Using ambulance service records to examine nonfatal heroin overdoses

Overdoses are a preventable health hazard associated with heroin use. In the first study of its kind, we examined the records on nonfatal overdoses of the Australian Capital Territory (ACT) Ambulance Service from August 1990 to July 1993. There was a dramatic increase in the number of overdoses in the second half of 1992 and the first half of 1993, but the reasons for the increase are not clear. Most overdoses occurred in men aged under 30, indoors, and many cases were taken to hospital. Often there was no information on why the overdose occurred; when information was available, about half the cases were attributed to taking heroin in combination with other drugs. Suggestions for improving the quality of the data collected are made. These include more systematic recording by ambulance officers of the drug involved in the overdose and whether the drug was used alone or in combination with others, and linkage of ambulance service records with survey data and information from analysis of heroin purity.     

Public opinion on the ambulance service in a rural and an urban region

Two groups of parents to schoolchildren (7 y and 15 y) were formed. The aim was to study if there were any differences in attitudes and knowledge concerning ambulance services in rural and urban areas. The results showed that knowledge about the ambulance service is good. Further, that day to day activities were considered more important than security measures to be used in emergencies. Parents living in rural parts considered the ambulance "near" but not as "near" as the parents in urban districts.     

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.     

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.     

Factors associated with illicit opioid use in methadone maintenance treatment clients in 5 Provinces,China

Objectives

To investigate factors associated with illicit opioid use among methadone maintenance treatment (MMT) population.

Methods

Participants were recruited from Beijing (2 clinics), Shanghai (2 clinics), Guangdong (2 clinics), Chongqing (2 clinics) and Gansu (1 clinic) provinces. Information about heroin use and MMT was obtained from a self-reported questionnaire, illicit opioid use was obtained from monthly medical records. Binary logistic regression was used to investigate factors associated with illicit opioid use.

Results

Five hundred ninety-eight eligible MMT participants were used for data analysis. Variables such as age, gender, route of heroin use and daily MMT dosages were associated with illicit opioid use. Compared with MMT participants aged <40 years, participants aged 40–44 years (P = 0.027, OR = 0.57, 95 % CI 0.35–0.94), 45–49 years (P < 0.001, OR = 0.41, 95 % CI 0.24–0.67) and ≥50 years (P = 0.008, OR = 0.52, 95 % CI 0.33–0.85) were more likely not to have illicit opioid use. Compared with male participants, females were more likely to have illicit opioid use (P = 0.044, OR = 1.53, 95 % CI 1.01–2.32). Compared with inhalation heroin abusers, abusers with route of inhalation + injection heroin use were more likely to have illicit opioid use (P = 0.009, OR = 2.00, 95 % CI 1.19–3.36). Compared with daily MMT dosages <60 mg participants, participants with daily MMT dosages >80 mg were more likely to have illicit opioid use (P = 0.003, OR = 2.37, 95 % CI 1.35–4.15).

Conclusions

Age, gender, route of heroin use and daily MMT dosages were associated with illicit opioid use. A tailored intervention is needed for a promotion of MMT.

     

Recognizing illicit drug use by pregnant women: reports from Oregon birth attendants.

OBJECTIVES. This study was undertaken to determine the prevalence of recognized prenatal illicit substance abuse and the characteristics of women being identified as illicit drug users in a statewide population-based cohort. METHODS. During a 1-month period, birth attendants of all singleton births in Oregon (n = 3200) were surveyed regarding their knowledge of prenatal illicit drug use by women who gave birth. Birth certificates were linked to surveys after removal of personal identifiers. RESULTS. Illicit drug use was recognized in 5.2% of delivering women. Nearly half had used cocaine, methamphetamine, or heroin. Recognized users were significantly more likely than nonusers to be unwed and to have used tobacco or alcohol, have received inadequate prenatal care, and have public assistance as a source of payment. Drug use was recognized twice as frequently by practitioners who routinely questioned their patients about it compared with those who relied on clinical judgment or the occurrence of complications during pregnancy. Birth certificate reporting identified only 41% of recognized users. CONCLUSIONS. Oregon practitioners are identifying seven times as many drug-using women as can be accommodated by available treatment programs for this population. Increased efforts are needed to ensure the adequacy of resources necessary to cope with the problem as already recognized.     

Use and misuse of an accident and emergency department in the East End of London

A study was made of all 587 new patients attending an accident and emergency department in the East End of London during one week. Two hundred and twenty-six (39%) cases were not accidents or emergencies; of these, 67% were self-referrals who had not previously seen their general practitioner (GP) and 21% were self-referrals who had previously seen their GP. The four main reasons that these self-referred patients had for attending were that they thought their condition needed immediate attention; they were insufficiently organized to see their GP; they were not registered with a GP; or they wanted a second opinion. Twenty-eight (12%) of the cases which were not accidents or emergencies were referred by a GP. Sixty-nine (12%) of all cases were not registered with a GP. The frequency of cases who were not accidents or emergencies was significantly higher in those not registered than in those registered (0.01 greater than P greater than 0.001). Nineteen (3%) patients were living rough or in hostels. Little abuse of the ambulance service was found.     

Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management

Clinicians have long been aware of the danger of overreliance on opioids to manage acute pain, such as the pain accompanying surgery. The risk of adverse drug events is higher with opioids than with any other common class of drugs. Overreliance on opioids increases length of stay and hospital costs, while decreasing patient satisfaction. Opioids can lead to problems that continue well after discharge, including chronic pain, abuse and addiction, and even death. Increasingly, prescribed opioids have proved to lead to heroin addiction. Studies show that the same professionals who prescribe, administer, and monitor opioids lack basic knowledge about their safe and effective use. The alternative to opioid monotherapy in controlling acute pain is multimodal analgesia, an approach that relies on a nonopioid foundation with addition of adjunctive opioids as needed. An increasing number of nonopioid analgesics have proved effective in this role, with fewer side effects and a higher degree of safety than opioids. Accordingly, multimodal analgesia is recommended as best practice by most recognized authorities. Increasingly, governmental authorities hold prescribing clinicians and institutions legally liable for the downstream negative effects of opioids, including abuse and addiction. Addressing this issue should be a top priority for hospital risk managers.     

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.     

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.     

Substance abuse, health and social welfare in Africa: an analysis of the Nigerian experience

Substance abuse has become a significant problem in the African continent in recent years. Reports of increasing abuse of alcohol and cannabis have appeared in many countries. In Nigeria, beginning from the early 1980s, the abuse of cocaine and heroin has been added to the problem. Even though epidemiological findings show low rates of abuse of these illicit substances in the general population, hospital-based studies point to a growing incidence of cocaine and heroin-related mental health problems. Information from recent studies in Nigeria is utilized in an analysis of the drug abuse scene. It is suggested that drug trafficking by Nigerians, which has been unprecedented in the past 10 years, has contributed to the observed shift in the pattern of drug abuse from cannabis and alcohol to cocaine and heroin. It is suggested that there should be regional sharing of information on drug abuse in the continent and that governments should treat as urgent the formulation and implementation of broadly-based drug policies.