Predictors of non-fatal overdose among a cohort of polysubstance-using injection drug users

BACKGROUND: Non-fatal overdose is a major determinant of morbidity among injection drug users (IDU). We sought to evaluate factors associated with non-fatal overdose among IDU in Vancouver. METHODS: We examined non-fatal overdose among participants in the Vancouver Injection Drug Users Study. Correlates of non-fatal overdose occurring between 1996 and 2004 were identified using generalized estimating equations (GEE). RESULTS: There were 1587 participants included in this analysis, including 576 (36%) women. At baseline, 750 (47%) reported a history of non-fatal overdose. In total, 985 reports of non-fatal overdose were made during follow-up by 519 (32.7%) participants. In multivariate GEE analyses, factors independently associated with non-fatal overdose included: heroin injection (AOR=2.67), cocaine injection (AOR=2.01), benzodiazepine use (AOR=2.00), requiring help injecting (AOR=1.58), binge drug use (AOR=1.52), homelessness (AOR=1.38), alcohol use (AOR=1.32), street injecting (AOR=1.22), non-injectable opiate use (AOR=1.16), speedball use (AOR=1.15), and recent incarceration (AOR=1.14). Younger age (AOR=0.99) and methadone use (AOR=0.51) were protective. CONCLUSIONS: We found that non-fatal overdose was common among local IDU. Non-fatal overdose was associated with several factors that may be amenable to intervention, including opiate and stimulant use, and the characteristic of requiring help with injecting. These findings indicate the need for the ongoing development of structural interventions to address this common cause of morbidity among IDU.     

A cross-sectional study on prevalence of non-fatal drug overdose and associated risk characteristics among out-of-treatment injecting drug users in North Vietnam

In a community-based cross-sectional survey among out-of-treatment male opiate injecting drug users (IDU) aged 18-45, data on non-fatal overdose were collected using a semi-structured questionnaire. From August to September 2003, 299 IDU were recruited in two districts of Bac Ninh, a semi-urban province in North Vietnam. Prevalence of lifetime and recent non-fatal overdose were 43.5 and 83.1%, respectively. Logistic regression analyses showed associations between non-fatal overdose and younger age, unemployment, residence in the provincial township, frequency of injecting, injecting heroin mixed with valium, and history of drug treatment. While recognizing the limitations of this study, it is the first in Southeast Asia to report on prevalence of drug use-related overdose. Future research is recommended on occurrence of fatal overdose in this population.     

Factors Associated with Nonfatal Overdose During a Public Health Emergency

Background: In 2016, in the Canadian province of British Columbia, the Provincial Health Officer declared drug-related overdose deaths a public health emergency. Objectives: In this study, we examine factors associated with recent non-fatal overdose during a time of unprecedented rates of overdose and increasing involvement of fentanyl and fentanyl derivatives in overdose deaths. Methods: Between June and September 2016, a cross-sectional survey was conducted among people who inject drugs (PWID) in Victoria, British Columbia, Canada. Bivariable and multivariable logistic regression analyses were used to examine factors associated with recent non-fatal overdose. Results: A total of 187 PWID were included in the present study, of whom 56 (29.9%) reported having overdosed in the previous 6 months. In multivariable analyses, fentanyl injection (Adjusted Odds Ratio [AOR]?=?2.60; 95% confidence interval [CI]: (1.08?–?6.27) and public injection (AOR?=?2.20; 95% CI: 1.09?–?4.43) were positively associated with recent non-fatal overdose. Conclusions: Fentanyl injection and public injection were associated with an increased likelihood of non-fatal overdose. These findings underscore the need for drug checking, safer sources of opioids and safer injecting interventions as part of overdose prevention strategies.     

The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis

BackgroundPeople who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event.MethodsWe conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence.ResultsAn estimated 3.2 (1.8–5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0–26.1%) and 41.5% (34.6–48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America.ConclusionAround one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.     

