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

Determining the Impact of Opioid Policy on Substance Use and Mental Health-Related Harms: Protocol for a Data Linkage Study

BACKGROUND

Increasing harms related to prescription opioids over the past decade have led to the introduction of a range of key national and state policy initiatives across Australia. These include introducing a mandatory real-time prescription drug-monitoring program in the state of Victoria from April 2020 and a series of changes to subsidies for opioids on the Pharmaceutical Benefit Scheme from June 2020. Together, these changes aim to influence opioid supply and reduce harms related to prescription opioids, yet few studies have specifically explored how these policies have influenced opioid prescribing and related harms in Australia.

OBJECTIVE

The aim of this study is to examine the impact of a range of opioid-related policies on hospital admissions and emergency department (ED) presentations in Victoria, Australia. In particular, the study aims to understand the effect of various opioid policies and opioid-prescribing changes on (1) the number and rates of ED presentations and hospital admissions attributed to substance use (ie, opioid and nonopioid related) or mental ill-health (eg, suicide, self-harm, anxiety, and depression), (2) the association between differing opioid dose trajectories and the likelihood of ED presentations and hospital admissions related to substance use and mental ill-health, and (3) whether changes in an individual's opioid prescribing change the risk related to ED presentations and hospital admissions related to substance use and mental ill-health.

METHODS

We will conduct a population-level linked data study. General practice health records obtained from the Population Level Analysis and Reporting platform are linked with person-level data from 3 large hospital networks in Victoria, Australia. Interrupted time series analysis will be used to examine the impact of opioid policies on a range of harms, including the rates of presentations related to substance use (opioid and nonopioid) and mental ill-health among the primary care cohort. Group-based trajectory modeling and a case-crossover design will be used to further explore the impact of changes in opioid dosage and other covariates on opioid and nonopioid poisonings and mental ill-health-related presentations at the patient level.

RESULTS

Given that this paper serves as a protocol, there are currently no results available. The deidentified primary health data were sourced from electronic medical records of approximately 4,717,000 patients from 542 consenting general practices over a 6-year period (2017-2022). The submission of results for publication is planned for early 2024.

CONCLUSIONS

This study will add to the limited evidence base to help understand the impact of opioid policies in Australia, including whether intended or unintended outcomes are occurring as a result.

TRIAL REGISTRATION

EU PAS Register EUPAS104005; https://www.encepp.eu/encepp/viewResource.htm?id=104006.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51825.

Prevalence and associates of non-fatal overdose among people who inject drugs in Saveh, Iran

Background

As a public health issue, non-fatal overdose (NFOD) is highly prevalent among people who inject drugs (PWID). This can lead to an elevated risk of future overdose, causing various harms including possible death. It is essential to improve knowledge concerning this problem and its associated risk factors to inform overdose prevention and assistance programs. The primary aim of the present study was to determine the prevalence of NFOD and associated risk factors among PWID in Saveh, Iran.

Methods

In the present cross-sectional study, 272 PWID living in Saveh, Iran were interviewed face-to-face using a structured survey. Data concerning socio-demographics, substance use, risky behaviors, and services utilization data were collected. The outcome variable (i.e., NFOD) was assessed by answering “Yes” to the question: “In the past three months, have you ever overdosed (at least once) by accident?”

Results

The prevalence of NFOD among PWID in the past three months was 54%. The characteristics and behaviors that were associated with an increased risk of experiencing NFOD in the past three months were being of older age (AOR = 5.2, p < 0.05), drug use initiation under the age of 22 years (AOR = 7.8, p < 0.05), being an alcohol user (AOR = 3.0, p < 0.05), and being a simultaneous multiple drug user (AOR = 5.8, p < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing a non-fatal overdose in the past three months. Findings also indicated that those who (i) attended a needle and syringe program (AOR: 0.3, p < 0.05), (ii) were visited by a general practitioner (AOR: 0.03, p < 0.05), and (iii) received a psychosocial intervention (AOR: 0.1, p < 0.05) were 0.3, 0.03 and 0.1 times less likely to report non-fatal overdosing than other participants, respectively.

Conclusions

The results indicate that intervention and prevention initiatives seeking to reduce NFOD among PWID should not only be focused on the primary drug used but also the use of alcohol and polysubstance use. Specific and tailored psychological interventions combined with pharmacotherapy may be highly beneficial for PWID who experience more severe types of substance use, including alcohol use disorders and/or polysubstance abuse.

The Melbourne Safe Injecting Room Attracted People Most in Need of Its Service

INTRODUCTION

In 2018, the first Medically Supervised Injecting Room in Melbourne, Australia was officially opened. This study assessed whether this facility attracted people who inject drugs, who were socially vulnerable, and who engaged in drug-related behaviors associated with increased morbidity and mortality risk.

METHODS

This was a cross-sectional analysis of the frequency of Medically Supervised Injecting Room use during the first 18 months after opening (July 2018-December 2019) among 658 people who inject drugs participating in the Melbourne Injecting Drug User Cohort Study (SuperMIX). To examine the differences between no Medically Supervised Injecting Room use, infrequent use (<50% injections within the facility), and frequent use (≥50% of injections within the facility), RRRs were estimated using bivariate multinomial logistic regression analyses and postestimation Wald tests. Analyses were conducted in 2020.

RESULTS

A total of 451 participants (68%) reported no Medically Supervised Injecting Room use, 142 (22%) reported infrequent use, and 65 (10%) reported frequent use. Participants who reported either infrequent or frequent use of the facility were more socially vulnerable (e.g., more often homeless) and more likely to report risky drug-related behaviors and poor health outcomes than those who reported no use. Participants who reported frequent use of the facility were also more likely to live close to the facility than those reporting infrequent use.

CONCLUSIONS

The Melbourne Medically Supervised Injecting Room attracted socially marginalized people who inject drugs who are most at risk of harms related to injecting drug use and therefore who are most in need of the service. To determine the long-term impact use of this facility on key health outcomes such as overdose, future studies should consider the differences in vulnerability and risk behavior of people who inject drugs who use the Medically Supervised Injecting Room when examining the outcomes associated with the use of the facility.

Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis

The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.

