The Committee would also like to thank several consultants who assisted the Committee during the literature review: Sarah Lewis, Katherine McLean, Adriana Van Breda, and Maya Yiadom. Third, even where mortality data are collected, they are often not comparable across countries, or even within countries, because of the lack of standardization and categorization. Anal sex has been reported to be more common among white injecting drug users than among black injectors Lewis and Watters, 1991 and more common among Latino injectors than either white or black injectors in New York Friedman et al. Years of injection are defined by subtracting age at first injection from current age. Since the limited resources and expertise available in some developing countries often preclude the use of large studies, particular consideration should therefore be given to the development and the implementation of simple rapid assessment methods which can inform cost-effective and culturally appropriate interventions. Second, both the legal and illegal drug industries have undergone globalization over the last two decades. Many areas reached a prevalence of 40 per cent or more among injectors within approximately 12 months.
Several commentators have highlighted the limitations of this research and conclude that the determinants of the relationship between drug use and sexual behaviour remain unclear Rhodes and Stimson, 1994. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible, and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. There is some evidence that drugs, and in particular opioids, may have physiological and psychological effects which impair sexual functioning and lower sexual activity Mirim et al. They were more helpful in Santos. Certain countries have a tradition of responding to 217 A.
Heroin is the most commonly injected drug, but cocaine use has also increased. Therefore, in most cases, detoxification can occur in non-medical settings, thereby reducing costs, increasing accessibility and enabling programmes to be sited within the community. Some studies appear to have identified a link between alcohol use and unsafe sexual practices Plant, 1990 , while others have found no evidence of such an association Weatherburn et al. Evidence from around the world, some of it presented in Chapters 12 and 13, has shown that drug injectors are capable of making rational decisions about health and are capable of changing their behaviours to remain healthy. These events had major implications for the development of heroin production in Myanmar and the later adoption of heroin smoking and injection there.
To take an example, in New York restrictions on the availability of injecting equipment to drug users has influenced the level of sharing. Possibly the earliest documented adverse health consequence of illicit drug injection was a case of tetanus in a female morphine injector Anonymous, 1876. They are both passed from person to person, both are communicable. The injectable forms of drugs are usually more compact than the non-injectable ones heroin is less bulky than opium, and so is cocaine hydrochloride compared to cocaine paste and therefore easier to smuggle. More specifically, efforts to stem the international illicit drugs industry have seen the establishment of new areas of production and routes for trafficking, and subsequently the emergence of new drug use patterns International Narcotics Control Board, 1996. The ongoing agency survey is managed by V. Treatment for chronic hepatitis C at 45 M.
With heroin, this is typified by the shift of refining to opium growing areas, a technology transfer that takes advantage of improved communications and transport, and the reduction of production and transport costs by moving production to areas of cheap labour. Similarly before using crack, 17 per cent of the drug users reported having exchanged sex for drugs. Various motivational methods have been developed to encourage drug users to assess their substance use and consider change Hester, 1993; Miller and Rollnick, 1991. This study represents the largest international project of its kind, using a standardized methodology and instrument for the collection of data. The overall health of drug users is not 52 Health and Social Consequences of Injecting Drug Use just an issue of individual pathology, but a public health issue which is determined by the wider environment in which drug use and drug injecting occur. These outbreaks have been associated with increases in injecting drug use and have accompanied major socio-political changes. The lack of analgesics in North Vietnam during the war resulted in the use of parenteral opium, and possibly heroin, 3 G.
Health Promotion The health of drug injectors is inexorably linked to the broader social context in which drug injectors lead their lives. Printed in the United States of America. The willingness of injectors to reduce injecting risk behaviour to a greater extent than sexual risk behaviour is sometimes interpreted as inconsistent. Choopanya 1991 heroin use has again increased, with a switch to injecting which is now the predominant mode of use. Not all drug users seeking treatment are prepared to stop using drugs immediately.
Hepatitis C is prevalent in many populations of drug injectors. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. Across all the centres, of those who did have intercourse with Table 4. What the low prevalence areas had in common, and what distinguished them from the high prevalence areas, was the speedy implementation of a policy of needle and syringe provision combined with outreach services to injectors see also Chapter 12. Contextual factors influence the overall level of sharing between injectors, who shares with whom, and the use or non-use of condoms.
In the majority of studies which have collected data on the sexual behaviour of injectors, fairly low levels of condom use have been identified. The experience of community-based agonist pharmacotherapy programmes in developing countries such as India, Nepal and Thailand as described above may help to inform the reorientation of substitution programmes in developed countries. At an extreme, mixing and mobility and consequent diffusion of drug use practices may be witnessed in multinational drug scenes that occur in many inner-city areas in Europe. Therefore it may prove more difficult to initiate change in sexual risk behaviour to the same degree as injection behaviour. The lowest rates of condom use with primary partners were found in Rio de Janeiro, Athens and Glasgow. By 1990 injecting, though still relatively rare, was found in many sectors of Madras. Chapter 9 makes comparisons of sexual behaviours among cocaine and opioid injectors.
The views expressed in this paper do not necessarily reflect the positions of the granting agencies or of the institutions by which the authors are employed. The diffusion of injecting and the transmission of infection occur through the networks created by drug injectors. One needs to be careful in using this hierarchical model. For each community it is likely that different sitespecific factors exist which influence transitions. As in Thailand, the expansion of poppy growing and heroin refining occurred at the time of the war in Vietnam.