Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98

Cocaine/crack cocaine consumption, treatment demand, seizures, related offences, prices, average purity levels and deaths in the UK (1990 - 2004)

A recent trend of escalating use of cocaine/crack cocaine was observed in the UK. The number of mentions on death certificates; last year use of cocaine; treatment demand, number of drug offenders, seizures, prices and average purity levels were the indicators used for this descriptive and correlational study. Figures (1990-2004) were taken from official UK sources. A total of 1022 cocaine/crack cocaine death mentions (i.e. deaths from any cause where the presence of cocaine/crack cocaine was also detected) were identified, with cocaine/crack cocaine being the sole drug mentioned in 36% of cases. The number of cocaine/crack cocaine death mentions showed a year-on-year increase and correlated positively with the following cocaine (powder) figures: last year use (p < 0.001); number of offenders (p < 0.001) and number of seizures (p < 0.001), but correlated negatively with price (p < 0.001). Furthermore, the number of cocaine/crack cocaine death mentions correlated positively with the number of crack offenders (p < 0.001) and seizures (p < 0.001), but correlated negatively with both crack purity ( p < 0.001) and price (p < 0.05). With conditions of increasing drug availability having been met in the UK, decrease in cocaine prices were associated with higher consumption levels and this, in turn, contributed to the increase in number of cocaine-related fatalities. There are limitations with the information collected, since no distinction is usually made on medical death certificates between cocaine and crack cocaine. The present study being an ecological one, it proved difficult to address the role of confounding variables that may well explain some of the associations observed.

Mortality in opioid-maintained patients after release from an addiction clinic

AIM

To investigate the mortality rate in a cohort of 269 opioid-dependent patients and the outcome of survivors meeting DSM-IV criteria for opioid dependence.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients enrolled in synthetic opioid maintenance therapy during a time frame from 1998 to 1999 originally at the Addiction Clinic and then discharged to general practitioners.

METHODS

Structured interviews (Europ-ASI), urinalysis at time of interview as well as autopsy findings from deceased patients.

RESULTS

After six mailings, information from 147 (54.6%) patients was gained. 85 patients (31.6%) were interviewed. From these 76.5% (n = 65) were still enrolled in maintenance therapy, 18.8% (n = 16) were drug-free and 4.7% (n = 4) relapsed. From 29 fatalities, 37.9% died of intoxication with illicit substances, 34.5% related to AIDS and 27.6% of somatic complications. The Standardized Mortality Ratio (SMR) was 29.13 (95% CI = 19.27-44.04). A higher lifetime frequency of hospitalization, less working days and a lack of social relationships were factors associated with high mortality.

CONCLUSIONS

The study confirms the high mortality rate in this patient group and supports the importance of maintenance therapy. Although great efforts were undertaken in locating patients, about 45% of the target group could not be located.

The effect of baseline cocaine use on treatment outcomes for heroin dependence over 24 months: Findings from the Australian Treatment Outcome Study

AIMS

The aim of this study was to determine the effects of baseline cocaine use on treatment outcomes for heroin dependence over a 24-month period.

DESIGN

A longitudinal cohort (24 months) study was carried out. Interviews were conducted at baseline, 3, 12, and 24 months.

SETTING

The study setting was Sydney, Australia.

PARTICIPANTS

Six hundred fifteen heroin users were recruited for the Australian Treatment Outcome Study.

FINDINGS

Cocaine use was common at baseline (40%) but decreased significantly over the study period. Even after taking into account age, sex, treatment variables, current heroin use, and baseline polydrug use, baseline cocaine use remained a significant predictor of poorer outcomes across a range of areas. Baseline cocaine users were more likely to report heroin use, unemployment, needle sharing, criminal activity, and incarceration over the 24-month study period.

CONCLUSIONS

Cocaine consumption among heroin users has repercussions across a range of areas that persist far beyond the actual period of use. Consequently, treatment providers should regard cocaine use among clients as an important marker for individuals who are at risk of poorer treatment outcome.

Is there a relationship between street heroin purity and drug-related emergencies and/or drug-related deaths? An analysis from Vienna, Austria

This study examines the quality of street heroin seized in Vienna in 1999 and whether there was a relationship between the purity of street heroin and the number of heroin-related emergencies as well as the number of heroin-related deaths. Street heroin confiscated by the Viennese police, run-sheets of drug-related emergencies, and postmortem reports of drug-related deaths in Vienna in 1999 were analyzed. A total of 415 retail samples with a total weight of 128.02 g contained a median percentage of 6.5% diacetylmorphine (range: 0.0-47.0%). All the samples contained a diluent, mainly lactose, as well as adulterants, such as caffeine and/or paracetamol. During the study period, 75 heroin-related deaths and 387 heroin-related emergencies were registered in Vienna. Time-series analysis revealed no statistically significant relationship between the rate of heroin-related incidents and the diacetylmorphine concentration of street heroin samples confiscated in Vienna in 1999. The widely held belief that the number of heroin-related deaths could be explained simply through fluctuations in the purity of street heroin could not be substantiated, even though the results of this study do not rule out an association between the purity of heroin and heroin-related deaths/emergencies.

Prevalence and correlates of opiate overdose among young injection drug users in a large U.S. city

OBJECTIVES

The current study examines the prevalence and correlates of witnessing and experiencing opiate overdoses among a sample of young, injection drug users (IDUs) and non-injection drug users (NIDUs) in Baltimore, MD.

METHODS

Data were derived from a longitudinal study of 15-30 year old IDUs and NIDUs (N=309) who had initiated heroin, cocaine, and/or crack use within 5 years prior to study enrollment. Chi-square and Wilcoxon rank-sum tests were used in bivariate analyses of demographic and drug use variables with each of the two dependent variables. Multivariate logistic regression models were used to identify correlates of experiencing and witnessing overdose.

RESULTS

Twenty-nine percent of participants reported having ever experienced an opiate overdose and 57% reported having ever witnessed an overdose. Having ever experienced an opiate overdose was independently associated with being White (Adjusted Odds Ratio [AOR]=3.2; 95% Confidence Interval [CI]: 1.6, 6.4) recent homelessness (AOR=2.9; 95%CI: 1.5, 5.7); and length of injection, 5.6-6.9 years versus <5.6 years (AOR=4.0; 95%CI: 1.8-8.9); injecting 7.0-7.9 years versus <5.6 years (AOR=2.5; 95%CI: 1.03-6.1); injecting >8 versus <5.6 years (AOR=4.7; 95%CI: 2.2-10.2). Having witnessed an opiate overdose was independently associated with being White (AOR=2.4; 95%CI: 1.4, 4.1) and injecting >8 years versus <5.6 years (AOR=2.2; 95%CI: 1.2, 4.0).