Prevalence and correlates of multiple non-fatal opioid overdoses among people who inject drugs who utilise needle syringe programs in Australia

BACKGROUND

Non-fatal overdose (NFOD) is a major cause of morbidity among people who inject drugs (PWID) and multiple NFOD is associated with increased risk of fatal overdose. Despite this, few studies have examined the prevalence and correlates of drug-specific multiple NFOD. The current study aimed to determine the prevalence and correlates of recent multiple non-fatal opioid overdose (NFOOD) among PWID who access needle syringe programs (NSPs) in Australia.

METHODS

The Australian Needle and Syringe Program Survey is conducted annually and was conducted at 46 sites across Australia in 2019. Participation involves completion of a self-administered questionnaire and a capillary dried blood spot for HIV and hepatitis C virus testing. In 2019, respondents who reported a minimum of one NFOOD in the previous 12 months (recent NFOOD) were asked to complete supplementary questions regarding their last NFOOD. Bivariate and multivariate logistic regression were used to determine factors independently associated with multiple recent NFOOD.

RESULTS

A total of 222 respondents reported recent NFOOD. Respondents were predominantly male (59%), one third (39%) were aged less than 39 years and 73% reported last injecting heroin at their last NFOOD. One in two respondents (48%, n = 107) reported multiple opioid overdoses (median 3, interquartile range 2-5). The odds of reporting multiple NFOOD were higher among respondents who reported injecting in a public location at their last NFOOD (adjusted odds ratio [AOR] 2.10, 95% CI 1.14-3.90, p = 0.018) and benzodiazepine use in the 12 h prior to NFOOD (AOR 2.74, 95% CI 1.50-4.99, p = 0.001).

CONCLUSIONS

Multiple NFOOD was prevalent among PWID who utilised NSPs who reported recent NFOOD. Public injecting and benzodiazepine use were associated with increased risk of multiple NFOOD, and there is a need for interventions specifically targeting PWID who report these high risk injecting practices.

Prevalence and correlates of simultaneous, multiple substance injection (co-injection) among people who inject drugs in Melbourne, Australia

AIMS

To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co-injection) among a community-recruited cohort of people who inject drugs.

DESIGN

Cross-sectional study.

SETTING

Melbourne, Australia.

PARTICIPANTS

A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted.

MEASUREMENTS

We constructed two statistical models: a logistic regression model analysing correlates of co-injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin-diphenhydramine co-injection only, co-injection of other substances and no co-injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non-fatal overdose.

FINDINGS

One-third [n = 226, 31%; 95% confidence interval (CI): 28-34%] of participants reported co-injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin-diphenhydramine (n = 121, 54%; 95% CI = 48-60%) and heroin-methamphetamine (n = 121, 54%; 95% CI = 48-60%). In logistic regression analyses, reporting co-injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18-2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31-3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin-diphenhydramine co-injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80-13.56, P < 0.001] and overdose (requiring an ambulance) in the past 12 months (aRRR = 2.81, 95% CI = 1.17-6.72, P = 0.021) compared with participants reporting no co-injection or co-injection of other substances.

CONCLUSIONS

A substantial proportion of people who inject drugs report co-injection of multiple substances, which is associated with a range of socio-demographic, drug use and health service use risk factors.

Do statutory holidays impact the number of opioid-related hospitalizations among Canadian adults? Findings from a national case-crossover study

OBJECTIVE

In Canada, emergency department visits, hospitalizations, and deaths due to opioid use have risen substantially in recent years. While these events have exhibited seasonal and day of week patterns, there have been no attempts to investigate the extent to which statutory holidays influence these patterns, particularly opioid-related hospitalizations.

METHODS

We applied a time-stratified case-crossover study design to investigate whether statutory holidays were predictive of opioid-related hospitalizations using the Canadian Discharge Abstract Database (excluding Quebec) for fiscal years 2011/2012 to 2016/2017. This design controls for day of week effects. We restricted analyses to opioid hospitalizations (ICD-10 codes: F11.x, T40.0-T40.4, and T40.6) among individuals 15 years and older. Conditional logistic regression models were fit to estimate the odds of opioid-related hospitalization on holidays relative to non-holidays. We examined these patterns across different holiday types, namely social gathering holidays (e.g., Canada Day) and family holidays (e.g., Christmas). Stratified analyses were done to identify whether these associations varied by age group and sex.

RESULTS

We identified a total of 59,965 opioid-related hospitalizations. Overall, we found a 12% reduced odds in opioid hospitalizations on holidays (odds ratio [OR] = 0.88, 95% CI 0.83, 0.93) relative to non-holidays. Similar reductions were observed for both family (OR = 0.86, 95% CI 0.79, 0.93) and social gathering holidays (OR = 0.90, 95% CI 0.84, 0.96). No substantive differences were noted by age group or sex.

CONCLUSIONS

Our findings support the hypothesis that opioid-related hospitalizations occur less frequently on statutory holidays. This knowledge may help inform healthcare resources and health promotion activities to reduce the impacts of opioid use.

Not what the doctor ordered: Motivations for nonmedical prescription drug use among people who use illegal drugs

BACKGROUND

Nonmedical Prescription Drug Use (NMPDU) is common among people who use illegal drugs. NMPDU is particularly problematic among this population however, as medications such as benzodiazepines and gabapentinoids can potentiate the harmful effects of opioids. Despite these harms, there is some evidence that NMPDU can have harm reducing and therapeutic potential for some people who use illegal drugs. This study provides further evidence of the harm reducing motives for NMPDU among people who use illegal drugs in community and prison settings in Wales, UK.

METHODS

In depth, semi-structured interviews were conducted with 60 interviewees recruited from statutory and third sector drug treatment providers operating in five towns and cities in Wales, and from two Welsh prisons. Eligibility was based primarily on whether the person was currently (or previously) a user of illegal drugs and had recent experience of NMPDU.

RESULTS

NMPDU was found to be largely driven by insufficient access to certain prescription medications and treatment. In this context, NMPDU played an important role in alleviating legitimate medical concerns and overcoming logistical and regulatory barriers associated with Opioid Substitution Therapy. NMPDU also had everyday practicality and mitigated many of the everyday harms experienced by people who use drugs, including opioid withdrawal and stimulant comedowns.

