Prison sentencing increases the risk of unemployment among illegal heroin users in Taiwan

Background Previous studies have rarely explored the effect of type of sentencing on employment status among illegal heroin users, therefore, we aims to examine the association of the sentencing types and employment outcomes among illegal heroin users in Taiwan. Methods Participants with illegal heroin use were identified through the national prison register system and deferred prosecution system: 2406 with deferred prosecutions, 4741 with observation and rehabilitation, 15 compulsory rehabilitation and 1958 sentenced to prison in calendar 2011. Logistic regression models were built to estimate the effect of sentencing type on unemployment status at 2 years after release. Stratification analysis was conducted to determine the effect of sentencing type based on the offender’s employment status before sentencing. Results Illegal heroin users receiving a prison sentence were more than twice as likely to be unemployed 2 years later than those receiving deferred prosecution. The unemployment rate was also higher for those with observation and rehabilitation and compulsory rehabilitation than deferred prosecution in the 2 years following sentencing. Males, older users, without a job before sentencing, divorced or widowed and higher prior drug use criminal records were also higher risk of unemployment. Subgroup analysis by prior employment status revealed that being sentenced to prison, observation and rehabilitation and compulsory rehabilitation affected the subsequent employment status only for those heroin users with a job before sentencing. The strength of associations showed dose-dependent relationship between different sentencing types (sentenced to prison> compulsory rehabilitation> observation and rehabilitation) and employment outcomes. Conclusions Illegal heroin users who receive a prison sentence have a much higher risk of unemployment than those who receive deferred prosecution after controlling potential confounders, especially those who had a job before sentencing. The implication is the stronger freedom of punishment, the higher risk of unemployment outcomes. Our study support that illegal heroin user is legally regarded as a patient before being regarded as a criminal, so giving priority to quit addition rather than imprisonment.

Feasibility of HCV micro-elimination: HCV test and treatment in two harm reduction services in Milan

Background Most of Harm Reduction Service (HRS) users represent a crucial high-risk population for blood borne infections, including HCV. With the advent of new direct antiviral agents (DAAs), HCV micro-elimination in this setting has become feasible. We evaluated HCV treatment cascade in two HRSs located in Milan. Methods We collected data on demographics, substance abuse history, HIV prevalence, HCV prevalence, testing and treatment on all register HRS users on 1 January 2019. Data collection was closed on 1 January 2020. Results A total of 881 HRS users (732M,149F) were included (median age: 45). The majority was addicted to heroin 67.5% (595), 24.1%(212) to cocaine, 5.3%(47) to THC and 3.1%(27) to other substances. The 28.0%(247/881) reported current or prior judiciary problems, 168/881(19.1%) were under psychiatric treatment. HCV serological screening (HCVAb) was performed for 587/881(66.7%), 113/881(12.8%) were in process, 2/881(0.2%) refused, 179/881(20.3%) were not HRS user anymore. 364/587(62%) resulted HCVAb positive, of whom 288(79.1%) were tested for HCV RNA. Among them 123/324(37.9%) were positive, 165/324(50.9%) were negative. Among HCVAb positive, 116/364(31.9%) were tested for HIV and 92(79.3%) resulted HIV positive. Among HCV RNA positive 92/123(74.8%) were initiated on DAAs treatment. Compliance to treatment was high; one treatment failure was registered. Individuals tested for HCV and HCVAb positive people had an average age significantly higher than the individuals not tested and HCVAb negative people (p < 0.001). Heroin user had a higher likelihood of being tested both for HCVAb and for HCV RNA and of being positive to the HCVAb test (p < 0.001). Conclusions Our study demonstrate that it is feasible to achieve good efficacy and compliance for HCV treatment among people who use drugs when decentralising treatment to HRS. To achieve the viral hepatitis elimination agenda goals, HRS-based model of treatment provision needs to be implemented at larger scale. Key messages Decentralising HCV test and treatment to harm reduction services is an effective strategy to achieve HCV micro-elimination among people who use drugs. Young people and people who are addicted to other substance than heroin resulted more difficult to link to HCV care through the harm reduction services. They require tailored intervention.

Remaining Undone

Despite numerous aid programs targeting both widows and heroin users in Afghanistan, a widow and heroin user in Kabul, Aisha, does not receive humanitarian aid and is not part of an addiction treatment program. This chapter looks at forms of kinship that emerge in Aisha’s life amidst serial war in Afghanistan—her relationship to another widow who cares for her, to a wider network of friends, and to heroin. The haalat (situation, condition) of Afghanistan of serial war spanning almost four decades is taken here as an analytical category to unsettle etiologies of addiction, and to critique liberal imaginaries of resilience. By ethnographically exploring the case of Aisha, this chapter asks us to consider the effects of war and humanitarianism on the health of those repeatedly subjected to it and the varied modes of attachment to life that are forged in Afghanistan.

