Deborah Zador, MD, MPH
Head, Drug and Alcohol Dept.
Concord Repatriation General Hospital
Concord, New South Wales 2139
Users' Perceptions of Cause and Risk of Heroin Overdose in Sydney, Australia:
Implications for Prevention
One hundred and forty-one (141) subjects were interviewed briefly within minutes of being treated by ambulance officers for heroin overdose in Sydney, Australia in 1998. Thirty-four per cent (34%) returned for in-depth interviews within seven days of their overdose. At follow-up, most subjects were aware that concomitant drug use increased the risk of heroin overdose, nevertheless those who used other drugs with heroin were just as likely to attribute their overdose to other reasons. Subjects consumed other drugs with heroin in order to enhance the pleasurable effects of drug use rather than to medicate symptoms of withdrawal or depression. It appears that heroin users believe the potential benefits of poly-drug use outweigh its risks. Some of these users may not be receptive to messages advising avoidance of poly-drug use because they are seeking a desired effect, regardless of risk. Most subjects (63%) did not worry about a future overdose or believe that a future overdose was likely (75%) i.e. the overdose event did not appear to change subjects' low level of concern about overdosing. In response to questions about the impact of overdose on subsequent heroin using behaviour, 77% of subjects stated that they would either try to or definitely stop using heroin, continue to use but more safely, or not use as frequently -- only 11% stated that they would seek treatment for assistance with abstinence from heroin. Fifteen per cent (15%) indicated there would be no change in heroin use. Experience of overdose, therefore, does not appear to be a motivating factor for entry into treatment. Education campaigns targeting perceptions of low risk of overdose should be included in future overdose prevention strategies. Any period where heroin users appear willing to change their drug-using behaviour should be viewed as an opportunity for intervention.
Shaun Seaman, PhD
16 av Paul Vaillant-Couturier
tel: 0033 1 45 59 52 92
fax: 0033 1 45 59 51 51
The Role of Prison and Jail in Increasing the Risk of Overdose
The risk of death from overdose may be greater in injecting drug users who resume drug use after a period of abstinence, during which their tolerance may have declined. Imprisonment is an enforced period of abstinence from, or may lead to a radical reduction in, drug use. We investigated the risk of death from overdose among male HIV-positive injecting drug users in Edinburgh, Scotland, in the two weeks after release from the local prison and compared the risk with that at other times. The risk during the two weeks after release was 34 times higher than during other time spent outside prison. This estimated relative risk was reduced to 7.7 (95% CI 1.5 - 39.1) when temporal matching was used to control for heterogeneity in drug use by restricting the comparison period to the next 10 weeks after release.
Shepard Siegel, PhD
University Professor of Psychology
Dept. of Psychology
Hamilton, Ontario L8S 4K1
tel: 905-525-9140, ext. 24238
Pavlovian Conditioning and Drug Overdose
There is a considerable amount of evidence that Pavlovian conditioning contributes to tolerance; organisms learn to make responses that attenuate the effect of the drug in the presence of cues previously paired with the drug. The conditioning analysis is relevant to understanding seemingly enigmatic "failures" of tolerance that occur when a drug-experienced (and presumably drug-tolerant) individual suffers an "overdose." There are several demonstrations that Pavlovian conditioning is relevant to understanding opiate (as well as barbiturate and alcohol) "overdose" deaths in laboratory studies with rats. There also are case-reports of human opiate "overdoses," both in illicit users and in patients receiving medically prescribed morphine, that are consistent with the conditioning interpretation of drug overdose.
Co-investigator, Field Director
UCSF Dept. of Epidemiology & Biostatistics
San Francisco General Hospital
995 Potrero Ave. Bldg. 90, Ward 95
San Francisco, CA 94110
Overdosing Among Young Injection Drug Users in San Francisco
Objective: Little is known about the prevalence of overdose among
injection drug users (YIDU). We examine the prevalence of overdose, risk factors and overdose experience of YIDU (<30 years of age) in San Francisco.
Methods: Using street-based peer outreach, participants were
screened and interviewed about demographic characteristics, drug use, sexual behavior, healthcare utilization and overdose experience. Overdose was defined using a ten point scale ranging from 1 indicating "a heavy nod", 4 "person turns blue", and 10 "death". Number 4 "person turns blue" or above on the scale was classified as an overdose.
Results: Among 312 YIDU, the median age was 22 (Interquartile
Range:20-25) and median years injecting was 5 (IQR 2-8). Over half (55%) had ever overdosed as defined by 4 "person turns blue" or above on the scale, and 72% of those had overdosed more than once. The median number of overdoses was 3 (IQR:1-5). Participants who had exchanged syringes in the last 30 days were more likely to have ever overdosed, as were those who had ever been tested for HIV. In multivariate regression analysis, age (Odds Ratio 1.1, 95% Confidence Interval = 0.99-1.16), duration of injection (OR 2.8, 95% CI= 1.5-5.2), sharing syringes (OR 1.9, 95% CI=1.04-3.43), and hepatitis C virus seropositivity (OR 2.2, 95% CI=1.26-3.84), were independently associated (p= <.05) with ever overdosing. Having been in jail in the last year was also associated with ever overdosing (OR 1.6, 95% CI= 0.97-2.73), but was of borderline significance (p=.07). Most (75%) of injectors have witnessed an overdose. At the most recent overdose witnessed, 52% called 911, 61% performed CPR, and 72% kept the person awake by walking them around or shaking them. Eleven percent reported that the person had died. Of those who called 911, 82% reported that the person survived. Of those who did not call 911, most (29%) reported that calling was unnecessary because the person was revived, or that they feared police involvement (22%). Five percent of study participants have been arrested as a result of their overdose or someone else's overdose.
Conclusions: Findings suggest that overdose is common among young injection drug users and is associated with injection risk behavior and incarceration. HIV test counseling and needle exchange should be considered as venues for overdose prevention and education. The number of overdoses witnessed suggests the opportunity for intervention by others present and reveals the need to train drug users on how to respond in the event of an overdose. CPR training, naloxone distribution and law enforcement policy changes which make it safer to call 911 are all ways in which fatal overdose may be prevented.
(co-authors: Hahn JA, Evans J, Shafer KP, Lum PJ, Moss AR. University of California, San Francisco Department of Epidemiology and Biostatistics)
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