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Overdose deaths from s treet heroin and prescribed methadone: analysis and prevention options. Professor John Strang National Addiction Centre, London, UK. Issues to be covered today. T opic 1: Analysis of the overdose death problem Topic 2: How could we respond more effectively?.

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Overdose deaths from s treet heroin and prescribed methadone analysis and prevention options

Overdose deaths from street heroin and prescribed methadone:analysis and prevention options

Professor John Strang

National Addiction Centre, London, UK


Issues to be covered today
Issues to be covered today

  • Topic 1: Analysis of the overdose death problem

  • Topic 2: How could we respond more effectively?


Issues to be covered today1
Issues to be covered today

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


Issues to be covered today2
Issues to be covered today

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone




Issues to be covered today3
Issues to be covered today

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


Total number of drug related deaths in england with associated substances 1993 2001 ons

Total number of drug-related deaths in England with associated substances: 1993-2001 (ONS).

1993 1997 2000 2001 (% change)

Total annual -England 821 1237 1561 1524 (-2%)

Heroin and Morphine 187 445 926 889 (-4%)

Methadone 232 421 238 207 (-13%)

Cocaine 12 39 80 96 (+20%)

MDMA/Ecstasy 8 12 36 55 (+53%)


associated substances: 1993-2001 (ONS).Methadone heals, but methadone also kills. The challenge is to achieve the former without incurring the latter”.


Trends in o d deaths heroin and methadone hickman et al ije 2006
Trends in O/D deaths – heroin and methadone associated substances: 1993-2001 (ONS).(Hickman et al, IJE, 2006)


Trends in o d deaths heroin and methadone hickman et al ije 2007
Trends in O/D deaths – heroin and methadone associated substances: 1993-2001 (ONS).(Hickman et al, IJE, 2007)


Issues to be covered today4
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


London pai study 1 438 early heroin users
London PAI Study #1: associated substances: 1993-2001 (ONS).438 Early Heroin Users

[48% in first 3 years; 45% SDS£6]

  • Overdose history among 98 (22%)

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

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

      (c2=44.2, p<0.001 [data missing on 4])

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


  • HOW COMMON associated substances: 1993-2001 (ONS).(among injectors)?


London pai study 2 312 injectors
London PAI Study #2: associated substances: 1993-2001 (ONS).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)


Aus adelaide pai study 2 218 heroin users i e injectors
Aus (Adelaide) PAI Study #2: associated substances: 1993-2001 (ONS).218 heroin users (i.e. injectors)

  • Personal overdose? - 48%

  • Witnessed overdose? - 70%

  • (Witnessed fatal O/D? - n/a)

    (McGregor, Darke, Ali and Christie, Addiction, 1998)


Issues to be covered today5
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


When in particular
When in particular? associated substances: 1993-2001 (ONS).

  • During methadone early treatment

  • Post-detox/rehab


Risk of death during and after treatment
Risk of death during and after treatment associated substances: 1993-2001 (ONS).

  • BMJ 2010;341:c5475


Issues to be covered today6
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


When in particular1
When in particular? associated substances: 1993-2001 (ONS).

  • Post-detox/rehab

  • During methadone early treatment

  • Prison release


Post release carnage
Post-release associated substances: 1993-2001 (ONS).‘carnage’

  • Seaman Brettle Gore, BMJ, 1998

  • Bird & Hutchinson, Addiction, 2002

  • Farrell & Marsden, Addiction, 2008


Prevalence of drug dependence
Prevalence of drug dependence associated substances: 1993-2001 (ONS).

Drug dependence prior to prison

Substance Misuse in Prisoners 2002 Singleton N, Farrell M, Meltzer H ONS.


Issues to be covered today7
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


Issues to be covered today8
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


Cochrane review of dose and methadone

Cochrane review of dose and methadone associated substances: 1993-2001 (ONS).

Faggianoet al (2007) Cochrane review of significance of dose in methadone OST

Retention rate - RCTs: High versus low doses at shorter follow-ups: RR=1.36 [1.13,1.63], and at longer ones: RR=1.62 [0.95,2.77].

