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Official websites use. Share sensitive information only on official, secure websites. Injection drug use has been increasing over the past decade in Iran. This study aims to review the epidemiological and qualitative evidence on factors that facilitate or protect against transition to injection in Iran. Two trained researchers screened documents to identify relevant studies and independently extracted data using a pre-specified protocol. A thematic analysis was applied to the qualitative data and a random effect meta-analysis model was used to determine age of first injection. The weighted mean age of first injection was Overall, drug users had used drugs for 6 to 7 years before starting to inject. Heroin was the first drug of injection in the majority of cases. Factors influencing transition to injection included 1 individual pleasure-seeking behavior and development of drug dependency , 2 social network role of peer drug users in first injection use , and 3 environmental the economic efficiency associated with injection and the wide availability of injectable form of drugs in the market. Harm reduction policies in Iran have almost exclusively focused on drug injectors. However, given the extent of non-injection drug use, evidence from this study can provide insight on points of interventions for preventing transition to injection use. Keywords: Substance use, harm reduction, risk factors for injecting, protective factors for injecting, first injection episode, systematic review, Iran. A report from estimated that 2. Smoking opium for medicinal and recreational purposes is deeply rooted in the Iranian culture and is considered less stigmatized than heroin use and drug injection. However, in the last decade, Iran has witnessed major changes in the pattern of substance use. In three national studies of drug use conducted between and , the proportion of those who use heroin or Kerack a crystallized form of heroin increased considerably Narenjiha et al. Also since , there has been an emerging epidemic of methamphetamine-based substance use although compared to opioids the overall figures are relatively low. In a recent systematic review of HIV among substance users, the prevalence rate was 4. However, until now, there has been little if any attention paid to preventing drug users from transitioning to injection drug use. This systematic review is the first of its kind, summarizing the existing evidence on factors that may influence transitions to or away from injection among substance users in Iran. We conducted a systematic review to identify studies in Iran reporting on the age of initiation of drug injection and the factors influencing transition. The review involved: 1 searching for scientific documents; 2 screening documents to identify relevant studies; 3 extracting data from included studies, and 4 synthesizing data. We have described these stages below. The search strategy involved: 1 comprehensive searching of electronic databases for published peer-reviewed articles, as well as other scientific documents grey literature ; 2 hand-searching of the reference section of relevant scientific documents; and 3 contacting experts in the field of substance use in Iran. An initial search of Medline — involved an iterative process to refine the search strategy through the testing of several search terms, incorporating new terms as relevant citations were identified. Multiple combinations of keywords and phrases were used to specify geographic location, population of interest e. We did not limit searches by language. For Iranian databases, we used both Farsi and English key terms. We also contacted other researchers in academic and governmental organizations. We imported all citations to an Endnote library. Since the automatic export of citations for Iranian databases was not available, we reviewed retrieved citations in Microsoft Word and manually entered relevant titles into Endnote. We hand-searched the reference section of relevant review studies or national program reports to identify studies containing primary data. Two of the co-authors reviewed retrieved scientific documents, applying pre-specified criteria to identify relevant studies through a step-wise process. Studies conducted on physiological, hormonal, and pathological changes related to drug use were excluded. Another co-author MA reviewed titles and abstracts of any papers which the initial screener was uncertain whether to include or not. A senior researcher ARM reviewed and adjudicated on studies where the reviewers had disagreed. No restriction was placed on study design, language, or publication year. Data were extracted on: 1 authors, year, type, and language of the publication; 2 study implementation year; 3 study design and setting; 4 study site i. In cases of ambiguity in the published data, we contacted authors for further clarification. If a document reported on more than one research project, each project was considered as an independent study and cited separately. For research projects reported in different forms i. Given that reported data on factors influencing the transition to injection use were sparse regarding geography, methods and context, we conducted formal quantitative meta-analysis only on the age of initiation of injection use. We calculated a summary mean and standard error for age of initiation, weighted by inverse of variance using a random-effect meta-analysis model in Stata version 13 and illustrated data in the form of forest plot. We applied principles of thematic analysis for qualitative data on the factors facilitating or protecting against injection drug use. We summarized these findings under thematic headings, aggregated them into categories, and presented them collectively in a table. Figure 1 presents the number of studies identified at each step of searching, screening, and data extraction. From a total of retrieved scientific documents after de-duplication , we identified and included 39 relevant scientific documents, reporting on a total of 31 original research studies; the co-authors were directly involved in 14 studies. Unpublished data from five studies were also used for data analysis. Table 1 presents characteristics of the 31 included studies. These were carried out between and , with more than half being conducted between and All studies, except for one longitudinal study Jafari, et al. Investigating the transition to injection drug use and correlated factors was not a main objective of most included studies so little data were available on this