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Groin injecting among a community-recruited sample of people who inject drugs in Thailand Ti, Lianping; Hayashi, Kanna; Kaplan, Karyn; Suwannawong, Paisan; Wood, Evan; Kerr, Thomas Jan 16, 2014

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RESEARCH Open AccessGroin injecting among a community-recruitedsample of people who inject drugs in ThailandLianping Ti1,2, Kanna Hayashi1,3, Karyn Kaplan4, Paisan Suwannawong4, Evan Wood1,5 and Thomas Kerr1,5,6*AbstractBackground: Use of the femoral vein for the injection of illicit drugs (i.e. groin injecting) has been linked to varioushealth-related harms, including deep vein thrombosis. However, little is known about the prevalence of groininjecting and factors that predict this practice among people who inject drugs (PWID) in Thailand. We sought toinvestigate the prevalence and factors associated with groin injecting in Bangkok, Thailand.Methods: Data were derived from the Mitsampan Community Research Project in Bangkok between July andOctober 2011. Multivariate logistic regression was used to identify factors associated with groin injecting in the lastsix months.Results: Among 437 participants, 34.3% reported groin injecting in the last six months. In multivariate analyses,factors positively associated with groin injecting included: having higher than secondary education (adjusted odds ratio[AOR] = 1.59; 95% confidence interval [CI]: 1.00 – 2.56), weekly midazolam injection (AOR = 8.26; 95% CI: 5.04 – 14.06), andreports of having had drugs planted on oneself by police (AOR = 2.14; 95% CI: 1.37 – 3.36).Conclusions: Over one-third of our sample of Thai PWID reported recent groin injecting. Frequent midazolam injectionand higher education were found to be associated with groin injecting. That high intensity PWID were more likely toinject in the groin is concerning given the known negative consequences associated with the groin as a site of injection.Additionally, PWID who reported drug planting by police were more likely to inject in the groin, suggesting that relianceon law enforcement approaches may undermine safe injection practices in this setting. These findings highlight the needfor evidence-based interventions to address the harms associated with groin injecting, including efforts to alert PWID torisks of groin injecting, the distribution of appropriate injecting equipment, and efforts to encourage use of other injectingsites.Keywords: Groin injection, People who inject drugs, Midazolam, Police, ThailandBackgroundIn recent years, there has been growing concern over theuse of the femoral vein for intravenous access (i.e. groininjecting) by people who inject drugs (PWID). While thegroin is rarely the initial site of injection for PWID, thereis often a progression towards groin injecting after yearsof continued injecting [1]. The most probable reason forthis progression may be related to the physical healthcomplications associated with repeated injecting in othersites, including the loss or perceived loss of peripheral veinaccess [1,2].Historically, groin injection has been described as an ex-tremely high-risk behaviour and a “last resort” for manyPWID [3]; yet more recently, the use of the femoral veinas a site of injection has become increasingly normalizedamong PWID populations [4]. Previous research haveidentified reasons for the increasing use of groin injecting,which include: the groin being a reliable site of injection,and that it allows for a convenient and speedy injection es-pecially among PWID who inject in public [4,5]. Further-more, the groin appears to be a discreet site of injection,and allows track marks to remain hidden from the publicand police [4,6].* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada5Department of Medicine, University of British Columbia, St. Paul’s Hospital,1081 Burrard Street, Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© 2014 Ti et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwisestated.Ti et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:4http://www.substanceabusepolicy.com/content/9/1/4In Thailand, there has been a rise in use of midazolamamong PWID [7,8]. Midazolam is a fast, short-actingbenzodiazepine that has potent amnesic and sedativeproperties [9]. The increasing use of midazolam is believedto be a consequence of the Thai government’s reliance onheavy drug law enforcement [7], which has indirectlyaffected the availability and pricing of heroin and otherillegal drugs [10,11]. The low price of midazolam, and thefact that midazolam is easy to acquire as a licit drug,makes this substance an appealing alternative to heroinfor Thai PWID [8]. The use of this particular drug may bea concern given that there may be health-related compli-cations (e.g., venous blockage leading to amputation) thatcould adversely impact the health of PWID [12].The normalization, and subsequently, the apparent in-creasing use of groin injection by PWID represents a ser-ious public health issue. Research suggests that groininjecting is associated with a wide array of health prob-lems, including deep vein thrombosis [13,14], leg ulcers[15], venous gangrene [16] and injection-related infections[17]. In addition, its close proximity to the femoral nerveincreases the risk of nerve damage and related complica-tions [2,16]. Despite the above issues, the practice of groininjecting has not, to our knowledge, been extensively doc-umented among PWID in Asia, a setting where evidenceof police corruption and violence have been observed [11].For instance, studies have indicated that police in Thailandhave been guilty of planting drugs on suspected PWID toextort money or provide grounds for arrest [18]. Wesought to identify the prevalence and factors associatedwith groin injecting among a community-recruited sampleof PWID in Bangkok, Thailand.MethodsThe Mitsampan Community Research Project is a col-laborative research project involving the MitsampanHarm Reduction Center (Bangkok, Thailand), the ThaiAIDS Treatment Action Group (Bangkok, Thailand),Chulalongkorn University (Bangkok, Thailand), and theBritish Columbia Centre for Excellence in HIV/AIDS(Vancouver, Canada). During July and October of 2011,the research partners undertook a cross-sectional studyinvolving 440 community-recruited PWID who were re-cruited through peer-based outreach efforts and word-of-mouth. Individuals residing in Bangkok or adjacentprovinces who had injected drug(s) in the past sixmonths were eligible for participation in the study. Allparticipants provided oral informed consent and com-pleted an interviewer-administered questionnaire elicitinginformation about demographic characteristics, drug use,HIV risk behaviour, and criminal justice system exposure.The survey instrument was developed in consultation withpeer researchers, which involved brainstorming key issuesin the community and designing a questionnaire to reflectthe community’s concerns. Prior to finalizing the sur-vey instrument, follow-up discussions, piloting, andfine-tuning were conducted to ensure the accuracy andfeasibility of the instrument. Additionally, language dis-crepancies between English and Thai versions were ad-justed with the assistance of bilingual co-authors (KK,PS) of the manuscript. While this survey instrumenthas yet to be officially validated, our findings using thesame questionnaire have been consistent with prior re-search conducted in Bangkok [19,20]. Upon completionof the questionnaire, participants were provided with astipend of 350 Thai Baht (approximately $11 USD).The study has been approved by the research ethicsboards at Chulalongkorn University and University ofBritish Columbia.For the present analysis, the outcome of interest wasgroin injection in the past six months. We comparedPWID who had and had not injected in the groin using bi-variate statistics and multivariate logistic regression. All par-ticipants who completed the survey between July andOctober 2011 were eligible for inclusion. Variables consid-ered included: median age (≥ 38 years vs. < 38 years), gen-der (male vs. female), higher than secondary level education(≥ secondary education vs. < secondary education), heroininjection (> weekly vs. ≤ weekly vs. none), midazolam injec-tion (> weekly vs. ≤ weekly vs. none), methamphetamine in-jection (> weekly vs. ≤ weekly vs. none), length of injectingcareer (years), binge drug use (yes vs. no), syringe sharing(yes vs. no), injecting in public places (yes vs. no), havinghad a non-fatal overdose (yes vs. no), reporting needinghelp injecting (yes vs. no), injected with others on a fre-quent basis (> 75% of the time