisms underlying facilitation of risky sexual behaviours during

intoxication with illicit, and in particular stimulant, drugs are not fully understood,

but they are likely to include impairment in self-control (dis-inhibition) and/or


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IDUs taking amphetamines may indulge in frequent high-risk (unprotected) sexual

activity and therefore their chances for acquiring STIs, including HIV, are greater

(Topp, 2012). Some have speculated that associations may be due to unmeasured

behavioural factors including prolonged sexual activity and/or increased trauma

during sex while under the influence of amphetamine-type stimulants (Semple,

Zians, Strathdee, & Patterson, 2009); poor recollection of self-reported events;

sexual network factors; or potential direct effects of amphetamine-type stimulant on

immune function (Leigh & Stall, 1993). In-vitro studies suggest that certain

neurological and physiological factors linked to methamphetamine use can affect

susceptibility to HIV infection and the development of AIDS-related pathology

(Liang et al., 2008). However, clinical implications of these findings remain un-

established (Kopnisky, Bao, & Lin, 2007).

Cocaine is also known to have an effect of increased sexual desire while users are


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chlamydia, gonorrhoea and syphilis, screening and access to appropriate treatment

often are limited for IDUs (Bradshaw, Pierce, Tabrizi, Fairley, & Garland, 2005; van

den Hoek, 1997).

Respiratory tract infections and tuberculosis

Respiratory tract infections are among the most frequent sequelae of drug use. IDUs

have significantly greater risk of community-acquired pneumonia (Hind, 1990).

Tobacco smoking is common and hence respiratory clearance mechanisms may be

impaired (Stein, 1990). IDUs are at increased risk of aspiration, particularly during

opioid overdose. An immune-compromised state resulting from HIV infection or

poor nutrition may also contribute to the increased risk of respiratory tract infection

(Boschini et al., 1996; Louria, Hensle, & Rose, 1967; Tumbarello et al., 1998). For

example, a retrospective analysis of hospitalisations due to infection in 175 IDUs in

Switzerland found that respiratory infection was the second major cause of

hospitalisation (Bassetti, Hoffmann, Bucher, Fluckiger, & Battegay, 2002) after skin


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than that in the general population (Roche et al., 2008). Conversely, studies from

Europe and north-America report relatively high prevalence of TB among IDUs. The

prevalence of positive tuberculin skin test results among IDUs in the United States of

America (USA) has ranged from 10.3 to 45.8 percent (MacGregor, Dunbar, &

Graziani, 1994; Reyes et al., 1995). In 1997, a cohort study with IDUs recruited via

street outreach in Vancouver reported that 25 percent of IDUs had a positive

tuberculin skin test result (Strathdee et al., 1997). However, there remain a number

of limitations of this test including subjective interpretation, false positivity, cross

reactivity with non-tuberculous mycobacteria, errors in administration and the

requirement for two client-visits (Khawcharoenporn, Apisarnthanarak,

Sungkanuparph, Woeltje, & Fraser, 2011).

The physiological effects of drug use, along with the environment, risk behaviours

and life-style, may all contribute to the high prevalence of TB among IDUs

internationally (Deiss et al., 2009). In-vitro studies have demonstrated harmful


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TB among IDUs has been attributed to both an increased prevalence of

mycobacterium tuberculosis infection and an increased likelihood of progression to

active TB (Perlman et al., 1999).

2.1.4 Non-infectious disorders

Drug dependence and drug use related disorders

Drug dependence typically is a chronic and relapsing medical condition, which is

defined in the DSM-IV (American Psychiatric Association, 1994) and ICD-10

(World Health Organization, 1993) as a pathologic condition manifested by three or

more of seven criteria. These criteria include the development of tolerance to drug

effects, withdrawal symptoms, unsuccessful attempts to cut down or control use, and

continued use in the face of problems that the user knows or perceives to be caused

by use such as legal difficulties, relationship and health problems.

