Attitudes about prescribing take-home naloxone to injection drug users for the management of heroin overdose: a survey of street-recruited injectors in the San Francisco Bay Area

Naloxone, an injectable opiate antagonist, can immediately reverse an opiate overdose and prevent overdose death. We sought to determine injection drug users’ (IDUs) attitudes about being prescribed take-home naloxone. During November 1999 to February 2000, we surveyed 82 street-recruited IDUs from the San Francisco Bay Area of California who had experienced one or more heroin overdose events. We used a questiomaire that included structured and open-ended questions. Most respondents (89%) had witnessed an overdose, and 90% reported initially attempting lay remedies in an effort to help companions survive. Only 51% reported soliciting emergency assistance (calling 911) for the last witnessed overdose, with most hesitating due to fear of police involvement. Of IDUs surveyed, 87% were strongly in favor of participating in an overdose management training program to receive take-home naloxone and training in resuscitation techniques. Nevertheless, respontdents expressed a variety of concerning attitudes. If provided naloxone, 35% predicted that they might feel comfortable using greater amounts of heroin, 62% might be less inclined to call 911 for an overdose, 30% might leave an overdose victim after naloxone resuscitation, and 46% might not be able to dissuade the victim from using heroin again to alleviate with drawal symptoms induced by naloxone. Prescribing take-home naloxone to IDUs with training in its use and in resuscitation techniques may represent a life-saving, peer-based adjunct to accessing emergency services. Nevertheless, strategies for overcoming potential risks associated with the use of take-home naloxone would need to be emphasized in an overdose management training program.     

Injection Drug Users Trained by Overdose Prevention Programs: Responses to Witnessed Overdoses

In response to the growing public health problem of drug overdose, community-based organizations have initiated overdose prevention programs (OPPs), which distribute naloxone, an opioid antagonist, and teach overdose response techniques. Injection drug users (IDUs) have been targeted for this intervention due to their high risk for drug overdose. Limited research attention has focused on factors that may inhibit or prevent IDUs who have been trained by OPPs to undertake recommended response techniques when responding to a drug overdose. IDUs (n = 30) trained by two OPPs in Los Angeles were interviewed in 2010–2011 about responses to their most recently witnessed drug overdose using an instrument containing both open and closed-ended questions. Among the 30 witnessed overdose events, the victim recovered in 29 cases while the outcome was unknown in one case. Participants responded to overdoses using a variety of techniques taught by OPPs. Injecting the victim with naloxone was the most commonly recommended response while other recommended responses included stimulating the victim with knuckles, calling 911, and giving rescue breathing. Barriers preventing participants from employing recommended response techniques in certain circumstances included prior successes using folk remedies to revive a victim, concerns over attracting police to the scene, and issues surrounding access to or use of naloxone. Practical solutions, such as developing booster sessions to augment OPPs, are encouraged to increase the likelihood that trained participants respond to a drug overdose with the full range of recommended techniques.     

Attitudes of Australian Heroin Users to Peer Distribution of Naloxone for Heroin Overdose: Perspectives on Intranasal Administration

Naloxone distribution to injecting drug users (IDUs) for peer administration is a suggested strategy to prevent fatal heroin overdose. The aim of this study was to explore attitudes of IDUs to administration of naloxone to others after heroin overdose, and preferences for method of administration. A sample of 99 IDUs (median age 35 years, 72% male) recruited from needle and syringe programs in Melbourne were administered a questionnaire. Data collected included demographics, attitudes to naloxone distribution, and preferences for method of administration. The primary study outcomes were attitudes of IDUs to use of naloxone for peer administration (categorized on a five-point scale ranging from “very good idea” to “very bad idea”) and preferred mode of administration (intravenous, intramuscular, and intranasal). The majority of the sample reported positive attitudes toward naloxone distribution (good to very good idea: 89%) and 92% said they were willing to participate in a related training program. Some participants raised concerns about peer administration including the competence of IDUs to administer naloxone in an emergency, victim response on wakening and legal implications. Most (74%) preferred intranasal administration in comparison to other administration methods (21%). There was no association with age, sex, or heroin practice. There appears to be strong support among Australian IDU for naloxone distribution to peers. Intranasal spray is the preferred route of administration. Kerr and Kelly are with the Joseph Epstein Centre for Emergency Medicine Research, Sunshine Hospital, St. Albans, Victoria, Australia; Kerr and Kelly are with the The University of Melbourne, Melbourne, Victoria, Australia; Dietze is with the Burnet Institute, Melbourne, Victoria, Australia; Dietze and Jolley are with the Monash Institute of Health Services Research, Melbourne, Victoria, Australia.     

