Older intravenous drug users in methadone treatment: numbers, stories and lessons learned for harm reduction
Methadone is used world-wide as a first choice treatment for opioid dependency. However, heroin use in treatment is common, especially for dual users of heroin and crack/cocaine or other stimulants. In addition, intravenous (IV) use increases the risk of health complications, and in an ageing population further chronic conditions such as diabetes, COPD, chronic pain, kidney and liver disease contribute to a deteriorating quality of life.
This is a secondary analysis of collected data exploring physical health and drug use in methadone treatment in older people with a history of IV heroin use.
Participants: Dual users of heroin and crack who have ever injected heroin and are currently in methadone treatment at two services in London, UK (age over 40, n=148 part 1; n=27 part 2 and 3)
Data collection: Clinical records (Part 1); interviews covering the history of drug use, treatment, and physical health (Part 2 and 3).
Groups compared: Group 1: currently using heroin, good health
Group 2: currently using heroin, poor health
Group 3: heroin abstinent, poor health
Predictors: drug and alcohol use, mental health, methadone dose, age of first use (part 1 and 2); use of high risk IV sites (groin, neck), switch from IV to smoking, cardiovascular risk, injecting technique, duration of IV use, methadone treatment (part 2)
Outcome: IV-related physical health
Statistical analyses: Chi2 (Part 1), t and Fisher’s exact tests, bivariate associations (part 2);
Compared to group 1, more people in group 2 have ever injected crack (53% vs 31% p=0.02), and were still injecting heroin (52% vs 29% p=0.02) and crack (34% vs 18% p=0.04), suggesting that IV use and history of crack injection are linked with poor health.
However, despite poor health, none of those in group 3 were injecting any drug, and as in group 1 only 31% have ever injected crack.
Bivariate associations showed significant correlations between poor health and (1) high risk IV sites (OR=9.6, 95%CI: 1.5–62.2) and (2) switch to smoking (OR=0.08, 95%CI: 0.01–0.76).
Group 1 differed from the other groups in the number of individuals who switched to smoking (90%, 50%, 29%, p=0.03), used high-risk sites (20%, 70%, 71%, p=0.04), and duration of injecting during methadone treatment (6, 11, 13 years, p=0.01).
Cases from each group are presented to illustrate why stopping heroin use did not help to preserve health for group 3, while users in group 1 were still in good health, and how chronic health conditions influenced choices between drug use and abstinence.
Possible harm reduction interventions for drug users in treatment are discussed.
Some people access methadone treatment to reduce rather than stop drug use. Routinely collected clinical data give only a partial view on long-term outcomes of IV users in treatment. The history of injecting behaviour, health, social life and users’ own narratives are necessary to understand poor outcomes in older age, and find ways to reduce health deterioration.