Injecting is an extremely efficient route of drug administration, causing very rapid


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with a faster progression to dependence than other routes of use (Barrio et al., 2001;

Gossop et al., 1992; Hall & Hando, 1994; O'Brien & Anthony, 2005).

Psychiatric disorders and pain

There is strong correlation between illicit drug dependence and psychiatric morbidity

(Kandel, Huang, & Davies, 2001). Dual diagnosis (according to DSM IV or ICD 10)

of mental illness and drug use disorder in IDUs is a common problem (Gu et al.,

2010; Zahari et al., 2010). The impact of injecting as a mode of drug use on

psychiatric disorders is difficult to assess. Data from a national survey of drug use

and health in the USA compared routes of administration of those who reported

heroin, methamphetamine, and cocaine use in the past year, and found that 60

percent (n=396) of IDUs met the DSM-IV criteria for drug dependence and co-

occurring mental disorders compared with slightly less than one-third of NIDUs

( p


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Zahari et al., 2010). In a survey involving 41 specialised drug and alcohol treatment

agencies in Brisbane and Sydney, McKetin and colleagues (2011) found that 40

percent of methamphetamine treatment entrants met DSM-IV criteria for a major

depressive episode in the previous year, and a further 44 percent had drug-induced

depressive symptoms that were similarly severe and disabling, 83 percent of

participants injected methamphetamine. However, the study was unable to

effectively distinguish between major depression and drug-induced symptoms of

depression.

Anxiety, another major psychiatric disorder, is also commonly associated with

injecting drug use, particularly during withdrawal from opiates and intoxication with

amphetamines and other stimulants. It can also occur as an independent condition

(World Health Organization, 2009). It is estimated that around half of females andone-quarter of males diagnosed with drug-related disorders also have an anxiety or

affective disorder, specifically panic, generalised anxiety disorder, post-traumatic

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The use of different instruments and samples of IDUs influences the prevalence of

psychiatric co-morbidity obtained. In comparing psychiatric syndromes experienced

by users of cigarettes, alcohol and illicit drugs, Kandel and colleagues (2001) found

the highest rate of psychiatric morbidity was among individuals dependent on an

illicit drug. Mental illness may be the cause or effect of substance use. A strong

association exists between drug-induced psychosis and amphetamine intoxication,

particularly in chronic amphetamine users (Darke, Kaye, McKetin, & Duflou, 2008;

Dore & Sweeting, 2006). Drug use (particularly stimulants) can precipitate psychotic

illness but on the other hand people with primary schizophrenia are more at risk of

becoming drug dependent.

Cannabis and psychosisCannabis is the world's most commonly used illicit drug (UNODC, 2008).

According to the 2004 National Drug Household Survey, around one-third (33.6%)

f A t li d 14 d t d th t th h d d bi t

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speech and actions do not make sense (American Psychiatric Association, 2000).

The syndrome of psychosis occurs in a range of mental health conditions including

schizophrenia and drug-induced psychosis (Ferran, Barron, & Chen, 2002).

Although risk of psychosis is approximately one in 50 among regular cannabis users

compared with approximately one in 100 among non-users (Hall & Degenhardt,

2010), even this increase in risk is of huge public health importance, because of the

high prevalence of cannabis consumption. Prompt referral to a psychiatrist is

important, because early psychiatric intervention is associated with better response to

treatment (McNally, Bryant, & Ehlers, 2003). If an immediate referral is not

required, then patients must be actively monitored for changes in their mental status.

Primary healthcare centres may not be appropriate venues for psychosis treatment,

but these are potential gateways of preventive interventions and appropriate referrals

to further treatment.

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conceptual and at the practical levels. One simple rationale for this is that all

pharmaceutical drug use follows the general rule that combinations of drugs tend to

increase the risks of adverse health effects. Such effects can occur (generally as acute

toxicity) shortly after the consumption of several substances, or within a short time

afterwards (EMCDDA, 2009e). They can also occur following a long period of use,

due to various mechanisms affecting body systems, including the liver and the

central nervous, cardiovascular or respiratory systems (Macleod et al., 2004;

McCabe, Cranford, Morales, & Young, 2006). Intensive cannabis use is often a

major, but overlooked, component of polydrug use. Cannabis also adversely affects

cognitive functioning which for polydrug users, particularly for IDUs, can impair

initiative in seeking attention for health or social needs (Solowij, Stephens, Roffman,

& Babor, 2002; Solowij, Stephens, Roffman, Babor, et al., 2002) and can enhance

the chance of risk taking behaviours.