CONCLUSION

Results suggest that NMPDU has the potential to mitigate a number of legitimate medical concerns in the absence of treatment. Finding nuanced ways of responding to patient need whilst reducing the potential for NMPDU are therefore needed, and harm reduction strategies that harness the knowledge and expertise of people who use drugs should be encouraged. Additional policy measures that attend to the inequities and social-structural factors that produce and maintain the need to consume prescription medications in ways that are not intended are also required.

Circumstances of overdose among street-involved, opioid-injecting women: Drug, set, and setting

INTRODUCTION

Current discourses about the causes of the overdose crisis largely focus on the harmful effects of drugs. Prior research, however, indicates that drug use experience is shaped by complex interactions of drugs with physiological and mental "sets" of people who use drugs and the wider social and physical "setting." Zinberg's "drug, set, and setting" theoretical framework was applied to identify patterns in circumstances leading up to women's overdose.

METHODS

In-depth semi-structured interviews were conducted with 29 opioid-injecting street-involved women, clients of a Philadelphia harm reduction program. Qualitative analysis with deductive and inductive coding was utilized to examine transcripts for theory-driven and emerging themes.

RESULTS

Ten out of 29 women attributed their overdose to "drugs," reporting the unpredictable quality of street opioids, concurrent use of benzodiazepines, or chasing the "high." Thirteen women reported "set" as a type of circumstance where their emotional states were affected by a "good" or "bad" day, leading them to unusual drug consumption practices. Six women described "setting" type of circumstances where their overdose was preceded by a recent change in context, such as release from prison, which prompted unsafe drug use to address physiological or psychological dependence on drugs.

CONCLUSION

While all overdoses result from the pharmacological action of drugs, some overdoses were triggered by circumstances occurring in women's set or setting. Overdose prevention policies should embrace not only individual-level behavioral interventions, but also structural measures to address stress, social isolation, and risky drug use contexts that plague the lives of street-involved women who inject opioids.

Harm reduction programs and policy in Australia: barriers and enablers to effective implementation

Abstract. Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.

Non-fatal drug overdose after release from prison: A prospective data linkage study

BACKGROUND

Adults released from prison are at increased risk of poor health outcomes and preventable mortality, including from overdose. Non-fatal overdose (NFOD) is a strong predictor of future overdose and associated with considerable morbidity. This study aims to the determine the incidence, predictors and clinical characteristics of NFOD following release from prison.

METHODS

We used pre-release interview data collected for a randomised controlled trial in 2008-2010, and linked person-level, state-wide ambulance, emergency department, and hospital records, from a representative sample of 1307 adults incarcerated in Queensland, Australia. The incidence of NFOD following release from prison was calculated. A multivariate Andersen-Gill model was used to identify demographic, health, social, and criminal justice predictors of NFOD.

RESULTS

The crude incidence rate (IR) of NFOD was 47.6 (95%CI 41.1-55.0) per 1000 person-years and was highest in the first 14 days after release from prison (IR = 296 per 1000 person-years, 95%CI 206-426). In multivariate analyses, NFOD after release from prison was positively associated with a recent history of substance use disorder (SUD), dual diagnosis of mental illness and SUD, lifetime history of injecting drug use, lifetime history of NFOD, being dispensed benzodiazepines after release, a shorter index incarceration, and low perceived social support. The risk of NFOD was lower for people with high-risk alcohol use and while incarcerated.

CONCLUSIONS

Adults released from prison are at high risk of non-fatal overdose, particularly in the first 14 days after release. Providing coordinated transitional care between prison and the community is likely critical to reduce the risk of overdose.

Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study

INTRODUCTION AND AIMS

Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India.

DESIGN AND METHODS

Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed.

RESULTS

The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose.

DISCUSSION AND CONCLUSION

The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.

Effect of Intranasal vs Intramuscular Naloxone on Opioid Overdose: A Randomized Clinical Trial

IMPORTANCE

Previous unblinded clinical trials suggested that the intranasal route of naloxone hydrochloride was inferior to the widely used intramuscular route for the reversal of opioid overdose.

OBJECTIVE

To test whether a dose of naloxone administered intranasally is as effective as the same dose of intramuscularly administered naloxone in reversing opioid overdose.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, double-dummy randomized clinical trial was conducted at the Uniting Medically Supervised Injecting Centre in Sydney, Australia. Clients of the center were recruited to participate from February 1, 2012, to January 3, 2017. Eligible clients were aged 18 years or older with a history of injecting drug use (n = 197). Intention-to-treat analysis was performed for all participants who received both intranasal and intramuscular modes of treatment (active or placebo).

INTERVENTIONS

Clients were randomized to receive 1 of 2 treatments: (1) intranasal administration of naloxone hydrochloride 800 μg per 1 mL and intramuscular administration of placebo 1 mL or (2) intramuscular administration of naloxone hydrochloride 800 μg per 1 mL and intranasal administration of placebo 1 mL.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the need for a rescue dose of intramuscular naloxone hydrochloride (800 μg) 10 minutes after the initial treatment. Secondary outcome measures included time to adequate respiratory rate greater than or equal to 10 breaths per minute and time to Glasgow Coma Scale score greater than or equal to 13.

RESULTS

A total of 197 clients (173 [87.8%] male; mean [SD] age, 34.0 [7.82] years) completed the trial, of whom 93 (47.2%) were randomized to intramuscular naloxone dose and 104 (52.8%) to intranasal naloxone dose. Clients randomized to intramuscular naloxone administration were less likely to require a rescue dose of naloxone compared with clients randomized to intranasal naloxone administration (8 [8.6%] vs 24 [23.1%]; odds ratio, 0.35; 95% CI, 0.15-0.66; P = .002). A 65% increase in hazard (hazard ratio, 1.65; 95% CI, 1.21-2.25; P = .002) for time to respiratory rate of at least 10 and an 81% increase in hazard (hazard ratio, 1.81; 95% CI, 1.28-2.56; P = .001) for time to Glasgow Coma Scale score of at least 13 were observed for the group receiving intranasal naloxone compared with the group receiving intramuscular naloxone. No major adverse events were reported for either group.