vs. ≤ 75% of the time),ever experienced barriers accessing healthcare services (anyvs. none), and reported a history of drug planting by police(i.e., having drugs planted on oneself by police) (yes vs. no).All variables refer to the previous six months unless other-wise indicated. All variables refer to the previous sixmonths unless otherwise indicated. Binge drug use refers tohaving injected drugs more than usual. PWID who injectedin public places were coded as “yes” if they injected drug(s)in the following places: public washroom, under highways,in bush/jungle, parking lot, abandoned building, bus, phonebooth, shopping mall, and temple. Barriers to accessinghealthcare were defined as in a previous study [21], and in-cluded barriers such as: long wait lists/times, stigma anddiscrimination by healthcare professionals, among others.‘Drug planting by police’ was included as a potential ex-planatory variable given that anecdotal evidence from astudy in Mexico, a setting with a similar law enforcementapproach to drug control as Thailand, suggested an associ-ation between a history of negative experiences with lawenforcement and groin injecting [6].To examine bivariate associations between each inde-pendent categorical variable and groin injecting, we usedTi et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:4 Page 2 of 7http://www.substanceabusepolicy.com/content/9/1/4the Pearson X2 test. Fisher’s exact test was used whenone or more of the cells contained values less than orequal to five. For continuous variables, we used simplelogistic regression. We applied an a priori-defined statis-tical protocol based on examination of the Akaike Infor-mation Criterion (AIC) and p-values to construct anexplanatory multivariate logistic regression model. First,we constructed a full model including all variables ana-lyzed in bivariate analyses. After noting the AIC of themodel, we removed the variable with the largest p-valueand built a reduced model. We continued this iterativeprocess until no variables remained for inclusion. We se-lected the multivariate model with the lowest AIC score.Given previous work suggesting a strong association be-tween drug planting by police and midazolam injecting[18], as a subanalysis, we examined potential interactioneffects between drug planting by police and midazolam in-jection in the previous six months. We also ran a secondmultivariate logistic regression model that included a his-tory of midazolam injection (yes vs. no) in replacement ofthe variable ‘weekly midazolam injection in the previoussix months’ on the basis that past injection of midazolamcould predict future groin injection. All p-values were twosided.ResultsIn total, 437 individuals completed the survey and partici-pated in this study. Three participants were excluded fromthe original sample given that data for these individualswere incomplete. The sample included 86 (19.7%) females.The median age of participants was 38 years (interquartilerange: 34 – 48 years). Among our study sample, 34.3% re-ported having injected in the groin in the past six months.As indicated in Table 1, in bivariate analyses, factors sig-nificantly and positively associated with groin injecting in-cluded: higher than secondary level education (odds ratio[OR] = 1.83; 95% confidence interval [CI]: 1.20 – 2.78), >weekly heroin injection vs. none (OR = 1.83; 95%CI: 1.09 –3.08), > weekly midazolam injection vs. none (OR = 10.93;95%CI: 5.59 – 21.37), binge drug use (OR = 1.90; 95%CI:1.25 – 2.90), and reporting having drugs planted by police(OR = 2.14; 95%CI: 1.43 – 3.20). Less than weekly metham-phetamine injection was negatively associated with the out-come in bivariate analysis (OR = 0.60; 95%CI: 0.37 – 0.98).The adjusted estimates of factors associated with groininjection are presented in Table 2. In Model 1, factorsthat remained positively and independently associatedwith groin injecting were weekly midazolam injection(adjusted odds ratio [AOR] = 9.67; 95% CI: 5.10 – 20.06)and having drugs planted by police (AOR = 2.09; 95% CI:1.33 – 3.29). An analysis of potential interaction effectsinvolving drug planting by police and a history of mid-azolam injection was conducted but failed to yield anystatistically significant effects. Alternatively in Model 2,which included a total of 439 participants with