Attitudes of emergency medical service providers toward naloxone distribution programs

Training and distributing naloxone to drug users is a promising method for reducing deaths associated with heroin overdose. Emergency Medical Service (EMS) providers have experience responding to overdose, administering naloxone, and performing clinical management of the patient. Little is known about the attitudes of EMS providers toward training drug users to use naloxone. We conducted an anonymous survey of 327 EMS providers to assess their attitudes toward a pilot naloxone program. Of 176 who completed the survey, the majority were male (79%) and Caucasian (75%). The average number of years working as an EMS provider was 7 (SD=6). Overall attitudes toward training drug users to administer naloxone were negative with 56% responding that this training would not be effective in reducing overdose deaths. Differences in attitudes did not vary by gender, level of training, or age. Providers with greater number of years working in EMS were more likely to view naloxone trainings as effective in reducing overdose death. Provider concerns included drug users’ inability to properly administer the drug, program condoning and promoting drug use, and unsafe disposal of used needles. Incorporating information about substance abuse and harm reduction approaches in continuing education classes may improve the attitudes of provider toward naloxone training programs.     

Risk Factors for Nonfatal Overdose at Seattle-Area Syringe Exchanges

Opioid-involved overdose deaths are on the rise, both nationwide and in the state of Washington. In a survey of 443 participants at syringe exchanges in Seattle, Washington, 16% had overdosed in the last year. Several factors were significantly associated in bivariate analysis: lack of permanent housing; incarceration of five or more days in the past year; gender of sex partners; sharing of syringes and other injection paraphernalia; use of speedballs (cocaine and heroin together), goofballs (methamphetamine and heroin together), buprenorphine; injection use of crack cocaine and sedatives; and use of opioids with sedatives. Adjusting for other variables in multivariate logistic regression analyses, only recent incarceration and sharing of injection materials were still significantly associated with overdose. Correctional facilities, syringe exchange programs, and other agencies serving opioid injectors should include overdose prevention components in release planning and services.     

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。     

Characterizing the drug-injecting networks of cocaine and heroin injectors in Montreal

BACKGROUND: There is little understanding about how the social networks of cocaine injectors are different from those of heroin users and about how such differences are associated with injection risk behaviours. Therefore, the objective of this study was to compare drug-injecting network characteristics of cocaine and heroin injectors believed to be associated with a risk of bloodborne infections. METHODS: Active injection drug users (IDUs) were recruited between April 2004 and January 2005 from three syringe exchange and two methadone treatment programs in Montreal, Canada. Characteristics of each participant and of up to 10 social network members (IDU and non-IDU) with whom frequent contact had occurred in the past month were elicited using a structured, interviewer-administered questionnaire. The current analysis focussed on the drug-injecting network members. Logistic regression was used to examine network characteristics in relation to cocaine and heroin injection. RESULTS: Of 282 study subjects, 81% used cocaine and 19% used heroin as their primary injected drug in the past 6 months. Compared to heroin injectors, participants who injected cocaine had lower odds of knowing their network members for a longer time (OR=0.92, 0.85-0.99), were more likely to report a larger IDU network (OR=1.64, 1.18-2.29) and have IDU partners who had a history of attending shooting galleries (OR=2.42, 1.05-5.56). INTERPRETATION: This study identified high-risk network-related factors associated with bloodborne infections in cocaine injectors. Prevention efforts may benefit from tailoring interventions according to type of drug used, with particular attention to the drug injecting-network of IDUs.     