CONCLUSIONS AND RELEVANCE

This trial showed that intranasally administered naloxone in a supervised injecting facility can reverse opioid overdose but not as efficiently as intramuscularly administered naloxone can, findings that largely replicate those of previous unblinded clinical trials. These results suggest that determining the optimal dose and concentration of intranasal naloxone to respond to opioid overdose in real-world conditions is an international priority.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000852954.

Does Starting to Smoke Cigars Trigger Onset of Cannabis Blunt Smoking?

Introduction

Among United States teens during the 1990s, increasing cigar use coincided with increasing use of tobacco cigar shells filled with cannabis, called "blunts." Cigar smokers are more likely to use cannabis, and we hypothesized that starting to smoke cigars might be a probabilistic "trigger" of blunt smoking. We turned to the case-crossover approach to evaluate this hypothesis.

Methods

Within US National Surveys on Drug Use and Health, 2009-2013, we identified a nationally representative sample of newly incident blunt smokers aged 12- to 21-years-old (n = 4868) and compared month-of-onsets for smoking of cigars and blunts. Using the subjects-as-their-own-controls case-crossover design, we specified the first month prior to blunt use as a "hazard interval" and the second month prior to blunt use as a "control interval." We used Mantel-Haenszel (MH) estimators to estimate the matched-pairs odds ratio (OR).

Results

The MH OR estimate was 1.7 (95% CI = 1.3, 2.3), with excess odds of cigar onsets during the hazard interval relative to the control interval. Two alternative control interval specifications yielded congruent estimates (OR = 2.7 and 2.9, respectively).

Conclusions

A short interval right after starting to smoke cigars may be one of increased risk of starting to smoke blunts. We discuss cigar, cigarillo, and "blunt wraps" control approaches that might reduce both tobacco and cannabis-related harms.

Implications

If this evidence is correct, increased market-targeting to promote youthful cigar and cigarillo smoking might be followed by increased rates of blunt smoking in a vulnerable population. As noted by others, enhanced risk of smoking-attributable harms might be a consequence of mixed tobacco-cannabis formulations.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

Understanding an emerging treatment population: Protocol for and baseline characteristics of a prospective cohort of people receiving treatment for pharmaceutical opioid dependence

INTRODUCTION AND AIMS

Despite large increases in pharmaceutical opioid dependence and related mortality, few studies have focused on the characteristics and treatment experiences of those with pharmaceutical opioid dependence. We describe the formation of a prospective cohort of people receiving treatment for pharmaceutical opioid dependence and describe their baseline characteristics.

DESIGN AND METHODS

People who had entered treatment for pharmaceutical opioid dependence (n = 108) were recruited through drug treatment services in New South Wales, Australia. We describe baseline characteristics of those that commenced pharmaceutical opioids for pain or other reasons and conducted a thematic analysis of responses regarding their treatment experience.

RESULTS

Mean age was 41 years (SD 11), half were male (48%). Just over half reported lifetime heroin use (57%). Oxycodone (49%) and codeine (29%) were the most common opioids reported. Most (85%) reported past-year problematic pain, 38% reported chronic pain. Half (52%) reported moderate to severe depression symptoms. Most (66%) commenced opioids for pain, and this group were older, less likely to report a previous overdose and less likely to report use of illicit drugs compared to those commencing for other reasons. Five themes related to treatment expectations: (i) stigma; (ii) the restrictive nature of treatment; (iii) knowledge; (iv) pain; and (v) positive experience with buprenorphine.

DISCUSSION AND CONCLUSIONS

This study describes the complexities in an important emerging treatment population of pharmaceutical opioid-dependent people. Findings highlights that addressing knowledge and perceptions around treatment may be critical to address the rising mortality associated with pharmaceutical opioid dependence.

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.

Managing opioid overdose in pregnancy with take-home naloxone

Programs have recently been established in Australia and internationally to allow wider access to naloxone to people at risk of opioid overdose yet there are no guidelines relating to the administration of naloxone to pregnant women, particularly regarding dose requirements and resuscitative measures peculiar to pregnancy. This paper provides practical guidelines to health workers in relation to any complications that may arise during opioid overdose response (including the administration of naloxone) for pregnant women and the follow up required ensuring best possible outcomes for mother and baby.

Association between public injecting and drug-related harm among HIV-positive people who use injection drugs in a Canadian setting: A longitudinal analysis

BACKGROUND

and Aims Injecting illicit drugs in public settings has been linked to a higher risk of a range of drug-related harms, including overdose and HIV infection. However, the factors associated with public injecting among HIV-positive individuals have not been previously explored. We investigated the links between public drug injecting, drug-related harm, and HIV treatment measures among a cohort of HIV-positive persons who inject drugs (PWID) in a Canadian setting.

METHODS

We used data from a prospective cohort of HIV-positive PWID recruited from community settings in Vancouver, Canada, linked to comprehensive clinical monitoring data in the context of an ongoing Treatment-as-Prevention (TasP) initiative to examine harms associated with public injecting. We used generalized linear mixed-effects analyses to identify longitudinal factors associated with self-reported public drug injection.

RESULTS

Between 2005 and 2014, 626 HIV-seropositive PWID were recruited, of whom 213 (34%) reported public injection in the preceding 180days. In a longitudinal multivariable model, public injection was positively associated with daily heroin injection (Adjusted Odds Ratio [AOR]=2.63), incarceration (AOR=1.78), and detectable plasma HIV-1 RNA viral load (VL, AOR=1.42).

CONCLUSIONS

Public injecting was linked to numerous drug-related harms among HIV-seropositive PWID in this setting. Given its link with detectable VL, an important marker of poor HIV treatment outcomes, our findings support prioritizing individuals engaged in public injecting with harm reduction strategies as well as clinical and social supports as a part of TasP-based efforts to prevent HIV-related morbidity and mortality, and HIV transmission.

Patient Simulation for Assessment of Layperson Management of Opioid Overdose With Intranasal Naloxone in a Recently Released Prisoner Cohort

INTRODUCTION

Investigators applied simulation to an experimental program that educated, trained, and assessed at-risk, volunteering prisoners on opioid overdose (OD) prevention, recognition, and layperson management with intranasal (IN) naloxone.