CONCLUSIONS

This study documents the high prevalence of witnessing and experiencing opiate overdoses among young, newly initiated IDUs and NIDUs. The results could inform the growing number of overdose prevention efforts throughout the U.S.

Screening for alcohol use patterns among methadone maintenance patients

Alcohol use among Methadone Maintenance Treatment (MMT) patients poses a major health risk, exacerbates psychopathology, and increases the risk of death by accidental overdose. Despite these factors, screening for alcohol use remains underutilized in the methadone community. Utilizing a self-report screening measure - the Michigan Alcohol Screening Test (MAST) - and consistent with the literature, we found high rates of alcohol problems among MMT patients. Benefits and limitations of using the MAST to screen for alcohol use patterns are discussed.

Injection drug users' perceptions regarding use of a medically supervised safer injecting facility

BACKGROUND

In recent years, there has been increased interest in supervised safer injecting facilities (SIF) as a strategy to reduce the harms of illicit drug use; however, little work has been done to assess drug users' satisfaction with this service. This study was undertaken to explore injection drug users' experiences and opinions regarding North America's first SIF in Vancouver, Canada.

METHODS

Injection drug users (IDU) were randomly recruited from within the Vancouver SIF and invited to enroll in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. For the present study, participants were then surveyed regarding their experiences and beliefs regarding the SIF.

RESULTS

Of 1082 IDU surveyed, 809 (75%) reported that their injecting behavior had changed as a result of using the SIF. Among these individuals, 80% indicated that the SIF had resulted in less rushed injecting, 71% indicated that the SIF had led to less outdoor injecting and 56% reported less unsafe syringe disposal. The three most common features always or usually limiting IDU's use of the SIF were: travel to the SIF (12%), limited operating hours (7%), and waiting times to access the SIF (5%). When asked in what ways the SIF might be improved, the three most common suggestions were: longer hours of operation (53%), addition of a washroom (51%), and reduced waiting times (46%).

CONCLUSIONS

Many IDU reported changes in their injecting behaviors that have important implications for community and public health. Addressing a number of programmatic issues related to operating hours and waiting times, and the provision of additional amenities within SIF, may help to further improve their impact.

Cocaine- and opiate-related fatal overdose in New York City, 1990-2000

Background

In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990–2000.

Methods

Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990–2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression.

Results

Overall, among decedents ages 15–64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62–0.82), Black (OR = 4.73, 95% CI 4.08–5.49) or Hispanic (OR = 1.51, 95% CI 1.29–1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06–1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44–0.56) and older age (55–64) (OR = 2.53 95% CI 1.70–3.75)).

Conclusion

As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.

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.

London audit of drug-related overdose deaths: characteristics and typology, and implications for prevention and monitoring

OBJECTIVES

To describe the circumstances and draft a typology of drug-related overdose deaths.

SETTING

London, 2003.

METHODS

An audit of 148 drug overdose deaths (involving heroin, methadone, dihydrocodeine, cocaine, amphetamine or MDMA) investigated by coroners during 2003. Information extracted on toxicology, pathology and circumstances were used to identify drug(s) implicated in the death.

RESULTS

Poly- or multiple drug use was detected in the majority of deaths with at least 69 different combinations, including 66% for heroin and 42% for cocaine. Six categories of death were identified involving an opiate (100, 68%); cocaine (14, 9%); other controlled drug (five, 3%); mixed drug overdose (18, 12%); other prescribed drug (five, 3%); and other causes (seven, 5%). A witness was present and the death was not instantaneous in 92 (61%) cases, although evidence in the coronial file suggested that in the majority of cases the overdose went unnoticed until too late to intervene. In all, 15 (one in 10) of the deceased were released from prison within 3 months of death; and 37 (one in four) were reported as in receipt of a methadone prescription.

CONCLUSIONS

Perhaps for the first time in the United Kingdom cocaine was detected in more drug overdose deaths than methadone. However, reducing heroin use is central to the prevention of drug-related deaths. We recommend that overdose prevention encompasses strategies to encourage a 'mutual duty of care' among problem drug users, and in the United Kingdom further investigation of the relationship of methadone treatment failures on overall trends in drug-related deaths is merited.

Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City

BACKGROUND

Fatal heroin overdose is a significant cause of mortality for injection drug users (IDUs). Many of these deaths are preventable because opiate overdoses can be quickly and safely reversed through the injection of Naloxone [brand name Narcan], a prescription drug used to revive persons who have overdosed on heroin or other opioids. Currently, in several cities in the United States, drug users are being trained in naloxone administration and given naloxone for immediate and successful reversals of opiate overdoses. There has been very little formal description of the challenges faced in the development and implementation of large-scale IDU naloxone administration training and distribution programs and the lessons learned during this process.

METHODS

During a one year period, over 1,000 participants were trained in SKOOP (Skills and Knowledge on Opiate Prevention) and received a prescription for naloxone by a medical doctor on site at a syringe exchange program (SEP) in New York City. Participants in SKOOP were over the age of 18, current participants of SEPs, and current or former drug users. We present details about program design and lessons learned during the development and implementation of SKOOP. Lessons learned described in the manuscript are collectively articulated by the evaluators and implementers of the project.

RESULTS

There were six primary challenges and lessons learned in developing, implementing, and evaluating SKOOP. These include a) political climate surrounding naloxone distribution; b) extant prescription drug laws; c) initial low levels of recruitment into the program; d) development of participant appropriate training methodology; e) challenges in the design of a suitable formal evaluation; and f) evolution of program response to naloxone.

CONCLUSION

Other naloxone distribution programs may anticipate similar challenges to SKOOP and we identify mechanisms to address them. Strategies include being flexible in program planning and implementation, developing evaluation instruments for feasibility and simplicity, and responding to and incorporating feedback from participants.

Drug use patterns and drug-related disorders of cocaine users in a sample of the general population in Germany

AIMS

The prevalence of cocaine use is still very low in Germany, but rates have been increasing over the past few decades. Patterns of drug consumption and related adverse consequences in individuals who have used cocaine were investigated in order to distinguish different types of cocaine users.