Pain

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medications if they are concerned the patient is seeking psychoactive medication for

nonmedical purposes (Monheit, 2010).

Some IDUs attend health services primarily to seek opioid based pain killers such as

Oxycontin® (Monheit, 2010) or psychoactive medications such as benzodiazepines

(Darke, Ross, Teesson, & Lynskey, 2003). Current efforts to introduce a live

electronic database for prescription drug monitoring (Perrone & Nelson, 2012) will

potentially reduce this reason for healthcare visits. Although true health issues may

not be the primary goal of these “doctor shoppers”, their visits to and consultation

with the healthcare providers may open an avenue to address some of their essential

health needs.

2.1.5 Other common health problems

Overdose and toxicity

Fatal overdose is a leading cause of death among IDUs (Darke & Hall, 2003). The

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particular concern in North America (Coffin et al., 2003; Lora-Tamayo, Tena, &

Rodriguez, 1994). In Australia, however, few drug-related deaths have psycho-

stimulant use as the underlying cause (Darke & Kaye, 2003; Degenhardt & Barker,

2003). This continental difference in fatal overdose rate is likely to be due to the

difference in prevalence and type of psycho-stimulant use. Consumption of cocaine,

which is the main psycho-stimulant responsible for fatal cases, is more prevalent in

the Americas, with less use in Australia. This is because the global supply of cocaine

originates almost exclusively from the South American countries of Peru, Bolivia

and Columbia (Darke, Kaye, McKetin, & Duflou, 2007).

Poor dental health/hygiene

Dental problems are very common among IDUs, yet have attracted little attention

(Laslett, Dietze, & Dwyer, 2008; Reece, 2008; Reece, 2009; Robbins, Wenger,

Lorvick, Shiboski, & Kral, 2010). Opioid and amphetamine use, poor housing, poor

hygiene, poor nutrition, and opioid substitution treatment including methadone

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sought help were dental (30%) followed by constipation (25%) and headache (24%)

(Winstock, Lea, & Sheridan, 2008).

Poor dental health is related to reduced saliva secretion (xerostomia), teeth grinding

(particularly associated with amphetamine use), poor dental hygiene (e.g. not

brushing), and trauma (World Health Organization, 2009). Poor dental health can

increase the risk of bacteraemia and infective endocarditis. Xerostomia, which is

associated with regular opioid use and so is also a side-effect of methadone

maintenance, can contribute to caries. Another very important issue associated with

poor dental health is pain, which can be severe and may impact on treatment

retention or stability if not appropriately managed, self-esteem may also be effected,

potentially impacting on treatment (Huff, Kinion, Kendra, & Klecan, 2006). There

are few programs available for this group. Given that life-style factors, including

history of homelessness and erratic eating patterns are related to dental problems,

any such programs should be developed and implemented in a manner amenable to

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p

OST clients at community pharmacies in NSW, Australia. It has been estimated that

eventually more than half of OST patients experience some degree of constipation

(Langrod, Lowinson, & Ruiz, 1981; Yuan, Foss, O'Connor, Moss, & Roizen, 1998).

Patients receiving opioids may require pharmacological agents (osmotic laxatives

e.g. lactulose, sorbitol, milk of magnesia) for constipation as primary prevention

strategies alone may be insufficient (World Health Organization, 2009).

