Intentional overdose among heroin overdose survivors

Prevalence of and Factors Influencing Suicide Ideation, Attempt, and Completion in Heroin Users: A Systematic Review and Meta-Analysis

BACKGROUND

Suicide is considered a fundamental problem in discussions on public and global health. Thus, the current study aimed to review the prevalence of and reasons for successful suicide attempts in heroin users.

METHODS

This study was conducted by systematically searching the electronic databases of PubMed, Scopus, Web of Science, and PsycINFO from 1960/1/1 to 2021/11/1 based on the PRISMA checklist and using MeSH keywords with no temporal or linguistic limitations. The primary and secondary impacts of suicide were identified, and all studies following an observational design (cohort, case-control, and cross-sectional studies) were included in the research. Data analysis was performed using Stata version 13. Finally, 17 studies were included in the work process for systematic review and meta-analysis.

FINDINGS

The results showed the most frequent reasons for suicide among the studied individuals were gender (being female), youngness, heroin overdose, multi-drug abuse, history of repeated suicide attempts, history of psychiatric disorder (especially depression), joblessness, homelessness, distorted family relationships, etc. Moreover, the results of synthesizing the studies revealed the prevalence of suicide attempts equaled the effect size (95% CI=0.3 [0.23-0.37]) among these individuals, and the prevalence of successful suicides approached the effect size (95% CI=0.03 [0.01-0.05]).

CONCLUSION

The results of the present study showed the high prevalence of suicidal thoughts and suicide attempts among the heroin-abusing population. Furthermore, according to the findings, the prevalence of unsuccessful suicide attempts was ten times more than that of successful ones in the target population.

Distinguishing clinical factors associated with unintentional overdose, suicidal ideation, and attempted suicide among opioid use disorder in-patients

Opioid and other drug-related overdoses and suicides are leading causes of injury death and represent a significant public health threat in the United States (U.S.). This study examined clinical factors of three patient groups from two inpatient addiction treatment facilities in Appalachian West Virginia (n = 66). Patients were classified as having: 1) unintentional overdose(s) (OD), 2) suicidal ideation or suicide attempt(s) (SI/SA), and 3) suicidal ideation or suicide attempt, and unintentional overdose (SI/SA/OD). Multinomial logistic regression models were used to determine whether adverse childhood experiences, self-injurious behaviors, substance use history, overdose history, and past year stressful life events were differentially associated with history of SI/SA/OD. Participants in the OD group were more likely to have used heroin in the 24-h preceding their most recent overdose compared to either the SI/SA or SI/SA/OD groups. The multivariable model found participants with history of SI/SA had higher adverse childhood experience scores and more participants with history of SI/SA endorsed childhood physical abuse and teen dating violence. Overall, there are characteristics that distinguish unintentional overdose from suicidal ideation and attempt. Patients with SI/SA/OD appear to have greater clinical severity. More thorough evaluation of drugs involved in overdose and history of self-injury may help distinguish future risk and inform treatment planning.

Suicidal motivations among opioid overdose survivors: Replication and extension

BACKGROUND

Several studies suggest suicidal motivation may contribute to opioid overdose fatalities in people with opioid use disorder. In this study, we sought to replicate and extend prior findings suggesting that a desire to die is common prior to nonfatal opioid overdose in people with opioid use disorder.

METHODS

Adults receiving inpatient detoxification and stabilization who reported a history of opioid overdose (N = 60) completed questions about suicidal cognition prior to their most recent overdose.

RESULTS

Approximately 45% reported some desire to die prior to their most recent overdose, with 20% reporting they had some intention to die. The correlation between these ratings was of a moderate magnitude (ρ = 0.58). Almost 40% of the sample perceived no risk of overdose prior to their most recent overdose event, suggesting a significant underestimation of risk in this population.

CONCLUSIONS

Desire to die was common in adults with opioid use disorder prior to nonfatal opioid overdose events, and 1 in 5 people with a history of opioid overdose reported intention to die prior to their most recent opioid overdose. Careful assessment of suicidal cognition in this population may improve prevention of opioid overdose deaths.

Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review

BACKGROUND

Non-fatal opioid-related overdoses have increased significantly over the past two decades and there have been increasing reports of brain injuries and/or neurocognitive impairments following overdose events. Limited preclinical research suggests that opioid overdoses may cause brain injury; however, little is known about such injuries in humans. The purpose this systematic review is to summarize existing studies on neurocognitive impairments and/or brain abnormalities associated with an opioid-related overdose in humans.

METHODS

PubMed, Web of Science, Ovid MEDLINE and PsyINFO were searched, without year restrictions, and identified 3099 articles. An additional 24 articles were identified by reviewing references. Articles were included if they were published in English, reported study findings in humans, included individuals 18 years of age or older, and reported an objective measure of neurocognitive impairments and/or brain abnormalities resulting from an opioid-related overdose. Six domains of bias (selection, performance, attrition, detection (two dimensions) and reporting were evaluated and themes were summarized.

RESULTS

Seventy-nine journal articles, published between 1973-2020, were included in the review. More than half of the articles were case reports (n = 44) and there were 11 cohort studies, 18 case series, and 6 case-control studies. All of the studies were categorized as at-risk of bias, few controlled for confounding factors, and methodological differences made direct comparisons difficult. Less than half of the studies reported toxicology results confirming an opioid-related overdose; 64.6 % reported brain MRI results and 27.8 % reported results of neuropsychological testing. Only two studies had within subject comparative data to document changes in the brain possibly associated with an overdose. Despite these limitations, existing publications suggest that brain injuries and neurocognitive impairments are associated with opioid overdose. Additional research is needed to establish the incidence of overdose-related brain injuries and the potential impact on functioning, as well as engagement in treatment of substance use disorders.

CONCLUSIONS

Respiratory depression is a defining characteristic of opioid overdose and prolonged cerebral hypoxia may cause brain injuries and/or neurocognitive impairments. The onset, characteristics, and duration of such injuries is variable and additional research is needed to understand their clinical implications.

Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality

The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.

Risk factors for heroin use following release from jail or prison in adults in a Central Appalachian state between 2012-2017

Background

Corrections-involved adults with a history of opioid use disorder are at elevated risk of opioid overdose following release from correctional settings. Increased opioid prescribing restrictions and monitoring during a time when heroin is becoming cheaper and ubiquitous means that adults who misused prescription opioids prior to incarceration may be reentering communities at greater risk for heroin exposure and use.

Objectives

Determine risk factors of post-release heroin use among a sample of adults who participated in corrections-based drug treatment in Kentucky released between 2012 and 2017.

Methods

Survey data obtained as part of an ongoing evaluation of corrections-based drug treatment were examined.

Results

The final sample (N = 1,563) was majority male (80.9%). Nearly 11.0% reported past-year heroin use following their release. Depressive symptoms, polydrug use, and urban proximity were more common among participants reporting post-release heroin use. Heroin use 30 days prior to incarceration was associated with a 432.1% increase in odds of heroin use subsequent to incarceration. Post-release suicidal ideation increased odds of heroin use by 154.2%, whereas reporting satisfaction from social interactions decreased odds of use by nearly 60%. Post-release use of cocaine and diverted buprenorphine were associated with increased likelihood of heroin use during this time period, increasing odds by 469.1% and 265.9%, respectively. Residing in Central Appalachia subsequent to incarceration was associated with decreased likelihood of use.

Conclusions

In this sample, post-release heroin use was associated with concerning features, such as polydrug use, lack of social satisfaction, and suicidal ideation. These features can serve as clear targets for clinical intervention.

Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder

BACKGROUND

Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization.

METHODS

Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die).

RESULTS

Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood.

CONCLUSIONS

Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.

Prescription opioid use among individuals with serious mental illness

Prevalence and correlates of prescription opioid use were explored in individuals with serious mental illness (SMI) by examining a sample of adults from two inner city community psychiatry clinics. Of 271 participants, 12.9% (n = 35) were on a prescribed opioid. Being on an opioid was significantly associated with history of heroin use and active prescription sedative-hypnotic use, including benzodiazepine use. Concurrent use of opioids with sedative-hypnotics was significantly associated with suicidal ideation. The results highlight risks of prescription opioid use in those with SMI, particularly in combination with prescription sedative-hypnotics.