METHODS

Data come from two national representative surveys on substance abuse in the German general population conducted in 1997 and 2000 using self- administered questionnaires. Overall response rates were 65 and 51%, respectively. The two samples were pooled (n = 16,159) and latent cluster analysis was conducted using a sub-sample of 272 lifetime cocaine users.

RESULTS

Three clusters were derived: the majority belonged to the group of mainly unproblematic users (UPG, 80%), the second group comprised non-amphetamine poly-problem drug users (NAPPG, 12%), and a small group was composed of poly-problem drug users (PPG, 8%). Comparisons of sociodemographic characteristics, consumption patterns and age of onset for licit and illicit drug use revealed significant differences between the groups.

CONCLUSIONS

The majority of cocaine users in the general population are experimental or occasional users of licit and illicit drugs. Rather than being a major drug, cocaine is one of many other licit and illicit drugs. Cocaine use as part of predominantly poly-drug use behaviour is strongly associated with substance-related disorders.

Drug-related overdose deaths in British Columbia and Ontario, 1992-2004

OBJECTIVE

To compare rates of fatal drug-related overdose death (OD) cases--a major harm outcome of illicit substance use--in the two provinces of British Columbia (BC) and Ontario, and the two largest municipalities in those provincial jurisdictions, namely the cities of Vancouver and Toronto, between 1992 and 2004.

METHODS

Provincial coroners' data of drug-related OD cases for the provincial jurisdictions of BC and Ontario, and the municipal jurisdictions of Vancouver and Toronto, are descriptively presented and compared.

RESULTS

After drastic increases in the initial part of the observation period, OD rates in BC have been declining; moreover, due to major reductions of OD cases in Vancouver, the ratio of OD cases between Vancouver and the province of BC has fallen considerably. Conversely, OD rates in Ontario have remained stable at low levels, whereas Toronto has seen a slight decline in such rates during the observation period.

INTERPRETATION

The recent establishment and expansion of treatment and harm reduction interventions may have influenced the decline of ODs in BC, yet similar interventions in Ontario did not have a similar effect, perhaps due to different patterns of illicit drug use. OD rates in jurisdictions across Canada need to be monitored and analyzed to inform evidence-based policy development.

Comparative cardiac pathology among deaths due to cocaine toxicity, opioid toxicity and non-drug-related causes

AIM

To compare cardiac and cerebrovascular pathology among deaths due to cocaine toxicity, deaths due to opioid toxicity and deaths from hanging that were toxicologically negative for cocaine/opioids.

DESIGN

Case-control.

FINDINGS

The cocaine group had significantly higher proportions of left ventricular hypertrophy and ischaemic heart disease than either comparison group. Coronary artery atherosclerosis was also detected in significantly higher proportions of cocaine cases than in either comparison group. The cocaine group was more likely than either comparison group to have atherosclerosis of the left anterior descending coronary artery, right coronary artery and circumflex artery. Only in the left anterior descending coronary artery did the cocaine group exhibit higher levels of moderate-severe atherosclerosis. Cocaine cases also had significantly higher levels of cerebrovascular atherosclerosis than either comparison group.

CONCLUSIONS

Levels of cardiac and cerebrovascular pathology were higher among cocaine users than either comparison group. The high levels of cardiac and cerebrovascular pathology seen among cocaine cases do not appear to be artefacts of a drug-dependent life-style, but relate specifically to cocaine.

Summary of findings from the evaluation of a pilot medically supervised safer injecting facility

In many cities, infectious disease and overdose epidemics are occurring among illicit injection drug users (IDUs). To reduce these concerns, Vancouver opened a supervised safer injecting facility in September 2003. Within the facility, people inject pre-obtained illicit drugs under the supervision of medical staff. The program was granted a legal exemption by the Canadian government on the condition that a 3-year scientific evaluation of its impacts be conducted. In this review, we summarize the findings from evaluations in those 3 years, including characteristics of IDUs at the facility, public injection drug use and publicly discarded syringes, HIV risk behaviour, use of addiction treatment services and other community resources, and drug-related crime rates. Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts. These findings should be useful to other cities considering supervised injecting facilities and to governments considering regulating their use.

Systemic disease among cases of fatal opioid toxicity

AIMS

To determine levels of systemic disease among cases of death due to opioid toxicity.

DESIGN

Analysis of coronial cases.

SETTING

Sydney, Australia.

CASES

A total of 841 cases of death due to opioid toxicity (1 January 1998-31 December 2002).

FINDINGS

Ventricular hypertrophy was present in 5.9% of cases and severe coronary artery atherosclerosis in 5.7%. Severe coronary pathology was more pronounced among older cases. Pre-existing bronchopneumonia was present in 13.2% of cases. Hepatic pathology was the most common type of pathology, and was far more marked among older cases. Cirrhosis was present in 25.3% of those aged > 44 years. Levels of renal pathology were comparatively low, but were related significantly to increasing age. Systemic disease in more than one organ system was present in 24.4% of cases, and was related to increasing age (44% of those aged > 44 years). The only pathology for which gender was an independent predictor among opioid cases was ventricular hypertrophy, more common in males.

CONCLUSIONS

Systemic disease, most prominently liver disease, is common among fatal opioid toxicity cases, and may be a factor in understanding the dynamics and age demographics of opioid-related death.

Causes of death among crack cocaine users

OBJECTIVE: The study accompanied 131 crack-cocaine users over a 5-year period, and examined mortality patterns, as well as the causes of death among them. METHOD: All patients admitted to a detoxification unit in Sao Paulo between 1992 and 1994 were interviewed during two follow-up periods: 1995-1996 and 1998-1999. RESULTS: After 5 years, 124 patients were localized (95%). By the study endpoint (1999), 23 patients (17.6%) had died. Homicide was the most prevalent cause of death (n = 13). Almost one third of the deaths were due to the HIV infection, especially among those with a history of intravenous drug use. Less than 10% died from overdose. CONCLUSIONS: The study suggests that the mortality risk among crack cocaine users is greater than that seen in the general population, being homicide and AIDS the most common causes of death among such individuals.

Trends in opioid-related fatal overdoses in Massachusetts, 1990-2003

Since 1997, poisoning, particularly from heroin and other opioids, has been the leading cause of injury mortality in Massachusetts. Our aim was to describe recent trends in opioid-related poisoning deaths among Massachusetts residents.