issue. The study utilized combination of methods. The method that provided information on transition to injection drug use is described in this table. From the 20 studies that reported on age at first injection AFI , we were able to retrieve the mean and standard error for 18 mean range: 24 to With respect to recruitment site, in two studies, there was no difference in mean AFI between PWID recruited from community, treatment centers, and prisons Narenjiha, et al. While one study reported no difference in mean AFI between those who had shared needles and syringes and those who had not Rafiey et al. Six studies reported on the length of time between the initiation of drug use and the transition to injection. Due to the heterogeneity of studies and reported outcomes, we did not calculate a summary mean for the length of time to transition. Four studies found that, on average, drug users were using drugs for six to seven years before their first injection Amin-Esmaeili, et al. Four studies reported on the proportion of PWID who had initiated drug use with injection Jafari, et al. From a total of PWID in three different cities, Seven studies provided information on the place or context of the first injection Haghdoost, Osouli, et al. Given the heterogeneity of terminologies used to describe place type, we did not calculate pooled frequencies. Other venues indicated as PFI included: public places e. Four studies reported data on the first drug of injection FDI. In the same year in the smaller city of Darab Jafari, et al. In , in Tehran, the majority of a small sample of PWID reported kerack as FDI, though a few participants had started with other drugs heroin, temgesic, and morphine Rahimi-Movaghar, et al. Sixteen studies reported on factors influencing the transition to drug injection Table 2. Social and individual factors were reported more frequently than familial factors. Two studies reported that in two-thirds of PWID participating in surveys, the first person to suggest using drug via injection was a friend Jafari, et al. The second most common social factor was the high price of drugs and economic efficiency 13 studies i. Another significant factor was the greater availability of injectable drugs e. In addition, given that injection drugs are odorless and smokeless, injections were considered a safer drug use route for indoor and populated places e. Social marginalization, manifested by unemployment, poverty, and homelessness, was also an important factor for the initiation of injection use 5 studies. Overall, six studies provided information about factors influencing the transition to injection in the context of prison, including the need for hiding drug use four studies , low availability and high price of drugs three studies , low availability of smoking paraphernalia inside prison one study , and presence of injecting prisoners one study. The most commonly reported factor at the individual level was pleasure-seeking behavior, particularly with substances that had a rapid effect 9 studies. This factor has not been reported for the initiation of injecting with temgesic mainly used as a self-medication for quitting other opioids, as mentioned in two studies and norjisak primarily used for weight gain and healthier look, as well as cessation of other opioid use, mentioned in one study. Development of drug dependence, seeking a less expensive method for controlling withdrawal, and reaching the same level of pleasure compared to when drug was ingested via non-injection route was also reported frequently in 7 studies and regarded as the most important factor in two studies Rahimi-Movaghar, et al. Curiosity was reported as a factor influencing the transition to injection use in 8 studies, though findings were not consistent on the importance of this factor Jafari, et al. Lack of knowledge and misconceptions about the consequences of injection e. With respect to familial factors, three studies found that having a family member e. Family intolerance of drug use was also reported as a factor resulting in the transition to injection use as it could be more easily hidden from family. With respect to gender, being the sexual partner of a male drug injector, being involved in sex work, and being homeless were reported as the main transition factors for female drug users Rahimi-Movaghar, et al. Only one qualitative study reported on protective factors Rahimi-Movaghar, et al. Being female, having knowledge about negative consequences of injection use, and having negative attitudes toward injections e. Other factors included: individual, e. Another study showed that using opioids is the main gateway to injection and those people who stay away from opiates are very likely to avoid injecting Vazirian, et al. To our knowledge this is the first comprehensive review of 31 Iranian studies on factors influencing the initiation of, or transition to, drug injection. The review showed that the mean age at first injection in Iran was around 26 years and the median in most studies was 25 years. In addition, no specific change was observed in the AFI in studies conducted between and The AFI reported from the 18 studies in Iran was higher than that reported in other countries. Some studies have reported a lower average age of initiation, such as 17 years in Moldova Rhodes et al. Many studies have shown that early-onset injection use is associated with homelessness Abelson, et al. Most studies in our review reported an average of 6 to 7 years of drug use before injecting. Although some time lag is common in many parts of the world Abelson, et al. For Iranian drug users who generally start injecting as adults, the long interim period is an opportune time for preventing the transition to injection use. Our review also showed that, up to 10 years ago, heroin was the FDI for almost all cases. Since , other drugs such as norjisak and temgesic, followed by kerack of heroin, have appeared as the first drugs of injection. No document in this review reported the initiation of drug injection by stimulants or cocaine. Heroin smoking and opium smoking were the predominant patterns of drug use before first injection. This finding suggests that among opioid users, growing tolerance and the high costs of large amounts of heroin - which has been reported frequently in the reviewed studies - may have played a major role in the initiation of injection drug use. Vazirian, et al showed that few non-opioid users had ever injected drugs. Accordingly, avoiding opiate use is a likely preventative strategy against injecting in Iran. In Iraq and Pakistan, prescription