DYING FOR HEROIN

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DYING FOR HEROIN

• Overlooked or ignored options for preventing
  opiate overdose deaths
• Professor John Strang
• Director
• National Addiction Centre,
• Institute of Psychiatry and the Maudsley, London,
  UK

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STRUCTURE OF THE TALK

• WHY THE INTEREST?
• Dont forget .
• ----------------------------------------------
• HOW COMMON?
• WHICH DRUGS?
• INTERVENTION OPPORTUNITY

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WHY THE INTEREST?

• GROWING PROBLEM
• SOMETHING WE COULD DO ABOUT IT

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Tables for Mortality from Opioids in Republic of
Ireland
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Percent of total deaths in Ireland (for each age
group) attributable to opioids in Ireland
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7
6
5
4
Percentage of deaths
3
2
1
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
Year
All ages
Age 35-44
Age 25-34
Age 15-24
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Age-standardised mortality rate from opioids and
odds ratios amongst population aged 15-44,
between 1980 and 1999 (per 1,000,000)
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Heroin purity 1986 - 2001
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Dont 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

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Dont forget .

• High-risk individuals, groups and times
• Impact of the treatment we provide
• Inevitable ?
• Inexcusable ?

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STRUCTURE OF THE TALK

• WHY THE INTEREST?
• ----------------------------------------------
• HOW COMMON?
• WHICH DRUGS?
• INTERVENTION OPPORTUNITY

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A guide to the studies - London

• 2 PAI studies of community samples (n438 early
  heroin users (Gossop et al, 1996)) and (n312
  injectors (Powis et al, 1999 Strang et al,
  1999)).
• 2 studies of methadone maintenance treatment
  samples (n142 m.m. clients (Strang et al, 1999))
  and (n155 outpatients (Best et al, 2000)).

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London PAI Study 1438 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
• (c244.2, plt0.001 data missing on 4)
• (Gossop, Griffiths, Powis, Williamson and Strang,
  BMJ, 1996)

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• HOW COMMON (among injectors)?
• WHICH DRUGS?
• INTERVENTION OPPORTUNITY?

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

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London PAI Study 2312 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)

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Conclusion number 1

• Overdose is common hazard
• Overdose frequently witnessed

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• HOW COMMON?
• WHICH DRUGS?
• INTERVENTION OPPORTUNITY?

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London PAI Study 2312 injectors

• Personal overdose? (38)
• Witnessed overdose? - (50)
• Witnessed fatal O/D? - (15)
• (Strang, Griffiths, Powis, Fountain, Williamson
  and Gossop, Drug and Alcohol Review, 1999)

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PAI Study 2 312 InjectorsLast personal
overdose (n117)
Other opiate (n21) meth 13
Heroin (n94 )
Non-opiate (n51)
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PAI Study 2 312 InjectorsLast witnessed O/D
(n157)
Other opiate (n12) meth 8
Heroin (n141)
Non-opiate (n43)
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PAI Study 2 312 InjectorsLast witnessed fatal
O/D (n46)
Other opiate (n12) meth 5
Heroin (n37)
Non-opiate (n25)
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Conclusion number 2Drugs involved with overdose

• HEROIN
• Heroin and sedative mixtures

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• HOW COMMON?
• WHICH DRUGS?
• INTERVENTION OPPORTUNITY?

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INTERVENTION OPPORTUNITY?

• Extensive witnessing of overdoses (including
  fatal outcomes)

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INTERVENTION OPPORTUNITY?

• Sydney - 86 had witnessed O/D
• Adelaide - 70 had witnessed O/D
• London PAI injectors -50
• (London treatment sample - 83/97)

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INTERVENTION OPPORTUNITY?

• O.K., so extensive witnessing of overdoses
  (including fatal outcomes)
• but what about resuscitation efforts (even if
  incorrect)?

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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)

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TREATMENT SAMPLE 2b 115 methadone maintenance
clients
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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 pain
• 71 (55) had walked them about the room
• 70 (55) had called an ambulance
• 63 (49) had waited for the ambulance
• 58 (45) had splashed them with water
• 56 (44) had placed them in recovery position
• 49 (38) had given mouth-to-mouth resusc
• identifies user assessment of urgency

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REPORTS OF WITNESSED OVERDOSES THAT RESULTED IN
FATALITIES

• He ODed at a friends 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

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COMMENTS ON THE ACTIONS TAKEN AT THE LAST
WITNESSED OVERDOSE

• I injected her with salt it brought her back,
  didnt 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

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INTERVENTION OPPORTUNITY?

• Extensive witnessing of overdoses (including
  fatal outcomes) AND
• Frequent resuscitation efforts (even if
  incorrect).

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Conclusion number 3O/D intervention opportunity?

• Yes

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surely there is now a case for

• Resuscitation training
• Naloxone distribution

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Take-home naloxone

• The idea
• Early exploration
• Nest steps

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• 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.

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• 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.

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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 9-17
• Bird Hutchinson (2003) Addiction, 98 185-190
• Strang et al (2003) British Medical Journal,
  3267-8

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Possible target populations (Training)

• Non-medic drug workers
• Key agency personnel
• Patients
• Carers
• Wider clients (e.g.IEES,etc)
• Users (i.e. not linked to patient status)
• Strang, Kelleher and Bown, submitted for
  publication

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Does the naloxone ever get used?

• Initial experience
• Berlin/Jersey about 10 used within a year
• New Mexico, USA 2/100 within few months
• Chicago, USA, 2001 52/550
• Chicago, USA, 2003 144/2000
• Dettmer, Saunders and Strang, BMJ, 2001
• Baca et al, BMJ, 2001
• Bigg, BMJ, 2002 and 2003

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Cost per life saved?

• At least 10 used in earnest
• Use appears appropriate
• Lives saved no lives lost
• 3-5 per naloxone amp
• Even 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

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Take-home naloxonethe 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.

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CONCLUSIONS(1)Optimise Dont 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

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CONCLUSIONS (2)

• NEW PREVENTION OBJECTIVES
• fewer overdoses, and

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CONCLUSIONS (2)

• NEW PREVENTION OBJECTIVES
• fewer overdoses, and
• less dangerous overdose

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CONCLUSIONS (3)

• NEW INTERVENTIONS,but what?
• CPR,esp assisted breathing
• rapid ambulance call
• naloxone administration

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• Thank You