Nonfatal heroin overdoses in Queensland,Australia: an analysis of ambulance data

In the past decade, the utilization of ambulance data to inform the prevalence of nonfatal heroin overdose has increased. These data can assist public health policymakers, law enforcement agencies, and health providers in planning and allocating resources. This study examined the 672 ambulance attendances at nonfatal heroin overdoses in Queensland, Australia, in 2000. Gender distribution showed a typical 70/30 male-to-female ratio. An equal number of persons with nonfatal heroin overdose were between 15 and 24 years of age and 25 and 34 years of age. Police were present in only 1 of 6 cases, and 28.1% of patients reported using drugs alone. Ambulance data are proving to be a valuable population-based resource for describing the incidence and characteristics of nonfatal heroin overdose episodes. Future studies could focus on the differences between nonfatal heroin overdose and fatal heroin overdose samples.     

Ambulance calls to suspected overdoses: New South Wales patterns July 1997 to June 1999

AIM: Using data on New South Wales ambulance calls to suspected overdoses from July 1997 to June 1999 to: a) examine temporal and geographic trends in calls; and b) compare geographic patterns of fatal and non-fatal opioid overdose. METHOD: The NSW Ambulance Service provided data on the occasions when an ambulance attended a person on whom the drug overdose/poisonings protocol was used, and to whom naloxone was administered. The geographic distribution of ambulance attendances was approximated to the Australian Bureau of Statistics Statistical Local Area (SLA) and Statistical Subdivision (SSD). Estimates of social disadvantage were correlated with the rate of ambulance attendances for each region. RESULTS: 9,116 callouts were made. In cases with data on age and gender, 89% were aged 15-44 years, and 31% were female. South Sydney (n=1,819) and Liverpool (n=1,602) SLAs accounted for 37% of calls; the higher rates outside Sydney were in Newcastle, Orange and Kiama. There was a strong correlation between rates of ambulance callouts and fatal heroin overdoses. The number of calls increased from an average of 361 calls per month in 1997-98 to 399 in 1998-99. The majority of calls (54%) were made between midday and 9 pm. CONCLUSIONS: Rates of ambulance attendance at suspected overdoses is a promising indicator that allows monitoring of trends and identification of areas with high rates of opioid use.     

Characteristics of non-fatal opioid overdoses attended by ambulance services in Australia

OBJECTIVE: To examine the feasibility of establishing a database on non-fatal opioid overdose in order to examine patterns and characteristics of these overdoses across Australia. METHODS: Unit record data on opioid overdose attended by ambulances were obtained from ambulance services in the five mainland States of Australia for available periods, along with information on case definition and opioid overdose management within these jurisdictions. Variables common across States were examined including the age and sex of cases attended, the time of day and day of week of the attendance, and the transportation outcome (whether the victim was left at the scene or transported to hospital). RESULTS: The monthly rate of non-fatal opioid overdose attended by ambulance was generally highest in Victoria (Melbourne) followed by NSW, with the rates substantially lower in the remaining States over the period January 1999 to February 2001. Non-fatal opioid overdose victims were most likely to be male in all States, with the proportion of males highest in Victoria (77%), and were aged around 28 years with ages lowest in Western Australia (m=26) and highest in NSW (m=30). Most of the attendances occurred in the afternoon/early evening and towards the later days of the working week in all States. The rates of transportation varied according to ambulance service practice across the States with around 94% of cases transported in Western Australia and around 18% and 29% of cases transported in Melbourne and NSW respectively. CONCLUSIONS: It is feasible to establish a database of comparable data on non-fatal opioid overdoses attended by ambulances in Australia. This compilation represents a useful adjunct to existing surveillance systems on heroin (and other opioid) use and related harms.     

Heroin overdose: Research and evidence-based intervention

Drug overdose is a major cause of premature death and morbidity among heroin users. This article examines recent research into heroin overdose to inform interventions that will reduce the rate of overdose death. The demographic characteristics of overdose cases are discussed, including factors associated with overdose: polydrug use, drug purity, drug tolerance, routes of administration, and suicide. Responses by heroin users at overdoses are also examined. Potential interventions to reduce the rate of overdose and overdose-related morbidity are examined in light of the emerging data in this field.     

