Russia's increasing wealth means it no longer qualifies for many Global Fund grants that have helped fund its harm reduction programmes for injecting drug users. But the Russian Government, rather than honour an earlier commitment to continue funding these programmes, has indicated it will instead focus on promoting healthy lifestyles in the general population. The issues are discussed in the lead Editorial in this week's edition of the Lancet.
The Editorial says: "Given Russia's much documented appalling health record (which President Dmitry Medvedev has acknowledged is two-thirds due to lifestyle factors), together with a history of focusing on treatment over prevention and the lofty status given to hospitals compared with community health programmes, the country's recent focus on health promotion is a most welcome step. However, it would be incomprehensibly short-sighted if the Russian Government decided that such a positive policy change for population health should be to the detriment of the 1•8 million people who inject drugs."
The Editorial urges the Russian government to continue funding the harm reduction programmes as well as the population health programmes. It also asks the Global Fund to reconsider its funding strategy, so that it does not only take account of a population's wealth as a whole. The Editorial says: "Although wealth is an important criterion, NGOs and civil society groups (such as GLOBUS*) working in countries that persistently neglect the needs of their most vulnerable populations should be considered eligible for funding so they can provide crucial services to people who would otherwise not receive them."
It concludes: "At the 3rd Eastern Europe and Central Asia AIDS Conference in Moscow later this month, the Russian Government could show great leadership and announce that it will financially support harm reduction programmes for its vulnerable groups. Such a move would show the international community that Russia is a serious partner in tackling the HIV epidemic."
A Review also in this week's Lancet discusses the issues related to the admission of injecting drug users to hospital. The Review is written by Professor Paul S Haber, Drug Health Services, Royal Prince Alfred Hospital, Sydney, Australia, and colleagues.
Of the world population aged 15-64 years, an estimated 16 million people inject drugs regularly. The most commonly injected drugs are amphetamine-type stimulants, opiates, and cocaine. The authors say that when injecting drug users need hospital treatment, the first challenge is to engage them into hospital care. They say: "A non-judgmental approach towards patients and acceptance of their lifestyle choices facilitates engagement. Pragmatic clinical goals can be negotiated and achieved."
The most frequent presentations to emergency departments were soft-tissue infections, overdose, intoxication, and withdrawal. Most hospital admissions were due to bacterial infections related to drug injection, such as cellulitis and soft-tissue infections. Other reasons for admissions include trauma and injuries sustained while intoxicated, or associated with drug-related violence. Injecting drug users may be admitted to specialist wards for complications of infections such as hepatitis C, HIV/AIDS, and sexually-transmitted infections, or for consequences of comorbid alcohol abuse.
Treatment of intoxication is generally supportive and symptomatic, with regular assessment for cardiorespiratory safety. Initial management priorities for opioid overdose are airway protection, correction of hypoxia (reduced oxygen content in the blood), and stabilisation. For management of withdrawal symptoms, short-term interventions, such as detoxification, are not successful in the management of opioid dependence. By contrast, the effectiveness of opiate substitution (eg, methadone) treatment is clear. These strategies, along with harm reduction programmes in the community, are discussed at length in the Review. The authors also discuss the pain management in injecting drug users in hospital, and the importance of not simply dismissing such requests as attempts to seek additional drugs.
The authors conclude: "Substance misuse is common, and it is likely that most medical practitioners will be required at times to assess and manage patients who inject illicit substances and have associated complications. Management involves adopting a non-judgmental and problem-solving approach for both psychosocial and medical issues, with pharmacotherapy where appropriate. While these disorders can be challenging, management is often relatively straightforward and rewarding."
The Lancet Press Office. T) +44 (0) 20 7424 4949 E) pressoffice@lancet.com
Professor Paul S Haber, Drug Health Services, Royal Prince Alfred Hospital, Sydney, Australia. Contact by e-mail only. E) phaber@mail.usyd.edu.au
For full Editorial and Review, see: http://press.thelancet.com/idu.pdf
Note to editors: * GLOBUS=Global Efforts Against AIDS in Russia
Journal
The Lancet