Health effects associated with poverty and violence

Illicit drug use is both a cause and effect of poverty and violence, which in turn may

seriously affect health. Illicit drug use and poverty go hand-in-hand (Kaestner,

1999). Perhaps the greatest impact of poverty on the life of a drug user is its effect on

affordability of food intake and medical care. For those living in poverty, a substance

use problem can perpetuate financial difficulties by making it more challenging to

obtain employment. Conversely, the complex relationships between substance abuse

and violence have posed challenges to the public health. A study in USA examined

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p

2.2 Barriers to access to healthcare

Because of this wide range of physical and mental complications and co-morbidities,

IDUs are among those who have a disproportionate need for healthcare services

(French et al., 2000; McBride, VanBuren, Terry, & Goldstein, 2000; McCoy,

Metsch, Chitwood, & Miles, 2001; Rowe, 2004, 2005). However, despite this

increased need, the literature documents a trend of lower healthcare utilisation

among IDUs (Mor, Fleishman, Dresser, & Piette, 1992; Morrison et al., 1997;

Selwyn, Budner, Wasserman, & Arno, 1993) compared to socio-demographically

similar groups who do not use drugs (Chitwood, McBride, French, & Comerford,

1999; Chitwood, McBride, Metsch, Comerford, & McCoy, 1998; McCoy et al.,

2000; McGeary & French, 2000). When they are admitted to hospital, IDUs are also

more likely than other patients to leave against medical advice (Bradley & Zarkin,

1996). This lower rate of healthcare access and adherence by IDUs is likely the

result of a number of direct and indirect barriers Broadly those barriers can be

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Table 2.2 Common barriers to access to healthcare by IDUs

Structural or system

barriers

• Insufficient service provision

• Access to information about service availability

• Inability to comply with paperwork

• Lack of comprehensive services

• Structured appointment system, challenge in chaotic lives

• Distance from the healthcare provider and lack of suitable

transportation

• Lack of valid documents (e.g. identification cards)

• Legal barriers

• Conditional services (e.g. abstinence-based treatment)

Interpersonal barriers

- Provider barriers • Social stigma, negative attitudes toward IDUs

• Moral conflicts

• Provider beliefs about abstinence-focused care

• Concern about the effect of IDUs’ presence on other

clients

• Frustrations over patients’ frequent relapse to drug use

• Concerns about the effectiveness of intervention

L k f kill d i i d li i h d

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2.2.1 Structural or system barriers

Although barriers vary across settings, the main structural barrier to healthcare

seeking is insufficient service provision – the absolute lack of services accessible to

IDUs (Freund & Hawkins, 2004; Metsch & McCoy, 1999) or an insufficient number

of services to deal with their demand (Deck & Carlson, 2004; Metsch & McCoy,

1999; Sterk, Elifson, & Theall, 2000). In addition, there is also poor information

available to IDUs about healthcare availability (Table 2.2), that is, many IDUs are

unaware of the full range of services available to them (Carroll & Rounsaville, 1992;

Swift & Copeland, 1996). IDUs are often unable to access the desired assistance

because they are ineligible for the service, they lack support, and they are refused.

There may be no clear help or assistance, or they may be unable to complete the

necessary paperwork (Neale, Tompkins, & Sheard, 2008). There is typically a lack

of holistic or comprehensive services, which forces IDUs to access and work with

many different services and providers to meet their complex physical and mental

health needs, often in a variety of locations (Holt et al., 2007). Consequently, the

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(Drumm et al., 2003; McCoy et al., 2001; Porter, 1999; Porter, Coyte, Barnsley, &

Croxford, 1999).

Criminal sanctions against illicit drug use pose further barriers (Bluthenthal, Kral,

Lorvick, & Watters, 1997) particularly where the legal status of treatment is

ambiguous (e.g. in Malaysia, where MMT was endorsed without legal validation),

negative attitudes persist, or law enforcement agencies are ill-informed about the

medical approach to treating drug dependence (Burris & Davis, 2008). Even when

IDUs try to access mainstream healthcare services, they may be anxious and

concerned about presenting for treatment. For example, mothers who desire

treatment may fear being notified to child protection services (Anex, 2005; Neale et

al., 2008), or employed drug users may fear negative effects on employment (Ahern,

Stuber, & Galea, 2007; Link & Phelan, 2006; Stafford & Petway, 1977). Abstinence-

based health services, limited staff skill and confidentiality risks are also important

barriers to access to healthcare (Regen, Murphy, & Murphy, 2002; Rowe, 2004).