Heroin and opiate emergencies in Vienna: analysis at the municipal ambulance service

Vienna suffered an epidemic of heroin abuse in recent years, with drug-deaths due to opioids increasing from 62 in 1991 to 143 in 1993. The aim of this study was to make observations about illicit opioid-use with the ambulance service as a data source. From June 1994 to August 1995, the structured run records of the ambulance service were reviewed. Those with a presumptive diagnosis of "heroin or opiate" overdose were collected, characteristics of emergencies and patients were analyzed. The run records demonstrated a large number of non-fatal emergencies due to opioids, involving 528 men and 179 women in 1087 emergencies. These emergencies were on the average 6.8 times as prevalent as drug-fatalities. A group of 189 persons could be identified, who caused 52.2% of all emergencies and showed a threefold mortality rate during the observation period. In Vienna, the records of the municipal ambulance service provided valuable insights on opioid-abuse. We suggest local analysis of non-fatal emergencies due to opioids, as this might lead to a new source of information on illicit abuse of these drugs.     

The incidence and characteristics of volatile substance use related ambulance attendances in metropolitan Melbourne, Australia

While there has been substantial community discussion and concern expressed about volatile substance use (VSU), there has been little research on the use and related harms of these substances compared to other drugs. In this study we address a need in existing epidemiological research on VSU harms by describing the incidence and characteristics of VSU ambulance attendances between August 1998 and May 2004 across metropolitan Melbourne relative to heroin attendances, a drug class that has received more research attention. Our analysis showed that the crude rate of VSU attendance (5.03 per 100,000 population) over the period was substantially lower than the rates of heroin "involved" and heroin "overdose" attendances (33.40 and 54.87 per 100,000, respectively). Mean age of VSU cases was 20, with users on average 8 years younger than heroin cases. Two-thirds of VSU cases were male, with the likelihood of male attendance similar to heroin involved, but significantly less likely than heroin overdose. VSU attendances were geographically more evenly distributed than heroin attendances, with VSU cases more likely to occur at public and outdoor spaces. VSU cases were also less likely to be in an altered conscious state than heroin cases, but more likely to be co-attended by police and accept transportation to hospital. We conclude that VSU and heroin related harms occurred in different cohorts across metropolitan Melbourne, and that ambulance data can supplement existing data sources to inform policy and programme development, and the monitoring of VSU harms.     

Factors related to experiencing respiratory failure in cases of opiate overdose for which care was provided in an open setting. Barcelona, Spain

BACKGROUND: To determine the factors associated with respiratory arrest in opiate overdoses (coma, pupillary miosis, respiratory depression, and response to naloxone) among injecting drug users in the Can Tunis quarter of Barcelona. METHODS: We ran a transversal observational study where all overdoses assisted between March, 2001 and June, 2002. After overdose treatment, data were collected using a standard questionnaire, including: patients' sociodemographic data, opiate and other substances' use prior to overdose, clinical signs and symptoms presented, and medical intervention received, by way of a standardised questionnaire. Logistic regression was used as a tool for analysis. RESULTS: Of 222 opiate overdose cases, 60.8% showed respiratory arrest. Of all risk factors tested, only prior abstinence heroin abstinence for 2 weeks or longer days (OR=1.893; p=0.04), and no previous consumption of benzodiazepines (OR:0.462; p=0.017), proved to have a statistically significant association with suffering a respiratory arrest. Concomitant use of alcohol, cocaine or methadone appeared not associated with suffering respiratory arrest in opiate overdose. CONCLUSIONS: The main risk factor for respiratory arrest in opiate overdoses was a prior abstinence period of more than 2 weeks. Benzodiazepines use was associated with absence of respiratory arrest in overdose cases. Alcohol or methadone use, as well as the use of larger quantities of heroin, was not associated with suffering respiratory arrest in opiate overdoses. A study of other factors, not included in this study, and that could interfere with our results, should be considered for their possible relationship to benzodiazepine use as well as to absence of respiratory arrest in overdose cases.     

