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Harm Reduction Journal volume 16Article : 65 Cite this article. Metrics details. In several countries, especially in Africa, the dominant method of heroin intake is smoking a t of cannabis laced with heroin. There is no data exploring the impact of smoking heroin with cannabis on treatment outcomes. To compare treatment outcomes between people who inject heroin and people who smoke heroin with cannabis. Three hundred heroin users were assessed on admission to inpatient rehabilitation and after treatment.

The sample comprised There were no ificant differences in psychopathology, general health, criminality and social functioning between IV users and heroin-cannabis smokers at all three time points. Heroin users who do not inject drugs but use other routes of administration may have increased risk for relapse to heroin use after inpatient rehabilitation and should therefore have equal access to harm reduction treatment services. Advocating a transition from injecting to smoking heroin in an African context may pose unique challenges. Injecting and chasing heroin are the most common methods of heroin use described in the literature.

Injecting heroin is reported to pose the most harmful effects due to risks of overdose, transmission of blood borne viruses, more severe symptoms of dependence, longer heroin-using careers and higher rates of criminality and homelessness [ 1 ]. Due to the severe harms associated with injecting, there have been harm reduction campaigns aimed at helping heroin injectors transition to inhaling heroin [ 234 ].

This could be a possible intervention in some African countries where there is a high prevalence of HIV and there are concerns about an increasing of injecting heroin users. South Africa, Kenya and Tanzania have reported a ificant proportion of heroin users who smoke heroin combined with cannabis [ 5678 ]. Data are however limited and the papers from Kenya and Tanzania are qualitative and therefore do not report on the specific s of heroin-cannabis smokers.

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The common street names for heroin in South Africa are nyaopewhoonga and thai. Typically, a user rolls a t of cannabis, pours over a bag of nyaope and smokes it [ 5 ]. The reasons behind different routes of intake and drug combinations are not always fully understood.

Different methods of drug use may however influence the severity of dependence and treatment outcomes. Furthermore, different methods of use may impact access to treatment. For example, in Kenya, access to opioid agonist maintenance treatment OAMT and other harm reduction services are reserved for injecting heroin users, and heroin-cannabis smokers have limited access [ 6 ].

Similarly, in South Africa, of the few state- and non-government-funded OAMT clinics, the majority exclusively serve people who inject drugs [ 9 ]. In some African regions, much needed harm reduction services are slowly gaining impetus due to national HIV prevention and treatment campaigns for people who inject drugs. Whilst the roll-out of OAMT is much needed, it is also important to consider the larger heroin-using population and compare characteristics and treatment outcomes between heroin-cannabis smokers and heroin injectors.

It is therefore worthwhile investigating different methods of heroin use and the biological, psychological and social sequelae thereof. These data may also help inform whether harm reduction campaigns that advocate a transition from injecting to smoking heroin would be advisable in areas where heroin is predominantly smoked with cannabis. Participants were recruited from two state-funded drug and alcohol rehabilitation centres in the Gauteng Province of South Africa.

The programmes entailed 1 week of inpatient detoxification followed by 6 to 8 weeks of psychosocial rehabilitation. Upon completion, most participants returned home and were encouraged to see their local social workers for follow-up and attend community-based self-help groups such as Narcotics Anonymous. A convenience sample of new admissions whose primary drug of use was heroin was screened for inclusion and exclusion criteria. In order to be enrolled in the study, participants were expected to.

Participants were not compensated for their participation but were given 7 USD transport compensation if they returned to the research site for their follow-up interview. Participants that were seen at home or hangout spots were not compensated. No telephonic interviews were done. All baseline and follow-up interviews were conducted face-to-face by the PI who is a psychiatrist.

Recruitment and data collection were conducted between July and February The PI was not part of the treating team at the rehabilitation facilities. Participants did not read or answer any of the questionnaires on their own. At baseline, a detailed socio-demographic and past substance use questionnaire created specifically for the study was administered.

The Opioid Treatment Index OTI [ 14 ], which included sections on the past month drug use, past month injecting and sexual practices, social adjustment, past month criminal history and general health, was administered at baseline and both follow-up occasions. Drug use estimates in the OTI are based on the average use episodes of a substance per day. Drug use is expressed as a Q score which describes the frequency of drug use. A Q score of 1. Screening for ASPD was only done at baseline interview.

Urine collection was unsupervised; however, a research assistant was trained to identify any unusual changes in colour, temperature or smell. The MDUT tested for the presence of opioids, cocaine, amphetamines, methamphetamine, cannabis and benzodiazepines.

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Those who relapsed to heroin use after rehabilitation were classified as continued heroin users CHU. Therefore, in cases where no MDUT was available, self-reported substance alone was used to determine drug use. A sample size of for this project corresponds to a precision of 5.

