Death matters: understanding heroin/opiate overdose risk and testing potential to prevent deaths

Abstract

Aims To describe work undertaken over a 20-year period, investigating overdose characteristics among survivors, effects of acute heroin administration, clustering of risk of overdose fatality and potential interventions to reduce this fatal outcome. Methods Privileged-access interviewers obtained data from non-treatment as well as treatment samples; experimental study of drop in oxygen saturation following heroin/opiate injection; investigation of clusterings of death following prison release and treatment termination; and study of target populations as intervention work-force, including family as well as peers, and action research built into pilot implementation. Results Overdose has been experienced by about half of heroin/opiate misusers, with even higher proportions having witnessed an overdose, and with high levels of willingness to intervene. Heroin/opiates are associated with the majority of drug-related deaths, despite relative scarcity of use. Heroin injection causes a rapid drop in oxygen saturation, recovering only slowly over the next half hour. Deaths from drug overdose are greatly more likely on prison release and post-discharge from detoxification and other in-patient or residential settings. High levels of declared willingness to intervene are matched by active interventions. Both drug-using peers and family members show ability to improve knowledge and gain confidence from training. Audit study of take-home schemes finds approximately 10% of dispensed naloxone is used in real-life emergency situations.Conclusions Overdose is experienced by most users, with heroin/opiates contributing disproportionately to drug overdose deaths. High-risk times (e.g. after prison release) are now clearly identified. Peers and family are a willing potential intervention work-force, but are rarely trained or given pre-supply of naloxone. Large-scale naloxone provision (e.g. national across Scotland and Wales) is now being delivered, while large-scale randomized trials (e.g. N-ALIVE prison-release trial) are finally under way. Better naloxone products and better-organized provision are needed. The area does not need more debate; it now needs proper implementation alongside good scientific study.

High drug related mortality rates following prison release: Assessing the acceptance likelihood of a naltrexone injection and related concerns

“…Injections of naltrexone provide one clinical means of potentially reducing drug related elevated mortality rates in prisoners in the 4 weeks following their release into the community, and its availability as an option to prevent unnecessary deaths does not preclude the provision of other interventions such as "take-home" naloxone supplies (European Monitoring Centre for Drugs and Drug Addiction, 2018;Strang, 2015). It is recommended that further investigations take place into the effectiveness of naltrexone injections as an intervention for the population of heroin users facing release from prison, and into the regulatory changes which may be necessary for its implementation.…”

“…One intervention for minimising the risk of a post-release opiate overdose is the provision of the opiate antagonist naloxone and the equipment to inject it, so as to counteract the overdose (Bird & Hutchinson, 2003;European Monitoring Centre for Drugs and Drug Addiction, 2018;Parmar, Strang, Choo, Meade, & Bird, 2016;Strang, 2015). However, this strategy does not diminish the likelihood of an overdose initially occurring, and relies upon either the user being sufficiently capable of self-administering the injection, or another person being present who is capable and willing to administer it.…”

Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review

“…This suggests a need to expand access to and use of medication-assisted treatment for opioid dependence, a strategy that is gaining wide support. 32,33–35 Additionally, overdose education combined with community distribution of naloxone, an antidote for opioid poisoning, significantly reduces opioid overdose fatalities 36,37,38 and should be a component of overdose prevention efforts for homeless populations, particularly given the high number of deaths that occurred in a private residence.…”

The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland

“…Overdose is a major cause of mortality among people who inject drugs (PWID), especially in those who inject opioids such as heroin (Pierce, Bird, Hickman, & Millar, 2015;Strang, 2015). The United Nations World Drug Report 2015 described the number of these premature deaths in drug users as "unacceptable" (United Nations Office on Drugs and Crime, 2015) because the majority are preventable through interventions such as long-term opioid substitution therapy and the use of opioid antagonists, such as naloxone.…”