DYING FOR HEROIN Overlooked or ignored options for preventing opiate overdose deaths Professor John Strang Director National Addiction Centre, Institute

DYING FOR HEROIN

Overlooked or ignored options for preventing

opiate overdose deaths

Professor John StrangDirectorNational Addiction Centre,Institute of Psychiatry and the Maudsley, London, UK

STRUCTURE OF THE TALK

WHY THE INTEREST?Don’t forget ….----------------------------------------------

HOW COMMON?WHICH DRUGS?INTERVENTION OPPORTUNITY

WHY THE INTEREST?

GROWING PROBLEM

SOMETHING WE COULD DO ABOUT IT

Tables for Mortality from Opioids in Republic of Ireland

Time Period

deaths outside Dublin

deaths inside Dublin

Total number of deaths

1980 -1984 1 13 14 1985-1989 1

18 19

1990-1994 3

41 44

1995-1999 28

201 229

1980-1999 33 273 306*

Percent of total deaths in Ireland (for each age group) attributable to opioids in Ireland

0

1

2

3

4

5

6

7

8

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998Year

Per

cen

tag

e o

f d

eath

s

All ages Age 35-44 Age 25-34 Age 15-24

Age-standardised mortality rate from opioids and odds ratios amongst population aged 15-44, between 1980 and 1999 (per 1,000,000)

Factor

Age-corr. mort. rate

Odds Ratio(95% CI)

Time Period

1980-1984

1.9 13.6(7.9, 23.1)1995-1999

25.9

Gender Female

1.9 8.4(5.6, 12.6)Male

16.1

Area of residence

Outside Dublin

1.3 20.0(13.6, 29.3)Inside Dublin

27.0

Heroin purity 1986 - 2001

0102030405060708090100

86-1

87-1

88-1

89-1

90-1

91-1

92-1

93-1

94-1

95-1

96-1

97-1

98-1

99-1

00-1

2001-1

perc

ent

Don’t forget ….

Unmet need Waiting lists incomplete penetration

Poorly-met need Sub-optimal dosing Unacceptable reliance on drug alone Fondness for eccentricity

Iatrogenic harm In our own hands

Don’t forget ….

High-risk individuals, groups and times

Impact of the treatment we provide Inevitable ? Inexcusable ?

STRUCTURE OF THE TALK

WHY THE INTEREST? ----------------------------------------------

HOW COMMON?

WHICH DRUGS?

INTERVENTION OPPORTUNITY

A guide to the studies - London

2 PAI studies of community samples (n=438 early heroin users (Gossop et al, 1996)) and (n=312 injectors (Powis et al, 1999; Strang et al, 1999)).

2 studies of methadone maintenance treatment samples (n=142 m.m. clients (Strang et al, 1999)) and (n=155 outpatients (Best et al, 2000)).

London PAI Study #1:438 Early Heroin Users

[48% in first 3 years; 45% SDS6]

Overdose history among 98 (22%)

Of 309 ever-injectors, 96 (31%) had overdosed

Of 125 never-injectors, 2 (2%) had overdosed

(2=44.2, p<0.001 [data missing on 4])

(Gossop, Griffiths, Powis, Williamson and Strang, BMJ, 1996)

HOW COMMON (among injectors)?

WHICH DRUGS?

INTERVENTION OPPORTUNITY?

… personal O/D… witnessed O/D… (witnessed fatal O/D)----------------------and then detail on last event

London PAI Study #2:312 injectors

Personal overdose? - 117 (38%)

Witnessed overdose? - 157 (50%)

Witnessed fatal O/D? - 46 (15%)

(Strang, Griffiths, Powis, Fountain, Williamson and Gossop, Drug and Alcohol Review, 1999)

Conclusion number 1

Overdose is common hazard

Overdose frequently witnessed

HOW COMMON?

WHICH DRUGS?


London PAI Study #2:312 injectors

Personal overdose? (38%)

Witnessed overdose? - (50%)

Witnessed fatal O/D? - (15%)

(Strang, Griffiths, Powis, Fountain, Williamson and Gossop, Drug and Alcohol Review, 1999)

PAI Study #2: 312 InjectorsLast personal overdose (n=117)Heroin (n=94) Other opiate (n=21)

[of which methadone =13]

60 3 [2] 3[1]

8[6]

23 7[4]

13

Non-opiate drug (n=51)

Figure 1 : Last personal overdose (n=117):Types of drug involved

(Strang, Griffiths, Powis, Fountain, Williamson and Gossop, Drug and Alcohol Review 1999)

60 3[1]

13

23 7[4]

8[6]

3[2]

Heroin (n=94 ) Other opiate (n=21) [meth =13]

Non-opiate (n=51)

PAI Study #2: 312 InjectorsLast witnessed O/D (n=157)Heroin (n=94) Other opiate (n=21)


60 3 [2] 3[1]

8[6]

23 7[4]

13




107 6[3]

5

33 5[5]

0

1[0]

Heroin (n=141) Other opiate (n=12) [meth =8]

Non-opiate (n=43)

PAI Study #2: 312 InjectorsLast witnessed fatal O/D (n=46)Heroin (n=94) Other opiate (n=21)


60 3 [2] 3[1]

8[6]

23 7[4]

13




15 2[0]

3

16 4[4]

2[1]

4[0]

Heroin (n=37) Other opiate (n=12) [meth =5]

Non-opiate (n=25)

Conclusion number 2:Drugs involved with overdose

HEROIN

Heroin and sedative mixtures

HOW COMMON?

WHICH DRUGS?



