Transient changes in behaviour lead to heroin overdose: results from a case-crossover study of non-fatal overdose

A spatial analysis of the physical and social environmental correlates of discarded needles

The role that the urban environment plays in influencing drug users' injection and needle disposal decisions is poorly understood. We identified potential attractors and deterrents of needle discarding, and then used a geographic information system (GIS) to quantify these factors for a neighborhood in Montréal, Canada. In multivariate logistic regression, discarded needles were found to have more associations with physical factors than with social factors. Visual exposure and proximity to a single-room occupancy hotel, a pay phone, an adult service or a pawnshop were important physical environmental predictors. These findings are discussed in relation to developing public health and urban design-based harm reduction approaches to needle discarding in public space.

The self-reported personal wellbeing of a sample of Australian injecting drug users

AIMS

To examine the self-reported personal wellbeing of a sample of Australian injecting drug users (IDU) using a standardized instrument and determine the key correlates of variations in self-reported personal wellbeing.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional survey of 881 Australian IDU.

MEASUREMENTS

Self-reported personal wellbeing collected using the Personal Wellbeing Index (PWI).

FINDINGS

IDU scored significantly lower than the general Australian population on the PWI and all subscales. Lower PWI scores were associated with a range of socio-demographic, drug use and other health and social characteristics. Across all PWI subscales, lower personal wellbeing scores were associated with unemployment, past 6-month mental health problems and more frequent injecting (all P < 0.05).

CONCLUSIONS

The PWI is sufficiently sensitive to distinguish between IDU and the general population, and to identify key correlates of PWI among IDU. Some domains canvassed within the scale, such as health, standard of living and life achievements, are well within the scope of current intervention strategies, such as pharmacotherapy maintenance treatment and housing and employment support services. This suggests that the PWI could be useful in clinical settings by allowing structured identification of the areas of a person's life to be addressed as a part of a treatment regimen. In order to inform targeted prevention and intervention efforts, longitudinal studies of PWI and its correlates among IDU are required.

Elevated overdose mortality rates among First Nations individuals in a Canadian setting: a population-based analysis

AIMS

To determine the total burden of illicit drug overdose mortality over the study period in the province of British Columbia and investigate possible population-level determinants by estimating rates among subgroups including First Nations individuals.

DESIGN

Review of coroner case files.

SETTING

The province of British Columbia, Canada.

PARTICIPANTS

Individuals dying from an illicit drug overdose between 2001 and 2005.

MEASUREMENTS

Age-adjusted mortality rates, standardized mortality ratios (SMR) and years of potential life lost (YPLL), stratified by major population groups.

FINDINGS

Over the study period, 909 individuals died from illicit drug overdoses, including 104 (11.4%) First Nations individuals. Compared to the general population, First Nations males and females suffered from substantially elevated SMR and YPLL. In a multivariate logistic regression analysis, First Nations deaths were significantly more likely to be among women, related to injection drug use and to have occurred in the Downtown Eastside area of Vancouver, the local epicentre of human immunodeficiency virus infection and open drug use (all P< 0.05).

CONCLUSIONS

This report found highly elevated overdose death rates and levels of premature mortality among First Nations Canadians in British Columbia compared to the general population. While previously unidentified, these findings are consistent with the poorer population health profile of First Nations Canadians. Although further research is needed to identify the causes of the elevated death rates, our findings support increased availability of evidence-based overdose prevention measures.

Alcohol and drug use in suicidal behaviour

PURPOSE OF REVIEW

To present a summary of estimates of the risk of suicidal behaviour (ideation, plan and attempt) among those with substance use disorders in the general population and risk estimates for those with acute alcohol and drug consumption (intoxication) immediately prior to a suicide attempt.

RECENT FINDINGS

In Mexico and elsewhere studies have emerged on the risk of suicidal behaviour among those with substance use disorders that are not affected by treatment selection bias or by psychiatric comorbidity. In developed and developing groups of nations, alcohol use disorders were associated with increased odds ratio (OR) of ideation (range 2.0-2.5) and attempt (2.6-3.7), whereas drug use disorders were associated with increased risk of ideation (2.3-3.0) and attempt (2.0-4.0). Follow-up studies of general population samples reported an OR for drug use disorders from 1.9 to 3.7 for ideation, and an OR of 3.0 for attempt. Alcohol dependence increased suicide ideation with an OR of 1.5. Those drinking alcohol prior to the suicide attempt had ORs in the range of 6.2-9.6. This increase may have a dose-response relationship. We found no studies providing risk estimates for drug use prior to a suicide attempt.