METHODS

Consenting inmates were assessed for OD-related experience and knowledge then exposed on-site to standardized didactics and educational DVD (without simulation). Subjects were provided with IN naloxone kits at time of release and scheduled for postrelease assessment. At follow-up, the subjects were evaluated for their performance of layperson opioid OD resuscitative skills during video-recorded simulations. Two investigators independently scored each subject's resuscitative actions with a 21-item checklist; post hoc video reviews were separately completed to adjudicate subjects' interactions for overall benefit or harm.

RESULTS

One hundred three prisoners completed the baseline assessment and study intervention and then were prescribed IN naloxone kits. One-month follow-up and simulation data were available for 85 subjects (82.5% of trained recruits) who had been released and resided in the community. Subjects' simulation checklist median score was 12.0 (interquartile range, 11.0-15.0) of 21 total indicated actions. Forty-four participants (51.8%) correctly administered naloxone; 16 additional subjects (18.8%) suboptimally administered naloxone. Nonindicated actions, primarily chest compressions, were observed in 49.4% of simulations. Simulated resuscitative actions by 80 subjects (94.1%) were determined post hoc to be beneficial overall for patients overdosing on opioids.

CONCLUSIONS

As part of an opioid OD prevention research program for at-risk inmates, investigators applied simulation to 1-month follow-up assessments of knowledge retention and skills acquisition in postrelease participants. Simulation supplemented traditional research tools for investigation of layperson OD management.

High enhancer, downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

BACKGROUND

Benzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular-a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use.

METHODS

For qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18-32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18-29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use.

RESULTS

Participants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use.

CONCLUSION

Nonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.

Fatal and non-fatal overdose after narcology hospital discharge among Russians living with HIV/AIDS who inject drugs

OBJECTIVES

Among Russians living with HIV/AIDS who inject drugs, we examined the incidence of fatal and non-fatal overdoses following discharge from a narcology hospital and the associations with more advanced HIV infection.

DESIGN

Prospective cohort study of data collected at baseline, 3 and 6 months from HIV-infected patients with a history of injection drug use who were not treated with anti-retroviral therapy. Participants were recruited between 2012-2014 from a narcology (addiction) hospital in St. Petersburg, Russia.

METHODS

Fatal overdose was determined based on contact reports to study staff in the year after discharge. Non-fatal overdose was self-reported at the 3- and 6-month assessments. The main independent variable for HIV severity was CD4 cell count at the baseline interview (<200cells/mm³≥200cells/mm³). Secondary analyses assessed time since HIV diagnosis and treated with anti-retroviral treatment (ART) prior to enrolment as independent variables. We fit Cox proportional hazards models to assess whether HIV severity is associated with either fatal or non-fatal overdose.

RESULTS

Among 349 narcology patients, 18 participants died from overdose within one year after discharge (8.7%, 95% CI 3.4-14.2 by Kaplan-Meier); an estimated 51% [95% CI 34-68%] reported at least one non-fatal overdose within 6 months of discharge. HIV severity, time since HIV diagnosis and ever ART were not significantly associated with either fatal or non-fatal overdose events.

CONCLUSION

Fatal and non-fatal overdose are common among Russians living with HIV/AIDS who inject drugs after narcology hospital discharge. Overdose prevention interventions are urgently warranted among Russian narcology patients with HIV infection.

Hazardous Alcohol Use Associated with Increased Sexual Risk Behaviors Among People Who Inject Drugs

BACKGROUND

Alcohol is associated with a multitude of severe health consequences. While risk behaviors related to illicit drug use are commonly studied among people who inject drugs (PWID), the role of alcohol use has received substantially less attention in this population. We explored whether drug and sexual risk behaviors as well as experiences of violence were associated with hazardous alcohol use in a cohort of PWID.

METHODS

Analyses were conducted using observational data from a prospective cohort of community-recruited HIV-negative PWID in Vancouver, Canada. We used the U.S. National Institute on Alcohol Abuse and Alcoholism definition of hazardous alcohol use (i.e., >14 drinks/wk or >4 drinks on 1 occasion for men, and >7 drinks/wk or >3 drinks on 1 occasion for women). We used multivariable generalized estimating equations (GEE) to identify the factors associated with hazardous alcohol use.

RESULTS

Between 2006 and 2012, 1,114 HIV-negative individuals were recruited, and 186 (16.7%) reported hazardous alcohol use in the previous 6 months at baseline. In multivariable GEE analyses, having multiple sex partners (adjusted odds ratio [AOR] = 1.25), history of sexually transmitted infection (AOR = 1.50), experiencing violence (AOR = 1.36), and incarceration (AOR = 1.29) were each independently associated with hazardous alcohol use. Caucasian ethnicity (AOR = 0.56), ≥ daily heroin injection (AOR = 0.81), and engagement in addiction treatment (AOR = 0.84) were negatively associated with hazardous alcohol use (all p < 0.05).

CONCLUSIONS

A considerable proportion of PWID reported hazardous alcohol use, which was independently associated with reporting sexual, but not drug-related, HIV risk behaviors and experiencing recent violence. Findings suggest a need to integrate regular screening and evidence-based alcohol interventions into treatment efforts for PWID.

Differences in polysubstance use patterns and drug-related outcomes between people who inject drugs receiving and not receiving opioid substitution therapies

AIMS

To test if polysubstance use profiles and drug-related outcomes differ between those receiving and not receiving opioid substitution therapies (OST) among people who inject drugs (PWID).

DESIGN

An annual cross-sectional, sentinel sample of PWID across Australia.

SETTING

Data came from 3 years (2011-13) of the Illicit Drug Reporting System (IDRS).

PARTICIPANTS

A total of 2673 participants who injected drugs from the combined national IDRS samples of 2011 (n = 868), 2012 (n = 922) and 2013 (n = 883).

MEASUREMENTS

Latent class analysis (LCA) was used to summarize participants' self-reported use of 18 types of substances, with the resulting polysubstance use profiles then associated with participant experience of a number of drug-related outcomes.