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et al., 2000; Drumm et al., 2003; Neale et al., 2008; Salvalaggio, 2008). Greater

contact with a stigmatised population such as IDUs may reduce prejudice and a large

body of research in social psychology has supported this conclusion (Pettigrew &

Tropp, 2006). Hence, in settings where a harm reduction policy is supported, IDUs

are likely to have greater contact with healthcare providers with a lesser degree of

prejudice than IDUs in other settings. However, social stigma about injecting drug

use is just one of many barriers. McLaughlin and colleagues (2000) demonstrated

that healthcare workers commonly describe IDUs as among the most unpopular

patients and expect them to be more dangerous, more manipulative, less grateful,

less co-operative, less pleasant, more aggressive, less truthful, and more demanding

than most other patients (Link & Phelan, 2006). Moral conflicts, suspected

deceptions (Gourlay, Heit, & Almahrezi, 2005), power differentials in the patient-

provider relationship (Salvalaggio, 2008), provider beliefs about abstinence-focused

care (Rowe, 2004), and concerns about possible disruption to their usual practices

(Abouyanni et al., 2000) are prominent provider deterrents to offering care to IDUs.

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Although GPs are often the first point of contact for patients who are dependent on

drugs and alcohol (Miller & Gold, 1998), many GPs lack the skill or confidence to

deal with drug users; have concerns about the effectiveness, compliance and safety

of opioid maintenance; and fear that IDUs or OST clients will be difficult, aggressive

or demanding (Abouyanni et al., 2000; Roche, Furay, & Saunders, 1991). Some GPs

have expressed concern about turning their practices into drug and alcohol clinics if

they cater for the needs of IDUs (Table 2.2). For example, a Sydney-based study of

GPs found that most of the 416 GPs interviewed raised this as a concern (Abouyanni

et al., 2000). Other perceived barriers include lack of time or remuneration for

managing these complex problems, concerns about possible disruption to their

practices, and the adequacy of support provided to them by public drug and alcohol

services (Abouyanni et al., 2000).

There is also concern about the capacity of IDU populations to demonstrate

adherence to therapeutic regimens which is translated into reluctance to provide

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attention to these issues in medical education appears to have had only a modest

impact on medical students’ attitude (Silins, Conigrave, Rakvin, Dobbins, & Curry,

2007).

IDU barriers

Drug dependence and withdrawal exerts an inescapable influence on an IDU’s

lifestyle. Healthcare needs may take a lower priority than more immediate concerns

related to obtaining food, clothing and shelter and raising enough money to support

drug use (Bruce, 2012; Carr et al., 1996). Apart from this, some IDUs do not

perceive their drug use as problematic and so do not want to seek help (Carroll &

Rounsaville, 1992; Kennedy, Neale, Barr, & Dean, 2001). The transitional nature of

the lives of homeless IDUs makes it even harder to establish and maintain effective

relationships with healthcare providers (Anex, 2005; Rowe, 2004).

Past history of discrimination and fear of rejection has a serious effect on IDUs’

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also encourage lying to hide the fact of injecting drug use, and so a negative cycle

can be established.

Stigma associated with injecting drug use and discrimination is an important barrier

to help-seeking for many with drug-related conditions (Day, Ross, et al., 2003; Kelly

& Westerhoff, 2010; Paterson, Backmund, Hirsh, & Yim, 2007). A cross-cultural

study conducted by the World Health Organization in 14 countries examined 18 of

the most stigmatised conditions (included being a criminal, HIV positive, or

homeless) and found that alcohol dependence was ranked as the fourth most

stigmatised condition, while other drug dependence was ranked as the most

stigmatised condition (Room, Rehm, Trotter, Paglia, & Üstün, 2001). Many

individuals who are affected by drug-related problems experience feelings of shame

and guilt and often fear that personal disclosure or public knowledge of their

condition would lead to broader social disapproval (Ahern et al., 2007; Link &

Phelan, 2006; Stafford & Petway, 1977). Co-morbidity with health problems that are

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that the majority of IDUs have substandard education and have only minimal

income, these material barriers profoundly limit IDUs’ access to healthcare (Islam,

Topp, Day, et al., 2012a; Topp et al., Epub ahead of print).

