title: High rates of midazolam injection and associated harms in Bangkok, Thailand.
abstract: OBJECTIVE
  To identify the prevalence and correlates of midazolam injection among injecting drug users in Thailand.
  
  
  METHODS
  Serial cross-sectional mixed-methods study.
  
  
  METHODS
  Bangkok, Thailand.
  
  
  METHODS
  A total of 435 adults who had injected drug(s) in the past 6 months were recruited through peer outreach and word of mouth in Bangkok in 2011.
  
  
  METHODS
  Multivariable logistic regression was used to analyze self-reported data collected through an interviewer-administered survey in July-October 2011 (n = 435). Additionally, qualitative data were collected in June-July 2009 (n = 10) and analyzed to explore the health problems attributable to midazolam injection.
  
  
  RESULTS
  Among 435 survey participants, the prevalence of daily midazolam injection in the past 6 months was 37.0% (95% confidence interval: 32-42). While 75.8% of the daily midazolam injectors identified heroin as their drug of choice, 91.8% of these individuals reported substituting heroin with midazolam when heroin was unavailable. In multivariable analyses, daily midazolam injection was associated with femoral vein injection [adjusted odds ratio (AOR) = 4.48], polydrug use (AOR = 4.94), daily heroin injection (AOR = 3.25), binge use (AOR = 1.75) and perceived increase in policing pressure (AOR = 1.95) (all P < 0.05). Qualitative accounts indicated severe health problems associated with midazolam injection, including nerve and vascular injuries.
  
  
  CONCLUSIONS
  Midazolam misuse is increasing among injecting drug users in Bangkok and appears to be used primarily as a substitute for heroin. Midazolam injection was associated independently with various risk factors for injection-related complications. Given the many deleterious effects of midazolam injection, novel interventions for midazolam injectors are needed urgently.
authors.affiliation: Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.
authors.forename: Kanna
authors.initials: K
authors.lastname: Hayashi
authors.forename: Paisan
authors.initials: P
authors.lastname: Suwannawong
authors.forename: Lianping
authors.initials: L
authors.lastname: Ti
authors.forename: Karyn
authors.initials: K
authors.lastname: Kaplan
authors.forename: Evan
authors.initials: E
authors.lastname: Wood
authors.forename: Thomas
authors.initials: T
authors.lastname: Kerr
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D003932:Heroin / Q000008:administration & dosage*; D006556:Heroin Dependence / Q000453:epidemiology*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D008297:Male; D008874:Midazolam / Q000008:administration & dosage*; D008875:Middle Aged; D009294:Narcotics / Q000008:administration & dosage*; D015995:Prevalence; D012307:Risk Factors; D057566:Self Report; D015819:Substance Abuse, Intravenous / Q000453:epidemiology*; D013785:Thailand / Q000453:epidemiology
chemical_list: D006993:Hypnotics and Sedatives; D009294:Narcotics; D003932:Heroin; D008874:Midazolam