METHODS

Massachusetts death files for the years 1990-2003, as coded by International Classification of Disease, Ninth Revision and International Classification of Disease, Tenth Revision, were used to identify all poisoning deaths and opioid-related poisoning deaths; rates were age-adjusted and grouped by year, sex, and race/ethnicity.

RESULTS

From 1990 to 2003, opioid-related fatal poisoning rates increased by 529% from 1.4 per 100,000 in 1990 to 8.8 per 100,000 in 2003. The proportion of total poisoning deaths associated with opioids rose from 28% in 1990 to 69% in 2003.

CONCLUSIONS

Massachusetts experienced a significant increase in opioid-related poisoning death rates. To guide future public health interventions, further investigation is necessary to better delineate the specific opioids involved, the circumstances surrounding these deaths, and the medical and behavioral health care options available.

Opiate users' knowledge about overdose prevention and naloxone in New York City: a focus group study

Background

Drug-induced and drug-related deaths have been increasing for the past decade throughout the US. In NYC, drug overdose accounts for nearly 900 deaths per year, a figure that exceeds the number of deaths each year from homicide. Naloxone, a highly effective opiate antagonist, has for decades been used by doctors and paramedics during emergency resuscitation after an opiate overdose. Following the lead of programs in Europe and the US who have successfully distributed take-home naloxone, the Overdose Prevention and Reversal Program at the Lower East Side Harm Reduction Center (LESHRC) has started providing a similar resource for opiate users in NYC. Participants in the program receive a prescription for two doses of naloxone, with refills as needed, and comprehensive training to reduce overdose risk, administer naloxone, perform rescue breathing, and call 911. As of September 2005, 204 participants have received naloxone and been trained, and 40 have revived an overdosing friend or family member. While naloxone accessibility stands as a proven life-saving measure, some opiates users at LESHRC have expressed only minimal interest in naloxone use, due to past experiences and common misconceptions.

Methods

In order to improve the naloxone distribution program two focus groups were conducted in December 2004 with 13 opiate users at LESHRC to examine knowledge about overdose and overdose prevention. The focus groups assessed participants' (i) experiences with overdose response, specifically naloxone (ii) understanding and perceptions of naloxone, (iii) comfort level with naloxone administration and (iv) feedback about increasing the visibility and desirability of the naloxone distribution program.

Results

Analyses suggest that there is both support for and resistance to take-home naloxone, marked by enthusiasm for its potential role in reviving an overdosing individual, numerous misconceptions and negative views of its impact and use.

Conclusion

Focus group results will be used to increase participation in the program and reshape perceptions about naloxone among opiate users, also targeting those already prescribed naloxone to increase their comfort using it. Since NYC is advancing toward a citywide naloxone distribution program, the LESHRC program will play an important role in establishing protocol for effective and wide-reaching naloxone availability.

Evaluating methamphetamine use and risks of injection initiation among street youth: the ARYS study

Many Canadian cities are experiencing ongoing infectious disease and overdose epidemics among injection drug users (IDU). These health concerns have recently been exacerbated by the increasing availability and use of methamphetamine. The challenges of reducing health-related harms among IDU have led to an increased recognition that strategies to prevent initiation into injection drug use must receive renewed focus. In an effort to better explore the factors that may protect against or facilitate entry into injection drug use, the At Risk Youth Study (ARYS) has recently been initiated in Vancouver, Canada. The local setting is unique due to the significant infrastructure that has been put in place to reduce HIV transmission among active IDU. The ARYS study will seek to examine the impact of these programs, if any, on non-injection drug users. In addition, Vancouver has been the site of widespread use of methamphetamine in general and has seen a substantial increase in the use of crystal methamphetamine among street youth. Hence, the ARYS cohort is well positioned to examine the harms associated with methamphetamine use, including its potential role in facilitating initiation into injection drug use. This paper provides some background on the epidemiology of illicit drug use among street youth in North America and outlines the methodology of ARYS, a prospective cohort study of street youth in Vancouver, Canada.

Unintentional prescription drug overdose deaths in New Mexico, 1994-2003

BACKGROUND

New Mexico has the highest rate of drug-induced mortality in the United States. The contribution of prescription drugs to the total overdose death rate has not been adequately described.

METHODS

A total of 1,906 unintentional drug overdose deaths occurring in 1994 to 2003 in New Mexico were analyzed. Unintentional drug overdose death was defined as death caused by prescription, illicit, or a combination of drugs, as determined by a pathologist. Deaths were investigated annually by the medical examiner and data were analyzed in 2004-2005. Rates and trends of total and prescription drug overdose death were calculated, decedent characteristics were analyzed, and common drug combinations causing death were described.

RESULTS

The rate of unintentional prescription drug overdose death increased by 179% (1.9 to 5.3/100,000) from 1994 to 2003. A high percentage of prescription drug overdose decedents were white non-Hispanic (63.2%) and female (43.9%). These decedents were older and less frequently had alcohol listed as an additional cause of death than decedents of other drug overdose categories. Of all deaths caused by prescription drug(s) (n =765), 590 (77.1%) were caused by opioid painkillers, 263 (34.4%) by tranquilizers, and 196 (25.6%) by antidepressants.

CONCLUSIONS

The rate of prescription drug overdose death in New Mexico increased significantly over the 10-year study period. Comprehensive surveillance of drug overdose deaths is recommended to describe their occurrence in the context of both medical and diverted use of prescription drugs. Understanding decedent profiles and the potential risk factors for prescription drug overdose death is crucial for effective drug overdose prevention education among healthcare providers.

Provision of naloxone to injection drug users as an overdose prevention strategy: early evidence from a pilot study in New York City

INTRODUCTION

Naloxone, an opiate antagonist that can avert opiate overdose morality, has long been prescribed to drug users in Europe and in a few US cities. However, there has been little documented evidence of naloxone distribution programs and their feasibility in the peer reviewed literature in the US.

METHODS

A pilot overdose prevention and reversal program was implemented in a New York City syringe exchange program. We assessed demographics, drug use, and overdose history, experience, and behavior at baseline, when participants returned for prescription refills, and 3 months after baseline assessment.

RESULTS

25 participants were recruited. 22 (88%) participants were successfully followed-up in the first 3 months; of these, 11 (50%) participants reported witnessing a total of 26 overdoses during the follow-up period. Among 17 most-recent overdoses witnessed, naloxone was administered 10 times; all persons who had naloxone administered lived.