The lack of support and assistance during times of crisis is another key barrier to

healthcare access (Neale et al., 2007). The involvement of family members and

friends in the treatment processes of drug dependence and related health problems

helps to promote positive treatment outcomes (Orford, 1994). Drug use does not

affect individuals in isolation from their social networks. However, IDUs often have

poor family relationships and limited social networks (Neale et al., 2007). When

family members and friends offer tangible and/or emotional support, IDUs are more

likely to access healthcare (Drumm et al., 2003). While support from family, friends

and networks are important enablers, unproductive peer influences (e.g. from fellow

IDUs) may deter IDUs from accessing healthcare (Drumm et al., 2003).

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These barriers to healthcare, consequent poor health outcomes, and excessive use of

ED services by IDUs for health problems which may be prevented and/or treated in a

PHC setting have led authorities in some settings to establish low-threshold and

IDU-targeted PHC facilities (Islam, Day, et al., 2010; Islam, Topp, Day, et al.,

2012a). The key harm minimisation interventions offered to IDUs are NSPs and/or

OST, coverage of which varies considerably across the world (Mathers et al., 2010).

PHC centres may be co-located with such services in order to facilitate their

utilisation among the target population (Islam, Reid, et al., 2012). Thus these

targeted healthcare centres could be enhanced NSPs (Day et al., 2011), OSTs

(Federman & Arnsten, 2007; Umbricht-Schneiter, Ginn, Pabst, & Bigelow, 1994) or

medically supervised injecting centres (MSICs) (Small, Van Borek, Fairbairn,

Wood, & Kerr, 2009; Small, Wood, Lloyd-Smith, Tyndall, & Kerr, 2008) or may be

stand-alone services in areas frequented by the target population ( Norman, Mugavin,

& Swan, 2006). As mentioned earlier, these offer low-threshold healthcare that

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dependence are universal and have the potential to affect access to care. Although

such IDU-targeted PHC centres are increasingly being established across a range of

settings and utilising a variety of models, evidence for their effectiveness is scant and

it has been the focus of few studies. In the next chapter, a literature review examines

the accessibility, acceptability, and health impact and cost implications of PHC

services that target IDUs.

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CHAPTER 3Primary healthcare services that target injectingdrug users: A narrative synthesis of literature1

The preceding chapter showed that IDUs experience a wide range of health problems

despite most of these problems being treatable and/or preventable in a PHC setting,

and the context of and rationale for introduction of IDU-targeted PHCs which offer

various degrees of preventative and therapeutic healthcare services for IDUs.

Although IDU-targeted PHC facilities are increasingly being established across a

range of settings and utilising a variety of models, a systematic review on this topic

has not been conducted. A scoping exercise undertaken as part of this study revealed

that a systematic review was not possible as the relevant literature is widely

dispersed across a number of disciplines and includes both qualitative and

quantitative study designs, and many of the available reports are simply describing

process evaluations. This review synthesizes available documentation in order to

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b) synthesize the findings from evaluations of these PHCs with respect to their

impact on health outcomes, cost implications and operational challenges.

