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• W2418522010 abstract "The debate regarding treatment of polysubstance use is renewed by unexpected findings of increased criminal behavior associated with receiving opioid substitution therapy (OST) among people who inject drugs (PWID). Studies using respondent-driven sampling or quasi-experimental matching methodologies may provide clearer explanations. The drug use profiles of people who inject drugs (PWID) are heterogeneous and many PWID use multiple drugs, which could further exacerbate negative consequences experienced. The study by Betts and colleagues examined drug injectors from the 2011, 2012 and 2013 waves of the Illicit Drug Reporting System, a survey of PWID recruited via needle exchange programs (NEP), advertisements and peer referrals in Australia 1. The researchers stratified participants by enrollment in Opioid Substitution Therapy (OST) and subsequently used latent class analysis to derive profiles based on 18 different drugs. Those with profiles indicating use of multiple substances, i.e. polysubstance users, were significantly more likely than other groups to engage in violent criminal behavior, inject a used needle and experience thrombosis. Understanding the mechanisms driving these associations may enhance public health policy. Undoubtedly, multiple pathways with multiple substances drive the association between polysubstance use and negative consequences. For example, the use of non-injection drugs may impair decision-making, increasing the propensity to engage in risky injection practices 1, 2. This, in turn, can give rise to physical health issues, such as abscesses, thrombosis and infectious diseases. These painful conditions can then encourage self-medication, perpetuating a cycle of abuse 3. Increased risky sexual behavior is an additional concern among this population. Both stimulants and alcohol are known to increase sexual arousal and promote high-risk sexual behaviors 4-6. Polysubstance use may also be an indicator of overall problem severity connected to multiple domains, such as psychiatric comorbidity 7, functional impairment 8 and socio-economic status 1, 9. The prevention and treatment of polysubstance use should be a major public health priority. NEP and OST both provide interfaces between PWID and public health agencies that could potentially be leveraged to prevent or reduce polydrug use. One common concern is that people receiving OST do not necessarily cease drug injection 10. Continued injection is often cited as a failure of OST, leading to suggestions that OST should be reduced in favor of abstinence-only rehabilitation models 11. Generally, engagement in OST by NEP participants is associated with improved outcomes, but as study participants are not randomized to receive OST, it is unclear whether this finding is a direct result of OST or instead due to the comparatively high levels of motivation to change among OST patients 12. The paper by Betts and colleagues is similar to prior work, in that OST patients were less likely to report a non-fatal overdose. However, the paper also presents a contradiction to the prevailing trend of improved outcomes associated with OST, as some PWID were more likely to report criminal activity despite OST 1. OST in the general population is found typically to be effective in reducing crime 13, 14. Studies assessing the association of OST with crime among PWID are less common, but also have found lower rates of crime associated with OST 10, 15. As noted by the authors, this includes findings of associations between OST and reduced criminal activity by PWID recruited at a Norwegian/Dutch NEP facility 10. It is unclear what may be driving the apparent divergent finding reported by Betts and colleagues. It may be that polysubstance use, rather than OST generally, is driving the effect. Additionally, as suggested by the authors, there may be something unique about the Australian sample compared with other samples. Further, the finding may be related to the inclusion by Betts and colleagues of individuals recruited outside of NEP. Future study may help discriminate between the variety of potential pathways linking substance use and various outcomes, thereby providing clearer policy prescriptions. For example, respondent-driven sampling (RDS) or quasi-experimental ‘matching’ methodologies may yield additional useful information. RDS can produce weighted estimations that approximate more closely the true prevalence of behaviors of interest 16. Perhaps more importantly, various matching methodologies, such as propensity scores or coarsened exact matching, can be helpful in approximating random assignment by reducing the imbalance between groups in key covariates 17. For example, Betts and colleagues note that past-month criminal behavior may result in apprehension and enrollment in OST. However, they discount the possibility that crime caused OST enrollment because OST was occurring continuously for at least 6 months for these patients. None the less, it is possible that the link between criminality and OST is best explained by long-lasting pre-existing differences that predict both criminality and OST enrollment. Matching methodologies can help to address this possibility. OST in general is linked to improved outcomes 18, 19, but the sustained use of OST among those who continue to inject drugs remains a public health challenge. P.H. received consultant funding on an unrelated project for American Legacy Foundation in 2013 and honoraria for an unrelated presentation for Gulf Coast North Area Health Education Center in 2013. This commentary was supported by the National Cancer Institute and FDA Center for Tobacco Products (CTP, R03CA195124). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration." @default.
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• W2418522010 date "2016-06-07" @default.
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• W2418522010 title "Commentary on Bettset al. (2016): Polysubstance use and opioid substitution therapy among people who inject drugs" @default.
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• W2418522010 doi "https://doi.org/10.1111/add.13417" @default.
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