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Best practice portal:
Harm reduction interventions for stimulant injectors
This page refers to the current evidence on the effectiveness of the available harm reduction options for stimulant injectors. Information on the methodology used and the definition of terms can be found on the methodology page.
Date of last update: 09.12.2010. Next update: February 2012.
Harm reduction interventions for stimulant injectors
Summary: Several interventions for stimulant users, such as providing materials promoting safer use in general, or safer groin injection training, remain controversial or illegal and thus systematic evaluations are lacking.
Beneficial
No interventions met the criteria for this category.
Likely to be beneficial
Outreach treatment programmes to reduce medical problems
Outreach treatment programmes were found to be effective in a randomized controlled study (Henskens, 2008 cited in EMCDDA 2010) (N=124) in:
- reducing related medical problems (psychiatric status EurASI score) p. 0.05.
Trade-off between benefits and harms
No interventions met the criteria for this category.
Unknown effectiveness
Some specific interventions that have been proposed but not yet assessed:
- Provision of large volumes of sterile injection equipment and means of sexual protection, requiring liberal exchange and distribution policies, extended opening hours and, where needed, outreach activities in injecting and sexual risk environments.
- Injection kits including a range of materials based on local assessment of drug use patterns and the social situation of injectors.
- Interventions for home-made stimulants users such as: offering syringes both for injecting and for preparing drugs, distributing litmus paper to allow production of less acidic drugs.
- Dissemination of information on proper injection techniques, antibacterial creams and ointments and rotation of injection sites, basic hygiene (hand washing, short nails) and vein care as well as simple wound care.
Evidence of ineffectiveness
No interventions met the criteria for this category.
References and definitions
List of references
Explanation of terms used
Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.
- Affective-focused prevention intervention
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A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).
- BA
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Before-after (BA) study design
- Beneficial
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Interventions for which precise measures of the effects in favour of the treatment were found in the systematic review of randomised controlled trials (RCTs), and that were recommended in guidelines with reliable methods for assessing evidence (such as GRADE). A treatment ranked as 'beneficial' is suitable for most patients.
- CBA
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Controlled before-after (CBA) study design
- CCT
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Controlled clinical trials (CCT)
- Confidence Interval (CI)
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The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.
Practical interpretation
- If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
- If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
- If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
- CPS
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Current population survey (CPS)
- Evidence of ineffectiveness
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Interventions that gave negative results if compared with a placebo, for example.
Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.
- ITS
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Intermittent time series design (CPS)
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Knowledge-focused prevention intervention
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A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.
- Likely to be beneficial
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Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited, and those that are recommended with some caution in guidelines with reliable methods for assessing evidence (such as GRADE). A treatment ranked as 'likely to be beneficial' is suitable for most patients, with some discretion.
- Number Needed to Treat (NNT)
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The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.
- Odds Ratio (OR)
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The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies
- p value
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A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.
- RCT
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Randomised controlled trial (RCT)
- Relative Risk (RR)
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The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.
Practical interpretation
- If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
- If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
- If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
- Trade-off between benefits and harms
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Interventions that obtained measures of effects in favour of treatment and are recommended in guidelines with reliable methods for assessing evidence (such as GRADE), but that showed some limitations or adverse effects that need to be assessed before providing them to patients.
- Unknown effectiveness
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Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.
Additional information for prevention
For prevention interventions, this is also known as 'zero effect'. - Skill-focused prevention intervention
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A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.
- Standardised Mean Difference (SMD)
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The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.
- z score (Standard Score)
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The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.
About stimulant injectors
Case definition
Risks at individual level
HIV and hepatitis B and C
Transmission of blood-borne viruses has been associated with stimulant use due primarily to high-frequency use and to increased risky sexual behaviours. HIV and hepatitis C (HCV) transmission among stimulants injectors has been associated with higher injecting frequency and needle sharing. Frequent cocaine injection is a factor in the failure of selected syringe exchange programmes to prevent HIV transmission. HCV rates are very high, even among recent initiates to cocaine injection. In central and eastern Europe, home-produced stimulants such as methcathinone and cathinone are injected up to 10 times daily and are associated with increased sexual activity as well as sharing of equipment in home drug preparation.
Sexually transmitted diseases (STIs)
Stimulants use is associated with infrequent condom use, amphetamine use preceding sex, risk behaviours among young gay men, and trading sex for drugs or money.