Opioid use (self reported), times/w - RCTs: high versus low doses WMD= -2.00 [-4.77,0.77] high vs middle doses WMD= -1.89[-3.43, -0.35]

Opioid abstinence, (urine based) at >3-4w-RCTs: high versus low doses: RR=1.59 [1.16,2.18] high vs middle doses RR=1.51[0.63,3.61]

Cocaine abstinence (urine based) at >3-4 w - RCTs: high versus low doses RR=1.81 [1.15,2.85]

Overdose mortality: high dose versus low dose at 6 years follow up: RR=0.29 [0.02-5.34] high dose vs middle dose at 6 years follow-up: 0.38 [0.02-9.34] middle dose vs low dose at 6 years follow-up: RR=0.57 [0.06-5.06]


Issues to be covered today9
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


What is the OD4 Index? associated substances: 1993-2001 (ONS).

OD4 = ODDDD (Overdose Deaths per Daily Dispensed Dose)

Thus essentially a measure of safety of a medication, as applied


Issues to be covered today10
Issues to be covered today associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


Pre filled syringe 1 mg per ml 2 ml syringe available from antigen aurum mayne 6 30
Pre-filled syringe associated substances: 1993-2001 (ONS).1 mg per ml, 2 ml syringe available from: Antigen, Aurum, Mayne £6.30


  • First investigated: associated substances: 1993-2001 (ONS).

  • 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.


Structure 4 areas
Structure – 4 areas associated substances: 1993-2001 (ONS).

  • Training elements

    • (a) how to recognise overdose

    • (b) how to manage situation – general

    • (c) how to give naloxone


How to recognise opiate overdose
How to Recognise associated substances: 1993-2001 (ONS). Opiate Overdose

Person unconscious, and cannot be

woken – UNROUSABLE

CYANOSIS – BLUE lips or tongue

Not breathing at all or breathing slowly –

deep snoring.

Pin point pupils


Actions on discovering overdose
Actions associated substances: 1993-2001 (ONS). on Discovering Overdose

A – Ambulance - CALL AMBULANCE

B- Breathing - Check Airway – clear if blocked, Check breathing.

C – reCovery - If breathing, place in recovery position – if not breathing, begin basic life support

Administer naloxone


How to inject naloxone intramuscular into muscle
How to inject Naloxone – intramuscular (into muscle) associated substances: 1993-2001 (ONS).

  • Remove syringe from box and packet

  • Attach needle to syringe

  • Inject into the outer thigh, upper arm or outer part of buttock

  • Hold needle 90 degree above skin

  • Insert needle into muscle (needs pressure)

  • Slowly and Steadily push plunger all the way down

  • Put syringe back in box. Don’t cover needle


Changes in knowledge after training
Changes in knowledge after training associated substances: 1993-2001 (ONS).

***All significant at p<0.001


Carers the overlooked intervention workforce
Carers – the overlooked intervention workforce associated substances: 1993-2001 (ONS).

102 carers attending 4 organisations

  • 80% parents, 20% other relative/partner

  • 96% of opiate users, 87% IDU, 57% in Tx,

  • 1/3 used in presence of carer, 47% had past OD

  • 20% of carers had witnessed an OD

  • 5 had lost user to fatal OD (3 children 2 partners)

  • 16% would ‘panic’ or ‘not know what to do’

  • 83% expressed an interest OD management & N training

    Evidence of potential to extend naloxone…

    Strang, Manning, Mayet et al, (2008) Family carers and prevention of heroin overdose deaths: ……

    Drugs: Education, Prevention & Policy, 15: 211-218.


Does the naloxone ever get used
Does the naloxone ever get used? associated substances: 1993-2001 (ONS).

  • Initial experience ……

  • Berlin/Jersey – about 10% used within a year

  • New Mexico, USA – 2/100 within few months

  • Chicago, USA – 52/550

    • Dettmer, Saunders and Strang, BMJ, 2001

    • Baca et al, BMJ, 2001

    • Bigg, BMJ, 2002


N alive trial pilot main phase
N-ALIVE trial – pilot & main phase associated substances: 1993-2001 (ONS).

  • N-ALIVE research trial proposal to test/prove reduced deaths post-release

  • Pilot – n=5600

  • Main study – n=56000 (28k + 28k)


Conclusiona
Conclusiona associated substances: 1993-2001 (ONS).

  • Topic 1: Analysis of the overdose death problem

    • Why the special attention to the opiates?

    • Methadone as well as heroin (in the UK)

    • Injecting heroin, in particular

    • Special time of risk – at start and after the end of treatment

    • Special time of risk – on release from prison

  • Topic 2: How could we respond more effectively?

    • Methadone – dose

    • Methadone – supervision

    • Take-Home Emergency Naloxone


Thank you
Thank you associated substances: 1993-2001 (ONS).


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