DISCUSSION

Naloxone administration by injection drug users is feasible as part of a comprehensive overdose prevention strategy and may be a practicable way to reduce overdose deaths on a larger scale.

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.

Service uptake and characteristics of injection drug users utilizing North America's first medically supervised safer injecting facility

In 2003, the city of Vancouver, British Columbia, opened North America's first government-sanctioned safer injecting facility, where injection drug users (IDUs) can inject preobtained illicit drugs under the supervision of nurses. Use of the service by IDUs was followed by measurable reductions in public drug use and syringe sharing. IDUs who are frequently using the program tend to be high-intensity cocaine and heroin injectors and homeless individuals. The facility has provided high-risk IDUs a hygienic space where syringe sharing can be eliminated and the risk of fatal overdose reduced. Ongoing evaluation will be required to assess its impact on overdose rates and HIV infection levels, as well as its ability to improve IDU contact with medical care and addiction treatment.

Deaths From Drug Overdose and Toxicity in Turkey

Turkey is located on the main overland connection between Asia and Europe, making the country potentially vulnerable to drug trafficking and its associated harms. The aim of the present study is to explore the frequency of all deaths from drug overdose and toxicity in Turkey and to describe some of the characteristics of these deaths. We collected data on all deaths from drugs in Turkey between 1997 and 2001 using records from the Council of Forensic Medicine. Data obtained from autopsy reports were retrospectively analyzed. In the present study, 374 deaths from drugs were reported in Turkey, with a mortality rate of 0.17 per 100,000 population. Highest mortality rates were found in Istanbul (0.83) and Gaziantep (0.71). The mean age was 34.0, and most cases (71.7%) were below the age of 40. The proportion of female cases was 13.6%. Opiates were implicated in 91.5% of deaths and benzodiazepines in 25.9%. Two fifths (38.8%) of the cases involved use of more than 1 drug. In 36.6% of cases, the route of final drug administration was by injection. The most common location of death was at a home (33.7%). Interventions to reduce drug use nationally are urgently required. International cooperation in social-educational activities, scientific research, and security measures is essential for this war.

Overdoses among friends: Drug users are willing to administer naloxone to others

The distribution of naloxone to heroin users is a suggested intervention to reduce overdose and death rates. However, the level of willingness of drug users to administer this medication to others is unclear. Drug users recruited from the community between January 2002 and January 2004 completed a structured interview that assessed topics including drug use, overdose history, and attitudes toward using overdose remedies to assist others. Of the 329 drug users, 82% had used heroin and 64.3% reported that they had injected drugs. Nearly two thirds (64.6%) said that they had witnessed a drug overdose and more than one third (34.6%) had experienced an accidental drug overdose. Most participants (88.5%) said that they would be willing to administer a medication to another drug user in the event of an overdose. Participants who had used heroin (p = .024), had injected drugs (p = .022), had witnessed a drug overdose (p = .001), or had a history of one or more accidental drug overdoses (p = .009) were significantly more willing to treat a companion who had overdosed. Drug users were willing to use naloxone in the event of a friend's overdose. Specific drug use and overdose histories were associated with the greatest willingness to administer naloxone.

The effect of persistence of cocaine use on 12-month outcomes for the treatment of heroin dependence

AIMS

To determine the effects of cocaine use across the study period on outcomes of treatment for heroin dependence 12 months post-treatment entry.

DESIGN

Longitudinal cohort (12 months). Interviews were conducted at baseline, 3 and 12 months.

SETTING

Sydney, Australia.

PARTICIPANTS

Four hundred ninety-five heroin users recruited for the Australian Treatment Outcome Study and re-interviewed at 12-month follow-up.

FINDINGS

Cocaine was widely used among treatment entrants in NSW, with almost all having a lifetime history of cocaine use and almost half having used in the month preceding baseline. While there was an overall decline in cocaine use across the study period, individual use patterns varied widely. Approximately half of the cohort did not report cocaine use at any data point, with the remainder reporting having used at one (29%), two (12%), or at all three (5%) points. Cocaine use across the study period was an independent predictor of most major treatment outcomes, with more cocaine use points predicting poorer outcome. Persistent cocaine use predicted a higher prevalence of homelessness, heroin use, daily injecting, needle sharing and injection-related health problems at 12 months as well as more extensive recent polydrug use.

CONCLUSIONS

Cocaine use was common among individuals seeking treatment for primary heroin dependence in NSW. Any cocaine use over the study period was associated with poorer outcomes in virtually all areas. Persistent cocaine use over the study period, however, appeared particularly detrimental. Cocaine use among clients should evidently be a cause for concern amongst treatment providers and may warrant being specifically targeted during treatment.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND

Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California.

METHODS

Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews.

RESULTS

On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients.

CONCLUSIONS

SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study

PROBLEM

Illicit use of injected drugs is linked with high rates of HIV infection and fatal overdose, as well as community concerns about public drug use. Supervised injecting facilities have been proposed as a potential solution, but fears have been raised that they might encourage drug use.

DESIGN

A before and after study. Participants and setting 871 injecting drug users recruited from the community in Vancouver, Canada.

KEY MEASURES FOR IMPROVEMENT

Rates of relapse into injected drug use among former users and of stopping drug use among current users.

STRATEGIES FOR CHANGE

Local health authorities established the Vancouver supervised injecting facility to provide injecting drug users with sterile injecting equipment, intervention in the event of overdose, primary health care, and referral to external health and social services.

EFFECTS OF CHANGE

Analysis of periods before and after the facility's opening showed no substantial increase in the rate of relapse into injected drug use (17% v 20%) and no substantial decrease in the rate of stopping injected drug use (17% v 15%).

LESSONS LEARNT

Recently reported benefits of supervised injecting facilities on drug users' high risk behaviours and on public order do not seem to have been offset by negative community impacts.

Concurrent crack and powder cocaine users from Sao Paulo: do they represent a different group?

BACKGROUND

Cocaine abuse is a serious and socially damaging illegal drug problem. Different routes of administration are associated with a specific progression of use, different degrees of abuse liability, propensity for dependence and treatment response. There have been relatively few studies comparing different cocaine users groups and no studies into the characterization of the group of individuals reporting concurrent use of powder cocaine and crack cocaine.

METHODS

Six hundred and ninety-nine cocaine users were assessed during the period August 1997 to October 1998 in one outpatient and six inpatient clinics located in the São Paulo, Brazil. Patients were interviewed using a structured questionnaire schedule in Portuguese, designed specifically for the Brazilian population. The statistical analyses were performed using either ANOVA or a chi-squared test and focusing on their preferred form of use/route of administration and other variables.