Extensive witnessing of overdoses (including fatal outcomes) …


Sydney - 86% had witnessed O/D

Adelaide - 70% had witnessed O/D

London PAI injectors -50%

(London treatment sample -

83/97%)


O.K., so extensive witnessing of overdoses (including fatal outcomes);

but what about resuscitation efforts (even if incorrect)?

TREATMENT SAMPLE 2b 115 methadone maintenance clients (current or former injectors) 57 (50%) had previously overdosed 112 (97%) had witnessed an overdose (fuller data on 98)

For last witnessed overdose, Mostly friends - 70% Partner - 10% Acquaintance - 14% Stranger - 1%

(Strang, Best, Man, Noble and Gossop, IJDP, 2000)

TREATMENT SAMPLE 2b 115 methadone maintenance clients

Willingness to implement different interventions – For

Partner For

Friend For

Family For

Acqaint. For

Stranger Recovery position

97% 96% 96% 91% 89%

Mouth-to-mouth

97% 97% 97% 77% 69%

Walk them about

97% 97% 97% 93% 92%

Call ambulance

97% 97% 97% 93% 93%

Wait for ambulance

97% 97% 97% 95% 93%

(Strang, Best, Man, Noble and Gossop, I JDP, 2000)

TREATMENT SAMPLE #2 155 clients in/or seeking methadone treatment

72 (47%) had personal overdose history 128 (83%) had witnessed an overdose (includes 43 witnessing fatality)

Of these 128,75 (59%) had inflicted pain71 (55%) had walked them about the room70 (55%) had called an ambulance***63 (49%) had waited for the ambulance58 (45%) had splashed them with water56 (44%) had placed them in recovery position**49 (38%) had given mouth-to-mouth resusc*

[*** identifies user assessment of urgency]

REPORTS OF WITNESSED OVERDOSES THAT RESULTED IN FATALITIES

“He OD’ed at a friend’s house. The guy looked asleep, in fact he had already overdosed and died”.

“I was with a friend who collapsed. We tried to revive him but the ambulance took 20 minutes to arrive, by which time he had died. He had taken lots of Valium”.

Best, Gossop et al, 2002, Drug and Alcohol Review

COMMENTS ON THE ACTIONS TAKEN AT THE LAST WITNESSED OVERDOSE

“I injected her with salt; it brought her back, didn’t need an ambulance”;

“I cleared the air pathways and put an upside down spoon in his mouth”;

“…after going very blue, he was given crack when he started coming round, and that brought him back”;

“I used naloxone, and it saved his life”.Beswick et al, 2002, Journal of Drug Issues


Extensive witnessing of overdoses (including fatal outcomes);

ANDFrequent resuscitation efforts (even if incorrect).

Conclusion number 3:O/D intervention opportunity?

Yes

surely there is now a case for …

Resuscitation training

Naloxone distribution

Take-home naloxone

The idea

Early exploration

Nest steps

First mooted: JS - Keynote on Harm reduction - pushing at the envelope (Melbourne Harm Reduction conference, 1992)

First serious consideration:Strang, J., Darke, S., Hall, W., Farrell, M. & Ali, R. (1996) Heroin overdose: the case for take-home naloxone? British Medical Journal, 312: 1435.

First investigated: Strang J, Powis B, Best D et al (1999)

Preventing opiate overdose fatalities with take-home naloxone: pre-launch study of possible impact and acceptability. Addiction , 94 (2): 199-204.

Possible first target populations (naloxone)

Treatment-related risk of overdose Induction onto methadone Post-release from prison Post-detox treatment

Capelhorn (1998) Drug & Alcohol Review, 17: 9-17Bird & Hutchinson (2003) Addiction, 98: 185-190Strang et al (2003) British Medical Journal, 326:7-8

Possible target populations (Training)

Non-medic drug workersKey agency personnelPatientsCarersWider clients (e.g.IEES,etc)Users (i.e. not linked to patient status)

Strang, Kelleher and Bown, submitted for publication

Does the naloxone ever get used?

Initial experience ……Berlin/Jersey – about 10% used within a

yearNew Mexico, USA – 2/100 within few monthsChicago, USA, 2001 – 52/550Chicago, USA, 2003 – 144/2000

Dettmer, Saunders and Strang, BMJ, 2001 Baca et al, BMJ, 2001 Bigg, BMJ, 2002 and 2003

Cost per life saved?

At least 10% used in earnestUse appears appropriateLives saved; no lives lost£3-5 per naloxone ampEven if successful only 10% of times, then

each life saved at drug cost of £300-500[n.b. could be much cheaper]

Dettmer, Saunders and Strang, BMJ, 2001

Take-home naloxone:the next steps

Embed within resusc training (Nalox-box +)

Improve the product (route, device, drug)

? eventual wider availability ?

Other populations to train and empower

Strang (1999) Addiction, 94: 207.

CONCLUSIONS(1)Optimise …Don’t forget ….Unmet need

Waiting lists incomplete penetration

Poorly-met need Sub-optimal dosing Unacceptable reliance on drug alone Fondness for eccentricity

Iatrogenic harm In our own hands

CONCLUSIONS (2)

NEW PREVENTION OBJECTIVES:

fewer overdoses, and

CONCLUSIONS (2)

NEW PREVENTION OBJECTIVES:

fewer overdoses, and less dangerous overdose

CONCLUSIONS (3)

NEW INTERVENTIONS,but what?

CPR,esp assisted breathing

rapid ambulance call

naloxone administration

Thank You

Documents

DYING FOR HEROIN Overlooked or ignored options for preventing opiate overdose deaths Professor John Strang Director National Addiction Centre, Institute