吸毒人员死亡原因及相关因素调查

目的:收集分析已故吸毒人员的死亡原因,为降低吸毒人群死亡率后续活动提供依据。方法:云南、广西17县为调查点,立意抽样,通过对死者家属或亲友问卷调查,回顾收集2009年以来,3 a死亡吸毒人员相关人口学信息、吸毒史、死亡原因等。Epidata建立数据库,SPSS 17.0进行统计学分析。结果:共调查188名死亡吸毒人员,其中男性占83.3%;年龄为:37.4 a±s 5.7 a;187人使用毒品为海洛因(其中1人漏答),46.5%吸毒人员死于吸毒注射过量,24.1%死于艾滋病,注射吸毒方式是吸毒过量导致死亡的危险因素,OR值为1.445。结论:吸毒人员多中年死亡,注射吸毒过量及艾滋病是造成死亡的最主要原因,加强吸毒过量预防宣传培训及扩大过量急救可及性,增加吸毒人员入组抗病毒治疗将有效降低吸毒人员死亡率。     

An evaluation of a heroin overdose prevention and education campaign

Introduction and Aims. Following detection of an upward trend in the frequency of fatal heroin overdoses in Victoria between 2001 and 2003, Victoria's Department of Human Services planned a campaign aimed at increasing injecting drug users' (IDU) awareness of overdose risks and prevention strategies. Stickers, wallet cards and posters featuring five key messages were distributed via needle and syringe programs (NSP) and other drug and alcohol services between November 2005 and April 2006. An evaluation of the campaign was commissioned to be conducted in late 2006. Design and Methods. The evaluation consisted of analysis of three independent data sets––quantitative data collected from IDU during the campaign period (n = 855 at baseline; and a range of 146–656 at follow up); qualitative interviews with IDU who were NSP clients during the campaign period (n = 16) and qualitative interviews with NSP staff and other key stakeholders (n = 9). Results. While key experts felt that the campaign messages had engendered lasting impact for at least some IDU, these positive impressions were not borne out by the NSP client data, with less than one quarter of all campaign messages being mentioned by a significantly higher proportion of clients during the post‐campaign period compared with baseline. Key experts perceived the greatest weakness of the campaign to be the delay between issue identification and the introduction of campaign materials. Discussion and Conclusions. While IDU are generally responsive to health promotion campaigns, future initiatives in this domain should be designed and implemented rapidly and in ways that are sufficiently flexible to cope with shifts in drug markets which could influence the reception of key messages.[Horyniak D, Higgs P, Lewis J, Winter R, Dietze P, Aitken C. An evaluation of a heroin overdose prevention and education campaign. Drug Alcohol Rev 2009]     

Editorial

The increase in the number of non-fatal opioid overdoses in Melbourne, Australia has occurred concomitantly with the emergence of street heroin dealing / using areas across different parts of Melbourne. The aim of this study was to examine the social and environmental factors that contribute to the risk of illicit drug overdose in a street heroin dealing / using setting. A detailed examination of overdose experiences, and consultations with drug users, police and shop traders, suggests that the harm related to drug overdose and the factors which contribute to the risk of overdose in a street-using / dealing environment may be significantly underestimated. The clinical definition of drug overdose may underestimate the harm associated with illicit drug use. Through not fully understanding drug user's experiences of drug overdose, and thus incorrectly defining drug overdose, significant opportunities to intervene in what is a significant medical and social problem may be lost.     

Heroin and Methamphetamine Injection: An Emerging Drug Use Pattern

Objective: We sought to describe an emerging drug use pattern characterized by injection of both methamphetamine and heroin. We examined differences in drug injection patterns by demographics, injection behaviors, HIV and HCV status, and overdose. Methods: Persons who inject drugs (PWID) were recruited as part of the National HIV Behavioral Surveillance (NHBS) system in Denver, Colorado. We used chi-square statistics to assess differences between those who reported only heroin injection, only methamphetamine injection, and combined heroin and methamphetamine injection. We used generalized linear models to estimate unadjusted and adjusted prevalence ratios to describe the association between drug injection pattern and reported nonfatal overdose in 2015. We also examined changes in the drug reported as most frequently injected across previous NHBS cycles from 2005, 2009, and 2012. Results: Of 592 participants who completed the survey in 2015, 173 (29.2%) reported only injecting heroin, 123 (20.8%) reported only injecting methamphetamine, and 296 (50.0%) reported injecting both drugs during the past 12 months. Injecting both heroin and methamphetamine was associated with a 2.8 (95% confidence interval: 1.7, 4.5) fold increase in reported overdose in the past 12 months compared with only injecting heroin. The proportion of those reporting methamphetamine as the most frequently injected drug increased from 2.1% in 2005 to 29.6% in 2015 (p < 0.001). Conclusions: The rapid increase in methamphetamine injection, and the emergence of combining methamphetamine with heroin, may have serious public health implications.     