3.1 Methods

A comprehensive search was undertaken of the electronic databases Medline,

Medscape, Current Contents, HealthSTAR, Addiction Abstracts and CINAHL from

1966 to the end of 2010. Search terms entered were “primary healthcare for

intravenous drug users”, “targeted primary healthcare for drug users”, “primary

healthcare for marginalised population”, “healthcare for IDUs”, “primary health

clinic for drug users”, “healthcare from needle syringe program outlet”, “syringe

exchange program based healthcare”, “opportunistic healthcare for drug users”,

“drug users targeted healthcare”, “harm reduction based healthcare”, “primary health

services for drug users”, “enhanced healthcare”, “locally enhanced healthcare”,

“nationally enhanced healthcare”, and “directed enhanced healthcare”. Hand

searching of reference lists was also undertaken. As targeted PHC for drug users is a

relatively recent innovation and there are likely to be service-related documents not

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Records identified throughdatabase searching

(n = 71)

S C R E E N I N G

E L I G I B I L I T Y

I D E N

T I F I C A T I O N

Records after duplicates removed(n = 1)

Titles and abstractsscreened(n =75)

Exclusion / inclusioncriteria applied

(n = 29)

Full-text articlesassessed for eligibility

(n = 46)

Full-text articlesexcluded(n = 11)

Records identified through personal communication

(n = 5)

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Inclusion-exclusion criteria were developed, based upon a checklist of research

questions, methodology used and study outcomes derived from this review’s aims

and the quality of methods, findings and interpretation (Eakin & Mykhalovskiy,

2003), to assess the literature identified through the search strategy. Articles/reports

that described implementation or evaluation or outcomes of interventions and

epidemiological studies were included in this review, as these are likely to report

factors shaping implementation, acceptability and accessibility. Thirty-five papers

concerning targeted PHC for drug users were identified. Eighteen peer-reviewed

articles identified through electronic database searching directly or indirectly

described PHC that targets IDUs. An additional three articles and two reports located

through hand-searching the reference lists of papers were also included.

Narrative synthesis was employed to analyse the selected material as per current

guidelines (Arai et al., 2007; Popay et al., 2006). This methodology is well suited to

this study as one-third of the retrieved literature described implementation studies or

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Table 3.1 Table stating the criteria of literature suitable for a narrativesynthesis

When to consider a narrative synthesis?

• The studies included in the review are too diverse, and a systematic review

or meta analysis is not possible

• Literature are mostly implementation studies, consider how or why

interventions have particular impacts, including what went wrong when

interventions did not have the anticipated impact. These studies focus on

how factors/processes, operating at the level of systems (which might

include international, national, regional or local level systems, depending on

the intervention)

•

Studies commonly involve multiple methods and may involve routine dataon the ‘reach’ of the intervention, new surveys or other methods generating

quantitative data and any of a range of qualitative methods including in-

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IDU-targeted PHC facilities. Moreover, the literature around services provided by

supervised injecting facilities has to date focussed on elements related to their core

mandate, namely the provision of a supervised place to inject. Limited information,

and no outcome evaluations, are available on the PHC provided by these services;

thus inclusion of this information would add little to this review.

Primary healthcare is defined as socially appropriate, universally accessible,

scientifically sound first level care supported by integrated referral systems in a way

that addresses health inequalities; maximises community and individual self-

reliance, participation and control; and involves collaboration and partnership with

other sectors to promote public health. It includes health promotion, illness

prevention, treatment and care of the sick, community development, and advocacy

and rehabilitation (Australian Primary Health Care Research Institute, 2005). More

specifically, as defined by the WHO (World Health Organization, 2009), primary

healthcare for IDUs refers to a comprehensive harm-reduction package including

t h l d i t ti i f ti d ti d i ti

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healthcare? Service “acceptability” was indicated by measures such as clients’ return

rate; perceived friendliness of and/or ease of communication with staff; and uptake

of referrals to other services (Rowe, 2004).

Operational models were categorised by three major variables: main services

provided, workforce profile and flexibility of service delivery, for example, outreach

and/or drop-in capacity.

3.2 Results

3.2.1 Operational Models

Twenty of 35 papers described implementation of IDU-targeted PHC, with

information concerning workforce profile, range of services and/or service modality(Table 3.1). The underlying approaches vary. They may be “distributive”, providing

basic harm reduction services and simple healthcare with facilitated referrals to

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8/19/2019 Targeted primary healthcare for injec

targeted primary healthcare for injecting drug users: client characteristics, service utilisation...

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