FINDINGS

Polysubstance use profiles exhibiting a broad range of substance use were generally at increased risk of negative drug-related outcomes, whether or not participants were receiving OST, including thrombosis among OST receivers [odds ratio (OR) = 2.13, 95% confidence intervals (CI) = 1.09-4.17], injecting with used needles among OST receivers and non-receivers, respectively (OR = 2.78, 95% CI = 1.50-5.13; OR = 2.15, 95% CI = 1.34-3.45) and violent criminal offences among OST receivers and non-receivers, respectively (OR =2.30, 95% CI = 1.16-4.58; OR = 1.87, 95% CI = 1.14-3.07). An important exception was non-fatal overdose which was related specifically to a class of PWID who were not receiving OST and used morphine frequently (OR = 1.83, 95% CI = 1.06-3.17) CONCLUSION: Regardless of opioid substitution therapies usage, people who inject drugs who use a broad-range of substances experience greater levels of injecting-related injuries and poorer health outcomes and are more likely to engage in criminal activity than other groups of people who inject drugs.

Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain

Rising overdose fatalities among U.S. veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk. The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group. In the current study, 90 veterans on chronic opioid medication, for either opioid use disorder or pain management, completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose. Nearly all veterans in both groups had multiple overdose risk factors, although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 versus 8.5, p < .0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 versus 13.5, p < .01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors. Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.

Cessation of injecting drug use: The effects of health service utilisation, drug use and demographic factors

BACKGROUND

Injecting drug use is associated with a range of harms, however cessation of injecting is rare. There is a lack of evidence on factors associated with cessation, notably those related to health services other than drug treatment. We examined the incidence and identified longitudinal correlates of first episode of cessation in a cohort of people who inject drugs (PWID).

METHODS

Using discrete-time survival analysis, we examined correlates of the first episode of cessation (no self-reported injecting drug use in the past 12 months), including the use of health services, socio-demographics and drug-related behaviour in a cohort of PWID recruited between 2008 and 2010.

RESULTS

The cohort of 467 participants contributed 1527 person-years from recruitment to 2014. Under a fifth (17.8%) of people reported cessation of 12 months or more, yielding a cessation rate of 5.4 events per 100 person-years. Younger age (25-29 compared to 30 and above) (adjusted hazard ratio (AHR) 1.79, 95% confidence interval (CI) 1.07-3.00) and male gender (AHR 1.67, 95% CI 2.01-2.76) were positively associated with cessation, while past year use of benzodiazepines (AHR 0.45, 95% CI 0.28-0.72), arrest in the past year (AHR 0.50, 95% CI 0.30-0.83) and low SF-8 physical dimension score (AHR 0.42, 95% CI 0.20-1.88) were negatively associated with cessation. Outpatient service use had the largest effect on cessation (AHR 2.28, 95% CI 0.94-5.48, p=0.067).

CONCLUSIONS

Low rates of cessation emphasise the need for sustained and comprehensive harm reduction services. The relationship between outpatient services and cessation suggests that further research into the use in health services among PWID is warranted.

Can differences in the type, nature or amount of polysubstance use explain the increased risk of non-fatal overdose among psychologically distressed people who inject drugs?

BACKGROUND

This study investigates whether the type, nature or amount of polysubstance use can explain the increased risk of non-fatal overdose among people who inject drugs with severe psychological distress.

METHODS

Data came from three years (2011-2013) of the Illicit Drug Reporting System (IDRS), an annual sentinel sample of injecting drug users across Australia (n=2673). Structural Equation Modelling (SEM) was used on 14 drug types to construct five latent factors, each representing a type of polysubstance use. Tests of measurement invariance were carried out to determine if polysubstance use profiles differed between those with and without severe psychological distress. Next, we regressed non-fatal overdose on the polysubstance use factors with differences in the relationships tested between groups.

FINDINGS

Among those with severe psychological distress a polysubstance use profile characterised by heroin, oxycodone, crystal methamphetamine and cocaine use was associated with greater risk of non-fatal overdose. Among those without severe psychological distress, two polysubstance use profiles, largely characterised by opioid substitution therapies and prescription drugs, were protective against non-fatal overdose.

CONCLUSION

The types of polysubstance use profiles did not differ between people who inject drugs with and without severe psychological distress. However, the nature of use of one particular polysubstance profile placed the former group at a strongly increased risk of non-fatal overdose, while the nature of polysubstance use involving opioid substitution therapies was protective only among the latter group. The findings identify polysubstance use profiles of importance to drug-related harms among individuals with psychological problems.

Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia

INTRODUCTION

Release from prison is a period of elevated risk for drug-related harms, particularly among people who inject drugs (PWID). Non-fatal overdose can cause serious morbidity and predicts future fatal overdose, however neither the incidence nor the risk factors for non-fatal overdose following release from prison are well understood.

METHODS

Structured health-related interviews were conducted with 1051 adult prisoners in Queensland, Australia prior to release and approximately 1, 3 and 6 months post-release. Incidence of self-reported overdose in the community was calculated for PWID and all prisoners for three discrete time periods. Negative binomial regression with robust error variance was used to identify pre-release predictors of overdose among PWID.

RESULTS

The incidence of reported overdose was highest between 1 and 3 months post-release (37.8 per 100 person-years (PY) among PWID; 24.5/100 PY among all ex-prisoners). In adjusted analyses, the risk of post-release non-fatal overdose was higher for PWID who reported: being unemployed for >6 months before prison, having been removed from family as a child, at least weekly use of benzodiazepines and/or pharmaceutical opiates in the 3 months prior to prison, and ever receiving opioid substitution therapy (OST). Pre-release psychological distress and a lifetime history of mental disorder also predicted overdose, whereas risky alcohol use in the year before prison was protective.

CONCLUSIONS

PWID have a high risk of overdose following release from prison. Imprisonment is an opportunity to initiate targeted preventive interventions such as OST, overdose prevention training and peer-delivered naloxone for those with a high risk profile.

Drug use patterns predict risk of non-fatal overdose among street-involved youth in a Canadian setting

BACKGROUND

Non-fatal drug overdose is a major cause of morbidity among people who use drugs, although few studies have examined this risk among street-involved youth. We sought to determine the risk factors associated with non-fatal overdose among Canadian street-involved youth who reported illicit drug use.

METHODS

Using data from a prospective cohort of street-involved youth in Vancouver, Canada, we identified youth without a history of overdose and employed Cox regression analyses to determine factors associated with time to non-fatal overdose between September 2005 and May 2012.