Methodological issues in the surveillance of poisoning,illicit drug overdose,and heroin overdose deaths in new Mexico

New Mexico leads the nation in poisoning mortality, which has increased during the 1990s in New Mexico and the United States. Most of this increase has been due to unintentional deaths from illicit drug overdoses. Medical examiner and/or vital statistics data have been used to track poisoning deaths. In this study, the authors linked medical examiner and vital statistics records on underlying cause of death, coded using the International Classification of Diseases, Ninth Revision, to assess the extent to which these data sources agreed with respect to poisoning deaths. The authors used multiple-cause files, which are files with several causes listed for each death, to further assess poisoning deaths involving more than one drug. Using vital statistics or medical examiner records, 94.7% of poisoning deaths were captured by each source alone. For unintentional illicit drug and heroin overdose deaths, each data source alone captured smaller percentages of deaths. Deaths coded as E858.8 (unintentional poisoning due to other drugs) require linkage with medical examiner or multiple-cause records, because this code identifies a significant percentage of illicit drug overdose deaths but obscures the specific drug(s) involved. Surveillance of poisoning death should include the use of medical examiner records and underlying- and multiple-cause vital statistics records.     

Nonpharmaceutical fentanyl-related deaths--multiple states, April 2005-March 2007

On April 21, 2006, increases in overdoses were reported among illicit drug users in Camden, New Jersey, via the CDC Epidemic Information Exchange (Epi-X). This alert elicited reports of similar increases in overdoses in other parts of New Jersey, and in Maryland; Chicago, Illinois; Detroit, Michigan; and Philadelphia, Pennsylvania. The increases in Chicago and Detroit had been recognized several months earlier but attributed to heroin overdoses until fentanyl was detected in the blood or urine of some decedents. Illicitly manufactured nonpharmaceutical fentanyl (NPF), a synthetic opioid 30-50 times more potent than heroin, also was found by law enforcement personnel and medical examiner staffs at the scene of some overdoses. In May 2006, to identify NPF-related deaths in six state and local jurisdictions, CDC implemented an ad hoc case-finding and surveillance system, later managed by the Drug Enforcement Administration (DEA). This report summarizes the results of that effort, which identified 1,013 NPF-related deaths that occurred during April 4, 2005-March 28, 2007. As a result, on April 23, 2007, DEA began regulating access to N-phenethyl-4-piperidone, a chemical used to make illicit NPF. Increased public health efforts are needed to improve epidemiologic data collection on drug overdoses, enable early detection of increases in drug overdoses, educate illicit drug users regarding the risks for overdose, and help users obtain treatment for their addictions.     

Fatal heroin-related overdose in San Francisco, 1997–2000: a case for targeted intervention

Heroin-related overdose is the single largest cause of accidental death in San Francisco. We examined demographic, location, nontoxicological, and toxicological characteristics of opiate overdose deaths in San Francisco, California. Medical examiner’s case files for every opioid-positive death from July 1, 1997, to June 30, 2000, were reviewed and classified as overdose deaths or other. Demographic variables were compared to two street-based studies of heroin users and to census data. From 1997 to 2000, of all heroin-related overdoses in San Francisco 47% occurred in low-income residential hotels; 36% occurred in one small central area of the city. In 68% of deaths, the victim was reportedly alone. When others were present between last ingestion of heroin and death, appropriate responses were rare. In three cases, police arrested the person who called emergency services or others present on the scene. We recommend the development of overdose response training targeted at heroin users and those close to them, including the staff of residential hotels.     

Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study

Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin overdose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants’ knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.     

Continuing outbreak of hepatitis A linked with intravenous drug abuse in Multnomah County

A communitywide outbreak of hepatitis A occurred in Portland, OR, from 1983 through 1986. At the peak of the outbreak, the age- and sex-specific annual incidence rate approached 400 cases per 100,000 population among men ages 25 to 34, the highest risk group. The community incidence rate was nearly 10 times the relevant national incidence rate. A review of the records concerning cases of hepatitis A reported in the last 6 months of 1985 revealed that about half the number of young adults whose cases were investigated during that time reported a history of intravenous (IV) drug use--a proportion about 50 times greater than expected among persons in that age range. A simultaneous epidemic of overdose deaths from heroin and a concomitant increase in hepatitis B incidence rates led to the suspicion that this was a drug-abuse-associated epidemic of hepatitis among new IV drug users. Control of this outbreak was difficult because the population most at risk was distrustful of public health officials. Increased surveillance in food service establishments and schools might have prevented outbreaks from a common source in the general population; however, an increase of sporadic cases in the nondrug-using population clearly occurred.     