SUMMARY

Current evidence points to a causal role of alcohol and drug use disorders exerting a distal effect on suicidal behaviour. Evidence for the proximal role of alcohol and drug use, as triggers of suicidal behaviour, are still very limited in number, analytical techniques and scope of substances other than alcohol.

Longitudinal observation of a sample of German drug consumption facility clients

INTRODUCTION

We aimed at investigating whether attendance of a drug consumption facility (DCF) was associated with both a reduction of drug-associated at-risk behavior and referral to the health care treatment system.

METHODS

A sample of 129 consecutive clients out of those 256 who self-referred to the DCF during the 13-month observation period (i.e., from November 2002 to December 2003) was interviewed both at baseline and at 1-, 2-, 3-, and 6-month follow-ups. Subjects were repeatedly assessed using a structured approach based on both the European Addiction Severity Index (EuropASI) and the Deutsche Gesellschaft fuer Suchtforschung und Therapie (DG-Sucht).

RESULTS

Typical DCF clients were males, in their early 30s, single, with no vocational training, and with a long history of injectable opiate addiction in the context of polydrug misuse. A recent discharge from prison was recorded in 37% of cases. Median length of DCF attendance was of 5 weeks; 22% of clients attended for less than 1 week. Although with respect to the period previous to recruitment at-risk behavior rates remained unchanged, by the 3-month follow-up 13 (10%) clients out of those 129 who had initially enrolled had taken advantage of the DCF counseling opportunities. Some 37% of clients were referred on to start a methadone treatment following their DCF experience.

DISCUSSION

DCF attendance was not associated with reduction in at-risk behavior over time, but a need was here identified for additional intervention to be available in the DCF to address clients' psychosocial issues. Limitations of the present study include both issues related to the representativeness of the sample of clients here recruited and the lack of a control/comparison group.

Acute risk of drug-related death among newly released prisoners in England and Wales

AIMS

To investigate drug-related deaths among newly released prisoners in England and Wales.

DESIGN

Database linkage study.

PARTICIPANTS

National sample of 48,771 male and female sentenced prisoners released during 1998-2000 with all recorded deaths included to November 2003.

FINDINGS

There were 442 recorded deaths, of which 261 (59%) were drug-related. In the year following index release, the drug-related mortality rate was 5.2 per 1000 among men and 5.9 per 1000 among women. All-cause mortality in the first and second weeks following release for men was 37 and 26 deaths per 1000 per annum, respectively (95% of which were drug-related). There were 47 and 38 deaths per 1000 per annum, respectively, among women, all of which were drug-related. In the first year after prison release, there were 342 male deaths (45.8 were expected in the general population) and there were 100 female deaths (8.3 expected in the general population). Drug-related deaths were attributed mainly to substance use disorders and drug overdose. Coronial records cited the involvement of opioids in 95% of deaths, benzodiazepines in 20%, cocaine in 14% and tricyclic antidepressants in 10%. Drug-related deaths among men were more likely to involve heroin and deaths among women were more likely to involve benzodiazepines, cocaine and tricyclic antidepressants.

CONCLUSIONS

Newly released male and female prisoners are at acute risk of drug-related death. Appropriate prevention measures include overdose awareness education, opioid maintenance pharmacotherapy, planned referral to community-based treatment services and a community overdose-response using opioid antagonists.

Unintentional drug overdose death trends in New Mexico, USA, 1990-2005: combinations of heroin, cocaine, prescription opioids and alcohol

AIMS

To determine the contribution of heroin, prescription opioids, cocaine and alcohol/drug combinations to the total overdose death rate and identify changes in drug overdose patterns among New Mexico subpopulations.

DESIGN

We analyzed medical examiner data for all unintentional drug overdose deaths in New Mexico during 1990-2005. Age-adjusted drug overdose death rates were calculated by sex and race/ethnicity; we modeled overall drug overdose death adjusting for age and region.