completedata, the following variables were positively and independ-ently associated with groin injecting: higher than secondarylevel education (adjusted odds ratio [AOR] = 1.62; 95%CI:1.05 – 2.53), ever injected midazolam (AOR= 4.12; 95%CI:2.06 – 9.16), binge drug use (AOR= 1.72; 95%CI: 1.11 –2.69), and drug planting by police (AOR = 1.89; 95%CI:1.25 – 2.88).DiscussionIn the present study, we found that just over one-third ofa community-recruited sample of PWID in Bangkok re-ported groin injecting in the past six months. Havinginjected in the groin was positively associated with higherthan secondary level education and frequent midazolaminjection. In addition, those who reported drug plantingby police were also more likely to report groin injecting.The high prevalence of groin injecting observed inour study builds on a growing body of literature demon-strating the common use of the groin as a site of injectionamong PWID [17,22,23]. Studies conducted in Seattle,Washington and six locations in the United Kingdom (UK)(i.e., Manchester, Bristol, Teeside, Plymouth, Exeter, andWigan) reported that 40% and 45% of PWID in their sam-ple had injected in the femoral vein, respectively [4,24]. Sev-eral reasons for the increasing prevalence of groin injectingamong PWID have been proposed, and these relate to thewide array of physical health problems, including injection-related infections and abscesses resulting from frequent in-jection in peripheral veins (i.e., cubital fossa) [1].Findings from our first and second model revealed thatmidazolam injection in the past six months and a historyof midazolam injection was strongly associated with groininjecting, respectively. This supports our hypothesis thatprevious midazolam injection may predict future groininjecting among this population, given that this drug in itssoluble form is highly acidic and can be damaging to veins.Our findings are consistent with previous studies that havedocumented that many PWID who inject midazolam haveresorted to groin injection once more convenient sites be-come inaccessible [7]. Given the known adverse healthoutcomes associated with groin injecting [14,25], publichealth interventions should first focus on educating PWIDon the risks and harms associated with this practice inaddition to improving the distribution of appropriateinjecting paraphernalia, including sterile needles and sy-ringes, as well as alcohol swabs [8]. Furthermore, a recentstudy conducted in the UK by Zador and colleagues(2008) revealed that groin injectors were able to success-fully access and use alternative peripheral injecting sitesfollowing complications due to chronic groin injecting. Inan effort to encourage those engaging in high-risk femoralinjecting behaviour to utilize lower-risk peripheral sites, itmay be of benefit for healthcare workers to support PWIDTi et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:4 Page 3 of 7http://www.substanceabusepolicy.com/content/9/1/4Table 1 Bivariate analyses of factors associated with groin injection among PWID in Bangkok, Thailand (n = 437)Groin injection in the last six months n (%)Characteristic Yes 150 (34.3%) No 287 (65.7%) Odds ratio (95% CI) pMedian age≥ 38 years 80 (53.3) 151 (52.6) 1.03 (0.69 – 1.53) 0.89< 38 years 70 (46.7) 136 (47.4)GenderMale 119 (79.3) 232 (80.8) 0.91 (0.56 – 1.49) 0.71Female 31 (20.7) 55 (19.2)Education level≥ Secondary education 105 (70.0) 161 (56.1) 1.83 (1.20 – 2.78) <0.01< Secondary education 45 (30.0) 126 (43.9)Heroin injection*> Weekly 41 (27.3) 54 (18.8) 1.83 (1.09 – 3.08) 0.02≤ Weekly 58 (38.7) 110 (38.3) 1.27 (0.81 – 2.01) 0.30nNone 51 (34.0) 123 (42.9) 1.00 (reference)Midazolam injection*> Weekly 127 (84.7) 113 (39.4) 10.93 (5.59 – 21.37) <0.01≤ Weekly 12 (8.0) 67 (23.3) 1.74 (0.73 – 4.17) 0.02None 11 (7.3) 107 (37.3) 1.00 (reference)Methamphetamine injection*> Weekly 29 (19.3) 59 (20.6) 0.79 (0.47 – 1.33) 0.38≤ Weekly 30 (20.0) 81 (28.2) 0.60 (0.37 – 0.98) 0.04None 91 (60.7) 147 (51.2) 1.00 (reference)Length of injecting careerMedian value (years) 19 18 1.02 (1.00 – 1.04) 0.08IQR (years) 15 – 27 14 – 24Binge drug use*Yes 59 (39.3) 73 (25.4) 1.90 (1.25 – 2.90) <0.01No 91 (60.7) 214 (74.6)Syringe sharing*Yes 33 (22.0) 43 (15.0) 1.60 (0.97 – 2.65) 0.07No 117 (78.0) 244 (85.0)Inject in public places*Yes 45 (30.0) 74 (25.8) 1.23 (0.80 – 