Cardiovascular effects
As cocaine is directly toxic to heart muscle cells while amphetamines exert toxicity primarily through blood pressure elevation, reducing or discontinuing use with onset of the cardiovascular disease that comes with age is paramount to reducing the harm of these drugs.
Mental health problems
Many mental health problems associated with stimulant use are dose, frequency and mode of administration related, and might be mitigated by specific harm reduction measures.
Overdose
Ecstasy
Overdose on ecstasy without concomitant use of other drugs is notably rare and difficult to define.
Amphetamine
In a survey of all amphetamine-related deaths, cardiopulmonary arrest and trauma were the most common direct causes of death, and drug metabolite levels were notably variable.
Cocaine
The concomitant use of cocaine and opioids substantially increases the risk of both nonfatal and fatal overdose. Rates of overdose among cocaine injectors and non-injectors are similar.
Overdose caused by body packing
Among cocaine body-packers, overdose can result from the rupture of a container and requires immediate laparotomy for chance of survival. Extreme overdose on stimulants can result in profound hyperthermia, with subsequent risks for rhabdomyolisis, seizures, and death.
Risk at community level
Public nuisance and criminal activity
Public nuisance is identified as offences that affects the local community as a whole rather than the individuals. Drug-related public nuisance actually refers to a very wide range of ‘deviant behaviours’. Some activities are minor in their effect; others, can be perceived as causing major distress. (EMCDDA SI 2005 Drug-related public nuisance — trends in policy and preventive measures).
Aetiology
In comparison to heroin users, stimulant users are more likely to have unstable social situations, larger drug-using social networks, riskier injection practices (e.g. increased frequency, chaotic drug preparation, injecting in unstable settings) and increased sexual activity.
Prevalence
Amphetamine injecting
Amphetamine users in treatment frequently report the use of other drugs, mainly cannabis and alcohol, and sometimes opioids. In those countries where primary amphetamine users make up a high proportion of those entering treatment, injection is the most frequently reported method of use (more than 60 %). Amphetamine injecting is a long-established problem in the Czech Republic and is increasing in Slovakia and Hungary (where methamphetamine use and injection is common) as well as Estonia and countries across the eastern borders.
Cocaine injecting
Less than the 7 % of cocaine users entering treatment report injecting as a route of administration.
Interventions
Needle Syringe Programmes (NSPs) for stimulants injectors
It has been observed that NSPs should specifically address stimulants injectors taking into account their peculiarities. For instance, in response to homemade stimulants, some NSPs in Eastern Europe offer syringes both for injecting and for preparing drugs. Injection kits include a range of materials based on local assessment of drug use patterns and the social situation of injectors.
Information, education and communication programs
Safer injecting, and interventions supporting transition to less harmful routes of drug administration, are interventions offered to stimulants users as well as overdose prevention and medical care of vein, skin and other infections.
Shelter
Offering sleep and day rest facilities to help reducing sleep deprivation, and alleviate the mental health strain of stimulant use.
Brief interventions among recreational amphetamine users
Include information about potential mental health problems arising from regular use.
Outreach treatment programmes (OTP)
Outreach treatment programmes (OTP) consist of a combination of approahces. OTPs can include: intensive outpatient treatment with assertive outreach (programmes aimed at hard to reach clients), a time-out service , case management, and adjunctive services.
Outcomes
- reduction of incidence of HIV, HCV, STI
- reduction of mortality
- reduction of morbidity
- reduction of criminality
- reduction of public nuisance
Primary outcomes
- reduction of risky behaviours (self-reporting injecting risk behaviour)
- reduction of overdoses and overdoses related morbidity
- reduction of imprisonment
- reduction of illegal activities
- reduction of public nuisance (opinion polls, victim surveys and ethnographic studies).
References
- Statistical bulletin
- EMCDDA (2009), 2009 Annual report: the state of the drugs problem in Europe, EMCDDA, Lisbon.
- EMCDDA (2010), Harm reduction: evidence and impacts, EMCDDA Monographs, Rhodes, T. and Hedrich, D. (editors), Publications Office of the European Union, Luxembourg.
- EMCDDA (2005), Drug-related public nuisance — trends in policy and preventive measures, EMCDDA Selected issues, EMCDDA, Lisbon.
Page last updated: Thursday, 10 March 2011