RESULTS

For 83% of the variables tested in this study, the Dual Users subgroup (using both powder and crack cocaine) demonstrated statistical differences from the single drug user subgroups. Those differences include the initiation of cocaine, the abuse of other illicit drugs, and rates of criminal history.

CONCLUSION

These data suggest cocaine-dependent individuals who report use of both powder and crack cocaine are an at least partially, distinct subgroup. However, further studies will be necessary to confirm this and to determine if they also show a different treatment response.

Take-home naloxone to reduce heroin death

BACKGROUND

This paper reviews the relevant literature related to the distribution of take-home naloxone.

METHODS

A Medline search was conducted on articles published between January 1990 and June 2004 to identify scientific literature relevant to this subject. Those publications were reviewed, and from them other literature was identified and reviewed.

RESULTS

The prevalence, pathophysiology and circumstances of heroin overdose, and also bystander response are included in this review. Naloxone peer distribution has been instituted to varying degrees in the United States, Italy, Spain, Germany and the United Kingdom.

CONCLUSION

At this point the evidence supporting naloxone distribution is primarily anecdotal, although promising. Although the distribution of naloxone holds promise for further reducing heroin overdose mortality, problems remain. Naloxone alone may be insufficient in some cases to revive the victim, and cardiopulmonary resuscitation (CPR), especially rescue breathing, may also be needed. A second dose of naloxone might be necessary. Complications following resuscitation from overdose may infrequently need in-hospital care. Mortality from injecting without anyone else present will be unaffected by take-home naloxone. Take-home naloxone should be studied in a rigorous scientific manner.

Patterns of opioid and cocaine co-use: a descriptive study in a Canadian sample of untreated opioid-dependent individuals

This study examined prevalence and patterns of co-use of opioids and cocaine in regular users of illicit opioids (N = 729) recruited from 5 Canadian cities. Fifty-seven percent (n = 417) reported having used both opioids and cocaine in the month and week preceding the interview; of these, 73% (n = 304) were able to identify a typical pattern of daily co-use. In a typical day, injectors of opioids and cocaine (n = 119) and injectors of opioids who inhaled cocaine (n = 111) showed stable opioid use but variable cocaine use, which peaked at 21 hr. Overall, 30% of the individuals used both drugs exclusively in a sequential fashion, 35% reported taking opioids and cocaine within the same hour, and 35% reported taking them together at the same time or mixing them. These findings indicate that different individuals display different patterns of opioids and cocaine co-use.

Do supervised injecting facilities attract higher-risk injection drug users?

BACKGROUND

In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection.

METHODS

We examined data from a community-recruited cohort study of IDUs. The prevalence of SIF use was determined based on questionnaire data obtained after the SIF's opening, and we determined predictors of initiating future SIF use based on behavioral information obtained from questionnaire data obtained before the SIF's opening. Pearson's chi-square test was used to compare characteristics of IDUs who did and did not subsequently initiate SIF use.

RESULTS

Overall, 400 active injection drug users returned for follow-up between December 1, 2003 and May 1, 2004, among whom 178 (45%) reported ever using the SIF. When we examined behavioral data collected before the SIF's opening, those who initiated SIF use were more likely to be aged <30 years (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.0-2.7], p=0.04); public injection drug users (OR=2.6, 95% CI=1.7-3.9, p<0.001); homeless or residing in unstable housing (OR=1.7, 95% CI=1.2-2.7, p=0.008); daily heroin users (OR=2.1, 95% CI=1.3-3.2, p=0.001); daily cocaine users (OR=1.6, 95% CI=1.1-2.5, p=0.025); and those who had recently had a nonfatal overdose (OR=2.7, 95% CI=1.2-6.1, p=0.016).

CONCLUSIONS

This study indicated that the SIF attracted IDUs who have been shown to be at elevated risk of blood-borne disease infection and overdose, and IDUs who were contributing to the public drug use problem and unsafe syringe disposal problems stemming from public injection drug use.

The medical complications of heroin use

PURPOSE OF REVIEW

Heroin use is associated with numerous adverse sequelae. As clinical services develop, addiction psychiatrists will increasingly be called upon to help identify and manage the complications of heroin use. This review focuses on recent research into the medical complications of heroin use and looks at strategies to minimize harm associated with this practice.

RECENT FINDINGS

Mortality associated with heroin overdose has increased substantially in many countries. Parenteral use of opioid drugs is a central factor and other risk factors include polydrug use, particularly benzodiazepines and alcohol, mental health issues and environmental factors not conducive to resuscitation. Unravelling the determinants of blood-borne virus transmission continues, the focus shifting from needle sharing to inadvertent sharing of other injecting equipment. Trials addressing the challenges of antiviral therapy in injecting drug users are emerging. A greater understanding of the effects of opioids on immune functioning complements our knowledge of infection in the heroin-using group as well as possibly explaining the reduced response to vaccination in this group.

SUMMARY

Medical complications of heroin affect a number of different organ systems. The role of the addiction specialist is to be aware of these so that early diagnosis and appropriate management is instituted. The latter will generally be done in collaboration with other specialists. The addictions specialist can play a significant role in the development of clinical systems to minimize these complications.

Underlying causes of cocaine, amphetamine and opioid related deaths in Australia

OBJECTIVE

To examine the characteristics of deaths in Australia where opioids, cocaine or amphetamines were mentioned, taking into account changes in the use and availability of these drugs in recent years.

DESIGN

Data were analysed from the Australian Bureau of Statistics and Causes of Death dataset between 1997 and 2002 on all deaths in which cocaine, amphetamines or opioids were mentioned including deaths where (a) the drugs were considered an underlying cause of death, (b) the drugs contributed to accidental drug-induced death, and (c) deaths primarily due to other causes. Data from the Australian National Drug Strategy Household Survey were also used to examine the prevalence of use of amphetamines, cocaine and opioids in Australia.

RESULTS

Thirteen deaths were attributed primarily to cocaine, 68 to amphetamines, and 4591 to opioids. An increase occurred in mentions of amphetamines, but half of these were primarily attributed to opioids. Opioid related deaths declined dramatically in 2001, consistent with a marked reduction in availability of heroin in Australia. Cocaine mentions remained relatively stable, with most cases primarily attributed to opioids. Of the other underlying causes of death, suicide was the most prevalent underlying factor, particularly for amphetamine and opioid related deaths.

