Drugscope Harm Reduction Workshop Drugscope Harm Reduction Workshops Overdose Prevention

1. This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation • In Slide Show, click on the right mouse button • Select “Meeting Minder” • Select the “Action Items” tab • Type in action items as they come up • Click OK to dismiss this box • This will automatically create an Action Item slide at the end of your presentation with your points entered. Drugscope Harm Reduction WorkshopDrugscope Harm Reduction WorkshopsOverdosePrevention Dr Linda Harris Clinical Director Wakefield Integrated Substance Misuse Service

2. What we will attempt to cover • Overview of overdose – what do we know about it and who is at risk • Policy and guidance in relation to overdose and the prevention of drug related deaths • The responsibilities of commissioners and service providers in reducing deaths from overdose • Overdose training initiatives • A look at how to apply learning from the study of actual cases

3. Overdose is the largest cause of death amongst injecting drug abusers • People who inject heroin are 14x more likely to die than their peers • About a third of injecting heroin users report having experienced an overdose • Drug users (many of them in contact with services) are often present at fatal overdoses • Deaths would be prevented if drug services provide appropriate information, training and support on how to respond to an overdose

4. Patients who OD from opiates have used an excessive amount of heroin In the case of heroin OD death is shortly after the drug is injected WRONG - Blood levels of opiates in those who die is often less than that of a person who is not used to taking heroin WRONG – in many cases death is more than 3 hours after the heroin is injected Dispelling Myths

5. Getting the message across • Stop injecting • Don’t mix drugs and alcohol • Don’t mix opiates with other drugs • Avoid using opiates when tolerance is low, after a break in use e.g. on release from prison • Encourage people who might witness an overdose to give appropriate first aid and call an ambulance

6. Causes of overdose • Only a minority are reported as heroin overdose or methadone overdose • The majority of deaths are opiates in combination with other CNS depressants (especially alcohol and benzodiazepines) • Failure to recognise the signs and act quickly to give first aid when someone is suspected to have “gone over”

7. Risk factors and behaviours that are linked to OD who is most likely to be at risk of OD? • Injector • < 30 years • History of previous nonfatal overdose • Longer history of injecting • High levels of drug use and presentations of intoxication • High levels of alcohol use • Low tolerance • Depression feelings of hopelessness and suicidal ideation • History of one additional mental disorder ( mainly depression) • History of using drugs in combination • Higher risk injecting behaviours • Out of treatment – not on a methadone

8. Policies and guidelines • 2000 - Advisory Council on Misuse of Drugs (ACMD) report – “Reducing Drug Related Deaths” 1 • 2001 - DoH publish their response to the ACMD report 2 • 2002 - DATs receive guidance on providing resuscitation for overdose from DoH 3 • Publication of guidance for DATs on the development of local confidential enquiries 4

9. Mortality surveillance Three main sources of information:- • National Programme on Substance Abuse Deaths (np – SAD) Based on reports from coroner ( form F97) taking into account both the verdict and the cause of death • Office for National Statistics (ONS) • Publishes annual mortality figures in February of each year for the year ending 14 months earlier. • Includes all deaths in England and Wales where the underlying cause of death is assigned to a given criteria of ICD 10 code using the cause of death reported on death certificates • Home Office Bulletin • Derived from Deaths reported to Coroners in England and Wales. Based on inquests where verdict on cause of death recorded as drug dependence or non dependent abuse of drugs

10. The important role of the coroner • Establish the circumstances and cause of death • Investigate any possible criminal involvement • To order a post mortem and include a request for toxicology when indicated • To conduct an inquest where reports from police/GP/hospital are considered to decide the cause of death and give a verdict • Complete the relevant mortality surveillance forms

11. The importance of mortality studies • Informing treatment provision, and commissioning • E.g. evidence to back the role diverted methadone plays in drug related deaths 10 • higher death rate from methadone overdose noted over weekend 11 • CARATS team activities – prison discharge • Used to identify at risk population and lifestyles • Used to influence national and local harm reduction interventions • Used by drug prevention organisation and charities in drugs awareness campaigns • Inform the NTA and DoH in policy initiatives and influences resource allocations

12. Drug related deaths in Britain • Britain has highest rate of drug related deaths in Europe 5 • Newly released offenders 40X more likely to die from a drug related cause than the general population 6 • 40% of the deceased have suffered from at least one additional mental disorder 7 • Deceased 60% more likely to have a history of use of concomitant drug of misuse - most commonly benzodiazepines and/or alcohol 8

13. Drug related deaths in Britain (ONS database 1998 – 2002 9) • In the period 1998 – 2002 around 30% of deaths were due to a multiple drug overdose – (ONS 2004) • ¼ of drug related deaths included alcohol + another drug • Deaths involving heroin are decreasing but deaths involving cocaine have risen to their highest level ever • Deaths involving amphetamine and benzodiazepine increased during this period

14. Govt supports local action on preventing DRDs • Increasing concern at the rising numbers of preventable drug related deaths • Almost as many life years are now lost due to drug-related deaths, as are lost from all road traffic accidents • DoH Action Plan(2001) sets target of 20% reduction in drug-related deaths by March 2004 (N.T.A, 2004)

15. Performance monitoring the reduction of drug related deaths • The NTA looks for evidence of prioritisation of the monitoring of drug related deaths in the DAT Treatment plan • DATs are tasked with setting up local confidential enquiries into drug related deaths • DRD audit along with recommendations to be published and disseminated • Evidence of service user involvement crucial throughout the process

16. DRD monitoring in Wakefield • DAT priority area. • Work picked up by the harm minimisation task group to look at local issues • Work with local paramedics (WYMAS) and police to develop a relevant OD policy • Establish DRD working group specifically to identify and audit those who die as a result of taking illicit drugs • Purchase videos ‘Going Over’ which are run in the waiting rooms of street agencies • Design and display leaflets to promote key messages around OD • Develop a training module on Overdose for service users and project workers

17. Why Overdose Training? • Evidence to suggest most overdose deaths preventable • Needs assessment research in this area has demonstrated poor levels of basic first aid knowledge amongst service users • Many misconceptions • A way of getting the message directly to the service using community

18. Overdose training in Wakefield • Follows national guidance (DOH, mainliners and other leading groups) • Aims to give users the information they need to respond to overdose situations • Training used as a vehicle to discuss experiences and dispel myths • Provides basic first aid training

19. The Session • Three hours with refreshments • Key messages: Dial 999, recovery position, principles of CPR • Delivered in partnership with WYMAS, with help from Turning Point to recruit participants • Neutral, local venues • Some incentives to attend

20. Feedback/evaluation • I think it is far better to let the participants speak for themselves………….

21. A case study

22. Learning Lessons • Users and carers need to know what to do in the case of an overdose • Overdose training needs to be accessible and skills updated regularly • Specific advice and prioritisation should be made in the case of prison releasers, dual diagnosis, young people • Steps taken to reduce poly drug misuse • There is a case for training service users and or carers to carry and use naltrexone

23. The future • Recruit and support users to be involved in delivery of sessions and cascading of key messages • Identify ‘at risk’ groups to target • Develop training modules to incorporate lessons learnt from case studies