An observational prospective cohort study of naloxone use at witnessed overdoses,Kazakhstan, Kyrgyzstan,Tajikistan, Ukraine

ObjectiveTo determine whether participation in the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization’s (WHO) Stop Overdose Safely (S-O-S) take-home naloxone training project in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine resulted in naloxone use at witnessed opioid overdoses.MethodsAn observational prospective cohort study was performed by recruiting participants in the implementation of the S-O-S project, which was developed as part of the broader S-O-S initiative. Training included instruction on overdose responses and naloxone use. Study participants were followed for 6 months after completing training. The primary study outcome was participants’ naloxone use at witnessed overdoses, reported at follow-up.FindingsBetween 400 and 417 S-O-S project participants were recruited in each country. Overall, 84% (1388/1646) of participants were interviewed at 6-month follow-up. The percentage who reported witnessing an overdose between baseline and follow-up was 20% (71/356) in Tajikistan, 33% (113/349) in Kyrgyzstan, 37% (125/342) in Ukraine and 50% (170/341) in Kazakhstan. The percentage who reported using naloxone at their most recently witnessed overdose was 82% (103/125) in Ukraine, 89% (152/170) in Kazakhstan, 89% (101/113) in Kyrgyzstan and 100% (71/71) in Tajikistan.ConclusionImplementation of the UNODC–WHO S-O-S training project in four low- to middle-income countries resulted in the reported use of take-home naloxone at around 90% of witnessed opioid overdoses. The percentage varied between countries but was generally higher than found in previous studies. Take-home naloxone is particularly important in countries where emergency medical responses to opioid overdoses may be limited.     

Take-Home Emergency Naloxone to Prevent Heroin Overdose Deaths after Prison Release: Rationale and Practicalities for the N-ALIVE Randomized Trial

The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.     

Service uptake and characteristics of injection drug users utilizing North America's first medically supervised safer injecting facility

In 2003, the city of Vancouver, British Columbia, opened North America’s first government-sanctioned safer injecting facility, where injection drug users (IDUs) can inject preobtained illicit drugs under the supervision of nurses. Use of the service by IDUs was followed by measurable reductions in public drug use and syringe sharing. IDUs who are frequently using the program tend to be high-intensity cocaine and heroin injectors and homeless individuals.

The facility has provided high-risk IDUs a hygienic space where syringe sharing can be eliminated and the risk of fatal overdose reduced. Ongoing evaluation will be required to assess its impact on overdose rates and HIV infection levels, as well as its ability to improve IDU contact with medical care and addiction treatment

     

Low-Frequency Heroin Injection among Out-of-Treatment, Street-Recruited Injection Drug Users

In this paper, we explore the understudied phenomenon of “low-frequency” heroin injection in a sample of street-recruited heroin injectors not in drug treatment. We conducted a cross-sectional study of 2,410 active injection drug users (IDUs) recruited in San Francisco, California from 2000 to 2005. We compare the sociodemographic characteristics and injection risk behaviors of low-frequency heroin injectors (low-FHI; one to 10 self-reported heroin injections in the past 30 days) to high-frequency heroin injectors (high-FHI; 30 or more self-reported heroin injections in the past 30 days). Fifteen percent of the sample met criteria for low-FHI. African American race, men who have sex with men (MSM) behavior, and injection and noninjection methamphetamine use were independently associated with low-FHI. Compared to high-FHI, low-FHI were less likely to report syringe sharing and nonfatal heroin overdose. A small but significant proportion of heroin injectors inject heroin 10 or less times per month. Additional research is needed to qualitatively examine low-frequency heroin injection and its relationship to drug use trajectories.     