1.91) 0.35No 105 (70.0) 213 (74.2)Non-fatal overdose*Yes 6 (4.0) 10 (3.5) 1.15 (0.41 – 3.24) 0.79No 144 (96.0) 277 (96.5)Need help injecting*Yes 25 (16.7) 57 (19.9) 0.81 (0.48 – 1.35) 0.42No 125 (83.3) 230 (80.1)Injected with others*> 75% of the time 57 (38.0) 113 (39.4) 0.94 (0.63 – 1.42) 0.78≤ 75% of the time 93 (62.0) 174 (60.6)Ti et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:4 Page 4 of 7http://www.substanceabusepolicy.com/content/9/1/4in learning how to access peripheral veins even when thesesites are believed to be no longer accessible [23]. For thosePWID where peripheral vein access is not possible, otherharm reduction interventions such as education on safergroin injection techniques and the provision of appropri-ate injection equipment, such as filters and appropriateneedles, may be of value in this setting [5]. Given the highdegree of stigma and discrimination associated with illicitdrug use in Thailand [26,27], educational efforts and ma-terials might be best provided through existing drug user-run drop-in centres operating in Bangkok [28].Although we expected that PWID with higher educationwould avoid risky injection practices (i.e., groin injecting),we found a positive association between higher than sec-ondary level education and a history of groin injecting inour study. One possible explanation for this finding maybe that these individuals may be more likely to try to hidetheir injecting behaviour from family, friends, healthcareworkers, or law enforcement officials for fear of furtherdiscrimination.Of concern, PWID who reported having drugs plantedon them by police were more likely to report groininjecting. While in other settings this finding would likelyreflect the fact that groin injecting allows PWID to hidevisible track marks from law enforcement [6], previous re-search conducted in Thailand suggest that increasing ratesof midazolam injection may be playing a role in drivingthe aforementioned association. Fairbairn et al. (2009) alsofound that a history of midazolam use was associated withevidence planting by police among Thai PWID. It wasproposed that this may be attributed in part to the drowsyappearance of PWID when under the influence of midazo-lam, making these individuals more vulnerable and identi-fiable to police [18]. As well, midazolam injectors tend tobe of older age and thus, may already have a history withpolice [7]. However, our subanalysis focused on identifyinginteraction effects between drug planting by police andmidazolam injection failed to yield a statistically significantresult. Given the limited and inconsistent available evi-dence examining the relationship between policing prac-tices, midazolam use, and reporting groin injection in thissetting, future research using in-depth qualitative methodsshould seek to explore this further. Nevertheless, given theineffectiveness of drug law enforcement approaches inTable 1 Bivariate analyses of factors associated with groin injection among PWID in Bangkok, Thailand (n = 437)(Continued)Barriers to accessing health servicesAny 118 (78.7) 204 (71.1) 1.50 (0.94 – 2.39) 0.09None 32 (21.3) 83 (28.9)Drug planting by policeYes 84 (56.0) 107 (37.3) 2.14 (1.43 – 3.20) <0.01No 66 (44.0) 180 (62.7)PWID: people who inject drugs, CI: confidence interval; IQR: interquartile range.*Activities in the previous six months.Table 2 Multivariate logistic regression analyses of factors associated with groin injection among PWID inBangkok, ThailandModel 1 (n = 437) Model 2 (n = 439)Variable AOR 95% CI p-value AOR 95% CI p-valueEducation level(≥ Secondary education vs. < Secondary education) 1.55 (0.97 – 2.50) 0.07 1.62 (1.05 – 2.53) 0.03Midazolam injection*(> Weekly vs. None) 9.67 (5.10 – 20.06) <0.01 - - -(≤ Weekly vs. None) 1.56 (0.64 – 3.82) 0.33Ever injected midazolam(Yes vs. No) - - - 4.12 (2.06 – 9.16) <0.01Binge drug use*(Yes vs. No) 1.43 (0.88 – 2.30) 0.15 1.72 (1.11 – 2.69) 0.02Drug planting by police(Yes vs. No) 2.09 (1.33 – 3.29) <0.01 1.89 (1.25 – 2.88) <0.01PWID: people who inject drugs; AOR: adjusted odds ratio; CI: confidence interval.