Death Ambivalence and Treatment Seeking: Suicidality in Opiate Addiction

PURPOSE OF REVIEW

Rates of suicide and opiate overdose have recently skyrocketed in the United States. In light of impulsivity and impaired motivation common in people with substance use disorders, suicidality is common in addiction.

RECENT FINDINGS

Chart review surveys indicate two primary suicidal populations that are important to distinguish for clinical practice and healthcare policy. One group is heavily composed of people with SUDs, in whom chronic compulsive use fosters a numb ambivalence about death (low death intentionality). Many of these individuals with opiate use disorder (OUD) exaggerate suicidality to get prompt psychiatric care to treat the OUD. The second group is composed of those who have co-morbid psychiatric disorders and/or chronic pain who have a higher intent to die consistent with traditionally understood suicide risk factors.

SUMMARY

We contend that easier access to outpatient opiate agonist treatment would avoid unnecessary hospitalizations for death-ambivalent OUD patients, and for OUD patients in either group. First line treatment with an opioid agonist has high potential to effectively treat suicidal ideation as a secondary benefit.

Dancing with Death: The Grey Area between Suicide Related Behavior, Indifference and Risk Behaviors of Heroin Users

Suicide-related behavior (SRB) among heroin users is a complex and multifaceted continuum, including such fringe areas as indifference and “risky” behavior. The article investigates the nuances and intersections of SRB, using qualitative semi-structured interviews with 60 regular heroin users recruited primarily from syringe programs in Geelong, Australia. Twenty-eight percent of interviewees reported a previous suicide attempt and 45% reported serious consideration of it. Types of SRB reported included: Suicide attempts, instrumental suicide-related behaviors, suicidal ideation, indifference and risk-taking thoughts and behaviors. Heroin users engage in much behavior which inhabits a grey area of SRB. The use of a nomenclature which addresses the elements of lethality and intent improves the ability of research to properly define and categorize SRB in drug-using populations. But the categories should not be over inclusive; indifferent attitudes towards death and risk-taking behaviors can sometimes be a functional response to the risk environment of heroin users.

Illegal Drug-Attributable Mortality and Potential Years of Life Lost in Canada 2002: Implications for Prevention and Policy

The article estimates the deaths and years of life lost due to use of illegal drugs in Canada in the year 2002. In 2002, for Canada, 1,695 deaths were attributable to illegal drug use, 0.8% of all deaths: 1,183 of men (1.0%) and 512 in women (0.5%). Main causes of illegal drug use-attributable death were drug overdose, suicide, and hepatitis C. In 2002 in total, 62,110 years of life were lost prematurely, 42,306 years among men and 19,805 years among women. Illegal drug use constitutes a major contributor to the burden of mortality in Canada. A mixture of prevention and harm reduction measures is proposed to reduce the burden of mortality associated with drug use.

The Association between Intentional Overdose and Same-Sex Sexual Intercourse in a Cohort of People who Inject Drugs in Melbourne, Australia

BACKGROUND

People who inject drugs (PWID) are at disproportionately high risk of suicidal behaviors, as are individuals who report same-sex attraction or experience. However, there is little evidence of compounded risk of suicide for individuals who report same-sex sexual intercourse (SSI) and are PWID.

OBJECTIVES

To explore the associations of lifetime intentional overdose amongst a cohort of PWID, with particular attention to those reporting SSI.

METHODS

The sample included 529 participants, from an ongoing cohort of 757 PWID. An "ever" SSI variable was created for participants who reported sexual intercourse with a same-sex partner at any longitudinal interview. We explored the adjusted associations between SSI and lifetime intentional overdose using logistic regression.