RESULTS

Among 615 participants, 98 (15.9%) reported a non-fatal overdose event during follow-up, resulting in an incidence density of 7.67 cases per 100 person-years. In multivariate Cox regression analyses, binge drug use (adjusted hazard ratio [AHR]=1.85; 95% confidence interval [CI]=1.20-2.84), non-injection crystal methamphetamine use (AHR=1.70; 95% CI=1.12-2.58), non-injection prescription opiate use (AHR=2.56; 95% CI=1.36-4.82), injection prescription opiate use (AHR=2.49; 95% CI=1.40-4.45) and injection heroin use (AHR=1.85; 95% CI=1.14-3.00) were positively associated with time to non-fatal overdose. Social, behavioural and demographic factors were not significantly associated with time to non-fatal overdose event.

CONCLUSIONS

Rates of non-fatal overdose were high among street-involved youth. Drug use patterns, in particular prescription opiate use, were associated with overdose. These findings underscore the importance of addiction treatment and prevention efforts aimed at reducing the risk of overdose among youth.

Heavy alcohol use and suicidal behavior among people who use illicit drugs: A cohort study

BACKGROUND

People who use illicit drugs (PWUD) are known to experience high rates of suicidal behavior. While heavy alcohol use has been associated with suicide risk, its impact on the suicidal behavior of PWUD has not been well characterized. Therefore, we examined the relationship between heavy alcohol use and suicidal behavior among PWUD in Vancouver, Canada.

METHODS

Data are derived from two prospective cohort studies of PWUD in Vancouver, Canada, from 2005 to 2013. Participants completed questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. We used recurrent event survival analyses to estimate the independent association between at-risk/heavy drinking (based on National Institute of Alcohol Abuse and Alcoholism [NIAAA] criteria) and risk of incident, self-reported suicide attempts.

RESULTS

Of 1757 participants, 162 participants (9.2%) reported 227 suicide attempts over the 8-year study period, resulting in an incidence rate of 2.5 cases per 100 person-years. After adjusting for potential confounders, including intensive illicit drug use patterns, heavy alcohol use (adjusted hazard ratio [AHR] = 1.97; 95% confidence interval [CI] = 1.39, 2.78) was positively associated with an increased risk of suicidal behavior.

CONCLUSIONS

We observed a high burden of suicidal behavior among a community-recruited sample of PWUD. Heavy alcohol use predicted a higher risk of suicide attempt, independent of other drug use patterns. These findings demonstrate the need for evidence-based interventions to address suicide risk among PWUD, particularly those who are heavy consumers of alcohol.

Two cases of intranasal naloxone self-administration in opioid overdose

BACKGROUND

Overdose is a leading cause of death for former prisoners, exacting its greatest toll during the first 2 weeks post release. Protective effects have been observed with training individuals at high risk of overdose and prescribing them naloxone, an opioid antagonist that reverses the effects of the opioid-induced respiratory depression that causes death.

CASES

The authors report 2 people with opiate use histories who self-administered intranasal naloxone to treat their own heroin overdoses following release from prison. Patient A is a 34-year-old male, who reported having experienced an overdose on heroin the day after he was released from incarceration. Patient B is a 29-year-old female, who reported an overdose on her first injection of heroin, 17 days post release from incarceration. Both patients self-administered the medication but were assisted at some point during the injury by a witness whom they had personally instructed in how to prepare and administer the medication. Neither patient experienced withdrawal symptoms following exposure to naloxone.

DISCUSSION

Self-administration of naloxone should not be a goal of overdose death prevention training. A safer, more reliable approach is to prescribe naloxone to at-risk patients and train and also equip members of their household and social or drug-using networks in overdose prevention and response.

Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011

BACKGROUND

There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution.

METHODS

Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone).

RESULTS

In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates.

CONCLUSIONS

Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.

Drug-related deaths between 2002 and 2013 with accent to methadone and benzodiazepines

AIM

The aim of the study is to assess the trends of overdose and drug related fatalities in the Republic of Macedonia during the 11 years.

MATERIAL AND METHODS

Cross-sectional retrospective survey and reviewed of postmortem toxicological analyses which examined fatal poisonings with illegal drugs in years 2002-2013. Information about gender, age, drug consumption, reported years were analyzed. Narcotics were confirmed with toxicological semi quantitative fluorescence polarization immunoassay (FPIA) in urine (range 250-4000 ng/ml).

RESULTS

Total of 165 deaths were observed. Out of them 145 (87.9%) were male. There is statistical significant differences between male and female DRD due to age (Mann-Whitney U Test = 925, Z = -2626, p = 0.0087). For p < 0.05 there is significant differences between genders due to cause of overdose (Pearson Chi-square = 9743, df = 4, p = 0.0449). DRD among male were mainly because of overdose due to heroin in 80 (51.17%) cases followed by DRD due to combination of methadone and BZD in 25 (11.72%) cases. Out of all DRD cases 50 (30.3%) are related to polydrug use. For p < 0.01 there is a significant differences between analyzed age groups due to cause of overdose (Pearson Chi-square = 33,886, df = 12, p = 0.0007).

CONCLUSIONS

Death cause analysis reveals the difficulties in determining the role of substitution drugs, as many other factors may be involved. The findings also highlight the importance of further enhancing treatment interventions for benzodiazepine misuse among patients on methadone substitution treatment.

Benzodiazepines

Benzodiazepines have been in clinical use since the 1960s. Benzodiazepines act through allosteric modulation of the GABA_A receptor to enhance the activity of GABA, an inhibitory neurotransmitter, resulting in a slowing of neurotransmission and sedative and anxiolytic effects. Initially benzodiazepines were thought to have low dependence liability, though over time there has been increasing evidence of benzodiazepine dependence. Benzodiazepines are commonly used to treat anxiety and insomnia, though increasingly they are considered second line treatments for most indications. Concerns about the effects of benzodiazepines on cognition, falls and their implication in opioid related mortality have emerged. Few pharmacological treatments for benzodiazepine dependence have been shown to be effective with gradual taper the most common treatment strategy for benzodiazepine dependence.

High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study

BACKGROUND

Overdose is the leading cause of death among opioid users, but no data are available on overdose among people who inject drugs in Malaysia. We present the first estimates of the prevalence and correlates of recent non-fatal overdose among people who inject drugs in Malaysia.