FINDINGS

The total unintentional drug overdose death rate in New Mexico increased from 5.6 per 100 000 in 1990 to 15.5 per 100 000 in 2005. Deaths caused by heroin, prescription opioids, cocaine and alcohol/drug combinations together ranged from 89% to 98% of the total. Heroin caused the most deaths during 1990-2005, with a notable rate increase in prescription opioid overdose death during 1998-2005 (58%). During 1990-2005, the 196% increase in single drug category overdose death was driven by prescription opioids alone and heroin alone; the 148% increase in multi-drug category overdose death was driven by heroin/alcohol and heroin/cocaine. Hispanic males had the highest overdose death rate, followed by white males, white females, Hispanic females and American Indians. The most common categories causing death were heroin alone and heroin/alcohol among Hispanic males, heroin/alcohol among American Indian males and prescription opioids alone among white males and all female subpopulations.

CONCLUSIONS

Interventions to prevent drug overdose death should be targeted according to use patterns among at-risk subpopulations. A comprehensive approach addressing both illicit and prescription drug users, and people who use these drugs concurrently, is needed to reduce overdose death.

Dynamic compartmental model of trends in Australian drug use

A five-state compartment model of trends in illicit drug use in Australia is parameterized using data from multiple sources. The model reproduces historical prevalence and supports what-if analyses under the assumption that past trajectories of drug escalation and desistance persist. For fixed initiation, the system has a unique stable equilibrium. The chief qualitative finding is that even though some users escalate rapidly, regular injection drug use still adjusts to changes in incidence with considerable inertia and delay. This has important policy implications, e.g., concerning the timing of reductions in drug-related social cost generated by interventions that reduce the social cost per injection user versus those that cut drug initiation.

Concurrent buprenorphine and benzodiazepines use and self-reported opioid toxicity in opioid substitution treatment

AIMS

To examine concurrent buprenorphine and benzodiazepine consumption and to compare opioid toxicity symptoms induced by methadone and buprenorphine, examining factors associated with the reporting of these symptoms.

DESIGN

Self-report cross-sectional survey.

SETTING

Five needle syringe programmes and five opioid substitution treatment services in Melbourne, Australia.

PARTICIPANTS

A total of 250 people who had experience with methadone or buprenorphine. Eligibility criteria were current or previous methadone or buprenorphine use.

MEASUREMENTS

Structured questionnaire covering: demographic characteristics; current treatment and drug use; concurrent use of buprenorphine and benzodiazepines, including route of administration and source of medications; and opioid toxicity symptoms reported in association with methadone and buprenorphine consumption.

FINDINGS

Of those reporting buprenorphine use, two-thirds reported concurrent benzodiazepine use, with a median dose reported of 30 mg diazepam equivalents. A greater number of opioid toxicity symptoms were reported in relation to methadone consumption compared with buprenorphine. Those reporting opioid toxicity with buprenorphine were more likely to report intravenous use compared with those reporting opioid toxicity with methadone.

CONCLUSIONS

The risk of opioid toxicity appeared greater with methadone compared with buprenorphine, despite high levels of benzodiazepine consumption and injection being reported in relation to buprenorphine use. The prevalence of buprenorphine injection and the normalization of methadone-induced sedation are two findings that merit further investigation. Establishing recommendations as to the safest and most effective way to manage benzodiazepine-using people in opioid substitution treatment is necessary for the optimization of treatment for opioid dependence in polydrug-using individuals.

It's time for Canadian community early warning systems for illicit drug overdoses

Although fatal and non-fatal overdoses represent a significant source of morbidity and mortality, current systems of surveillance and communication in Canada provide inadequate measurement of drug trends and lack a timely response to drug-related hazards. In order for an effective early warning system for illicit drug overdoses to become a reality, a number of elements will be required: real-time epidemiologic surveillance systems for illicit drug trends and overdoses, inter-agency networks for gathering data and disseminating alerts, and mechanisms for effectively and respectfully engaging with members of drug using communities. An overdose warning system in an urban area like Vancouver would ideally be imbedded within a system that monitors drug trends and overdoses by incorporating qualitative and quantitative information obtained from multiple sources. Valuable information may be collected and disseminated through community organizations and services associated with public health, emergency health services, law enforcement, medical laboratories, emergency departments, community-based organizations, research institutions and people with addiction themselves. The present paper outlines considerations and conceptual elements required to guide implementation of such systems in Canadian cities such as Vancouver.