CONCLUSIONS

Compared with opioid-related deaths, there are small numbers of deaths related to psychostimulants in Australia. Accidental drug induced deaths account for the majority of deaths in which these drugs are mentioned, although minorities of drug related deaths are attributed to suicide.

Cocaine-related fatalities in New South Wales, Australia 1993-2002

AIM

To ascertain the demographic characteristics, circumstances of death, toxicological results, and major autopsy findings of cocaine-related fatalities.

DESIGN

Inspection of the coronial records of all cocaine-related deaths that occurred in New South Wales, Australia between 1 January 1993 and 31 December 2002.

SETTING

New South Wales, Australia.

FINDINGS

146 cases were identified. Cocaine was implicated in the direct cause of death in 86% of cases, an antecedent cause in 8% and a significant condition contributing to death in 7%. The mean age of decedents was 34.1 years, and 84% were male. Half were employed, and 26% were in professional employment. The predominant route of administration was injection (86%), however nasal (8%), oral (3%), smoking (1%), and anal (1%) administration were all recorded. The most common location of death was a private home (53%). No intervention occurred prior to death in 82% of cases. The median blood benzoylecgonine concentration was 0.40 mg/L (range 0.00-20.00 mg/L). Cases had a mean of 3.5 drugs, with morphine (79%) the most common co-occurring drug. In 5% of cases cocaine was the sole drug detected. Cardiac pathology was noted in 57% of cases, most commonly coronary artery atherosclerosis (39%) and cardiac hypertrophy (14%). In 15% of cases moderate to severe arterial occlusion was noted. Cerebrovascular pathology was noted in 22% of cases, most commonly cerebrovascular atherosclerosis (10%).

CONCLUSIONS

Cocaine-related deaths are a significant clinical problem in New South Wales.

The effect of a reduction in heroin supply on fatal and non‐fatal drug overdoses in New South Wales, Australia

OBJECTIVE

To examine the impact of a sudden and dramatic decrease in heroin availability, concomitant with increases in price and decreases in purity, on fatal and non-fatal drug overdoses in New South Wales, Australia.

DESIGN AND SETTING

Time-series analysis was conducted where possible on data on overdoses collected from NSW hospital emergency departments, the NSW Ambulance Service, and all suspected drug-related deaths referred to the NSW Coroner's court.

MAIN OUTCOME MEASURES

The number of suspected drug-related deaths where heroin and other drugs were mentioned; ambulance calls to suspected opioid overdoses; and emergency department admissions for overdoses on heroin and other drugs.

RESULTS

Both fatal and non-fatal heroin overdoses decreased significantly after heroin supply reduced; the reductions were greater among younger age groups than older age groups. There were no clear increases in non-fatal overdoses with cocaine, methamphetamines or benzodiazepines recorded at hospital emergency departments after the reduction in heroin supply. Data on drug-related deaths suggested that heroin use was the predominant driver of drug-related deaths in NSW, and that when heroin supply was reduced overdose deaths were more likely to involve a wider combination of drugs.

CONCLUSION

A reduction in heroin supply reduced heroin-related deaths, and did not result in a concomitant increase, to the same degree, in deaths relating to other drugs. Younger people were more affected by the reduction in supply.

Patterns of polydrug use among ketamine injectors in New York City

Polydrug use is an important public health issue since it has been linked to significant adverse health outcomes. Recently, club drugs, including ketamine and other drugs used in dance/rave scenes, have been identified as key substances in new types of polydrug using patterns. While seemingly a self-explanatory concept, "polydrug" use constitutes multiple drug using practices that may impact upon health risks. Ketamine, a club drug commonly administered intranasally among youth for its disassociative properties, has emerged as a drug increasingly prevalent among a new hidden population of injection drug users (IDUs). Using an ethno-epidemiological methodology, we interviewed 40 young (<25 years old) ketamine injectors in New York during 2000-2002 to describe the potential health risks associated with ketamine and polydrug use. Findings indicate that ketamine was typically injected or sniffed in the context of a polydrug using event. Marijuana, alcohol, PCP, and speed were among the most commonly used drugs during recent ketamine using events. Polydrug using events were often quite variable regarding the sequencing of drug use, the drug combinations consumed, the forms of the drug utilized, and the modes of administrating the drug combinations. Future research should be directed towards developing a more comprehensive description of the risks associated with combining ketamine with other drugs, such as drug overdoses, the transmission of bloodborne pathogens, such as HIV and HCV, the short- and long-term effects of drug combinations on cognitive functioning, and other unanticipated consequences associated with polydrug use.

Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users

BACKGROUND

North America's first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature.

METHODS

Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall.

RESULTS

In stratified linear regression models, the 12-week period after the facility's opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5-5.4) during the period before the facility's opening and 2.4 (95% CI 1.9-3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0-13.2) and 5.4 (95% CI 4.7-6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings.

INTERPRETATION

The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.

Non-fatal cocaine overdose among injecting and non-injecting cocaine users in Sydney, Australia

AIM

To investigate the frequency of non-fatal cocaine overdose, and responses to overdoses, among injecting and non-injecting cocaine users.

DESIGN

Cross-sectional study.

SETTING

Sydney, Australia.

PARTICIPANTS

Two hundred current cocaine users.

MEASUREMENTS

Structured interview.

FINDINGS

Thirteen per cent of the sample had overdosed on cocaine, 7% in the preceding 12 months. Cocaine injectors were more likely to have overdosed, both ever (17 v 6%) and in the preceding 12 months (9 v 3%). The most common symptoms of overdose were palpitations (68%), intense sweating (44%) and seizures (40%). The use of other drugs in combination with cocaine prior to the most recent overdose was prevalent (64%), most commonly opioids (40%), alcohol (24%) and cannabis (24%). Those who had overdosed were more likely to be female, had longer cocaine use careers, had used more cocaine in the preceding month and preceding 6 months, had higher levels of cocaine dependence and more extensive polydrug use. Twenty-four per cent had witnessed a cocaine overdose, 13% in the preceding 12 months. Injectors were more likely to have witnessed overdoses, both ever (35% v 8%) and in the preceding 12 months (20% v 3%).

CONCLUSIONS

Experience of, and exposure to, overdose were not rare events. Cocaine users need to be aware of the possibility and nature of overdose, and that cocaine overdose can occur irrespective of method of use. There is a need to emphasise the potential danger of combining cocaine with other drugs.