Reductions in non-fatal overdose after drug misuse treatment: results from the National Treatment Outcome Research Study (NTORS)

Few studies have reported changes in rates of overdose after drug misuse treatment. This paper investigates changes in non-fatal overdose between treatment intake and 1 year follow-up among a sample of 753 clients recruited to the National Treatment Outcome Research Study (NTORS). A relatively high rate of overdose (15%) was reported during the 3 months prior to treatment. Variables predictive of overdose at intake to treatment included injecting, frequency of benzodiazepine and cocaine use, quantity of alcohol consumption, and levels of anxiety. At 1 year follow-up, the rate of non-fatal overdose had fallen to 6%. Reduced rates of non-fatal overdose were found for clients treated in both residential and community treatment settings. Reductions in overdose were linked to improvements in frequency of drug use and lower rates of injecting. Clients who overdosed at follow-up showed no improvements in their substance use, except for frequency of crack cocaine use. The risk of non-fatal overdose at 1 year was associated with injecting and multiple drug use. These findings support the view that treatment an important role can play in reducing deaths among drug misusers.     

The role of depression and social support in non-fatal drug overdose among a cohort of injection drug users in a Canadian setting

Objectives

Non-fatal overdose remains a significant source of morbidity among people who inject drugs (IDU). Although depression and social support are important in shaping the health of IDU, little is known about the relationship between these factors and overdose. Therefore, we sought to determine whether depressive symptoms and social support predicted non-fatal overdose among IDU in a Canadian setting.

Methods

Data were derived from three prospective cohorts of people who use drugs: the Vancouver Injection Drug Users Study (VIDUS), the ACCESS Cohort, and the At-Risk Youth Study (ARYS). Multilevel modeling was used to determine if depression and social support were significant predictors of non-fatal overdose across time. Analyses were stratified by sex.

Results

There were 1931 participants included in this analysis, including 653 (33.8%) females and 69 (3.6%) youth 20 years old or younger. Depressed men (adjusted odds ratio [AOR] = 1.53, 95% confidence intervals [CI] = 1.25, 1.87) and women (adjusted odds ratio [AOR] = 2.23, 95% confidence intervals [CI] = 1.65, 3.00) were more likely to experience a non-fatal overdose. Further, among women, those who reported having 3 or more persons they could rely upon for social support were less likely to experience a non-fatal overdose (AOR = 0.54, 95% CI 0.31, 0.93).

Conclusion

Although depression was a significant predictor of non-fatal drug overdose, social support was a significant predictor among women only. Possible strategies to prevent non-fatal overdose may include identifying IDU experiencing severe depressive symptoms and providing targeted mental health treatments and mobilizing interpersonal social support among IDU, especially among women.     

149例疑为药物过量患者血中苯二氮类药物浓度测定

目的 :寻找快速测定药物过量患者苯二氮类药物 (BZDs)血药浓度的方法。方法 :对149例急诊疑为药物过量患者 ,采用荧光偏振免疫法测定其BZDs血药浓度。结果 :104例血中测出BZDs ,且不同种类的BZDs血药浓度高低不一。结论 :以本法测定BZDs血药浓度对临床及时诊断和治疗有一定参考价值 ,但其浓度高低与患者病情的轻重并无必然联系。     

The Role of Physician and Nurse Attitudes in the Health Care of Injecting Drug Users

In 2005, 60 health care workers were recruited through services that attract injecting drug users (IDUs) and asked to complete attitude measures regarding IDU clients. Mediation analyses indicated that conservative health care workers displayed more negative attitudes toward their IDU clients because they believe that injecting drug use is within the control of the IDU. Negative attitudes toward IDU clients, in turn, were associated with worry about IDU clients’ behavior in the clinic and with beliefs that IDU clients should disclose their hepatitis C status to their health care worker. Perceptions of controllability of drug use were also associated with the belief that IDU clients’ ailments were caused by their IDU status. The study's limitations are noted.     