METHODS

In 2010, 460 people who inject drugs were recruited using respondent-driven sampling (RDS) in Klang Valley to assess health outcomes associated with injection drug use. Self-reported history of non-fatal overdose in the previous 6 months was the primary outcome. Sociodemographic, behavioral and structural correlates of non-fatal overdose were assessed using multivariable logistic regression.

RESULTS

All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Most injected daily (91.3%) and were male (96.3%) and ethnically Malay (90.4%). Overall, 20% of participants had overdosed in the prior 6 months, and 43.3% had ever overdosed. The RDS-adjusted estimate of the 6-month period prevalence of overdose was 12.3% (95% confidence interval [CI] 7.9-16.6%). Having injected for more years was associated with lower odds of overdose (adjusted odds ratio [AOR] 0.6 per 5 years of injection, CI: 0.5-0.7). Rushing an injection from fear of the police nearly doubled the odds of overdose (AOR 1.9, CI: 1.9-3.6). Alcohol use was associated with recent non-fatal overdose (AOR 2.1, CI: 1.1-4.2), as was methamphetamine use (AOR 2.3, CI: 1.3-4.6). When adjusting for past-month drug use, intermittent but not daily methadone use was associated with overdose (AOR 2.8, CI: 1.5-5.9).

CONCLUSION

This study reveals a large, previously undocumented burden of non-fatal overdose among people who inject drugs in Malaysia and highlights the need for interventions that might reduce the risk of overdose, such as continuous opioid substitution therapy, provision of naloxone to prevent fatal overdose, treatment of polysubstance use, and working with police to improve the risk environment.

Associations among pain, non-medical prescription opioid use, and drug overdose history

BACKGROUND AND OBJECTIVE

Recently, use of prescription opioids (POs) has increased; non-medical PO (NMPO) use is linked to overdose. NMPO use is common among individuals prescribed opioids for pain, and those in substance use disorder (SUD) treatment with pain could be at increased risk for unintentional overdose due to NMPO use. We examined associations between pain, NMPO use, and overdose among SUD treatment patients.

METHODS

Among 342 patients at a residential SUD treatment center, logistic regression examined the association of overdose with pain, adjusting for substance use, suicide attempts, and demographics.

RESULTS

Pain was positively related to NMPO use. Heroin use, suicide attempts, pain, and NMPO use were positively associated with overdose; but NMPO use attenuated the pain-overdose relationship.

CONCLUSIONS

The relationship between pain and overdose among substance users may be, in part, explained by the association between pain and heavy NMPO use.

The relationship between alcohol use and injecting drug use: impacts on health, crime and wellbeing

BACKGROUND AND OBJECTIVES

People who inject drugs (PWID) are at risk of a variety of adverse outcomes. Previous research suggests that alcohol, when consumed with opioids, is a risk factor for overdose, but there has been less investigation of the effects of alcohol consumption on other health, criminogenic or life satisfaction outcomes. In this paper we explore the effects of alcohol on outcomes for PWID across a variety of life domains.

METHODS

Baseline data were drawn from the Melbourne Injecting Drug User cohort study, which is a cohort of 688 PWID. Drinking scores were generated from the AUDIT-C (0, 1-7, 8+) and associations between them and health (recent heroin overdose, Emergency Department use), criminogenic (violent and nonviolent crime) and life satisfaction (personal wellbeing) outcomes were examined using logistic and linear regression.

RESULTS

While around 36% of the cohort reported past-month abstinence from alcohol, 44% scored between 1 and 7 and 20% above 7 on the AUDIT-C. A score above 7 was associated with perpetration of violent crime and lower personal wellbeing ratings than a score of 0, after adjusting for potential confounders. There was no association between alcohol and other outcomes examined, after adjustment for confounders.

CONCLUSION

Cohort participants who drink heavily were more likely to report engaging in violent crime and poorer life satisfaction. The relationship between alcohol and the offending behaviours of the cohort was consistent with the effects of alcohol on violent offending in the broader community.

Problematic use of prescription-type opioids prior to heroin use among young heroin injectors

Background

Misuse of prescription-type opioids and related adverse health effects are increasing, but little is known about the role of these drugs as a precursor to heroin use. We conducted an exploratory study to determine the proportion of young heroin injectors reporting problematic use of prescription-type opioids prior to using heroin, and to describe the factors associated with prior problematic prescription-type opioid use.

Methods

Between March 2009 and June 2010, we recruited injection drug users (IDUs) for a cross-sectional study of hepatitis C virus infection risk. Participants were aged 18–40 years and had injected illicit drugs within the previous six months. A computerized self-administered survey assessed sociodemographics, drug use history, human immunodeficiency virus (HIV)/hepatitis C virus risk behaviors and perceptions, and medical history. We added questions on prescription-type opioid use to the parent study in March 2010; heroin injectors who subsequently enrolled and reported problematic prescription-type opioid use prior to heroin initiation were compared with other heroin IDUs using univariate and multivariate regression methods.

Results

Among 123 heroin IDUs, 49 (39.8%) reported problematic prescription-type opioid use prior to heroin initiation (“prescription-type opioid first injection drug users” [PTO-First IDUs]). PTO-First IDUs had higher odds of injecting with friends (adjusted odds ratio [AOR] 6.01; 95% confidence interval [CI] 1.90–19.07), getting new syringes from a spouse/family member/sex partner (AOR 23.0; 95% CI 2.33–226.0), knowing about the local syringe exchange program (AOR 7.28; 95% CI 1.17–45.05), using powder cocaine (AOR 3.75; 95% CI 1.43–9.86), and perceiving themselves as less likely than other IDUs to get HIV (AOR 4.32; 95% CI 1.26–14.77). They had lower odds of ever being tested for HIV (AOR 0.25; 95% CI 0.08–0.80).

Conclusion

A high proportion of young heroin IDUs reported problematic prescription-type opioid use prior to initiating heroin use. Our study provides several avenues for future investigation to help further characterize this subset of IDUs and their risks and perceptions related to HIV and other blood-borne pathogens.

Individual and network factors associated with non-fatal overdose among rural Appalachian drug users

BACKGROUND

Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States--especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users.

METHODS

Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses.

RESULTS

Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network.

CONCLUSIONS

Rural drug users with history of overdose were more likely to have injected with prescription opioids--which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.