RESULTS

Ninety-one (17%) participants reported ever experiencing an intentional overdose. Forty-one (8%) participants reported SSI at any interview. Three hundred and sixty (68%) participants reported diagnosis of a mental health condition. Diagnosis of a mental health condition (AOR = 2.02, 95% CIs: 1.14, 3.59) and SSI (AOR = 2.58, 95% CIs: 1.22, 5.48) significantly increased the odds of lifetime intentional overdose. Conclusions/Importance: We found a heightened risk of intentional overdose amongst PWID reporting SSI, after controlling for diagnosis of a mental health condition. Services need to be aware of this heightened risk and target interventions appropriately.

Opioid-Involved Overdose Among Male Afghanistan/Iraq-Era U.S. Military Veterans: A Multidimensional Perspective

BACKGROUND

Mirroring nationwide trends in a broad range of U.S. populations, an alarming number of Afghanistan/Iraq-era U.S. Military veterans have experienced opioid-related overdoses. A growing body of research has examined the proximal behaviors that can precipitate an overdose; considerably less is known about more distal physiological, psychosocial and structural influences on these risk behaviors.

OBJECTIVES

This study adopts a multidimensional approach to better understand opioid-related overdose among U.S. Military veterans, and seeks to explore not only the proximal behavioral precipitants of overdose events, but also the complex nexus of physiological, psychological, and sociological influences that undergird overdose events.

METHODS

This qualitative examination is based on interview data from 36 male veterans who were discharged from the military after September 2001 and experienced at least one opioid-related overdose during or after military service. Participants were recruited in New York City during 2014 to share narrative accounts of their overdoses.

RESULTS

Veterans' accounts indicate that background experiences, such as self-medication for social and psychological pain, trauma, social alienation and isolation, and histories of illicit drug use, precondition the more immediate factors and behaviors that precipitate overdose (including bingeing on drugs, mixing drugs, naiveté about dosage, and ambivalence about life/death).

CONCLUSIONS

Findings suggest the need for comprehensive drug safety and overdose education that is sensitive to veterans' physiological, psychological, and sociological conditions. A multidimensional understanding of the distal and proximal overdose risks faced by veterans and other vulnerable groups may help lay a foundation for more inclusive/holistic approaches to overdose prevention and education.

Fatal and non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone

BACKGROUND

Illicit opioid use is associated with high rates of fatal and non-fatal opioid overdose. This study aims to compare rates of fatal and serious but non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone, and to identify risk factors for fatal opioid overdose.

METHODS

Opioid dependent patients treated with methadone (n=3515), buprenorphine (n=3250) or implant naltrexone (n=1461) in Western Australia for the first time between 2001 and 2010, were matched against state mortality and hospital data. Rates of fatal and non-fatal serious opioid overdoses were calculated and compared for the three treatments. Risk factors associated with fatal opioid overdose were examined using multivariate cox proportional hazard models.

RESULTS

No significant difference was observed between the three groups in terms of crude rates of fatal or non-fatal opioid overdoses. During the first 28days of treatment, rates of non-fatal opioid overdose were high in all three groups, as were fatal opioid overdoses in patients treated with methadone. However, no fatal opioid overdoses were observed in buprenorphine or naltrexone patients during this period. Following the first 28 days, buprenorphine was shown to be protective, particularly in terms of non-fatal opioid overdoses. After the cessation of treatment, rates of fatal and non-fatal opioid overdoses were similar between the groups, with the exception of lower rates of non-fatal opioid overdose in the naltrexone treated patients compared with the methadone treated patients. After the commencement of treatment, gender, and hospitalisations with a diagnosis of opioid poisoning, cardiovascular or mental health problems were significant predictors of subsequent fatal opioid overdose.

CONCLUSIONS

Rates of fatal and non-fatal opioid overdose were not significantly different in patients treated with methadone, buprenorphine or implant naltrexone. Gender and prior cause-specific hospitalisations can be used to identify patients at a high risk of fatal opioid overdose.

“Take home” naloxone: what does the evidence base tell us?