A micro-environmental intervention to reduce the harms associated with drug-related overdose: evidence from the evaluation of Vancouver's safer injection facility

BackgroundConventional drug overdose prevention strategies have been criticised for failing to address the macro- and micro-environmental factors that shape drug injecting practices and compromise individual ability to reduce the risks associated with drug-related overdose. This in turn has led to calls for interventions that address overdose risks by modifying the drug-using environment, including the social dynamics within them. Safer injection facilities (SIFs) constitute one such intervention, although little is known about the impact of such facilities on factors that mediate risk for overdose.MethodsSemi-structured qualitative interviews were conducted with fifty individuals recruited from a cohort of SIF users in Vancouver, the Scientific Evaluation Of Supervised Injecting (SEOSI). Audio recorded interviews elicited injection drug users’ (IDU) accounts of overdoses as well as perspectives regarding the impact of SIF use on overdose risk and experiences of overdose. Interviews were transcribed verbatim and a thematic analysis was conducted.ResultsFifty IDU, including 21 women, participated in this study. The perspectives of participants suggest that the Vancouver SIF plays an important role in mediating various risks associated with overdose. In particular, the SIF addresses many of the unique contextual risks associated with injection in public spaces, including the need to rush injections due to fear of arrest. Further, SIF use appears to enable overdose prevention by simultaneously offsetting potential social risks associated with injecting alone and injecting in the presence of strangers. The immediate emergency response offered by nurses at the SIF was also valued highly, especially when injecting adulterated drugs and drugs of unknown purity and composition.ConclusionThe perspectives of IDU participating in this study suggest that SIFs can address many of the micro-environmental factors that drive overdose risk and limit individual ability to employ overdose prevention practices. Although challenges related to coverage remain in many settings, SIFs may play a unique role in managing overdoses, particularly those occurring within street-based drug scenes.     

Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data

Introduction and Aims. Experiencing previous non‐fatal overdoses have been identified as a predictor of subsequent non‐fatal overdoses; however, few studies have investigated the association between previous non‐fatal overdose experiences and overdose mortality. We examined overdose mortality among injecting drug users who had previously been attended by an ambulance for a non‐fatal heroin overdose. Design and Methods. Using a retrospective cohort design, we linked data on non‐fatal heroin overdose cases obtained from ambulance attendance records in Melbourne, Australia over a 5‐year period (2000–2005) with a national death register. Results. 4884 people who were attended by ambulance for a non‐fatal heroin overdose were identified. One hundred and sixty‐four overdose deaths occurred among this cohort, with an average overdose mortality rate of 1.20 per 100 person‐years (95% CI, 1.03–1.40). Mortality rate decreased 10‐fold after 2000 coinciding with widely reported declines in heroin availability. Being male, of older age (>35 years) and having been attended multiple times for previous non‐fatal overdoses were associated with increased mortality risk. Discussion and Conclusions. As the first to show a direct association between non‐fatal overdose and subsequent overdose mortality, this study has important implications for the prevention of overdose mortality. This study also shows the profound effect of macro‐level heroin market dynamics on overdose mortality.[Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data. Drug Alcohol Rev 2009;28:347–352]     

The relationship between drug use settings,roles in the drug economy,and witnessing a drug overdose in Baltimore,Maryland