Attempted suicide among injecting and noninjecting cocaine users in Sydney, Australia

A sample of 183 current cocaine users, 120 primary injecting cocaine users (ICUs), and 63 primary noninjecting cocaine users (NICUs) were administered a structured interview to ascertain attempted suicide histories, methods used, and factors associated with suicide attempts. All respondents were volunteers and current cocaine users recruited through a wide range of sources. The mean age of participants was 30.1 years, and 65% were male. The ICUs were older (32.3 vs. 26.7 years, respectively), more likely to be male (72% vs. 54%, respectively), to be unemployed (84% vs. 23%, respectively) and to have a prison history (53% vs. 1%, respectively) compared to NICUs. Of the sample, 31% had attempted suicide, 18% had done so on more than one occasion, and 8% had made an attempt in the preceding 12 months. Overall, 28% of the sample had been treated by a medical practitioner after an attempt. ICUs (38%) were significantly more likely than NICUs (10%) to have attempted suicide and to have done so on more than one occasion (23% vs. 3%, respectively). The most common method used among both groups was self-poisoning (ICUs 28%, NICUs 8%), primarily by drug overdose. Violent methods had been used by 22% of ICUs and 3% of NICUs. Multivariate analyses revealed that injecting, female gender, and more extensive polydrug use were independent predictors of a suicide attempt. The prevalence of suicide in this study indicates that it represents a major clinical issue among ICUs and to a lesser extent among noninjectors of the drug. Those treating cocaine users for drug dependence need to be aware of the salience of suicide as a problem, among injectors in particular.

Determinants of overdose incidents among illicit opioid users in 5 Canadian cities

BACKGROUND

Drug overdose is a major cause of death and illness among illicit drug users. Previous research has indicated that most illicit drug users experience nonfatal overdoses and has suggested a variety of factors that are associated with risk of overdose. In this study, we examined the occurrence of and the factors associated with nonfatal overdoses within a Canadian sample of illicit opioid users not enrolled in treatment at the time of study recruitment.

METHODS

Interviewers used a standard questionnaire to collect data on sociodemographic characteristics, drug use, health and health care, experience in the criminal justice system and treatment for drug problems; they also performed standard assessments for mental health and infectious disease. The association between overdose and sociodemographic and drug-use factors was examined with chi(2) and t test analyses; marginally significant variables were examined with logistic regression to determine independent effects.

RESULTS

A total of 679 subjects were interviewed; 651 provided answers sufficient for this analysis. One hundred and twelve (17.2%) of the 651 respondents reported an overdose episode in the previous 6 months. In the logistic regression analysis (after adjustment for sociodemographic factors), homelessness, noninjection use of hydromorphone in the past 30 days and involvement in drug treatment in the past 12 months were predictors of overdose (p < 0.05).

INTERPRETATION

Overdose poses a considerable health risk for illicit opioid users. We found that a diverse set of factors was associated with overdose episodes. Prevention efforts will likely be more effective if they can be directed to specific causal factors.

Overdose deaths attributed to methadone and heroin in New York City, 1990-1998

AIMS

Methadone treatment has been shown to be an effective intervention that can lower the risk of heroin-induced overdose death. Recent reports have suggested increases in methadone-induced overdose deaths in several locations in the USA and in Europe. This study investigated the role of methadone and opiates in accidental overdose deaths in New York City.

DESIGN

We analysed data from the Office of the Chief Medical Examiner to examine all accidental drug overdose deaths in New York City between 1990 and 1998.

FINDINGS

Of 7451 total overdose deaths during this period, there were 1024 methadone-induced overdose deaths, 4627 heroin-induced overdose deaths and 408 overdose deaths attributed to both methadone and heroin. Fewer than a third as many accidental overdose deaths were attributed to methadone than were attributed to heroin during this period. The proportion of accidental overdose deaths attributed to methadone did not change appreciably (12.6-15.8% of total overdose mortality), while the proportion of overdose deaths attributed to heroin increased significantly (53.5-64.2%) during the period of study.

CONCLUSIONS

There was no appreciable increase in methadone-induced overdose mortality in New York City during the 1990s. Both heroin-induced overdose mortality and prescriptions of methadone increased during the same interval.

Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users

It was recently found that 94% of the nearly $500 million allocated annually to Canada's illicit drug strategy has been spent on enforcement-based interventions. As a result, lack of funds for addiction treatment has meant demand for substance abuse treatment among illicit drug users has exceeded availability. This study evaluated whether injection drug users (IDUs) who reported being unable to access addiction treatment were at elevated risk of HIV infection. A prospective analysis was done of factors associated with syringe borrowing by baseline HIV-negative IDUs among participants enrolled in the Vancouver Injecting Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with syringe borrowing were evaluated using generalized estimating equations (GEEs) with logit link for binary outcomes. Overall, 1157 HIV-negative IDUs were enrolled into the VIDUS cohort between May 1996 and May 2002. Unsuccessful attempts to access addiction treatment were associated with reporting syringe borrowing during follow-up in both univariate (odds ratio 1.72; 95% CI 1.47-2.00; P<0.001) and in multivariate GEE analyses (adjusted odds ratio 1.29; 95% CI 1.09-1.53; P=0.003). Inability to access addiction treatment was independently associated with syringe borrowing among HIV-negative IDUs at risk for HIV infection. These findings suggest that the limited provision of addiction treatment may result in a major missed opportunity to reduce HIV transmission behavior among IDUs and that the expansion of addiction treatment services has major potential to reduce the substantial human and fiscal costs of HIV infection.

Rationale for evaluating North America's first medically supervised safer-injecting facility

Many cities throughout the world are experiencing ongoing infectious disease and overdose epidemics among illicit injection drug users (IDUs). In particular, HIV and hepatitis C virus (HCV) have become endemic in many settings and bacterial infections, such as endocarditis, have become extremely common among this population. In an effort to reduce these public health concerns, in September 2003, Vancouver, Canada, opened a pilot medically supervised safer- injecting facility (SIF), where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff. Before and since the facility's opening, there has been a substantial misunderstanding about the rationale for evaluating SIF as a public-health strategy. This article outlines the evidence and rationale in support of the Canadian initiative. This rationale involves limitations in conventionally applied drug-control efforts, and gaps in current public-health policies in controlling the spread of infectious diseases, and the incidence of overdose among IDUs.