Purpose

– Opiod users are at high risk of suffering from drug overdoses. Naloxone has been used for decades in emergency treatment settings to reverse the symptoms of opioid overdose. Pilot studies and regional programmes have been rolled out to make naloxone more widely available. This review of user/carer administration of naloxone – so-called “take home naloxone” – aims to provide health professionals and interested readers with an up-to-date evidence base, clinical implications and practical concern considerations for such community management. The paper aims to discuss these issues.

Design/methodology/approach

– A review and analysis of the recent literature on naloxone.

Findings

– The evidence base suggests training and education is effective in preparing users for wider naloxone distribution. Furthermore, studies of varying quality indicate that naloxone may prove useful in reducing overdose-related deaths. However, even after implementation ineffective response techniques continued to be used at times and there remained a heistance to call medical services post overdose. Intranasal naloxone may reduce some of the risks associated with intramuscular naloxone. Ethical considerations, including provision of a needle and syringe kit to the community, should be considered. Studies suffered from a lack of follow-up data and methodological difficulties are associated with establishing opioid-related deaths post implementation. Two running trials in the UK might mitigate these concerns.

Research limitations/implications

– Future research is needed to address wider context of an overdose and targeting associated risk factors.

Originality/value

– Clinicians and other professionals will be informed on the most up-to-date evidence base and which areas are improtant to consider when take-home naloxone is introduced in their services.

A procedure that differentiates unintentional from intentional overdose in opioid abusers

OBJECTIVE

The purpose of this study is to develop a procedure for assessing unintentional overdose (OD) in opiate abusers that differentiates it from intentional OD, and provides reliable information about the incident.

METHODS

A sample of 121 patients in a methadone maintenance program at an urban university hospital completed a baseline assessment. A total of 70 participants completed an identical assessment at least 14 days later. The ability of an OD item to differentiate unintentional OD from intentional OD was tested, as was the test-retest reliability of questions assessing symptoms and treatment of OD.

RESULTS

The procedure is reliable and differentiated unintentional OD from intentional OD. Questions assessing symptoms of OD were endorsed in almost every unintentional OD incident, although reliability was affected by loss of consciousness. The reliability of questions assessing emergency treatment and Narcan administration was outstanding.

CONCLUSIONS

Our procedure for assessing OD differentiates unintentional OD from intentional OD. The use of follow-up questions assessing acute treatment for OD is recommended. Items concerning symptoms of OD are not needed to confirm the presence of an OD, but may be used to clarify whether an event was an OD.

Unintentional overdose and suicide among substance users: a review of overlap and risk factors

Substance use is a risk factor for suicide, suicide attempts, and fatal and non-fatal overdose, but to date, little has been done to integrate the research on suicidal behavior and overdose among substance users. This study reviews the literature on suicide and overdose among substance users with the goal of illuminating the similarities and differences between these two events. A structured review resulted in 15 articles (describing 14 unique studies) published between 1990 and 2010 that examined both overdose and suicide in samples of substance users. There is some evidence that substance users who attempt suicide are more likely to report an overdose and vice versa. This relationship may be partially explained by the fact that overdose is a common method of suicide. The results of the literature review also indicate that substance users with a history of both events may represent a group with particularly poor psychological and social functioning and severe drug-related problems. Further research is needed to understand the overlap of, and differences between, suicide and accidental overdose among individuals who misuse substances, particularly individuals who primarily use substances other than heroin. An improved understanding of the interrelationships between suicide and unintentional overdose among individuals who use alcohol or drugs is necessary to guide the development of effective prevention and intervention approaches.

Nonfatal Overdose Among Heroin Users in Southwestern China

OBJECTIVE

To evaluate the prevalence of and risk factors for nonfatal overdose among heroin users in southwestern China.

METHODS

In 2005, 731 heroin users in Sichuan Province, China were interviewed for overdose experiences in the past 12 months. Factors hypothesized to be associated with overdose were evaluated with logistic regression models.