drugs such as antihistamines and opioid analgesics are the primary injected drugs Rahimi-Movaghar, et al. In the available studies from other parts of the world, cocaine was reported to be the drug of choice for initiating injection use, followed by amphetamines in Brazil Oliveira et al. Many have used these drugs by non-injection route before their first injection, thus indicating that high levels of dependence facilitate injection use Harocopos, et al. Generally, heroin is the drug with high liability for injection use. In areas with higher rates of heroin use among non-injecting drug users, such as Iran and other countries in Middle and South Asia, one might expect a higher rate of transition to injection use than in areas with higher use of stimulants Cheng, et al. However, this review also showed that an average of This finding is similar to findings from Australia Abelson, et al. The role of peer drug users was the most frequently reported influential factor in the studies included in this review. Other studies have identified social network factors as important determinants in the transition to injecting. In Northern India, the vast majority of first injections were witnessed by at least one friend and the injection was usually administered by someone who was well-known to the injected Kermode, et al. In a multi-city study in Australia, early-onset injection was associated with group presence at the first injection and cases in which the first injection was administered by someone else Abelson, et al. We also found pleasure and curiosity as the most common individual factor reported in the studies from Iran. A belief that injection administration increases the effect of the drug and curiosity to experience this effect increase the likelihood of injection Roy, Godin, et al. Injecting peers usually evoke curiosity by highlighting the potency of injected drugs. Prison was a common first place of injection in the latest study. Incarceration was described as a context which facilitated the transition to injecting because of low availability, poor quality, and high cost of drugs, as well as the normalization of injecting as the main form of drug use in prison. This finding is in line with results from studies conducted in other developing countries Cheng, et al. However, expansion of harm reduction interventions, including opioid substitution treatment inside prisons, can prevent such transition. Female gender has been reported as a protective factor against injection drug use. This might be because of cultural factors, like a very high stigma attached to female injection drug use, or because of a higher level of fear of injection and its consequences in the female population Rahimi-Movaghar, et al. In two studies, having a family member or a sexual partner who injects drugs was reported as the main factor influencing the initiation of injection use in women. Gender differences on this issue have been documented in other countries. Studies have repeatedly reported that women had been injected first by a male friend, sexual partner, or relative Bravo et al. Since Iran has adopted large-scale harm reduction policies i. Although MMT is the most essential preventive measure against drug use injection Bridge, , lessons learned from other settings e. For instance, addressing individual susceptibility, by educating non-injecting drug users to control their substance use Roy, Godin, et al. This finding suggests that family-based strategies for the prevention of injection drug use should be explored. Further high quality research i. Although 31 studies provided some evidence regarding the initiation of injection drug use, only a few studies had assessed the influential factors extensively and only one study provided longitudinal data. We were unable to identify any study addressing drug transitions among street youth in Iran, nor about the role of alcohol in initiation to injection. A thorough assessment of interactions between individual and social network factors on the transition to injecting drug use may provide further insight on intervention points. Also, greater assessment of protective factors against transition to injection, especially among those not enrolled in MMT programs, is essential. Most studies in the review reported an average of 6 to 7 years of drug use before starting to use injections. The long interim period is an opportune time for preventing mechanisms of the transition to injection use in Iran. An average of The funding source had no role in the study design; the collection, analysis and interpretation of data; the writing of the report; and in the decision to submit the article for publication. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Afarin Rahimi-Movaghar, Email: rahimia tums. Masoumeh Amin-Esmaeili, Email: dr. Behrang Shadloo, Email: behrang. Mohsen Malekinejad, Email: MMalekinejad ucsf. As a library, NLM provides access to scientific literature. Int J Drug Policy. Published in final edited form as: Int J Drug Policy. Find articles by Afarin Rahimi-Movaghar. Find articles by Masoumeh Amin-Esmaeili. Find articles by Behrang Shadloo. Find articles by Mohsen Malekinejad. Issue date Sep. PMC Copyright notice. The publisher's version of this article is available at Int J Drug Policy. Open in a new tab. Characteristics of 31 studies on transition to injecting drug use conducted in Iran. Factors facilitating transition to injection reported in 16 studies, in Iran. Factors No. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Rahimi-Movaghar, et al. Haghdoost, Osouli, et al. Jamali, First drug of injection, factors of initiation. Samimi-Rad, et al. Shoghli et al. Zamani, Radfar, et al. Dolan et al. Afsar Kazerooni et al. Narenjiha, et al. Saberi- Zafarghandi, et al. Amin-Esmaeili, et al. Malekinejad, Zamani, Jafari, et al. Kheirandish et al. Razani, et al. Interviews: Median: Zamani, Farnia, et al. Mohammad, et al. Farhoudian, et al. Vazirian, et al. Rahimi-Movaghar et al. Rahimi-Movaghar, ; Rahimi-Movaghar, et al. Duration of DU before first injection, factors of initiation. Seeking pleasure and rapid induction of high via injection. Severity of addiction and development of tolerance. Preference for easier and quicker mode of drug administration. Lack of knowledge and misconceptions about harms of injection. Good socio-economic status and having private place for injection. Social and environmental factors. High cost of drugs and lower cost of injection. Social disadvantages e. Low availability of the drug, mainly in prison.

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