Prevalence and circumstances of opiate overdose among injection drug users in the Russian federation

Using a self-administered questionnaire, we examined the characteristics of opiate overdose in 16 cities of the Russian Federation. As indicated by responses from 763 injection drug users who took part in this study, 59% experienced an overdose, 81% reported seeing others experiencing an overdose, and 15% stated that they had witnessed a fatal overdose. The most common drug that caused opiate overdose was heroin (74%), although we also found that, in smaller towns, home-produced opiates tended to be a major overdose-causing agent. There were a number of factors that increased the likelibood of overdose, such as mixing opiates with alcobol and tranquilizers or having a longer history of opiate use. We also found that injecting drug users were reluctant to seek medical assistance when their peers experienced an overdose because of the perceived ineffectiveness of ambulance services and fear of police prosecution. At the same time, 57% of respondents admitted that they lacked appropriate skills to treat overdose. We discuss the implications of these findings for overdose prevention programs in Russia.     

Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users?

BACKGROUND: In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection. METHODS: We examined data from a community-recruited cohort study of IDUs. The prevalence of SIF use was determined based on questionnaire data obtained after the SIF's opening, and we determined predictors of initiating future SIF use based on behavioral information obtained from questionnaire data obtained before the SIF's opening. Pearson's chi-square test was used to compare characteristics of IDUs who did and did not subsequently initiate SIF use. RESULTS: Overall, 400 active injection drug users returned for follow-up between December 1, 2003 and May 1, 2004, among whom 178 (45%) reported ever using the SIF. When we examined behavioral data collected before the SIF's opening, those who initiated SIF use were more likely to be aged <30 years (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.0-2.7], p=0.04); public injection drug users (OR=2.6, 95% CI=1.7-3.9, p<0.001); homeless or residing in unstable housing (OR=1.7, 95% CI=1.2-2.7, p=0.008); daily heroin users (OR=2.1, 95% CI=1.3-3.2, p=0.001); daily cocaine users (OR=1.6, 95% CI=1.1-2.5, p=0.025); and those who had recently had a nonfatal overdose (OR=2.7, 95% CI=1.2-6.1, p=0.016). CONCLUSIONS: This study indicated that the SIF attracted IDUs who have been shown to be at elevated risk of blood-borne disease infection and overdose, and IDUs who were contributing to the public drug use problem and unsafe syringe disposal problems stemming from public injection drug use.     

Injection drug use: harbinger of HIV / AIDS

The spread of HIV infections in southeastern Asia is expected to be significant. In this area, as in other parts of the world, the habits of intravenous drug users (IDUs) who share needles and supplies and engage in high-risk sexual behavior will contribute to the spread of the disease in the general population. Because drug treatment programs that promote abstinence are only successful among the limited number of drug abusers who are motivated to stop taking drugs, a harm-reduction approach to this problem makes the best sense. Reducing HIV risk requires giving priority to HIV prevention rather than to control of drug use. Interventions to prevent HIV transmission among IDUs include counseling for in-treatment drug users, needle and syringe exchange programs, and preventive intervention programs that attempt to change high-risk behavior. In India, drug abuse has a long history, and the northeastern states have experienced a rapid increase in heroin use accompanied by the spread of HIV infection. In other areas, injection of Buprenorphine is increasing. It is important to recognize IDUs as a group at high risk of transmitting HIV infection and to design strategies, such as those that have been successful in New York City, to stabilize sera-prevalence in this rapidly increasing group.     

Characteristics of inmates witnessing overdose events in prison: implications for prevention in the correctional setting

Background  

Although prevention of opiate overdose has been gaining attention as a harm reduction measure with community drug users, there is scarce information about drug overdose in prison. In correctional institutions without a drug free environment, awareness of overdose events is an important public health concern. This study explores the frequency with which inmates in a state penitentiary system report having witnessed drug overdose events in prison. It also explores whether participants who have witnessed an overdose in prison and know someone who died from an overdose in prison significantly differ from those that do not in selected sociodemographic variables and drug use history to identify a target population for prevention interventions.