RESULTS

Eighty-eight (12%) drug users experienced at least one overdose, with a range from 1 to 20; 45 (51%) experienced 2 or more overdoses. Over half of participants with experience of overdose were recently released from prison (52%), and 56% used benzodiazepines before overdose. Longer methadone treatment in the past year (>or=180 vs. 0 days; OR, .3; 95% CI, .1-.8; P = .02), longer duration of using drugs (>or=7 vs. <7 years; OR, 2.2; 95% CI, 1.3-3.6; P = .002), and more frequency of injecting drugs in the past 3 months (>or=7 vs. <7 times/week; OR, 5.4; 95% CI, 3.2-9.0; P < .001) were independently associated with increased risk of nonfatal heroin overdose.

CONCLUSIONS

Nonfatal heroin overdoses are common among Chinese heroin users. Drug users should be encouraged to participate and remain in methadone treatment to prevent overdose and be educated about proper response to overdose to reduce risk of overdose death.

Factors associated with history of non-fatal overdose among opioid users in the Swedish criminal justice system

BACKGROUND

Overdose (OD) is a common cause of death in opioid users. Also, many current opioid users report a history of non-fatal OD. The present study aimed to identify factors associated with a history of non-fatal OD.

METHODS

A sample of 7085 Swedish criminal justice clients with alcohol or drug misuse was assessed, using the Addiction Severity Index. Subjects reporting use of opioids during the 30 days prior to incarceration were included (n=1113). Relevant variables of misuse pattern, heredity, psychiatric symptoms and previous criminal charges were analysed in a logistic regression model.

RESULTS

A history of non-fatal OD was reported by 55% (n=604). The estimated contribution to the variance in OD history was 25% for variables describing misuse pattern, compared to 10% for psychiatric symptoms, 8% for heredity, and 8% for previous criminal charges. The final model included the following variables: history of injection drug use (OR 3.28), history of heroin use (OR 2.87), history of suicide attempt (OR 1.92), history of tranquilliser use (OR 1.91), being born in Sweden or other Nordic countries (OR 1.74), difficulty in controlling violent behaviour (OR 1.68), and paternal alcohol problems (OR 1.57).

CONCLUSIONS

Suicide attempts and difficulty in controlling violent behaviour were associated with history of non-fatal OD, independent of variables of misuse pattern. This may indicate a possible association with impulse control disturbances, and may have clinical applications. Country of birth and heredity of alcohol problems also had some influence. As expected, severity of misuse most strongly contributed to history of non-fatal OD.

Cause and motivation in cases of non-fatal drug overdoses in opiate addicts

INTRODUCTION

Drug overdose (OD) is a frequent incident among opiate addicts. Survivors of ODs are at risk for additional and eventually fatal ODs. ODs may be classified as accidental (aOD) or deliberate (dOD). Investigations into the connection between OD and suicide attempts have led to insconsistent results.

PURPOSE

(1) to determine how many non-fatal ODs were dODs and how many were aODs; (2) to determine how many cases of dODs were motivated by explicit or by ambivalent suicidal intentions; (3) to determine how many cases of aODs had causes that might respond to preventative measures; (4) to compare the addiction histories of dODs and aODs; (5) to compare the drugs causing the ODs; and (6) to compare the severity of the ODs in both groups.

METHODS

Prospective study utilizing a standardized questionnaire to evaluate opiate-addicted patients admitted to our treatment unit for OD. All cases underwent standardized drug testing to identify drug use patterns.

RESULTS

Seventy-four cases of OD underwent standardized interviews after awakening. Forty-three percent of the cases were dOD. Cases of dOD had significantly more OA in substitution programs, more previous ODs, and more often consumed methadone and cocaine. Among dODs, 22.5% had suicidal intention and 9.6% were ambivalent about committing suicide; background motivations were most often conflicts with spouses. Fifty-seven percent of the cases were aOD. Cases of aODs had significantly more potential lethal intoxications and had heroin detected more frequently. aODs happened with unexpected pure heroin (46%), in combination with alcohol (36%), as relapse after abstinence (40%) or after institutionalized treatment (19%). This group should be accessible for targeted education.

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.

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

BACKGROUND AND AIMS

Heroin overdose is a serious consequence of heroin use and one of the leading causes of premature death and illness in Australia. Despite considerable research effort little is known about the effects of transient changes in heroin user behaviour and the links to overdose. This research is the first to use a suitable methodology to allow such ephemeral changes and their effects on non-fatal heroin overdose to be examined.