*Activities in the previous six months.Ti et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:4 Page 5 of 7http://www.substanceabusepolicy.com/content/9/1/4reducing drug use in Thailand [29,30], there is a clear needfor alternative policy approaches to be developed, imple-mented and evaluated. In the meantime, efforts should bemade to ensure that policing practices do not undermineexisting public health efforts, including those focused onpromoting safer injecting practices [31]. Additionally,given the lack of legal grounding for harm reduction ser-vices in Thailand, efforts to plan and implement a nationalharm reduction policy is urgently needed.This study is limited in several ways. The study samplewas not randomly selected and therefore, it may not bepossible to generalize the findings of this study to ThaiPWID more broadly. Additionally, given that our eligibilitycriteria only included individuals who had injected drugsin the past 6 months, we were unable to explore the riskfactors associated with groin injection among individualswith a history of injection drug use but who had notinjected drugs in the past six months. The data obtainedare also based on self-reports by PWID and may be sus-ceptible to socially desirable reporting or recall bias. Weshould also note that our findings were limited by thecross-sectional design of the study, and therefore, we can-not determine a temporal relationship between exposureand outcome. Finally, given the nature of the study, theremay be issues related to unmeasured confounding (e.g.,homelessness, problems accessing peripheral veins, mentalhealth issues, abuse) that we were not able to capture inthis analysis.ConclusionsIn sum, we found a high prevalence of groin injectingamong Thai PWID, with those who have completedhigher education, those who reported frequent midazolaminjecting, and those who reported drug planting by policewere more likely to engage in groin injecting. Given thevarious adverse effects of groin injecting among PWID,these findings highlight the need for evidence-based publichealth interventions that focus on educating PWID on theharms associated with injecting into the groin. As well, in-terventions that aim to harmonize public health and po-licing practices are urgently needed to minimize unsafeinjecting practices.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsThe specific contributions of each author are as follows: LT and TK wereresponsible for study design; LT conducted the statistical analyses andprepared the first draft of the analyses; All authors provided criticalcomments on the first draft of the manuscript and approved the finalversion to be submitted.AcknowledgementsWe would particularly like to thank the staff and volunteers at theMitsampan Harm Reduction Center, Thai AIDS Treatment Action Group andO-Zone House for their support and Dr. Niyada Kiatying-Angsulee of theSocial Research Institute, Chulalongkorn University, for her assistance withdeveloping this project. We also thank Tricia Collingham, Deborah Graham,Caitlin Johnston, Calvin Lai and Peter Vann for their research and administrativeassistance, and Prempreeda Pramoj Na Ayutthaya, Arphatsaporn Chaimongkonand Sattara Hattirat for their assistance with data collection. The study wassupported by Michael Smith Foundation for Health Research. This research wasalso undertaken, in part, thanks to funding from the Canada Research Chairsprogram through a Tier 1 Canada Research Chair in Inner City Medicine whichsupports EW.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2School of Population andPublic Health, University of British Columbia, 2206 East Mall, Vancouver,BC V6T 1Z3, Canada. 3Interdisciplinary Studies Graduate Program, Universityof British Columbia, 6201 Cecil Green Park Road, Vancouver, BC V6T 1Z1,Canada. 4Thai AIDS Treatment Action Group, 18/89 Vipawadee Road, Soi 40Chatuchak, Bangkok 10900, Thailand. 5Department of Medicine, University ofBritish Columbia, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada. 6Urban Health Research Initiative, BC Centre for Excellence inHIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.Received: 25 September 2013 Accepted: 15 January 2014Published: 16 January 2014References1. 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SubstanceAbuse Treatment, Prevention, and Policy 2014 9:4.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTi et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:4 Page 7 of 7http://www.substanceabusepolicy.com/content/9/1/4

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