Predictors of non-fatal overdose among a cohort of polysubstance-using injection drug users

BACKGROUND

Non-fatal overdose is a major determinant of morbidity among injection drug users (IDU). We sought to evaluate factors associated with non-fatal overdose among IDU in Vancouver.

METHODS

We examined non-fatal overdose among participants in the Vancouver Injection Drug Users Study. Correlates of non-fatal overdose occurring between 1996 and 2004 were identified using generalized estimating equations (GEE).

RESULTS

There were 1587 participants included in this analysis, including 576 (36%) women. At baseline, 750 (47%) reported a history of non-fatal overdose. In total, 985 reports of non-fatal overdose were made during follow-up by 519 (32.7%) participants. In multivariate GEE analyses, factors independently associated with non-fatal overdose included: heroin injection (AOR=2.67), cocaine injection (AOR=2.01), benzodiazepine use (AOR=2.00), requiring help injecting (AOR=1.58), binge drug use (AOR=1.52), homelessness (AOR=1.38), alcohol use (AOR=1.32), street injecting (AOR=1.22), non-injectable opiate use (AOR=1.16), speedball use (AOR=1.15), and recent incarceration (AOR=1.14). Younger age (AOR=0.99) and methadone use (AOR=0.51) were protective.

CONCLUSIONS

We found that non-fatal overdose was common among local IDU. Non-fatal overdose was associated with several factors that may be amenable to intervention, including opiate and stimulant use, and the characteristic of requiring help with injecting. These findings indicate the need for the ongoing development of structural interventions to address this common cause of morbidity among IDU.

Heroin and cocaine dependence and the risk of accidental non-fatal drug overdose

The relation between illicit drug dependence and the likelihood of drug overdose is unclear. We recruited 1,066 habitual drug users for this analysis through street-based outreach in New York City. In this sample, 99.3% of respondents used heroin in the past year and 87.1% of respondents used cocaine; 819 (77.5%) heroin users and 735 (79.2%) cocaine users were severely dependent on either drug respectively. In multivariable models, among heroin users, persons who were severely heroin dependent were less likely (OR = 0.6; 95% CI = 0.4-0.9) to have overdosed on any drug in the past year; among cocaine users, those who were severely cocaine dependent were more likely (OR = 1.6; 95% CI = 1.0-2.6) to have overdosed in the past year. The relation between illicit drug dependence and risk of overdose may vary for different patterns of drug dependence. These observations suggest that overdose prevention interventions, perhaps even those specifically targeting opiate overdose, may be more efficiently directed at individuals exhibiting cocaine dependence.

Endogenous opiates and behavior: 2005

This paper is the 28th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2005 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity, neurophysiology and transmitter release (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); immunological responses (Section 17).

Do young heroin users in Madrid, Barcelona and Seville have sufficient knowledge of the risk factors for unintentional opioid overdose?

To identify the self-perceived reasons for unintentional opioid overdose of young heroin users in three Spanish cities and their agreement with objective risk factors for overdose. Computer-Assisted Personal Interviews (CAPI) were held with 991 street-recruited current heroin users aged 18-30. The general reasons for overdose and the reasons for the last overdose suffered were explored with open-ended (OEQs) and pre-coded questions (PCQs). Limited knowledge of overdose risk factors was defined as mention of fewer than two objective risk factors for unintentional overdose in the OEQ. Univariate, bivariate, and logistic regression methods were used. 77.8% (Seville), 64.9% (Madrid) and 57.2% (Barcelona) of participants have limited knowledge of overdose risk factors. Residence in Seville and not having attended courses or meetings on overdoses were significantly associated with limited knowledge, after adjusting for other factors. The most frequently identified general reasons in OEQ or PCQ were using heroin in large amounts (66.8%), together with tranquilizers (62.0%), adulterated (60.7%), or purer than usual (57.6%). Most reasons were selected more frequently in PCQ than in OEQ, especially rapid injection of the entire dose and using heroin shortly after using tranquilizers or alcohol, by injection, or after a period of abstinence. The results were similar for overdoses suffered by participants. Most young heroin users do not have sufficient knowledge of overdose risk factors, especially the use of heroin by injection, after a period of abstinence, or together with alcohol or methadone. Specific informational or educational programs adapted to the local context are critically needed.