METHODS

A case-crossover design was used in which non-fatal heroin overdose survivors' recall of risk behaviours in the 12 hours prior to overdose (hazard period) was compared to their recall of risk behaviours in the 12 hours prior to a selected non-overdose heroin injection (control period).

RESULTS

A total of 155 participants were able to provide valid details of hazard and control periods. A dose-response relationship was observed between the self-reported amount of heroin used and likelihood of overdose (e.g. > AUD50, OR 12.97, 95% CI 2.54-66.31). The use of benzodiazepines (OR 28, 95% CI 3.81-205.79) or alcohol (OR 2.88, 95% CI 1.29-6.43), during the hazard period was related to overdose risk, but the effect of alcohol was attenuated by the effect of benzodiazepines. Shifting from private to public locations between control and hazard periods was also related to increased risk of overdose (OR 3.63, 95% CI 1.66-7.93).

CONCLUSIONS

We demonstrate the value of a new methodology to explore heroin overdose, as well as discussing its limitations and ways to overcome them in future. In terms of our findings, overdose prevention messages need to highlight the impact of these transient changes in behaviour and to emphasize the risks of using higher doses of heroin as well as continuing to emphasize the risks of combining heroin with other central nervous system (CNS) depressants. Safer environments for heroin use, such as injecting rooms, may also reduce the chances of overdose.

Recent life problems and non-fatal overdose among heroin users entering treatment

AIMS

To investigate the role of recent life problems in non-fatal overdose among heroin users entering various drug treatment settings.

DESIGN

Cross-sectional data from a longitudinal study investigating drug treatment effectiveness.

SETTING

Five prison drug treatment services, three residential rehabilitation units, three residential detoxification units and 21 community drug treatment services located in rural, urban and inner-city areas of Scotland.

PARTICIPANTS

Of a total of 793 primary heroin users commencing drug treatment during 2001-02, 337 (42.5%) were prison drug service clients; 91 (11.5%) were residential rehabilitation clients; 97 (12.2%) were residential detoxification clients; and 268 (33.8%) were community drug treatment clients.

MEASUREMENTS

Univariate and stepwise multivariate logistic regression analyses examined associations between overdosing in the 90 days prior to treatment entry and basic demographic characteristics, recent drug use and recent life problems.

FINDINGS

Ninety-one study participants (11.5%) reported at least one overdose and 19 (2.4%) reported more than one overdose in the 90 days prior to treatment entry. A chi2 test revealed no significant difference in rates of recent overdosing between the four treatment settings (P = 0.650). Recent drug use and recent life problems-but not demographic characteristics-were associated independently with recent overdosing. However, recent life problems were not associated independently with recent overdosing among clients entering prison, clients entering residential rehabilitation or with multiple recent overdosing.

CONCLUSIONS

Associations between recent life problems and recent overdose were evident, but varied by treatment setting. Treatment providers should identify and address heroin users' life problems as part of a broad strategy of overdose prevention.

Governing street-based injecting drug users: a critique of heroin overdose prevention in Australia

This article provides a critical analysis of existing approaches to the prevention of heroin overdose in Australia. It draws on almost 2 years of ethnographic research with street-based injecting drug users (IDUs), street-based sex workers and service providers in Melbourne, Australia's second largest city, and on recent anthropological and sociological work on governmentality. The substantive sections of the article argue: (1) that heroin overdose prevention in Australia contains implicit or explicit assumptions of rationality and personal autonomy, continues to emphasise individual behaviour change and inscribes a self-disciplined, self-aware, self-regulating subject; and (2) that the social, cultural and economic realities--the 'lived experience'--of street-based IDUs and sex workers may undermine or hinder the successful adoption of overdose prevention strategies. The paper concludes by arguing that the 'chaotic' practices of street-based IDUs and sex workers arise in response to particular 'risk environments', and that individually focused overdose prevention strategies, while an important first step, need to be complemented by measures addressing the macro- and micro-aspects of risk environments.