Continuous variables were assessed by the independent samples t test. Where the data did not meet the assumptions of these tests, a non-parametric alternative, the Wilcoxon rank sum test was used. Comparison of heroin-cannabis smokers and IV users was carried out analogously. Data analysis was carried out using SAS version 9. Over the recruitment period, clients were screened. Eight did not fit the inclusion and exclusion criteria and five refused participation. A total of participants ed consent and were enrolled in the study; however, four were withdrawn during baseline BL interviews as they were assessed as actively suicidal.

The final sample thus consisted of participants, Of the total, Fifty-nine participants The median duration of heroin use was 7 years IQR 4—9 year. Further details of the baseline sample have been presented in reports [ 19 ]. At baseline, The most common substances used, other than heroin and cannabis, were crack-cocaine, crystalmetamphetamine and methaqualone. At baseline, there was no ificant difference in the median of past month use episodes between IV users and heroin-cannabis smokers for heroin, crystalmetamphetamine, crack-cocaine and methaqualone.

Two hundred fifty-two participants Over the study period, 12 participants were not interviewed as they were incarcerated at the time of follow-up interview and four participants passed away. MDUTs were done on At 3-month follow-up, For this analysis, we only used data from the participants that were seen at all three time points. At the first follow-up, 42 At baseline, excluding ASPD, The most common were past major depressive episode At all three time points, there was no ificant difference in the prevalence of mental illnesses between heroin-cannabis smokers and injectors.

Social functioning scores reflect data on accommodation, relationships and employment. At all time points, there were no ificant differences between the median social functioning scores of heroin-cannabis smokers and injectors or in their median general health scores Table 2. There was a ificant decrease in the proportion of IV users from This however increased ificantly to Of the initial sample of Of those who knew their HIV status, This is the first study to compare characteristics and treatment outcomes between heroin-cannabis smokers and injecting heroin users. It was expected that IV users would fare more poorly in all domains of treatment outcome.

Contrastingly, heroin injectors demonstrated higher abstinence rates, had fewer heroin use episodes and used fewer substances compared with heroin-cannabis smokers. Heroin-cannabis smokers also did not differ ificantly to injectors in regard to psychopathology, general health, social functioning and criminality. Amongst injectors however, the overwhelming majority shared needles before and after treatment. There was also a higher prevalence of HIV and crystalmetamphetamine use than amongst heroin-cannabis smokers at both post-treatment follow-up points.

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In analysing thesethere are a few factors to consider, namely the impact of cannabis in the overall addiction severity, the role of smoked heroin and lastly contextual factors such as local treatment services and HIV prevalence. Interestingly, although there is a paucity of data on heroin-cannabis smokers, there are numerous animal model studies examining the synergistic interactions of the cannabinoid and opioid systems. Animal model data describe the ability of cannabinoids to prime the endogenous opioid system and attenuate the effects of opioid withdrawal [ 2021 ].

In this way, cannabinoids are said to readily interact with the opioid system and thereby modify behavioural responses linked to reward and relapse related phenomena. Some suggest that this potentiates the pharmaceutical benefits of cannabinoids in opioid dependence and pain management [ 2022 ]. It may also however provide insight into why heroin-cannabis smoking is a preferred method of use in some regions. Further studies of heroin-cannabis smokers may provide new insights in the field of cannabinoid-opioid biochemistry.

Clinical studies assessing the impact of cannabis use in heroin users in the United States US and Israel found that cannabis use in people receiving OAMT did not negatively impact heroin abstinence rates [ 232425 ]. In the US, currently there are also debates around the role of cannabis in the opioid epidemic [ 26 ]. It has been suggested that cannabis or cannabinoid products may be a less harmful alternative for those with opioid dependence and chronic pain [ 2627 ].

Those who refute this standpoint state that there is insufficient evidence to justify cannabis as an effective and safe analgesic and that cannabis acts as a companion drug that may increase use of opioids rather than abate it [ 28 ]. The data suggest that in this cohort cannabis use was not protective against heroin abstinence later on. Owing to the method of combination use, the risk for heroin relapse is expectedly higher in South Africa. There are however other challenges with relating international data to a South African cohort; from BL, a smaller proportion described using cannabis on its own Methods of heroin use have evolved at varying time periods in different countries [ 2930 ].

The findings that heroin-cannabis smokers had higher rates of CHU and a greater of daily heroin use episodes post-treatment is new. Furthermore, heroin-cannabis smokers and injectors did not differ in regard to the prevalence of psychopathology and total scores for social functioning and criminality.

The similarities in these domains suggest that smoking heroin with cannabis resulted in equal levels of psychosocial distress. Cross-sectional studies in the UK describe more severe symptoms of heroin dependence in injecting users than chasers [ 3132 ]. A Spanish study found no major differences in the severity of heroin dependence between heroin injectors, smokers and sniffers in long-term users [ 33 ]. The median age at enrolment for IV users was lower and IV users began heroin use at a ificantly younger age. This may reflect that IV users begin heroin use earlier however present sooner to rehabilitation presumably due to their concerns about the risks of injecting and sharing needles.

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