Considerations in the Diagnosis and Management of Lower-Extremity Infections in Injection Heroin Users: A Case Series

Background: On a national level, heroin-related hospital admissions have reached an all-time high. With the foot being the fourth most common injection site, heroin-related lower-extremity infections have become more prevalent owing to many factors, including drug preparation, injection practices, and unknown additives. Methods: We present a 16-month case series in which eight patients with lower-extremity infections secondary to heroin abuse presented to The Jewish Hospital in Cincinnati, Ohio. Results: Three cases of osteomyelitis were seen. All of the infections were cultured and yielded a wide array of microbes, including Staphyloccoccus, Streptococcus, Bacillus, Serratia, Prevotella, and Eikenella. All of the patients were treated with intravenous antibiotic agents, with nearly all receiving combination therapy. Seven of the eight patients underwent surgery during their hospital stay, with two undergoing amputation. Only half of the patients followed up after discharge. Conclusions: This case series brings to light many considerations in the diagnosis and management of the heroin user, including multivariable attenuation of immunity, existing predisposition to infection backed by unsterile drug preparation and injection practices, innocuous presentation of deep infections, microbial spectrum, and recommendations on antimicrobial intervention, noncompliance, and poor follow-up. By having greater knowledge in unique considerations of diagnosis and treatment, more efficient care can be provided to this unique patient population.

Analysis of a First Unilateral and Then Bilateral Internal Jugular Vein Thrombosis in a Heroin User

This report documents a first unilateral and then bilateral internal jugular vein (IJV) thrombosis as a result of repeated injections of heroin, which is rare in a practice of oral and maxillofacial surgeon. The patient was a 21-year-old male who was referred to a hospital with the diagnosis of phlegmon of the right neck. Emergency non-contrast computed tomography (5 images and 1 Supplemental Video are presented) revealed a hyperattenuating content in the lumen of expanded right IJV which fills its entire length. The patient received initial treatment according to the protocol. Ultrasound (US) (2 images and 2 Supplemental Videos are presented) in a first 24 hours supported the diagnosis describing a case as occlusive acute thrombosis. After 4 days of a positive dynamic the patient was transferred to outpatient mode. In a 10 day US examination (2 images and 2 Supplemental Videos are presented) simultaneously with positive changes in the lumen of a right IJV (partial clot lysis) an appearance of a left IJV thrombosis was noted. Analysis of thrombotic conditions of the neck, diagnostics methods, treatment options, and complications are performed.

How Top-Down and Bottom-Up Regulation in Fronto-Amygdalar Network Changes over Time during Drug Cue-Exposure: An fMRI Study among Abstinent Heroin User

Top-down regulation is one of the major neural cores in drug-craving management and relapse prevention. The dynamic temporal behavior of top-down regulation between the dorso-lateral and ventro-medial prefrontal cortices (DLPFC and VMPFC) and amygdala during drug cue-exposure has not been studied yet. Fifteen abstinent participants with heroin use disorder were scanned using drug cue-induced craving fMRI task. Using Dynamic Causal Modelling (DCM), the winning model showed a significant reciprocal connection between the VMPFC and DLPFC while there was a one-way effect of the VMPFC on the amygdala. There is also a top-down modulation by DLPFC on the VMPFC-Amygdala connection. Craving contrast input only modulated amygdala directly. Using sliding-window for temporal evaluation, craving input to amygdala increased over time, simultaneously, DLPFC top-down modulatory effect on VMPFC-amygdala connection decreased. Temporal changes in the network connectivity during cue exposure with enhancement in craving input to amygdala and reduction in top-down modulatory effects of DLPFC, could provide us with new insights towards the dynamic nature of the cue-reactivity and failure to control its motivational consequences. Dynamic response of top-down regulatory networks during cue exposure can be considered as a new potential biomarker in the future addiction fMRI studies.

Infective Endocarditis of a Left Ventricular Myxoma in a Heroin User

Infected cardiac myxomas are rare and can have disastrous sequelae; urgent surgical resection is typically indicated. We report the case of a 43-year-old user of intravenous heroin who presented with weakness and dyspnea. He was diagnosed with infective endocarditis of a myxoma attached to the left ventricular lateral wall. The patient underwent successful surgical resection of the myxoma and then completed 4 weeks of antibiotic therapy. In addition to discussing this patient's case, we briefly review the relevant medical literature, in which we found only 4 previous reports of left ventricular myxoma associated with infective endocarditis.