云南省部分地区注射吸毒者海洛因过量情况及影响因素分析

目的 了解云南省部分地区注射吸毒者(IDU)海洛因过量情况及其影响因素。方法 采用横断面调查的方法,于2015年7-8月对云南省红河州和德宏州的4个美沙酮维持治疗(MMT)门诊和2个州强制戒毒所的IDU进行问卷调查,内容包括社会人口学特征、毒品使用情况、过去1年海洛因过量情况以及最近1次海洛因过量情况等。对过去1年发生过海洛因过量的相关因素进行logistic回归分析。结果 共340名IDU符合入选标准,男性占85.3%(290/340),年龄为(37.7±8.7)岁,汉族占65.6%(223/340),HIV阳性检出率为49.4%(167/338),过去6个月使用过新型毒品占22.6%(77/340)。自吸毒以来,曾有过海洛因过量的比例为41.8%(142/340),海洛因过量次数M=3次。在过去1年中海洛因过量发生率为15.6%(53/340),M=1次。发生海洛因过量的年龄为(36.7±8.4)岁,吸毒年限为(16.5±7.6)年,男性占83.0%(44/53)。发生海洛因过量的主要原因为增加海洛因用量(26.4%,14/53)和多药滥用(28.3%,15/53)。非条件logistic回归模型分析显示:过去1年参加过MMT(OR=0.534,95%CI:0.290~0.980)可降低海洛因过量的风险,而过去6个月共用针具(OR=2.735,95%CI:1.383~5.407)和刚出戒毒所不满1年(OR=2.881,95%CI:1.226~6.767)会增加海洛因过量的风险。结论 云南省IDU过去1年海洛因过量发生率较高。需要持续促进该地IDU参加MMT并加强预防和应对吸毒过量宣传教育,特别是对戒毒所吸毒人员出所前的宣传教育,同时应建立针对吸毒人员的戒毒所与MMT门诊转介机制。     

Intentional overdose among heroin overdose survivors

Previous studies have reported varying rates of intentional overdose among heroin overdose survivors. This article reports on the prevalence of intentional heroin overdose among a sample of overdose survivors in Melbourne, Australia. This is part of a larger study examining the risk factors associated with nonfatal overdose. The study involved interviews, with 256 heroin overdose survivors successfully resuscitated by Melbourne Ambulance Service paramedics. A substantial minority (17%) of the sample indicated that they had ever had an intentional overdose, and 67% had one within the last 6 months (11% of the total sample). Of those who had ever intentionally overdosed, 21% did so at the overdose for which they were recruited into the study (4% of total sample). Self-reported reasons for intentional heroin overdose fell into two categories: precipitating events and emotional states prior to use. Intentional overdose appears to comprise a relatively low proportion of overall heroin overdoses. However, given the complexity of suicidal thought and behavior, it is possible that some heroin overdose survivors who report their overdose to be unintentional were in fact experiencing some degree of suicidal thinking at the time of the overdose. Future research could address the potentially ambiguous nature of some intentional heroin overdoses.     

The relationship between depressive symptoms and nonfatal overdose among a sample of drug users in Baltimore,Maryland

Nonfatal drug overdoses are common among heroin users. While several factors that increase risk of overdose have been identified, there is little research on the role of mental health status. The purpose of this study was to examine the association between depressive symptoms and history of overdose. A sample of 729 opiate and cocaine users completed a cross-sectional survey. Of the sample, 65% reported never having overdosed, 31% had overdosed longer than 12 months before the interview, and 4% had overdosed within the past 12 months. Results indicate that a high score on the Center for Epidemiological Studies Depression Scale (CES-D), a measure of depressive symptoms, was associated with having overdosed within the past 12 months (relative risk ratio [RRR]=3.06; 95% confidence interval [CI], 1.33 to 7.05) after adjusting for age, gender, injection frequency, and physical health impairment. These results suggest that drug users with depressive symptoms should be targeted for overdose prevention programs.