Background: There has been a dramatic increase in drug overdose deaths in the United States. In the current study, the authors examined factors associated with witnessing a drug overdose. Methods: A sample of 450 substance users in Baltimore, Maryland, were recruited for a behavioral intervention and were administered a survey. Multinomial logistic regression models were used to compare participants who never witnessed a drug overdose with those who witnessed one in the prior 6 months and those who witnessed an overdose over 6 months ago. Results: Most (58%) participants were male, 40% experienced homelessness in the prior 6 months, 63% reported a history of heroin injecting, 84% had snorted heroin, 75% reported witnessing a drug overdose, and 38% experienced an overdose. In multinomial logistic regression models, witnessing an overdose in the past 6 months was associated with number of different types of places where drugs were used (adjusted odds ratio [aOR] = 1.34), history of experiencing an overdose (aOR = 1.80), injecting heroin and/or speedball (aOR = 1.78), and snorting heroin (aOR = 1.54). Witnessing an overdose more than 6 months ago was associated with number of different places where drugs were used (aOR = 1.25), history of experiencing an overdose (aOR = 1.61), snorting heroin (aOR = 1.42), and injecting heroin or speedball (aOR = 1.47). Conclusions: These data suggest that people who engage in more public and frequent drug use, and hence are more likely to witness an overdose, should be targeted for interventions to prevent and treat drug overdose.     

Dose-effect relationship between overdose mortality and prescribed methadone dosage in low-threshold maintenance programs.

The present study evaluates the effectiveness of low-threshold methadone maintenance in reducing overdose mortality. In a prospective cohort study conducted in Amsterdam, 498 Dutch injecting drug users (IDU) provided 1,969 person years of follow-up (1989-1995). Forty-four IDU died in this period, 15 due to illicit drug overdose. Compared to IDU not in maintenance, the adjusted relative risk for overdose mortality among those receiving 5-50 mg, 55-70 mg, and 75+ mg were 0.35, 0.13, and 0.11, respectively (p < .05). Also current injection use and HIV-seropositivity were independent predictors for overdose mortality. Whereas previous studies indicated effectiveness of methadone-assisted detoxification and high-dose maintenance programs in reducing mortality, the present study findings suggest that low-threshold maintenance programs also reduce overdose mortality, with higher dosages being most protective.     

Perceived Severity of and Susceptibility to Overdose Among Injection Drug Users: Relationships With Overdose History

Background: Overdose is relatively common among injection drug users (IDUs) yet little is known about how overdose-related health beliefs influence overdose experiences or risk reduction. Objectives: This study examines the association of perceived susceptibility to and perceived severity of nonfatal overdose with overdose history among IDUs attending needle exchange programs (NEPs) to inform prevention efforts. Methods: In 2009–2010, IDUs (N = 91) attending NEPs completed self-report surveys. Negative binomial regression modeled the association between demographics, age of injection initiation, length of time attending the NEP, perceived severity of overdose, and perceived susceptibility to overdose with lifetime history of nonfatal overdose. Results: Over half (55%) of participants reported lifetime overdose, with a mean of 2.9 overdoses. A multivariable negative binomial regression model revealed that younger current age, older age of first injection, non-Caucasian race, higher perceived severity of overdose, and lower perceived susceptibility to overdose were significantly correlated with fewer lifetime overdoses. Conclusions: Although our methodology precludes causal inferences, these findings are consistent with the hypothesis that perceived severity and perceived susceptibility are among several factors associated with IDUs' use of protective behaviors, which could influence the likelihood of overdose. Future prospective research to explore the impact of this and other health beliefs on risk behaviors and overdose could help improve the effectiveness of behavioral interventions.     

Characterising opportunity to use heroin reveals new avenues for intervention: context,outcomes, and latency to initiation

Abstract

Preceding initiation, opportunity to use heroin is the earliest necessary condition for heroin-related outcomes to occur. This study aimed to characterise first heroin use opportunity (prior to initiation) and to identify heroin-related outcomes associated with earlier age at first opportunity. Structured interviews were conducted with 93 opiate substitution treatment clients in UK drug and alcohol treatment clinics. The majority of participants (64.8%) reported initiating heroin use on the same day as being first presented with the opportunity to use heroin. Of those who reported early age at opportunity to use heroin, 77.4% reported this came from friends/partner/family compared with 59.3% of those who reported later opportunities. After adjustment, overdose was found to be more than twice as likely amongst those who reported first opportunity to use heroin at age 17 or under (AOR 2.82 95% CI 1.57–5.05). Findings indicate the early drug use environment is linked to later risk of overdose. Greater consideration of context surrounding heroin use opportunity may indicate mechanisms to disrupt or prevent initiation of heroin use and later drug-related harms. Given short latency to initiation, focus should be placed on preventing initiation of heroin use through injecting.